Surgery with adequate surgical margins is a crucial determinant of survival in patients with vascular pythiosis. Itraconazole and terbinafine do not have synergistic effects on Thai P. insidiosum strains. The role of immunotherapy remains inconclusive for both vascular and ocular pythiosis.

Key Points Question What are the humoral immune response rates and risk factors associated with diminished response after COVID-19 vaccination in recipients of solid organ transplant? Findings In this systematic review and meta-analysis of 29 studies and 11 713 recipients of solid organ transplant, seroconversion rates increased with progressively increased numbers of mRNA COVID-19 vaccine doses. Older age, recent transplantation, deceased donor status, active use of antimetabolites, and recent exposure to antithymocyte globulin or rituximab were risk factors associated with diminished humoral immune response after receiving 2 doses of mRNA vaccines. Meaning These findings suggest that more efforts are needed to modulate the risk factors associated with reduced humoral responses among recipients of solid organ transplant.

Human vascular pythiosis is a life-threatening condition caused by Pythium insidiosum. Patients with unresectable intra-abdominal artery involvement have not previously survived, despite being treated with antifungal agents and immunotherapy. We report two novel cases of intra-abdominal pythiosis in patients for whom surgery could not be performed, who were successfully treated with adjunctive antibacterial agents.

A novel selective agar (RGM medium) has been advocated for the isolation of rapidly growing mycobacteria from the sputa of cystic fibrosis (CF) patients. The aim of this study was to compare RGM medium to selective agar (BCSA) and a standard acid-fast bacillus (AFB) culture method for the isolation of nontuberculous mycobacteria (NTM) from patients with CF. The applicability of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) for the identification of NTM isolated on RGM medium was also assessed. Respiratory samples ( = 869) were collected from 487 CF patients and inoculated directly onto RGM medium and BCSA. Cultures were incubated at 30°C and examined for up to 28 days. A subset of 212 samples (from 172 patients) was also cultured by using a mycobacterial growth indicator tube (MGIT) and on Lowenstein-Jensen medium following dual decontamination. By using a combination of all methods, 98 mycobacteria were isolated from 869 samples (11.3%). The sensitivity of RGM medium (96.9%) was significantly higher than that of BCSA (35.7%) for the isolation of mycobacteria ( < 0.0001). The sensitivity of RGM medium was also superior to that of standard AFB culture for the isolation of mycobacteria (92.2% versus 47.1%; < 0.0001). MALDI-TOF MS was effective for the identification of mycobacteria in RGM medium. RGM medium offers a simple and highly effective tool for the isolation of NTM from patients with CF. Extended incubation of RGM medium for 28 days facilitates the isolation of slow-growing species, including members of the complex (MAVC).

Ocular pythiosis is the second most common form of human pythiosis, and the rates of evisceration/enucleation in Thailand are 55–79%. This prospective study was conducted to evaluate treatment outcomes of the combination therapy protocol and the potential use of serum (1→3)-β-glucan (BG) and Pythium insidiosum-specific antibody (Pi-Ab) as an aid to diagnosis and monitoring of ocular pythiosis. Thirty patients were enrolled in the study and 14 (non-globe salvage) required evisceration/enucleation. The globe salvage group was significantly younger, and first ocular surgeries were performed significantly sooner than in the non-globe salvage group. Serum BG and Pi-Ab levels were similar among the 2 groups over time. In vitro susceptibility testing of antifungal agents revealed relatively high minimum inhibitory concentrations and lack of synergistic effect. Serum BG and Pi-Ab would not be useful in diagnosis and monitoring of ocular pythiosis. Until effective antimicrobial agents are discovered, ocular surgeries are still the mainstay therapy in Thailand.

A 34-year-old female from Mexico with a history of granulomatous mastitis of the left breast due to Corynebacterium kroppenstedtii presented to a surgery clinic with progressive pain, erythema, and swelling of the right breast. Fourteen months prior, she had noted a painful mass in her left breast that progressively worsened over 3 months and did not improve with a course of doxycycline. She was referred to an outpatient surgery clinic, where a breast ultrasound demonstrated a predominant 4-cm by 4-cm collection consistent with an abscess; 5 ml of serosanguinous fluid was aspirated. A Gram stain demonstrated 3ϩ polymorphonuclear leukocytes and 1ϩ Gram-positive rods; the aspirate grew C. kroppenstedtii on chocolate agar, as well as on anaerobic brain heart infusion agar and anaerobic Columbia agar with colistin and nalidixic acid (CNA). It was identified by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) (bioMérieux, Durham, North Carolina, USA). The patient continued to have breast tenderness and erythema over the next month despite multiple antibiotics (doxycycline, clindamycin, and amoxicillin-clavulanic acid) and another ultrasoundguided breast aspiration; thus, she underwent incision and drainage of the left breast, which resulted in operative findings notable for inflamed tissue with many pus-filled cavities. A Gram stain demonstrated 2ϩ polymorphonuclear leukocytes with no organisms; aerobic, anaerobic, and mycobacterial cultures demonstrated no growth. Surgical pathology demonstrated granulomatous inflammation with associated acute and chronic inflammation and fat necrosis; fungal and mycobacterial special stains were negative for microorganisms. An infectious disease specialist was consulted, and he felt that the abscesses persisted because they were never adequately drained and because the patient did not receive long-enough courses of antibiotic therapy. She was given a 4-week course of doxycycline and amoxicillin-clavulanic acid, and her abscesses resolved.However, 1 year later, she noted progressive pain, erythema, and swelling of the contralateral breast. A right breast ultrasound demonstrated multiple abscesses, and 7 ml of purulent fluid was aspirated. A Gram stain demonstrated 3ϩ polymorphonuclear leukocytes with no organisms; the aspirate grew Ͻ10 colonies of C. kroppenstedtii on CNA agar. Her abscesses did not improve despite multiple antibiotics (dicloxacillin, clindamycin, trimethoprim-sulfamethoxazole, doxycycline, amoxicillin-clavulanic acid, and ciprofloxacin), a course of prednisone, two ultrasound-guided breast aspirations, and two incision and drainage procedures over the next 4 months. C. kroppenstedtii was isolated from both breast aspirations on chocolate and CNA agar, and after the first incision and drainage procedure on CNA agar. Surgical pathology of the second incision and drainage procedure demonstrated fat necrosis with prominent histiocytic infiltration, acute and chronic inflammation, and reactive fibrosis; no granuloma formation w...

f This is a report of a Lagenidium sp. in a Thai patient who was diagnosed with severe keratitis that was unresponsive to antibacterial and antifungal drugs. Examination of a corneal biopsy specimen confirmed the presence of aseptate hyphae. The internal transcribed spacer DNA sequence of the strain isolated showed 97% identity with Lagenidium giganteum and other Lagenidium species. CASE REPORTA 43-year-old Thai housewife was referred to King Chulalongkorn Memorial Hospital with lid swelling, pain, redness, and itching of the left eye for 3 weeks. Her clinical symptoms began 2 days after she flushed her eyes with tap water because of eye irritation during house cleaning. She was treated with systemic and topical antibiotics, but her condition worsened. The initial diagnosis was presumed to be a fungal corneal ulcer unresponsive to both topical and systemic antifungal agents. The patient had been given topical cefazolin, topical amikacin, topical natamycin, topical voriconazole, oral acyclovir, and oral itraconazole prior to transfer. Her medical history was unremarkable.The initial examination revealed that the visual acuity of her left eye was finger counting at 1 foot. A slit lamp examination showed ciliary injection and a yellowish, midstromal, reticularpattern corneal infiltration measuring 5 by 5.6 mm with a feathery edge (Fig. 1A). A corneal epithelial defect 4 by 3 mm in diameter was detected over the infiltrated area. Posterior eye segment evaluation by ocular ultrasound demonstrated no sign of endophthalmitis. The right eye appeared normal.In vivo confocal microscopy identified numerous branching fungus-like elements with interlocking and hyperrefractive thin lines in the corneal stroma (Fig. 1B). Direct examination of a left corneal scraping specimen revealed aseptate hyphae (Fig. 1C). A corneal biopsy specimen stained with hematoxylin and eosin and

A large-scale surveillance is an important measure to monitor the regional spread of antimicrobial resistance. We prospectively studied the prevalence and molecular characteristics of clinically important Gram-negative bacilli, including Escherichia coli (EC), Klebsiella pneumoniae (KP), Acinetobacter baumannii complex (ABC), and Pseudomonas aeruginosa (PA) from blood, respiratory tract, urine, and sterile sites at 47 hospitals across Thailand. Among 187,619 isolates, 93,810 isolates (50.0%) were critically drug-resistant. Of which, 12,915 isolates (13.8%) were randomly selected for molecular characterization. EC was most commonly isolated from all specimens, except the respiratory tract in which ABC was predominant. Prevalence of extended-spectrum cephalosporin resistance (ESCR) was higher in EC (42.5%) than KP (32.0%), but carbapenem-resistant (CR)-KP (17.2%) was 4.5-fold higher than CR-EC (3.8%). A majority of ESCR-/CR-EC and KP carried bla CTX-M (64.6%-82.1%). bla NDM and bla OXA-48-like were the most prevalent carbapenemase genes in CR-EC/CR-KP (74.9%/52.9% and 22.4%/54.1%, respectively). Besides, 12.9%/23.0% of CR-EC/CR-KP co-carried bla NDM and bla OXA-48-like. Among ABC, 41.9% were extensively drug-resistant (XDR), and 35.7% were multidrug-resistant (MDR), while PA showed XDR/MDR at 6.3%/16.5%. A. baumannii (AB) was the most common species among ABC isolates. The major carbapenemase gene in MDR-AB/XDR-AB was bla OXA-23-like (85.8%/93.0%), which had much higher rates than other ABC species. bla IMP , bla VIM , bla OXA-40-like, and bla OXA-58-like were also detected in ABC at lower rates. The most common carbapenemase gene in MDR-/XDR-PA was bla IMP (29.0%/30.6%), followed by bla VIM (9.5%/25.3%). The findings reiterate an alarming situation of drug resistance that requires serious control measures.