Invasive aspergillosis in developing countries

Abstract

To review invasive aspergillosis (IA) in developing countries, we included those countries, which are mentioned in the document of the International Monetary Fund (IMF), called the Emerging and Developing Economies List, 2009. A PubMed/Medline literature search was performed for studies concerning IA reported during 1970 through March 2010 from these countries. IA is an important cause of morbidity and mortality of hospitalized patients of developing countries, though the exact frequency of the disease is not known due to inadequate reporting and facilities to diagnose. Only a handful of centers from India, China, Thailand, Pakistan, Bangladesh, Sri Lanka, Malaysia, Iran, Iraq, Saudi Arabia, Egypt, Sudan, South Africa, Turkey, Hungary, Brazil, Chile, Colombia, and Argentina had reported case series of IA. As sub-optimum hospital care practice, hospital renovation work in the vicinity of immunocompromised patients, overuse or misuse of steroids and broad-spectrum antibiotics, use of contaminated infusion sets/fluid, and increase in intravenous drug abusers have been reported from those countries, it is expected to find a high rate of IA among patients with high risk, though hard data is missing in most situations. Besides classical risk factors for IA, liver failure, chronic obstructive pulmonary disease, diabetes, and tuberculosis are the newly recognized underlying diseases associated with IA. In Asia, Africa and Middle East sino-orbital or cerebral aspergillosis, and Aspergillus endophthalmitis are emerging diseases and Aspergillus flavus is the predominant species isolated from these infections. The high frequency of A. flavus isolation from these patients may be due to higher prevalence of the fungus in the environment. Cerebral aspergillosis cases are largely due to an extension of the lesion from invasive Aspergillus sinusitis. The majority of the centers rely on conventional techniques including direct microscopy, histopathology, and culture to diagnose IA. Galactomannan, β-D glucan test, and DNA detection in IA are available only in a few centers. Mortality of the patients with IA is very high due to delays in diagnosis and therapy. Antifungal use is largely restricted to amphotericin B deoxycholate and itraconazole, though other anti-Aspergillus antifungal agents are available in those countries. Clinicians are aware of good outcome after use of voriconazole/liposomal amphotericin B/caspofungin, but they are forced to use amphotericin B deoxycholate or itraconazole in public-sector hospitals due to economic reasons.

Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction

“…In Brazil, the few reported cases involved immunosuppressed patients 10 . To our knowledge, this is the fi rst case of chronic invasive fungal rhinosinusitis in an immunocompetent Brazilian patient.…”

“…The usual presentation of fungal rhinosinusitis is nasal obstruction, disturbed smell, and postnasal drip associated with a nasal mass or polyp; it may be associated with orbital and intracranial invasion 10 .…”

“…Another serum marker commonly used to indicate the presence of IFIs is (1-3)-b-D-glucan (BDG). However, galactomannan or beta-glucan assays are not easily available, and conventional direct microscopy, histopathology, and culture analysis are the only available techniques in most centers for the diagnosis of IA 10 .…”

“…Both CT and magnetic resonance (MR) images help to determine the clinical diagnosis, recurrence rate, and delineation of the extension of fungal sinusitis as well as in surgery 10 . Fungal sinusitis should be considered in all patients with chronic sinusitis, especially when it occurs in association with certain clinical features like intractable symptoms, despite adequate treatment for bacterial sinusitis, allergic rhinitis, asthma, nasal polyposis (non-invasive types) or fever, headache, epistaxis, diabetes, nasal mucosal ulcer, orbital apex syndrome, or proptosis (invasive types).…”

“…Fungal sinusitis should be considered in all patients with chronic sinusitis, especially when it occurs in association with certain clinical features like intractable symptoms, despite adequate treatment for bacterial sinusitis, allergic rhinitis, asthma, nasal polyposis (non-invasive types) or fever, headache, epistaxis, diabetes, nasal mucosal ulcer, orbital apex syndrome, or proptosis (invasive types). However, the diagnosis of fungal sinusitis depends on direct microscopic examination, culture, and histopathological analysis of tissue or the cheesy material obtained from sinuses 9,10 .…”