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Fulltext Issues in identifying germ tube positive yeasts by conventional methods

Yazdanpanah A, Khaithir TM

J Clin Lab Anal, 2014 Jan;28(1):1-9.
PMID: 24375729 DOI: 10.1002/jcla.21635

Candida speciation is vital for epidemiology and management of candidiasis. Nonmolecular conventional methods often fail to identify closely related germ tube positive yeasts from clinical specimens. The present study was conducted to identify these yeasts and to highlight issues in conventional versus molecular methods of identification. A total of 98 germ tube positive yeasts from high vaginal swabs were studied over a 12-month period. Isolates were examined with various methods including growth at 42 °C and 45 °C on Sabouraud dextrose agar (SDA), color development on CHROMagar Candida medium, chlamydospore production on corn meal agar at 25 °C, carbohydrate assimilation using ID 32C system, and polymerase chain reaction using a single pair of primers targeting the hyphal wall protein 1 (Hwp1) gene. Of all the isolates studied, 97 were molecularly confirmed as C. albicans and one isolate was identified as C. dubliniensis. No C. africana was detected in this study. The molecular method used in our study was an accurate and useful tool for discriminating C. albicans, C. dubliniensis, and C. africana. The conventional methods, however, were less accurate and riddled with many issues that will be discussed in further details.
Fulltext Brief report: nail sampling technique and its interpretation

Leelavathi M, Tzar MN

Malays Fam Physician, 2011;6(2-3):58-9.
PMID: 25606224

The clinical suspicion of onychomyosis based on appearance of the nails, requires culture for confirmation. This is because treatment requires prolonged use of systemic agents which may cause side effects. One of the common problems encountered is improper nail sampling technique which results in loss of essential information. The unfamiliar terminologies used in reporting culture results may intimidate physicians resulting in misinterpretation and hamper treatment decision. This article provides a simple guide on nail sampling technique and the interpretation of culture results.
Fulltext Determination of ergosterol as a potential biomarker in pathogenic medically important fungal isolates

Ahmad Sh. A. Lafi, Fahrul Huyop, Jacinta Santhanam, Tzar Mohd Nizam Khaithi

Jurnal Sains Kesihatan Malaysia, 2018;16(2):15-21.
MyJurnal

Ergosterol, a component of fungal cell membrane, has been frequently detected as an indicator of fungal presence and mass
in environmental samples like soil. However, its detection in major pathogenic fungal species has not been investigated.
In this study, the ergosterol contents of ten pathogenic fungal species were determined. Liquid chromatography was used
for the detection and quantification of ergosterol extracted from fungal broth cultures. Results showed that ergosterol
eluted as a single, well resolved peak in the chromatogram profiles of all tested fungi. Based upon relative amounts of
ergosterol produced per fungal mycelial dry weight, three groups of fungal pathogens were identified, namely low ergosterol
(Aspergillus niger, Candida albicans and Cryptococcus neoformans at 4.62, 6.29 and 7.08 µg/mg, respectively), medium
ergosterol (Fusarium solani, Aspergillus fumigatus, Mucor sp., Penicillium sp., Cryptococcus gattii and Rhizopus sp.
at 9.40, 10.79, 10.82, 11.38, 12.60 and 13.40 µg/mg, respectively), and high ergosterol (Candida tropicalis at 22.84 µg/
mg), producers. Ergosterol was not detectable in bacterial samples, which were included as controls. This first report on
ergosterol detection in major pathogenic fungal species indicates that ergosterol may be used as a biomarker to diagnose
invasive fungal infections in clinical samples.
Dual panel multiplex PCR assay for rapid detection of medically important fungi and resistant species of candida and aspergillus

Jacinta Santhanam, Mohd Hanif Jainlabdin, Ang LC, Tzar Mohd Nizam

Sains Malaysiana, 2018;47:489-498.

Invasive fungal infections (IFIs) have risen dramatically in recent years among high risk immunocompromised patients.
Rapid detection of fungal pathogens is crucial to timely and accurate antifungal therapy. Two multiplex polymerase
chain reaction (PCR) assays were developed to detect major fungal species that cause invasive infections and identify
resistant species. Genus specific primers for Candida, Aspergillus, Fusarium and species specific primers for Candida
glabrata, Candida krusei and Aspergillus terreus which are known to be clinically resistant species, were designed from
the internal transcribed spacer (ITS) regions of ribosomal ribonucleic acid (rRNA) gene complex. Both assays were
performed simultaneously to promote rapid detection of fungal isolates based on distinct amplicon sizes. Inclusion of the
universal fungal primers ITS 1 and ITS 4 in the genus specific assay produced a second amplicon for each isolate which
served to confirm the detection of a fungal target. The limit of detection for the genus specific assay was 1 nanogram
(ng) deoxyribonucleic acid (DNA) for Aspergillus fumigatus and Candida albicans, 0.1 ng DNA for Fusarium solani, while
the species-specific assay detected 0.1 ng DNA of A. terreus and 10 picogram (pg) DNA of C. krusei and C. glabrata. The
multiplex PCR assays, apart from universal detection of any fungal target, are able to detect clinically important fungi
and differentiate resistant species rapidly and accurately, which can contribute to timely implementation of effective
antifungal regime.
Fulltext A Severe Case of Arthrographis kalrae Keratomycosis

Ramli SR, Francis AL, Yusof Y, Khaithir TM

Case Rep Infect Dis, 2013;2013:851875.
PMID: 24377053 DOI: 10.1155/2013/851875

A 52-year-old man with diabetes developed a unilateral central corneal ulcer after accidental foreign body inoculation. He complained of pain and loss of visual acuity in the injured eye, which displayed redness and edema and eventually discharged pus. A corneal scraping from the left eye orbit revealed fungal elements, and cultures of the material grew a fungus. The isolate was identified as Arthrographis kalrae based on gross and microscopic morphologies. The patient received amphotericin B intravenously and itraconazole orally. The wound healed following surgical intervention, but the patient lost the use of his left eye.
Fulltext Sporotrichosis atypical presentation as a soft tissue tumour

Ramli R, Abd Rashid AH, Phang KS, Khaithir TM

Malays J Pathol, 2009 Dec;31(2):143-5.
PMID: 20514859 MyJurnal

Sporotrichosis is a mycosis caused by a saprophytic dimorphic fungus named Sporothrix schenckii. Infections occur following traumatic inoculation of fungus from plants and infected cat bites and scratches. We report a case of a farmer who presented with a solitary subcutaneous nodule initially diagnosed as a soft tissue tumour. A history of agricultural activity and feline contact should draw the clinician's attention to sporotrichosis, as the diagnosis can be easily missed in atypical cases. The diagnosis, microbiology and management of the case are discussed.
Fulltext Candidaemia and antifungal susceptibility testing in a teaching hospital

Tzar MN, Shamim AS

Med J Malaysia, 2009 Mar;64(1):61-4.
PMID: 19852325 MyJurnal

We reviewed cases of candidaemia at Universiti Kebangsaan Malaysia Medical Centre from 1st January 2005 to 30th June 2006. All blood cultures positive for Candida species or its teleomorphs within the study period were identified and antifungal susceptibility testing was performed. Out of 50 blood isolates, 20 (40%) were identified as Candida albicans, 16 (32%) C. tropicalis, five (10%) C. parapsilosis, three (6%) C. famata, two (4%) C. glabrata, two (4%) Pichia ohmeri, one (2%) C. krusei and one (2%) P. etchell/carsonii. Susceptibility to amphotericin B was 100%, fluconazole 90%, itraconazole 40%, ketoconazole 88%, 5-flucytosine 98% and voriconazole 98%.
Antifungal susceptibility patterns among candida species isolated from blood at Universiti Kebangsaan Malaysia Medical Centre

Tzar Mohd Nizam Khaithir, Siti Umairah Hamid, Tan S, Siti Nurwani Ahmad Ridzuan, Mohd Syazwan Che Seman, Ramliza Ramli

Sains Malaysiana, 2012;41:961-967.

Many challenges arise in candidaemia treatment which involves emergence of antifungal resistance. New species have been identified due to improved methods of detection and some are resistant to commonly prescribed antifungal agents such as fluconazole and amphotericin B. Therefore, the objective of the study was to observe any changes in the susceptibility patterns and distribution of Candida species. This cross sectional study was conducted at the Department of Medical Microbiology and Immunology in UKMMC, a tertiary teaching hospital. One hundred and fifty one data were collected from the department’s laboratory records from January 2008 to December 2010. The yeasts were identified using ID32C carbohydrate assimilation tests whilst the antifungal susceptibility test was performed using Sensititre® YeastOne® broth microdilution method. Antifungal agents tested included amphotericin B, fluconazole, itraconazole, voriconazole, 5-flucytosine and caspofungin. Out of 151 blood isolates, 47 (31.1%) were Candida albicans and 104 (68.9%) were non-albicans Candida species. Candida tropicalis has surpassed C. albicans as the most commonly isolated Candida species from blood. Overall susceptibility (as compared to 2005-2006 data in brackets) to caspofungin was 99.3% (n/a), 5-flucytosine 97.4% (98%), amphotericin B 94.7% (100%), voriconazole 92.7% (98%), fluconazole 86.8% (90%) and
itraconazole 39.1% (40%). In conclusion, although the isolates were generally still susceptible to amphotericin B and fluconazole, resistance to these drugs is increasing.
Antibacterial effects of ellagitannins from Acalypha wilkesiana var. macafeana hort.: surface morphology analysis with environmental scanning electron microscopy and synergy with antibiotics

Din WM, Jin KT, Ramli R, Khaithir TM, Wiart C

Phytother Res, 2013 Sep;27(9):1313-20.
PMID: 23109276 DOI: 10.1002/ptr.4876

The present study served to gain further insight into the bactericidal effects of ellagitannins from Acalypha wilkesiana var. macafeana hort. against pathogenic bacteria. Ellagitannins from the aerial parts of A. wilkesiana var. macafeana hort. (EAW) inhibited the growth of Bacillus cereus (ATCC 11778), Bacillus subtilis (ATCC 6633), Staphylococcus aureus (ATCC 11632) and Methicillin-resistant Staphylococcus aureus (MRSA) clinical strain with inhibition zones equal to 11.01 ± 1.53 mm, 16.63 ± 0.11 mm, 11.40 ± 1.10 mm and 8.22 ± 0.19 mm, respectively. The minimal inhibition concentration and the minimal bactericidal concentration of ellagitannins from A. wilkesiana var. macafeana hort. (EAW) against MRSA were 750 µg/mL and 3000 µg/mL, respectively. We then examined the synergistic effect of EAW with three antibiotics, i.e. ampicillin, streptomycin and tetracycline, via the checkerboard assay and time-kill assay and observed that EAW is synergistic with ampicillin against S. aureus (ATCC 11632). Environmental electron scanning microscopy analysis showed cell lysis against S. aureus (ATCC 11632) upon treatment with the ellagitannin fraction. The ellagitannin fraction from A. wilkesiana var. macafeana hort. is bactericidal against gram-positive bacteria tested and works synergistically with ampicillin against S. aureus. Morphology analysis of the cell suggests that the bactericidal property of the ellagitannin fraction mechanism involves lysis of the cell wall. In summary, our studies demonstrate that A. wilkesiana var. macafeana hort. produces bactericidal ellagitannins of clinical and/or cosmetological value.
Cryptococcus humicolus meningitis: first case report in Malaysia

Ramli SR, Leong MC, Khaithir TM, Aziz MN, Loons LC, Rafia MH

Southeast Asian J Trop Med Public Health, 2012 Sep;43(5):1212-7.
PMID: 23431829

We report a case of Cryptococcus humicolus meningitis complicated by communicating hydrocephalus in an apparently immunocompetent 49-year-old psychiatric patient from a nursing home. He presented with a history of poor oral intake, weight loss, headache, vomiting, blurred vision, frequent falls and unsteady gait for the previous three months. He had a history of chronic cough, productive of whitish sputum for the previous month but no hemoptysis. Cerebrospinal fluid culture was positive for Cryptococcus humicolus. He was treated with intravenous amphotericin B and oral fluconazole and had clinical and microbiological improvement after three weeks of treatment. Unfortunately, the patient acquired nosocomial methicillin-resistant Staphylococcus aureus infection and died due to overwhelming sepsis.
Fulltext A systematic review of the outcomes of osteoporotic fracture patients after hospital discharge: morbidity, subsequent fractures, and mortality

Nazrun AS, Tzar MN, Mokhtar SA, Mohamed IN

Ther Clin Risk Manag, 2014;10:937-48.
PMID: 25429224 DOI: 10.2147/TCRM.S72456

PURPOSE:
Osteoporotic fracture is the main complication of osteoporosis. The current management is to discharge patients as early as possible so they can get back to their daily activities. Once discharged, there are three main issues relating to morbidity, mortality, and risk of a subsequent fracture that need to be addressed and discussed. Therefore, the aim of this systematic review was to summarize and evaluate the evidence from published literature, to determine the outcome of osteoporotic fracture patients after their hospital discharge.

METHODS:
The MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched, using the terms "osteoporosis", "fracture", "osteoporotic fracture", "hip fracture", and "vertebral fracture". We included only human studies published in English between 2004 and 2014. The reference lists of included studies were thoroughly reviewed in search for other relevant studies.

RESULTS:
A total of 18 studies met the selection criteria. Most were observational and cohort studies. Out of all the studies, five studies looked into the morbidity, six studies looked into the risk of subsequent fractures, and seven studies looked into mortality. Vertebral fracture caused the greatest health burden, but hip fracture patients were the main users of informal care after hospital discharge. There was an increased risk of a subsequent fracture after a primary fracture compared with the control group, a cohort comparison, or the general population. Osteoporotic fractures, especially hip fractures, are associated with higher mortality rate despite the advances in the management of osteoporotic fracture cases.

CONCLUSION:
There is strong evidence to show that after hospital discharge, osteoporotic fracture patients are faced with higher morbidity, subsequent fractures, and mortality.

KEYWORDS:
hip fracture; osteoporosis; vertebral fracture
Prevalence of albicans and non-albicans candiduria in a Malaysian medical centre

Ding CH, Wahab AA, Muttaqillah NA, Tzar MN

J Pak Med Assoc, 2014 Dec;64(12):1375-9.
PMID: 25842581

To determine the proportion of albicans and non-albicans candiduria in a hospital setting and to ascertain if fluconazole is still suitable as empirical antifungal therapy based on antifungal susceptibility patterns of Candida species.
Paecilomyces lilacinus fungaemia in an AIDS patient: the importance of mycological diagnosis

Ding CH, Tzar MN, Rahman MM, Muttaqillah NA, Redzuan SR, Periyasamy P

Pak J Med Sci, 2014 Jul;30(4):914-6.
PMID: 25097544

Fungaemia due to Paecilomyces lilacinus is generally not considered in AIDS patients because this condition is not categorised as an AIDS-indicator illness. We report a case of a 25-year-old lady who presented to our hospital with Guillain-Barré Syndrome, with the subsequent development of refractory fungaemia, multi-organ failure and disseminated intravascular coagulopathy. Amphotericin B was given as empirical antifungal therapy. HIV screening was reactive and Paecilomyces lilacinus was isolated from her blood. The fungaemia did not resolve after one week of amphotericin B treatment. The addition of itraconazole was also unsuccessful in clearing the fungaemia. Accurate mycological diagnosis is important in the care of AIDS patients with fungaemia because of the risk of treatment failure with empirical therapy.
Fulltext An approach to develop clinical prediction rule for candidemia in critically ill patients: A retrospective observational study

Jameran AS, Cheah SK, Tzar MN, Musthafa QA, Low HJ, Maaya M, et al.

J Crit Care, 2021 10;65:216-220.
PMID: 34252648 DOI: 10.1016/j.jcrc.2021.06.018

PURPOSE: Early detection of candidemia in critically ill patients is important for preemptive antifungal treatment. Our study aimed to identify the independent risk factors for the development of a new candidemia prediction score.
METHODS: This single-centre retrospective observational study evaluated 2479 intensive care unit (ICU) cases from January 2016 to December 2018. A total of 76 identified candidemia cases and 76 matched control cases were analyzed. The patients' demographic characteristics and illness severity were analyzed, and possible risk factors for candidemia were investigated.
RESULTS: Multivariate logistic regression analysis identified renal replacement therapy (RRT) (odds ratio [OR]: 52.83; 95% confidence interval [CI]: 7.82-356.92; P < 0.0001), multifocal Candida colonization (OR: 23.55; 95% CI: 4.23-131.05; P < 0.0001), parenteral nutrition (PN) (OR: 63.67; 95% CI: 4.56-889.77; P = 0.002), and acute kidney injury (AKI) (OR: 7.67; 95% CI: 1.24-47.30; P = 0.028) as independent risk factors. A new prediction score with a cut-off value of 5.0 (80.3% sensitivity and 77.3% specificity) was formulated from the logit model equation.
CONCLUSIONS: Renal replacement therapy, AKI, PN, and multifocal Candida colonization were the independent risk factors for the new candidemia prediction score with high discriminatory performance and predictive accuracy.
Fulltext Exophiala dermatitidis, 'the real black fungus' fungemia in a patient with COVID-19

Tzar MN, Meor Jamaludin WHB, Abdul Wahab A, Ding CH

IDCases, 2022;27:e01428.
PMID: 35127454 DOI: 10.1016/j.idcr.2022.e01428

The second wave of the COVID-19 pandemic in India had brought with it a surge of 'black fungus' co-infection, which is a misnomer for mucormycosis. The present case illustrates the 'real black fungus' infection in a 50-year old male patient with COVID-19 pneumonia, who otherwise had no significant previous medical history. He was admitted on day 8 of COVID-19 illness and was intubated due to persistently low oxygen saturation. Blood cultures were positive for flask-shaped dematiaceous budding yeasts with pseudohyphae formation, which grew as brown-black fuzzy colonies on Sabouraud dextrose agar. The isolate was identified as Exophiala dermatitidis based on phenotypic characterization. Despite antifungal therapy with amphotericin B and itraconazole, the patient deteriorated rapidly and succumbed to acute respiratory distress syndrome and multiorgan failure. A review of reported cases of Exophiala dermatitidis fungemia over the last 5-years is discussed.
Fulltext Isolation of an obscure fungus, Parengyodontium album, from the blood of a severely neutropenic patient: The first reported case from Malaysia

Mohamed N, Ding CH, Wahab AA, Tzar MN, Hassan M

J Infect Dev Ctries, 2022 Oct 31;16(10):1668-1670.
PMID: 36332225 DOI: 10.3855/jidc.17016

Parengyodontium album is a very rarely encountered opportunistic fungal pathogen. A severely neutropenic 11-year-old boy with acute T-cell lymphoblastic leukemia/lymphoma was febrile and lethargic during his admission for elective chemotherapy. No cutaneous lesion or obvious source of infection was noted, and clinical examination was otherwise unremarkable. A blood specimen was sent for culture and fungal elements were visualized. Amphotericin B was administered empirically while awaiting fungal identification. Morphologically, a hyaline mould with thin septate hyphae plus smooth-walled conidiophores and conidiogenous cells arranged in whorls of up to four was cultured. Internal transcribed spacer region sequencing identified the fungus conclusively as P. album. Repeat blood culture was also positive for the same fungus. Following a two-week course of amphotericin B, fungemia clearance was attained.
Fulltext Successful Treatment of Sternal Osteomyelitis and Mediastinitis Caused by Rhizopus Following Cardiac Surgery

Tiew TC, Md Ali NA, Ismail MI, Abdul Rahman MR, Ding CH, Tzar MN

Cureus, 2024 Jun;16(6):e62312.
PMID: 39006712 DOI: 10.7759/cureus.62312

Sternal osteomyelitis and mediastinitis are rare yet severe complications post-cardiac surgery, often associated with significant morbidity and mortality. Fungal etiologies, particularly those caused by Rhizopus spp., are infrequent but can lead to aggressive infections. Here, we present the case of a 68-year-old male who developed sternal osteomyelitis and mediastinitis caused by Rhizopus spp. two weeks following coronary artery bypass grafting surgery. Debridement and pectoralis flap reconstruction were performed following clinical identification and confirmation with microbiological examinations and a CT scan. Prompt recognition, aggressive surgical intervention, and targeted antifungal therapy were crucial for successful management. This case underscores the importance of considering fungal pathogens, such as Rhizopus, in the differential diagnosis of post-cardiac surgery infections, as well as aggressive treatment to improve outcomes for affected patients.
Fulltext Perception Regarding the NICE Guideline on Antibiotic Prophylaxis against Infective Endocarditis Following Dental Procedures: A Cross-Sectional Study

Mohd Yunus SS, Nabil S, Rashdi MF, Nazimi AJ, Nordin R, Tan HL, et al.

Antibiotics (Basel), 2023 Apr 02;12(4).
PMID: 37107058 DOI: 10.3390/antibiotics12040696

This study explores the opinions of Malaysian clinical specialists on the antibiotic prophylaxis against infective endocarditis (IE) as described in the 2008 National Institute for Health and Care Excellence (NICE) guideline. This cross-sectional study was performed from September 2017 to March 2019. The self-administered questionnaire comprised two sections: background information of the specialists and their opinions on the NICE guideline. The questionnaire was distributed to 794 potential participants, and 277 responded (response rate of 34.9%). In general, 49.8% of the respondents believed that clinicians should adhere to the guideline, although the majority of oral and maxillofacial surgeons (54.5%) actually disagreed with this view. The dental procedures that were perceived as presented moderate-to-high risk for IE were minor surgery for an impacted tooth with a recent episode of infection, dental implant surgery, periodontal surgery and dental extraction in patients with poor oral hygiene. The cardiac conditions that were strongly recommended for antibiotic prophylaxis were severe mitral valve stenosis or regurgitation and previous IE. Less than half of Malaysian clinical specialists agreed with the changes in the 2008 NICE guideline, contributing to their insistence that antibiotic prophylaxis is still needed for high-risk cardiac conditions and selected invasive dental procedures.
In Vitro Antifungal Susceptibility of Neoscytalidium dimidiatum Clinical Isolates from Malaysia

James JE, Santhanam J, Lee MC, Wong CX, Sabaratnam P, Yusoff H, et al.

Mycopathologia, 2017 Apr;182(3-4):305-313.
PMID: 27815659 DOI: 10.1007/s11046-016-0085-5

Neoscytalidium dimidiatum is an opportunistic fungus causing cutaneous infections mostly, which are difficult to treat due to antifungal resistance. In Malaysia, N. dimidiatum is associated with skin and nail infections, especially in the elderly. These infections may be mistaken for dermatophyte infections due to similar clinical appearance. In this study, Neoscytalidium isolates from cutaneous specimens, identified using morphological and molecular methods (28 Neoscytalidium dimidiatum and 1 Neoscytalidium sp.), were evaluated for susceptibility towards antifungal agents using the CLSI broth microdilution (M38-A2) and Etest methods. Amphotericin B, voriconazole, miconazole and clotrimazole showed high in vitro activity against all isolates with MIC ranging from 0.0313 to 1 µg/mL. Susceptibility towards fluconazole and itraconazole was noted in up to 10% of isolates, while ketoconazole was inactive against all isolates. Clinical breakpoints for antifungal drugs are not yet available for most filamentous fungi, including Neoscytalidium species. However, the results indicate that clinical isolates of N. dimidiatum in Malaysia were sensitive towards miconazole, clotrimazole, voriconazole and amphotericin B, in vitro.

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