{'fraction_non_alphanumeric': 0.030847859815642968, 'fraction_numerical': 0.012594688327096834, 'mean_word_length': 4.904094827586207, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
P383 ‘It's not Fungus, its Nocardia’—an elementary diagnostic challenge for draining sinus on abdominal wall (rare): a case report

Abstract   Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM Introduction: A rare finding of abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by Nocardia brasiliensis. Methods History: A 22-year-old presented to the Dermatology OPD with complaints of swelling and tenderness and discharging sinuses with no granules around the periumbilical region in the lower abdominal area for three years. His initial fine needle aspiration cytology specimen report was inconclusive. He received anti-Kochs treatment based on a positive Montoux test and family history from outside the hospital. Initially punch biopsy samples were sent for fungal processing to our laboratory which was inconclusive. Repeat pus aspirate and punch biopsy samples were subjected to conventional techniques. The sample was inoculated on Sabouraud's Dextrose agar, Brain heart Infusion agar, and Lowenstein-Jensen media. Direct Smear was subjected to Gram stain and Modified Zeihl Neelson stain with 1% Sulfuric acid as decoloriser. Results: On Gram stain, Gram-positive filamentous bacilli against a background of pus cells in pus aspirate only (not in punch biopsy specimens). Modified Zeihl Neelson stain with 1% Sulfuric acid decoloriser was performed on all three samples. Beaded acid-fast filamentous bacilli with plenty of pus cells in the background were seen in pus aspirate only (not in punch biopsy specimens). No fungal elements were observed on the 20% KOH mount. Clinicians were notified immediately with the provisional report of possible Actinomycetoma due to Nocardia sp. Growth was observed within 9 days on SDA as well as LJ. It was a chalky white, dry colony to begin with that turned orangish-yellow in another week's time. Smear from the colony showed Gram-positive filamentous bacilli which on Modified ZN Smear were acid-fast filamentous beaded bacilli. The isolate was identified as Nocardia species. This was further confirmed as Nocardia brasiliensis by MALDI-TOF. On admission, the patient was initially started on Inj. Amikacin and then changed to Modified Raman regime of double dose Cotrimoxazole and Gentamicin. His lesions started showing improvement over 2 weeks of in-patient treatment. He was discharged on oral treatment thereafter. Conclusion Abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by N. brasiliensis is a rare clinical entity as Mycetoma. The differential diagnosis would lead to either bacterial or fungal etiology or neoplasia. Delay in correct diagnosis led to the chronicity of the clinical presentation with inappropriate therapy. For a chronic destructive debilitating infective mycetoma presentation, appropriate microbiological diagnostics become essential to have early correct detection with proper sampling technique to guide the appropriate therapy as per the causative pathogen.

Poster session 3, September 23, 2022, 12:30 PM -1:30 PM Introduction: A rare finding of abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by Nocardia brasiliensis.
Methods: History: A 22-year-old presented to the Dermatology OPD with complaints of swelling and tenderness and discharging sinuses with no granules around the periumbilical region in the lower abdominal area for three years. His initial fine needle aspiration cytology specimen report was inconclusive. He received anti-Kochs treatment based on a positive Montoux test and family history from outside the hospital.
Initially punch biopsy samples were sent for fungal processing to our laboratory which was inconclusive. Repeat pus aspirate and punch biopsy samples were subjected to conventional techniques. The sample was inoculated on Sabouraud's Dextrose agar, Brain heart Infusion agar, and Lowenstein-Jensen media. Direct Smear was subjected to Gram stain and Modified Zeihl Neelson stain with 1% Sulfuric acid as decoloriser. Results: • On Gram stain, Gram-positive filamentous bacilli against a background of pus cells in pus aspirate only ( not in punch biopsy specimens ) .

•
Modified Zeihl Neelson stain with 1% Sulfuric acid decoloriser was performed on all three samples. Beaded acid-fast filamentous bacilli with plenty of pus cells in the background were seen in pus aspirate only ( not in punch biopsy specimens ) .

•
No fungal elements were observed on the 20% KOH mount.

•
Clinicians were notified immediately with the provisional report of possible Actinomycetoma due to Nocardia sp.

•
Growth was observed within 9 days on SDA as well as LJ. It was a chalky white, dry colony to begin with that turned orangish-yellow in another week's time. Smear from the colony showed Gram-positive filamentous bacilli which on Modified ZN Smear were acid-fast filamentous beaded bacilli. The isolate was identified as Nocardia species. This was further confirmed as Nocardia brasiliensis by MALDI-TOF.

•
On admission, the patient was initially started on Inj. Amikacin and then changed to Modified Raman regime of double dose Cotrimoxazole and Gentamicin. His lesions started showing improvement over 2 weeks of in-patient treatment. He was discharged on oral treatment thereafter.

Conclusion:
• Abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by N. brasiliensis is a rare clinical entity as Mycetoma. The differential diagnosis would lead to either bacterial or fungal etiology or neoplasia. • Delay in correct diagnosis led to the chronicity of the clinical presentation with inappropriate therapy.

•
For a chronic destructive debilitating infective mycetoma presentation, appropriate microbiological diagnostics become essential to have early correct detection with proper sampling technique to guide the appropriate therapy as per the causative pathogen. Objectives: Species belonging to the genus of Aspergillus are among the most common causative agents of human and animal infections. Less than 40 species among all Aspergillus species are known to be associated with human infections, including allergic bronchopulmonary aspergillosis, chronic pulmonary aspergillosis, and invasive aspergillosis. And of these, Aspergillus section Fumigati is one of the major infectious causes of death, followed by members of sections Flavi, Nigri, and Terrei . Aspergillus species in section Terrei are categorized into three series: Ambigui, Nivei, and Terrei. A. terreus sensu stricto is the first species described and the most common species found worldwide in different ecological habitats.

Characterization of the virulence potential of Aspergillus species of section Terrei in Galleria mellonella infection model
However, there are several other species within the section Terrei , stating cryptic species which are not distinguished by conventional morphological analysis, even though they are taxonomically accepted by forming a distinctive phylogenetic clade. Despite definitive species identification, there is still less known about the virulence potential of all species in this section, and it might be underestimated because of their lack of distinction by conventional diagnostic methods. In this ongoing study, the in vivo Galleria mellonella model has been utilized to examine the inter-and/or intraspecies virulence dependency of section Terrei .
Methods Background and Objectives: The emerging pathogen, C. auris , has been associated with nosocomial outbreaks in recent times. The true scale of the problem is difficult to comprehend due to several issues with the identification of C. auris using both phenotypic and molecular techniques. Most commonly, these isolates have been misidentified as C. haemulonii . Biofilm formation is strongly suggested given its association with intensive care settings, especially in patients with CVCs and long-term urinary catheters. Many isolates of C. auris have also shown raised MICs to multiple classes of antifungal agents, raising the possibility of pan-drug resistance.
Objective: To study the demographic characteristics, risk factors, and outcomes in patients with C. auris infection. Methodology: This is a retrospective study from a tertiary care hospital ( JPNATC, AIIMS ) including all patients from the time period of 2018-2022 that showed growth of C. auris in any site. C. auris was identified using conventional methods ( palepink growth on chromogenic medium, no pseudohyphae on germ-tube test, growth in presence of 10% NaCl ) and VITEK-2. To reduce the misidentification and the intertest variability, the results were confirmed with MALDI-TOF. The risk factors and other patient information were taken from the HIS. Statistical analysis was performed.
Results: During the study period, a total of 31 patients had a C. auris infection. The most common age group was 20-40 years ( n = 11,44% ) with a preponderance in males ( n = 23,74% ) . A total of 74% of the infections were found in blood, which was the most common site of infection followed by urine ( 10% ) . The other sites were pus-from-wound ( n = 2 ) , groin, nailbeds, and CVP tip ( n = 1 ) . Most of the cases were ICU patients ( 86% ) . All the patients with candidemia due to C. auris ( n = 17 100% ) had CVC, had surgery within the past 30 days, and were on broad-spectrum antibiotics and TPN. 71% ( n = 12 ) had a history of immunosuppression and 18% ( n = 14 ) had a history of prior antifungal therapy. Although 100% ( n = 17 ) had the presence of an indwelling urinary catheter, none of them had candiduria due to C. auris . No patient with C. auris infection had neutropenia. The median LOS was 34.5 days. Most of the isolates were resistant to fluconazole ( n = 13,93% ) , amphotericin B ( n = 13,93% ) , voriconazole ( n = 6,55% ) , flucytosine ( n = 10,71% ) . A total of 87% ( n = 12,87% ) of isolates were sensitive to caspofungin and micafungin by VITEK-2 ( limitation of this study ) . In all, 28% ( n = 7 ) of the patients died whereas 40% ( n = 10 ) were discharged. A total of 75% patients had clearing of the persistent candidemia when treated with caspofungin whereas only 25% patients had clearing of the candidemia when treated with voriconazole.
Conclusion: Most cases of C. auris infection were found in critical patients with the most common presentation being candidemia. The risk factors are similar to any other Candida infection. C.auris is the leading antimicrobial-resistant fungi and poses an additional burden to the healthcare system. The fungus has a high crude-mortality rate and we are running out of treatment options. A comprehensive intervention program with ongoing surveillance and good AMR practices is the need of the hour to reduce the burden of this dangerous pathogen.