Aspergillosis due to azole-resistant Aspergillus fumigatus is a worldwide problem with major therapeutic implications. In patients with invasive aspergillosis, a low yield of fungal cultures results in underestimation of azole resistance. To detect azole resistance in A. fumigatus, we applied the AsperGenius^® Resistance multiplex real-time polymerase chain reaction (PCR) assay to detect TR₃₄/L98H, and TR₄₆/T289A/Y121F mutations and the AsperGenius^® G54/M220 RUO PCR assay to detect G54/M220 mutations directly in bronchoalveolar lavage (BAL) samples of 160 patients with chronic respiratory diseases in Delhi, India. Only 23% of samples were culture-positive compared to 83% positivity by A. fumigatus species PCR highlighting concerns about the low yield of cultures. Notably, 25% of BAL samples (33/160 patients) had azole resistance-associated mutation by direct detection using PCR assay. Detection of resistance-associated mutations was found mainly in 59% and 43% patients with chronic pulmonary aspergillosis (CPA) and allergic bronchopulmonary aspergillosis (ABPA), respectively. Overall, a G54 mutation, conferring itraconazole resistance, was the predominant finding in 87.5% and 67% of patients with CPA and ABPA, respectively. In culture-negative, PCR-positive samples, we detected azole-resistant mutations in 34% of BAL samples. Azole resistance in chronic Aspergillus diseases remains undiagnosed, warranting standardization of respiratory culture and inclusion of rapid techniques to detect resistance markers directly in respiratory samples.

D. Deepak 1 brijsushma@gmail.com M. Singh Rajput 2 B. Sharma 2 A. Chowdhary 3 D. Deepak 1 brijsushma@gmail.com M. Singh Rajput 2 B. Sharma 2 A....

Background: Cryptococcal meningitis (CM) is the initial acquired immunodeficiency syndrome (AIDS) defining illness in 2% of patients with CD4 levels <100/μL and a leading cause of mortality in AIDS in the developing world. It is the most common opportunistic infection of the central nervous system in AIDS in various Indian studies. Detection of serum cryptococcal antigen (SCRAG) is the most widely used diagnostic method for cryptococcosis. The presence of cerebrospinal fluid cryptococcal antigen (CSF CRAG) is diagnostic of CM. CRAG can be determined by latex agglutination (LAT), enzyme-linked immunosorbent assay and now, by lateral flow (LFA)immunoassay. LFA is a point of care test that rapidly detects CRAG. Aims and Objectives: This study compares LAT and LFA for the detection of serum CRAG and diagnosing CM. Materials and methods: Two hundred and ten patients of HIV/AIDS were submitted to SCRAG LFA by dipstick. A sample was also sent to laboratory for SCRAG by LAT. CSF examination was done for those who were positive for SCRAG LFA and those who had symptoms suggestive of meningitis. SCRAG by LFA was compared with SCRAG by LAT, CSF CRAG by LAT and LFA, CSF cryptococcal culture and CSF India ink examination for Cryptococcus. Results: Fifteen patients were found positive for SCRAG by LFA dipstick. All of them were also positive for SCRAG by LAT. Twelve of them had C. D4 count below below 100 cells/mm3. CSF CRAG was positive in all 12 SCRAG positive who were submitted to CSF examination. Conclusion: We found that serum detection of CRAG by LFA dipstick is as sensitive as CRAG detection in serum by LAT and CSF CRAG detection by LFA and LAT. It is thus a rapid test for diagnosing CM in HIV patients with low CD4 counts.

Introduction: Rhizopuse Sp. are common infectious agents of invasive rhinosinusitis. Though Alternaria is known to cause allergic rhinosinusitis, invasive sinusitis because of Alternaria Sp. is rare. Coinfections with bacteria and fungus causing rhinosinusitis have been reported as have the Rhizopus infection with other fungus such as Aspergillus, Candida, and Exserohillum. However Rhizopus coinfection with Alternaria has not been reported to the best of our knowledge. Case Presentation: A sixty-year- old woman was admitted with periorbital pain, swelling and complete restriction of movement of her right eye. She had diabetes mellitus for fifteen years. Diagnosis of invasive sinusitis was confirmed by hyperintensities in her right maxillary and bilateral ethmoid sinuses on the MRI on her brain and demonstration of hyphal forms from sinus mucosa. Culture confirmed the presence of Alternariaalternata and Rhizopus arrhizus. Patient responded to treatment with Amphotercin B and had complete resolution. Conclusions: Co-infection with bacteria and mixed fungal infection should be looked for as treatment strategies may differ with different organisms. Presumptive treatment should include agents, which can cover the broadest possible range of organism known to cause invasive sinusitis. Keywords: Sinusitis; Coinfection; Alternariosis; Mucormycosis

Rheumatological diseases (RDs) are characterized by autoimmune-mediated organ damage, with the lungs being an important target organ. Almost all compartments of the pulmonary system may be involved, with considerable heterogeneity in the frequency, severity, and spectrum of pulmonary manifestations. This heterogeneity may result in delayed diagnosis and treatment, leading to adverse outcomes. The objective of this study was to characterize the clinical, demographic, serological, and radiological features of pulmonary manifestations across a spectrum of rheumatic diseases. This cross-sectional study was conducted between 2016 and 2023 at a tertiary care center in New Delhi, India. Patients aged ≥18 years with a diagnosed or suspected RD and pulmonary manifestations were included. Patients who did not fulfill the American College of Rheumatology/European League against Rheumatism classification criteria for RD or the American Thoracic Society/European respiratory Society criteria for interstitial pneumonia with autoimmune features (IPAF), as well as those with chronic hypersensitivity pneumonitis or sequelae of previous pulmonary infections, were excluded. Of the 783 patients screened, 170 were diagnosed with rheumatology-associated lung disease (RALD) or IPAF. The mean age was 44.3 years, with a marked female predominance (85%). Rheumatoid arthritis (RA) and systemic sclerosis (SSc) accounted for 70% of cases, followed by IPAF, overlap syndromes, Sjögren syndrome (SjS), systemic lupus erythematosus (SLE), and idiopathic inflammatory myositis. Twenty-six patients with idiopathic interstitial pneumonia were reclassified as having IPAF, one of whom subsequently progressed to RA. Pulmonary symptoms preceded the diagnosis of RD in 13.6% of patients, occurred concurrently with the diagnosis in 17%, and developed during the course of RD in 69.4%. Antinuclear antibodies and rheumatoid factor were the most commonly detected autoantibodies, while anti-aminoacyl-tRNA synthetase antibodies were identified in 11 patients. RA demonstrated the broadest spectrum of pulmonary manifestations. Interstitial lung disease was the predominant pulmonary manifestation across all RDs except SLE. Non-specific interstitial pneumonia and usual interstitial pneumonia patterns accounted for 87% of cases. Other pulmonary manifestations included infections in RA and SLE; vascular and pleural involvement in RA, SSc, and SLE; and airway involvement in RA and SjS. Pulmonary manifestations may precede, coincide with, or develop after the onset of systemic features in RDs. Comprehensive pulmonary evaluation and collaborative care involving rheumatologists and pulmonologists may facilitate earlier diagnosis and optimize the management of RALDs.