As azole-resistant Aspergillus fumigatus emerges globally, healthcare facilities face mounting challenges in managing invasive aspergillosis. This review synthesizes worldwide azole resistance data to reveal profound regional variability, demonstrating that findings from other regions cannot be directly extrapolated to local settings. Consequently, hospital-level environmental surveillance is crucial for tailoring interventions to local epidemiology and detecting resistant strains in real-time. We outline practical approaches—encompassing sampling site prioritization, diagnostic workflows (culture-based and molecular), and PDCA-driven continuous improvement—so that even resource-limited facilities can manage resistant isolates more effectively. By linking real-time surveillance findings with clinical decisions, hospitals can tailor antifungal stewardship programs and swiftly adjust prophylaxis or treatment regimens. Our approach aims to enable accurate, ongoing evaluations of emerging resistance patterns, ensuring that institutions maintain efficient and adaptive programs. Ultimately, we advocate for sustained, collaborative efforts worldwide, where facilities adapt protocols to local conditions, share data through international networks, and contribute to a global knowledge base on resistance mechanisms. Through consistent application of these recommendations, healthcare systems can better preserve azole efficacy, safeguard immunocompromised populations, and refine infection control practices in the face of evolving challenges.

Aims: Guidelines recommend non-invasive positive pressure ventilation (NPPV) for patients with acute decompensated heart failure (ADHF) with an inadequate response to initial oxygen therapy. During Japan's coronavirus disease 2019 pandemic, NPPV use in emergency departments (EDs) was limited due to aerosol-spreading concerns. This study compared the respiratory management and clinical outcomes of patients with ADHF in EDs before and during the pandemic. Methods and results: This retrospective cohort study was conducted at a single centre in Japan using hospital data from September to November 2019 (before the pandemic) and September to November 2020 (during the pandemic). Patients diagnosed with ADHF were included. Patients not responding to standard oxygen therapy were intubated or started on NPPV therapy. The primary outcome measure was discharge after death. The secondary outcomes were length of hospital stay and medical expenses. The study included 37 patients before the pandemic and 36 during the pandemic. No significant differences were found in vital signs or laboratory data between the groups. NPPV utilization decreased significantly from 26 (70.3%) to 7 (19.4%) (P < 0.01). Two patients required intubation during both periods, with no significant differences (P = 0.98). No significant intergroup disparities were observed in discharge after death (1/36 [2.7%] vs. 1/37 [2.7%]; P = 0.19), length of hospital stay (17.5 vs. 19.0 days; P = 0.65), and medical expenses (57 590 vs. 57 600 yen; P = 0.65). Conclusions: Despite a large decrease in NPPV use before and during the pandemic, there were no significant differences in discharge after death, hospital stay, or medical expenses.

An aspergilloma is a fungus ball that forms within a preexisting cavity, most commonly in the lungs but also in the paranasal sinuses. It represents a chronic inflammatory disorder that can persist for months and cause life-threatening hemoptysis. In this study, we hypothesized that the fungus ball is predominantly composed of non-viable hyphae and that chronic inflammation is maintained primarily by host responses to these non-viable elements rather than by ongoing fungal proliferation. To investigate this, we created a murine fungus ball model by implanting heat-killed Aspergillus fumigatus fungus balls, allowing for ≥16 weeks of longitudinal assessment. The model recapitulated key pathological features of the human disease, including progressive fibrosis and sustained angiogenesis, coinciding with elevated vascular endothelial growth factor (VEGF). A distinct immune response was observed where neutrophils infiltrated the fungus ball core, while macrophages accumulated at the periphery. Strikingly, these macrophages surrounding the lesion progressively became lipid-laden foam-like cells with an M1-skewed profile, a phenomenon reproduced in vitro by exposure to non-viable hyphae alone. Thus, the fungal material itself can sustain chronic inflammation and vascular remodeling, implicating macrophage lipid accumulation as a process potentially contributing to the chronic host response. These findings highlight lipid dysregulation and failed fungal clearance as key features of the host-response disorder associated with the fungus ball and establish a tractable platform for evaluating host-directed therapies. IMPORTANCE: Aspergilloma, a fungus ball that forms in preexisting cavities of the lung or paranasal sinuses, can cause chronic symptoms and life-threatening bleeding. Current fungicidal treatments, including antifungals, are often ineffective, and surgery to remove the fungal ball is risky. To better understand why these lesions can persist even when active fungal growth is limited, we developed a murine subcutaneous fungus ball model using non-viable Aspergillus fumigatus . In this model, a fungal mass composed largely of non-viable hyphae was associated with chronic inflammation, neovascularization, fibrosis, and the accumulation of lipid-laden, foam cell-like macrophages around the fungus ball. These findings support the concept that persistent non-viable fungal material can sustain key features of aspergilloma-like pathology through dysregulated host responses. They provide a conceptual rationale for future studies of host-directed strategies that modulate inflammatory and lipid-handling pathways in addition to conventional antifungal approaches.

Objective: Unusual clinical course Background: Coronavirus disease (COVID-19) can cause various complications. We report a case of severe COVID-19 acute respiratory distress syndrome (ARDS) in a patient receiving veno-venous extracorporeal membrane oxygenation (V-V ECMO), complicated by Guillain-Barr & eacute; syndrome (GBS) and cerebral infarction, as well as pulmonary embolism. Case Report: A 55-year-old Japanese man with a history of ulcerative colitis was admitted for COVID-19. His respiratory status worsened and progressed to ARDS, requiring intubation on hospital day (HD) 3. On HD 16, contrast computed tomography revealed PE. On HD 18, his respiratory condition worsened, and V-V ECMO was initiated. On HD 23, V-V ECMO was successfully discontinued. He regained consciousness on HD 44, but he had quadriplegia. Deep-tendon reflexes were absent in all limbs. Cranial nerve involvement, specifically bilateral facial nerve weakness, was noted. Magnetic resonance imaging showed bilateral scattered cerebral infarctions on HD 76. Nerve conduction studies indicated severe axonal neuropathy. Cerebrospinal fluid examination showed albuminocytologic dissociation. The antibody to the ganglioside GD1a was positive. These findings were consistent with the diagnosis of GBS. He received immunoglobulin treatment on HD 89, and his neurological findings slightly improved. Conclusions: This study emphasized that in COVID-19, neurological complications are not rare, are difficult to diagnose, and are prone to delays in detection.

Chronic disseminated candidiasis (CDC) is a type of invasive candidiasis. CDC commonly appears in the neutrophil recovery phase after chemotherapy in patients with hematologic malignancies, and immune reconstitution inflammatory syndrome (IRIS) is thought to play a major role in CDC development. This report describes the case of a 33-year-old man with CDC as a complication of acute myeloid leukemia. We describe the clinical course, body temperature, therapy, and (1,3)-β-D-glucan (BDG) levels over the course of 22 months. He was initially treated with antifungals, but corticosteroids were added because of a persistently elevated body temperature, which we attributed to IRIS. After starting corticosteroids, his clinical condition improved, but his BDG levels became markedly elevated. We hypothesize that the suppression of the excessive immune response by corticosteroids lead to granuloma collapse, fungal release, and hematogenous dissemination, resulting in elevated BDG levels. The patient's condition gradually improved over the course of follow-up.