Mycetoma is a chronic infectious disease of the subcutaneous tissue with a high morbidity. This disease has been reported from countries between 30°N and 15°S since 1840 but the exact burden of disease is not known. It is currently unknown what the incidence, prevalence and the number of reported cases per year per country is. In order to estimate what the global burden of mycetoma is, a meta-analysis was performed. In total 50 studies were included, which resulted in a total of 8763 mycetoma cases. Most cases were found in men between 11 and 40 years of age. The foot was most commonly affected. Most cases were reported from Mexico, Sudan and India. Madurella mycetomatis was the most prevalent causative agent world-wide, followed by Actinomadura madurae, Streptomyces somaliensis, Actinomadura pelletieri, Nocardia brasiliensis and Nocardia asteroides. Although this study represents a first indication of the global burden on mycetoma, the actual burden is probably much higher. In this study only cases reported to literature could be used and most of these cases were found by searching archives from a single hospital in a single city of that country. By erecting (inter)national surveillance programs a more accurate estimation of the global burden on mycetoma can be obtained. Mycetoma is a chronic infection resulting in large masses of the subcutaneous tissue of mainly the foot. It can be caused by bacteria or fungi. Treatment for most mycetoma cases is poor and amputations are common. Although this disease was already described almost 200 years ago, it is currently not known how many people over the globe actually suffer from this disease and which countries are mostly affected. These data are useful because they can be used to concentrate medical help in places where it is really needed and to focus to search on new medication on the most common causative agents. Since mycetoma is not a reportable disease, a meta-analysis was performed based from reports in literature, in order to estimate what the global burden of mycetoma is. In total 8763 mycetoma cases were analysed. It appeared that most cases were reported from Mexico, Sudan and India and that the fungus Madurella mycetomatis was the most prevalent causative agent world-wide. Although this study represents a first indication of the global burden on mycetoma, the actual burden is probably much higher. By erecting (inter)national surveillance programs a more accurate estimation of the global burden on mycetoma can be obtained.

Eumycetoma is a chronic fungal infection characterised by large subcutaneous masses and the presence of sinuses discharging coloured grains. The causative agents of black-grain eumycetoma mostly belong to the orders Sordariales and Pleosporales. The aim of the present study was to clarify the phylogeny and taxonomy of pleosporalean agents, viz. Madurella grisea, Medicopsis romeroi (syn.: Pyrenochaeta romeroi), Nigrograna mackinnonii (syn. Pyrenochaeta mackinnonii), Leptosphaeria senegalensis, L. tompkinsii, and Pseudochaetosphaeronema larense. A phylogenetic analysis based on five loci was performed: the Internal Transcribed Spacer (ITS), large (LSU) and small (SSU) subunit ribosomal RNA, the second largest RNA polymerase subunit (RPB2), and translation elongation factor 1-alpha (TEF1) gene. In addition, the morphological and physiological characteristics were determined. Three species were well-resolved at the family and genus level. Madurella grisea, L. senegalensis, and L. tompkinsii were found to belong to the family Trematospheriaceae and are reclassified as Trematosphaeria grisea comb. nov., Falciformispora senegalensis comb. nov., and F. tompkinsii comb. nov. Medicopsis romeroi and Pseudochaetosphaeronema larense were phylogenetically distant and both names are accepted. The genus Nigrograna is reduced to synonymy of Biatriospora and therefore N. mackinnonii is reclassified as B. mackinnonii comb. nov. Mycetoma agents in Pleosporales were phylogenetically quite diverse despite their morphological similarity in the formation of pycnidia, except for the ascosporulating genus Falciformispora (formerly in Leptosphaeria). Most of the species diagnosed from human mycetoma were found to be related to waterborne or marine fungi, suggesting an association of the virulence factors with oligotrophism or halotolerance.

The in vitro susceptibilities of 66 molecularly identified strains of the Mucorales to eight antifungals (amphotericin B, terbinafine, itraconazole, posaconazole, voriconazole, caspofungin, micafungin, and 5-fluorocytosine) were tested. Molecular phylogeny was reconstructed based on the nuclear ribosomal large subunit to reveal taxon-specific susceptibility profiles. The impressive phylogenetic diversity of the Mucorales was reflected in susceptibilities differing at family, genus, and species levels. Amphotericin B was the most active drug, though somewhat less against Rhizopus and Cunninghamella species. Posaconazole was the second most effective antifungal agent but showed reduced activity in Mucor and Cunninghamella strains, while voriconazole lacked in vitro activity for most strains. Genera attributed to the Mucoraceae exhibited a wide range of MICs for posaconazole, itraconazole, and terbinafine and included resistant strains. Cunninghamella also comprised strains resistant to all azoles tested but was fully susceptible to terbinafine. In contrast, the Lichtheimiaceae completely lacked strains with reduced susceptibility for these antifungals. Syncephalastrum species exhibited susceptibility profiles similar to those of the Lichtheimiaceae. Mucor species were more resistant to azoles than Rhizopus species. Species-specific responses were obtained for terbinafine where only Rhizopus arrhizus and Mucor circinelloides were resistant. Complete or vast resistance was observed for 5-fluorocytosine, caspofungin, and micafungin. Intraspecific variability of in vitro susceptibility was found in all genera tested but was especially high in Mucor and Rhizopus for azoles and terbinafine. Accurate molecular identification of etiologic agents is compulsory to predict therapy outcome. For species of critical genera such as Mucor and Rhizopus , exhibiting high intraspecific variation, susceptibility testing before the onset of therapy is recommended.

Introduction Azole resistance in Aspergillus fumigatus is increasingly reported. We describe the validation of AsperGenius®, a new multiplex real-time polymerase chain reaction (PCR) assay consisting of two multiplex real-time PCRs: one which identifies the clinically relevant Aspergillus species, and one which detects the TR34, L98H, T289A, Y121F mutations in CYP51A and differentiates susceptible from resistant A. fumigatus strains. Methods The diagnostic performance was tested on 37 bronchoalveolar lavage (BAL) samples from haematology patients and on 40 BAL samples from intensive care unit (ICU) patients using BAL galactomannan ≥1.0 or positive culture as the gold standard for the presence of Aspergillus. Results In the haematology and ICU groups combined, there were 22 BAL samples with IA (2 proven, 9 probable and 11 non-classifiable). Nineteen of the 22 BAL samples were positive according to the gold standard. The optimal cycle threshold value for the presence of Aspergillus was <36. Sixteen of the 19 BAL samples had a positive PCR (2 Aspergillus species and 14 A. fumigatus). This resulted in a sensitivity, specificity, positive and negative predictive value of 88.9%, 89.3%, 72.7% and 96.2% for the haematology group and 80.0%, 93.3%, 80.0% and 93.3% in the ICU group, respectively. The CYP51A real-time PCR confirmed 12 wildtype and 2 resistant strains (1 TR34/L98H and 1 TR46/Y121F/T289A mutant). Conclusion The AsperGenius® multiplex real-time PCR allows for a sensitive and fast detection of Aspergillus species directly in BAL samples. More importantly, this assay detects and differentiates wildtype from resistant strains even if BAL cultures remained negative.