Lymphocyte transformation studies in drug hypersensitivity

In a group of patients with clinically diagnosed drug hypersensitivity the in vitro lymphocyte response to the suspected drug was assessed by the lymphocyte transformation test. The test gave positive results in all 15 patients with penicillin-induced immediate or accelerated allergic reactions and positive immediate skin-test reactivity to the major or the minor antigenic determinant of penicillin, or both, but in only 3 of the 12 patients with delayed-onset maculopapular rashes induced by penicillin, despite positive immediate reactivity to the skin-test reagents.Lymphocyte stimulation greater than five times the control level was demonstrated for five patients with penicillin-induced erythroderma, Stevens-Johnson syndrome or a serum-sickness-like illness, or with methicillin-induced interstitial nephritis, all of whom had negative reactions to the appropriate skin-test reagents. A low level of stimulation was seen in eight other skin-test-negative patients with possible allergic reactions induced by penicillins. However, in all subjects tested the stimulation was significantly greater than the mean for control subjects.For 9 of 11 patients with isoniazid-induced hepatitis or maculopapular rashes, but for only 8 of 31 patients with eruptions induced by a variety of drugs other than penicillins and isoniazid, significant stimulation occurred in the lymphocyte transformation test.It is concluded that the lymphocyte transformation test is useful in the detection of hypersensitivity to the penicillins (although in IgE-mediated reactions skin testing is clearly preferable) and isoniazid but is of limited value in the demonstration of hypersensitivity to other drugs.     

米卡芬净与伊曲康唑治疗多发性骨髓瘤并发侵袭性真菌病的疗效和成本分析

目的 比较米卡芬净与伊曲康唑在多发性骨髓瘤并发侵袭性真菌病（IFD）病例治疗中的疗效及成本.方法 采用回顾性分析方法,入选2010年1月～2012年11月我科发生侵袭性真菌病的37例多发性骨髓瘤患者的临床资料.对比分析米卡芬净治疗组与伊曲康唑治疗组两组患者的疗效、治疗时间、治疗成本及不良反应.结果 米卡芬净组17例,伊曲康唑组20例,米卡芬净组治疗有效率为76.46％ （13/17）,伊曲康唑组治疗有效率70％ （14/20）,差异无统计学意义（P=0.42 ＞0.05）.米卡芬净组2例发生消化道不适反应.伊曲康唑组3例发生消化道不适反应,2例低钾血症并消化道不适反应;3例患者出现药物性肾功能损害,l例停药后肾功能恢复,2例出现急性肾功能损害.米卡芬净组不良反应发生率为11.76％ （2/17）,伊曲康唑不良发生率为40％ （8/20）,两组差异有统计学意义（P＜0.05）.以治疗第14天总有效率作为疗效判断标准,米卡芬净组和伊曲康唑组成本疗效比分别为263.73和289.11.结论 米卡芬净与伊曲康唑对骨髓瘤合并IFD的治疗有效率差异无统计学意义,不良反应差异有统计学意义,前者成本效益比优于后者.     

Treatment of chytridiomycosis with reduced-dose itraconazole

Effective treatment methods to eliminate infection with Batrachochytrium dendrobatidis (Bd) are required for development of sustainable captive survival assurance populations of amphibians and to reduce the risk of introducing Bd to new locations as part of amphibian trade or reintroduction programs. Treatment with itraconazole baths at 100 mg l-1 is commonly used in captive amphibians, but side effects are observed in some amphibian species and life stages. Naturally occurring outbreaks of chytridiomycosis in Wyoming toads Anaxyrus baxteri and White's tree frogs Litoria caerulea were treated with lower-dose itraconazole baths (e.g. 50 mg l-1 for White's tree frogs) and followed post-treatment with serial Taqman PCR testing to confirm elimination of Bd infection. Post-treatment PCR tests were consistently negative for the presence of Bd and treatment was deemed successful. Although this was not a controlled clinical trial, results suggest that lower doses of itraconazole may be effective for treatment of chytridiomycosis with resulting cost savings to amphibian conservation programs and a potential for a reduction in dose-related side effects from itraconazole treatment. Prospective clinical trials of alternative itraconazole treatment protocols are encouraged.     

<Emphasis Type="Italic">Saccharomyces cerevisiae</Emphasis> Vaginitis: Microbiology and In Vitro Antifungal Susceptibility

Genitourinary infections by Saccharomyces cerevisiae are rare. Here, we describe eight S. cerevisiae vulvovaginitis episodes where molecular (Affirm VPIII) and conventional microbiological methods (culture and carbohydrate assimilation) have proven to be inadequate for diagnostic purposes. DNA sequencing allowed the correct identification of the pathogen. All isolates were susceptible to most antifungal agents, with two of them also found to be susceptible-dose-dependent to itraconazole.     

伊曲康唑治疗严重烧伤患者真菌感染的疗效分析

目的 评价伊曲康唑治疗严重烧伤患者真菌感染的疗效及其安全性。方法 采用开放、随机研究单组评估设计,治疗前2d：伊曲康唑注射液2次／d,间隔12h,200mg／次。此后1次／d,剂量200mg,间隔24h,1疗程14d。试验结束后口服伊曲康唑口服液维持治疗至少4周,2次／d,200mg／次。结果 伊曲康唑治疗23例严重烧伤患者总有效率为60．87％;本组86．96％的患者临床疗效为改善;63．64％的患者真菌学疗效为真菌清除;8．70％和52．17％的患者综合疗效分别为痊愈和显效,未发生不良反应。结论 伊曲康唑治疗严重烧伤患者真菌感染有良好的疗效、不良反应少。     

Itraconazole suppresses the growth of glioblastoma through induction of autophagy: Involvement of abnormal cholesterol trafficking

Glioblastoma is one of the most aggressive human cancers with poor prognosis, and therefore a critical need exists for novel therapeutic strategies for management of glioblastoma patients. Itraconazole, a traditional antifungal drug, has been identified as a novel potential anticancer agent due to its inhibitory effects on cell proliferation and tumor angiogenesis; however, the molecular mechanisms involved are still unclear. Here, we show that itraconazole inhibits the proliferation of glioblastoma cells both in vitro and in vivo. Notably, we demonstrate that treatment with itraconazole induces autophagic progression in glioblastoma cells, while blockage of autophagy markedly reverses the antiproliferative activities of itraconazole, suggesting an antitumor effect of autophagy in response to itraconazole treatment. Functional studies revealed that itraconazole retarded the trafficking of cholesterol from late endosomes and lysosomes to the plasma membrane by reducing the levels of SCP2, resulting in repression of AKT1-MTOR signaling, induction of autophagy, and finally inhibition of cell proliferation. Together, our studies provide new insights into the molecular mechanisms regarding the antitumor activities of itraconazole, and may further assist both the pharmacological investigation and rational use of itraconazole in potential clinical applications.     

马尔尼菲蓝状菌病致溶骨性损害合并Sweet样皮疹1例

本文报道广西医科大学第一附属医院皮肤性病科收治的马尔尼菲蓝状菌病致溶骨性损害合并Sweet样皮疹1例。免疫力正常人群较少患马尔尼菲蓝状菌病。本例患者既往体健,起初合并融骨性损害,在两性霉素B、伊曲康唑治疗过程中逐渐出现Sweet样皮疹。患者经两性霉素B、伊曲康唑、激素等治疗后,病情逐渐好转。     

Congenital cutaneous candidiasis associated with maternal peripartum candidemia

BackgroundCutaneous congenital candidiasis (CCC) is a rare condition consisting of invasive fungal infection of the epidermis and dermis that mostly affects preterm infants. Maternal vaginal candidiasis is present in half of the cases, although the occurrence of invasive candidiasis during pregnancy or peripartum period is exceptional.Case reportWe present the case of a full-term infant that was born by vacuum-assisted vaginal delivery to an apparently healthy 33 year-old woman with no history of intravenous drug use or vaginal candidiasis during pregnancy. The newborn showed a diffuse maculopapular rash with respiratory distress and bilateral interstitial lung infiltrates, requiring nasal continuous positive airway pressure support. Blood cultures obtained from the mother due to intrapartum fever yielded Candida albicans. Cultures of vaginal discharge and neonate skin also yielded C. albicans with the same in vitro susceptibly pattern. No alternative source for candidemia was identified. The clinical course after starting a systemic antifungal therapy was favorable in both the mother and the neonate, with clearance of candidemia and resolution of the skin lesions.ConclusionsCCC must be considered in full-term newborns with maculopapular rash at birth or during the first days of life. The absence of alternative sources for bloodstream infection in the present case suggests a potential etiopathogenic relationship between CCC and maternal candidemia. It is reasonable to rule out postpartum candidemia when CCC is suspected.     

Anaphylaxis due to thiopental sodium anesthesia.

Anaphylaxis due to an anesthetic is one type of cardiovascular emergency that can occur during general anesthesia. Anaphylactic reactions to muscle relaxants have been documented. Barbiturates, used as sedatives, are well known to produce cutaneous reactions, but anaphylaxis after their ingestion seems to be rare. Generalized allergic reactions to thiopental sodium during anesthesia are mentioned in the product monograph for Penthothal sodium, and rare case reports of anaphylactic reactions to infused thiopental have appeared, generally in the anesthesiology literature. Documentation of the immunologic responses to thiopental sodium has been limited to the demonstration of an allergic reaction to thiopental by skin testing in some cases. This report describes a woman who, after having tolerated thiopental sodium and other general anesthetics, became sensitive to this agent and had a severe acute reaction at the time of induction of general anesthesia.     

Antifungal Susceptibility,Morphological and Molecular Characterization of <Emphasis Type="Italic">Lasiodiplodia theobromae</Emphasis> Isolated from a Patient with Keratitis

Lasiodiplodia theobromae is a rare ocular pathogen. We report a patient with fungal keratitis caused by L. theobromae. The patient was a 75-year-old male, a farmer with diabetes type II, and no previous history of ocular trauma. Histopathology analysis revealed the presence fungi invading Descemet’s membrane of the cornea. The fungus was characterized by septate, highly bulged fungal filaments involving full corneal thickness in the corresponding histopathology specimens. A dematiaceous mold was isolated and initally identified as L. theobromae by microscopic and macroscopic morphology, and further confirmed by PCR-based determination of internal transcribed spacer (ITS) regions of ribosomal DNA. Antifungal susceptibility tests showed sensitivity to amphotericin B (AMB) and voriconazole ( VRC), and resistance to other azoles, including itraconazole (ITC) and fluconazole (FLC). Corneal transplant was performed. Despite in vitro itraconazole resistance, the patient was successfully treated with oral itraconazole, topical voriconazole and natamycin, combined with ocular injections of amphotericin B and voriconazole.     

Isolated Skull Cryptococcosis in an Immunocompetent Patient

A 62-year-old immunocompetent rural woman who represents an isolated cryptococcal skull infection without systematic involvement is described. Diagnosis was based on positive India ink staining, positive histopathologic examination, and positive culture. Species identification was performed by growth on Sabouraud dextrose agar and CHROMagar medium and by sequencing of the intergenic and internal transcribed spacer regions of the rRNA genes. This case describes a rare presentation of Cryptococcus neoformans infection in a human immunodeficiency virus-negative patient. The lesions were significantly improved with treatment of daily oral itraconazole 400 mg. A maintenance therapy with a low-dose itraconazole was prescribed to warrant a clinical and mycological eradication. A two-year follow-up did not show any recurrence of infection.     

Diagnosis of penicillin allergy by skin testing: the Manitoba experience.

The reliability of skin testing in the diagnosis of penicillin allergy was studied in 86 adults and 167 children with a history of possible hypersensitivity reactions to penicillin. Skin testing was done with the major antigenic determinant of benzylpenicillin and minor determinants of benzylpenicillin, ampicillin, cloxacillin, methicillin and cephalothin. The overall frequency of positive skin reactions was 11.5%. Among the patients with positive skin reactions about half had a history of immediate or accelerated reactions to penicillins, but 2 of 11 adults and 50% of the children in this group had a history of maculopapular rash of delayed onset. There was a low frequency of positive skin reactions when there was a long interval between the times of clinical reaction and skin testing. Of 169 patients reacting negatively to skin testing who received a specific drug challenge only 2 manifested mild urticaria; this indicates the reliability of the skin tests in predicting penicillin allergy. The major and minor determinants of benzylpenicillin were the most useful reagents. One fifth of the patients with penicillin hypersensitivity would have been missed if the major determinant of benzylpenicillin alone had been used for skin testing. The additional use of the minor determinants of other penicillin derivatives, however, did not increase substantially the clinical reliability of the skin testing procedure.     

Immune responses to environmental antigens that act on the skin: the role of lymphokines in contact dermatitis.

Immune responses to enviornmental agents affecting the skin may take various clinical forms, among which contact dermatitis is the most prominent representative of delayed-type hypersensitivity. Whereas in industrialized countries a relatively restricted amount of chemical agents is responsible for the majority of contact dermatitis cases, other factors from the environment such as natural flora, seasonal or nutritional factors may also play a role. Like other immune responses, contact dermatitis is strongly influenced by genetic factors and the existence of immune response genes, in part linked to the major histocompatibility complex, has been established in experimental animals. Whereas the formation of conjugates between skin-specific proteins and contactant allergens is held by some to represent an important feature in contact dermatitis, recent experiments suggest that the direct binding of contactants to monocyte and lymphocyte membranes represents the most efficient way in inducing sensitization of the T lymphocytes primarily responsible for contact hypersensitivity. At the effector level, complete inhibition of contact dermatitis and other delayed type hypersensitivity reactions by an antiserum prepared against guinea pig lymphokines (especially migration inhibition factor) offers strong evidence that lymphokines, as products of activated lymphocytes, also play a decisive role in vivo. The properties of antibodies raised against purified lymphokine fractions are reviewed. Localized contact dermatitis reactions, as well as accompanying phenomenons such as flar-up reactions and generalized maculopapular rashes, may, however, still involve other elements than T lymphocytes and lymphokines. The participation of other secondary cell types and of local antibody formation is briefly discussed.     

Cutaneous <Emphasis Type="Italic">Exophiala oligosperma</Emphasis> Infection in a Patient with Bullous Pemphigoid with a Review of the Literature

Phaeohyphomycosis is an infection caused by a heterogeneous group of melanized fungi. Human infections due to members of genus Exophiala are rare but may occur at any part of the body. We herein report a case of an 85-year-old male with a history of bullous pemphigoid who presented with a chronic, non-healing wound on his right dorsal hand for a month. Direct microscopy of a pus sample from the base of the ulcer revealed strands of pigmented, moniliform hyphae. The isolate was identified as E. oligosperma based on morphological characters and sequencing of the rDNA internal transcribed spacers (ITS) and partial beta-tubulin gene. The patient received a three-month course of oral itraconazole with no recurrence.     

Benznidazole/Itraconazole Combination Treatment Enhances Anti-Trypanosoma cruzi Activity in Experimental Chagas Disease

The nitroheterocyclic drugs nifurtimox and benznidazole are first-line drugs available to treat Chagas disease; however, they have limitations, including long treatment courses and toxicity. Strategies to overcome these limitations include the identification of new drugs with specific target profiles, re-dosing regimens for the current drugs, drug repositioning and combination therapy. In this work, we evaluated combination therapy as an approach for optimization of the current therapeutic regimen for Chagas disease. The curative action of benznidazole/itraconazole combinations was explored in an established infection of the mice model with the T. cruzi Y strain. The activities of the benznidazole/itraconazole combinations were compared with the results from those receiving the same dosage of each individual drug. The administration of benznidazole/itraconazole in combination eliminated parasites from the blood more efficiently than each drug alone. Here, there was a significant reduction of the number of treatment days (number of doses) necessary to induce parasitemia suppression with the benznidazole/itraconazole combination, as compared to each compound administered alone. These results clearly indicate the enhanced effects of these drugs in combination, particularly at the dose of 75 mg/kg, as the effects observed with the drug combinations were four times more effective than those of each drug used alone. Moreover, benznidazole/itraconazole treatment was shown to prevent or decrease the typical lesions associated with chronic experimental Chagas disease, as illustrated by similar levels of inflammatory cells and fibrosis in the cardiac muscle tissue of healthy and treated mice. These results emphasize the importance of exploring the potential of combination treatments with currently available compounds to specifically treat Chagas disease.     

Delivery of Antifungal Agents from Bone Cement

Fungal osteoarticular infections, including prosthetic joint infections and osteomyelitis, are rare yet present a therapeutic challenge with no guidelines to direct optimal treatment. When these infections occur, the majority are due to Candida species. In addition to systemic therapy, adjunctive antifungal-loaded bone cement has been utilized to successfully treat these infections. Amphotericin B is used most commonly, but cases utilizing voriconazole, fluconazole, and itraconazole have been reported as well. In vitro data suggest better elution of voriconazole from bone cement while there is minimal elution of amphotericin B. Unfortunately, a lack of consistency in the methods of both in vitro studies and case reports makes it difficult to determine if the addition of an antifungal agent in bone cement improves outcomes in fungal osteoarticular infections. This article provides an overview of bone cement as a delivery system for antifungal agents in vitro and in clinical reports.     

Good response in a patient with deep-seated subcutaneous ulcer due to <Emphasis Type="Italic">Candida</Emphasis> species

Deep-seated subcutaneous ulcers infected with Candida species are rare. We are reporting a 51-year-old Cantonese woman who had a large, deep-seated subcutaneous ulcer on her right shoulder for more than a year. Direct smears of the purulent extrusion revealed many pseudohyphae and yeast cells. Candida species were isolated from the purulent extrusion and further identified as Candida albicans and C. parapsilosis. A skin lesion biopsy contained yeast cells and pseudohyphae. C. parapsilosis were once isolated from the biopsy specimen. Total healing was obtained with itraconazole (200 mg twice daily for 16 days and then 100 mg twice daily for 14 days) combined with phototherapy.     

Determination of antifungal activities in serum samples from mice treated with different antifungal drugs allows detection of an active metabolite of itraconazole

To establish an in vitro method of predicting in vivo efficacy of antifungal drugs against Candida albicans and Aspergillus fumigatus, the antifungal activities of fluconazole, itraconazole, and amphotericin B were determined in mouse serum. The minimum inhibitory concentration (MIC) of each drug was measured using mouse serum as a diluent. For C. albicans, the assay endpoint of azoles was defined as inhibition of mycelial extension (mMIC) and for A. fumigatus, as no growth (MIC). The MICs of amphotericin B for both pathogens were defined as the MIC at which no mycelial growth occurred. Serum MIC or mMIC determinations were then used to estimate the concentration of the drugs in serum of mice treated with antifungal drugs by multiplying the antifungal titer of the serum samples by the serum (m)MIC. The serum drug concentrations were also determined by HPLC. The serum concentrations estimated microbiologically showed good agreement with those determined by HPLC, except for itraconazole. Analysis of the serum samples from itraconazole-treated mice by a sensitive bioautography revealed the presence of additional spots, not seen in control samples of itraconazole. The bioautography assay demonstrated that the additional material detected in serum from mice treated with itraconazole was an active metabolite of itraconazole. The data showed that the apparent reduction in the itraconazole serum concentration as determined by HPLC was the result of the formation of an active metabolite, and that the use of a microbiological method to measure serum concentrations of drugs can provide a method for prediction of in vivo efficacy of antifungal drugs.     

The First Isolation of Cryptococcus neoformans from Eucalyptus Trees in South Aegean and Mediterranean Regions of Anatolia in Turkey despite Taurus Mountains alkalinity

Between April 2001 and April 2002 were studied 106 women with a clinical diagnosis of vaginal candidiasis seen at the Gynecology and Obstetrics Ambulatory of the Hospital das Clínicas da Universidade Federal de Goiás. The patients were assessed on two occasions, before starting treatment with itraconazole or fluconazole (initial visit) and 14 days after treatment (return). At two visits the signs and symptoms were recorded and vaginal secretion was collected. According to the clinical evaluation, itraconazole was effective in 64.3%, while fluconazole was effective in 71.0% of the patients. The mycological cure rates (negative culture) in the return were 64.3% for the patients treated with itraconazole and 78.9% for the patients treated with fluconazole. The MICs of itraconazole and fluconazole for 80 Candida isolates were determined by Etest method. We investigated the correlation between in vitro susceptibility (Susceptible, Susceptibility Depending Dose and Resistant) to itraconazole and fluconazole with clinical outcome of the patients. The success rates were 63.9% for itraconazole and 90.6% for fluconazole in the susceptible category, 100.0% for both drugs in the susceptible dose dependent category, and 0.0% for both drugs in the resistant category. Our results showed there were a positive correlation between in vitro susceptibility test results with clinical outcome in vaginal Candida infections and that both drugs might be one choice in the treatment of vaginal candidiasis.