Exserohilum rostratum was the major cause of an outbreak of fungal infections linked to injections of contaminated methylprednisolone acetate. Because almost 14,000 persons were exposed to product that was possibly contaminated with multiple fungal pathogens, there was unprecedented need for a rapid throughput diagnostic test that could detect both E. rostratum and other unusual agents of fungal infection. Here we report development of a novel PCR test that allowed for rapid and specific detection of fungal DNA in cerebrospinal fluid (CSF), other body fluids and tissues of infected individuals. The test relied on direct purification of free-circulating fungal DNA from fluids and subsequent PCR amplification and sequencing. Using this method, we detected Exserohilum rostratum DNA in 123 samples from 114 case-patients (28% of 413 case-patients for whom 627 samples were available), and Cladosporium DNA in one sample from one case-patient. PCR with novel Exserohilum-specific ITS-2 region primers detected 25 case-patients with samples that were negative using broad-range ITS primers. Compared to fungal culture, this molecular test was more sensitive: of 139 case-patients with an identical specimen tested by culture and PCR, E. rostratum was recovered in culture from 19 (14%), but detected by PCR in 41 (29%), showing a diagnostic sensitivity of 29% for PCR compared to 14% for culture in this patient group. The ability to rapidly confirm the etiologic role of E. rostratum in these infections provided an important contribution in the public health response to this outbreak.

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance.

Candida parapsilosis is the second or third most common cause of candidemia in many countries. The Infectious Disease Society of America recommends fluconazole as primary therapy for C. parapsilosis candidemia. Although fluconazole resistance among C. parapsilosis isolates is low in most US institutions, the resistance rate can be as high as 7.5%. This study was designed to assess the mechanisms of fluconazole resistance in 706 incident bloodstream isolates from US hospitals. We sequenced the ERG11 and MRR1 genes of 122 C. parapsilosis isolates with resistant (30 isolates; 4.2%), susceptible dose-dependent (37 isolates; 5.2%) and susceptible (55 isolates) fluconazole MIC values, and used RT-PCR on RNA from 17 isolates to investigate the regulation of MDR1. By comparing these isolates to fully fluconazole susceptible isolates we detected at least two mechanisms of fluconazole resistance: an amino acid substitution in the 14-alpha-demethylase gene ERG11, and overexpression of the efflux pump MDR1, possibly due to point mutations in the MRR1 transcription factor that regulates MDR1. The ERG11 single nucleotide polymorphism (snp) was found in 57% of the fluconazole resistant isolates and in no susceptible isolates. The MRR1 snps were more difficult to characterize, as not all resulted in overexpression of MDR1 and not all MDR1 overexpression was associated with a snp in MRR1. Further work to characterize the MRR1 snps and search for overexpression of other efflux pumps is needed.