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The fungal kingdom is characterized by significant biodiversity
within genera and species. Several hundred of fungi have been described as
cause of disease in humans. Abdulaziz and colleagues describe a case of
invasive fungal disease that supports their plea for more research into
polyene and azole combination therapy. In their case report the authors
make assumptions that do not take into account the fungal biodiversity...
The fungal kingdom is characterized by significant biodiversity
within genera and species. Several hundred of fungi have been described as
cause of disease in humans. Abdulaziz and colleagues describe a case of
invasive fungal disease that supports their plea for more research into
polyene and azole combination therapy. In their case report the authors
make assumptions that do not take into account the fungal biodiversity.
The case is presented as invasive pulmonary aspergillosis, but the
diagnosis is based on a tissue biopsy that shows septate hyphae which
might be consistent with aspergillosis. However, the morphology of fungi
in tissue is insufficient to provide a genus identification. There are
numerous fungi, including Fusarium, Paecilomyces, and Scedosporium, that
exhibit similar morphologic characteristics as Aspergillus in tissue.
Furthermore, the new taxonomy of Aspergillus has created a number of new
sibbling species, that might have very different antifungal susceptibility
profiles compared to the conventional species complexes. At best the
diagnosis in the presented case is proven invasive fungal disease. The
question is why additional tests such as PCR were not applied to obtain
identification of the fungus.
To support the plea for polyene plus azole combination therapy the authers
refer to an animal study that was performed with Cryptocuccus neoformans
in SCID-mice. Although in this model dose fractionation, PK/PD analysis
and drug interaction models were not used, it remains unclear if
observations with the yeast Cryptococcus can be extraprolated to the mold
Aspergillus. Also the case series of patients treated with polyene plus
azole combination therapy included a variety of pathogens and patient
groups.
The discussion on the use of combination therapy in patients with invasive
aspergillosis is not new and continues to deserve our attention,
especially with the emergence of azole resistance in many coutries. With
the new taxonomy and the possibility of resistance the need to identify
the fungal pathogen is essential to understand therapeutic responses.
Conflict of Interest:
I have received research grants from Gilead Sciences, Pfizer, Astellas and Merck.
This oversight indicates the shortcomings of present day medical
training. The emphasis is on technology and newer diagnostics at the cost
of patient centered clinical skills, which included detailed history
taking. We are in danger of churning out technicians rather than doctors.
Many thanks for raising another important point here. The primary
responsibility of making diagnosis of a patient lies with the clinician.
The radiology is a modality that helps in reaching diagnosis. The
clinician is expected to give a detailed note to the radiologist
mentioning the case history, clinical findings and his probable diagnosis.
This input is of utmost importance to a radiologist for concluding the
radiolog...
Many thanks for raising another important point here. The primary
responsibility of making diagnosis of a patient lies with the clinician.
The radiology is a modality that helps in reaching diagnosis. The
clinician is expected to give a detailed note to the radiologist
mentioning the case history, clinical findings and his probable diagnosis.
This input is of utmost importance to a radiologist for concluding the
radiological findings and giving a probable diagnosis. If this input is
not provided, it is wiser for the radiologist to mention only the
radiological findings in his report and leave the diagnosis to the
clinician. Another way is to interview the patient. Omission on both ends
may put the patient in trouble. For many inexperienced general
practitioners, the reported radiological diagnosis is a final word and
hence care needs to be taken while reporting X-rays.
The case report unfortunately reflects a common problem where the
referring clinician omits to include relevant clinical information. "The
chest radiogram was reported by a radiologist, who neither saw the patient
personally nor enquired into the patient's history." might well be amended
to read "the referring clinician omitted to mention the presence of
multiple large cutaneous neurofibromata"
The case report unfortunately reflects a common problem where the
referring clinician omits to include relevant clinical information. "The
chest radiogram was reported by a radiologist, who neither saw the patient
personally nor enquired into the patient's history." might well be amended
to read "the referring clinician omitted to mention the presence of
multiple large cutaneous neurofibromata"
Rubbish in-rubbish out!
David O'Keeffe FRCR FRCPI FFRRCPI
Consultant Radiologist
Galway University Hospital
Galway
Ireland
The fungal kingdom is characterized by significant biodiversity within genera and species. Several hundred of fungi have been described as cause of disease in humans. Abdulaziz and colleagues describe a case of invasive fungal disease that supports their plea for more research into polyene and azole combination therapy. In their case report the authors make assumptions that do not take into account the fungal biodiversity...
This oversight indicates the shortcomings of present day medical training. The emphasis is on technology and newer diagnostics at the cost of patient centered clinical skills, which included detailed history taking. We are in danger of churning out technicians rather than doctors.
This case report is a wake up call.
Conflict of Interest:
None declared
Many thanks for raising another important point here. The primary responsibility of making diagnosis of a patient lies with the clinician. The radiology is a modality that helps in reaching diagnosis. The clinician is expected to give a detailed note to the radiologist mentioning the case history, clinical findings and his probable diagnosis. This input is of utmost importance to a radiologist for concluding the radiolog...
The case report unfortunately reflects a common problem where the referring clinician omits to include relevant clinical information. "The chest radiogram was reported by a radiologist, who neither saw the patient personally nor enquired into the patient's history." might well be amended to read "the referring clinician omitted to mention the presence of multiple large cutaneous neurofibromata"
Rubbish in-rubbish...
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