COVID-19 associated invasive candidiasis To the Editor, We have read with special interest the excellent review by Louise Lansbury and colleagues 1 , 'Co-infections in people with COVID-19: a systematic review and meta-analysis'. In this review, four fungal pathogens were reported from three studies 2-4 , namely Candida albicans, Candida glabrata, Aspergillus flavus and Aspergillus fumigatus. In addition, Hughes et al. 5 retrospectively analysed hospitalised patients with confirmed COVID-19 infection (n = 836) across two acute NHS hospitals. Among the confirmed COVID-19 infection, C. albicans infections were attributed to central line source. Chen and colleagues 6 reported both bacterial and fungal co-infections. Recently, Verweij et al., 6 reported that Aspergillus species as co-pathogens are commonly identified in COVID-19 patients and are an important cause of mortality. Fungal co-infections and their impact on COVID-19 patients are still understudied. In this regards, we retrospectively analysed nosocomial mortality related to bloodstream infection and their risk factors associated with Covid-19 patients in the intensive care unit (ICU) at a single center in Oman. Five candidemia cases were reported from adult patients. The demographic and clinical description of patients is summarized in Table 1. All five patients were admitted to the ICU, had a central venous catheter (CVC) in place at the onset of candidemia, and received broad-spectrum antibiotic therapy. Patient 1, A 76 years old male, was admitted with COVID pneumonia. Three days later, he had worsening respiratory parameters requiring mechanical ventilation (MV) and ICU admission. Laboratory investigations revealed leukocytosis (12,0 0 0/mm 3) with neutrophilia (10,0 0 0/mm 3) and lymphocytopenia (50 0/mm 3). Results showed elevated inflammatory markers (CRP of 199 mg/l, d-dimer of 80, ferritin of 1240 μg/l, LDH of 565 IU/l and Ca of 1.94 mmol/l).

Candida auris has been recognised as a problematic healthcare-associated emerging yeast which is often misidentified as Candida haemulonii by commercial systems. Correct early identification of C. auris is important for appropriate antifungal treatment and implementing effective infection control measures. Here we report emergence of the first C. auris cases in Oman, initially misidentified as C. haemulonii.

(1) Background: Candida auris has been reported as emerging yeast pathogen that can cause invasive bloodstream infections in healthcare settings. It is associated with high mortality rates and resistance to multiple classes of antifungal drugs and is difficult to identify with standard laboratory methods. (2) Methods: We conducted a retrospective review of epidemiological, clinical, and microbiological records for 23 C. auris fungemia cases at the Royal Hospital, a tertiary care facility in Oman, between 2016 and 2018. Demographic data, risk factors associated with mortality, microbiology investigation and treatment regimens are described. Yeasts were identified by MALDI-TOF. (3) Results: We identified 23 patients with C. auris fungemia. All positive samples from patients were confirmed as C. auris using MALDI-TOF, and ITS-rDNA sequencing. Microsatellite genotyping showed that the Omani isolates belong to the South Asian clade I. The majority of patients had multiple underlying illnesses and other risk factors that have been associated with fungemia. All isolates were non-susceptible to fluconazole. Isolates from all patients were sensitive to echinocandins and these were used as first line therapy. (4) Conclusions: Candida auris affects adults and children with a variety of risk factors including central venous catheters and overuse of antibiotics. Infections occur in both immunocompromised and immunocompetent individuals. Mortality was high in this series, and the organism can be transmitted in healthcare settings. Programs for raising awareness in Oman hospitals are warranted. Caspofungin remains 1st line therapy as MICs are still low despite its wide use.

A 37-year-old male living in Oman was seen by his physician with complaints of cough, body aches with bilateral lower limb weakness and on and off fever. He was diagnosed with HIV infection and culture from blood and bone marrow grew Talaromyces marneffei. He had travelled to Malaysia on several occasions. Treatment with liposomal amphotericin B resulted in complete cure. This case is reported for its rarity and unusual presentation to alert clinicians and microbiologists to consider T. marneffei as an etiology in high risk individuals. Our case is the first recorded diagnosis of T. marneffei in Oman.

The respiratory syncytial virus (RSV) usually causes a lower respiratory tract infection in affected patients. RSV has also been infrequently linked to extrapulmonary diseases in children. We report four children who had unusually severe clinical manifestations of RSV infections requiring critical care admission. These patients presented to the Royal Hospital, Muscat, Oman, in December 2013 with acute necrotising encephalopathy (ANE), acute fulminant hepatic failure with encephalopathy, pneumatoceles and croup. A unique presentation of ANE has not previously been reported in association with an RSV infection. All patients had a positive outcome and recovered fully with supportive management.

Although colistin resistance caused by the mcr-1 gene is not common in our collection of clinical isolates, the occurrence of the plasmid-mediated colistin resistance in an E. coli ST10 strain is of concern as this clonal group was already shown to spread ESBL genes and quinolone resistance worldwide. It is especially worrisome that as the mcr-1 gene occurred in a non-ESBL, carbapenem-susceptible E. coli strain, current susceptibility testing algorithms may not detect its presence.

Anemia after kidney transplant is not uncommon. This paper reports a case of unexplained anemia in a kidney transplant recipient that persisted for more than two months, and that did not respond to recombinant human erythropoietin treatment but was successfully treated after diagnosing Parvovirus B19 (ParvoV B19) infection. A middle-aged male underwent living-unrelated kidney transplantation from Pakistan in April 2015. He was on triple immuno-suppression therapy consisting of prednisolone, tacrolimus, and mycophenolate mofetil. He presented with anemia which persisted for more than two months that did not improve with Darbepoetin alpha and required blood transfusions. A bone marrow biopsy demonstrated pure erythroid hypoplasia and occasional giant pronormoblasts characteristic of a ParvoV B19 infection. The serum was highly positive for ParvoV B19 DNA polymerase chain reaction. The anemia resolved completely three weeks after the administration of intravenous immunoglobulin. ParvoV B19 infection should be considered in the differential diagnosis of kidney transplant recipients who present with anemia associated with a low reticulocyte count.

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