title: Treatment outcomes of surgery, antifungal therapy and immunotherapy in ocular and vascular human pythiosis: a retrospective study of 18 patients.
abstract: OBJECTIVE
  Human pythiosis is a life-threatening disease for which no standard treatment protocols with proven efficacy exist. We present the results of our institutional pythiosis treatment protocol, composed of surgery, antifungal agents, iron chelator (only vascular cases) and immunotherapy.
  
  
  METHODS
  We retrospectively analysed patients with proven vascular and ocular pythiosis in King Chulalongkorn Memorial Hospital from April 2003 to May 2013. Fisher's exact test and Wilcoxon's rank-sum test were used. The MICs of seven antifungal agents and combination drugs were investigated in eight clinical Pythium insidiosum strains.
  
  
  RESULTS
  Eighteen patients were evaluated. Disease-free surgical margins were obtained in all surviving patients with vascular pythiosis (P = 0.08). Patients who underwent eye enucleation were significantly older than those who did not (P < 0.05). Patients with vascular or ocular pythiosis did not differ significantly in the median time from disease onset to first surgery or in the relationship between the type of P. insidiosum antigen and treatment outcomes. In vitro susceptibility profiles of all isolates demonstrated that no single agent or combination treatment was substantially more effective than the others. The highest MIC was detected for amphotericin B, followed in order by voriconazole, fluconazole, anidulafungin, caspofungin, itraconazole and terbinafine. No synergistic effects of the combination drug treatments were found.
  
  
  CONCLUSIONS
  Surgery with adequate surgical margins is a crucial determinant of survival in patients with vascular pythiosis. Itraconazole and terbinafine do not have synergistic effects on Thai P. insidiosum strains. The role of immunotherapy remains inconclusive for both vascular and ocular pythiosis.
authors: Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA.
authors: Nitipong
authors: N
authors: Permpalung
authors: Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
authors: Navaporn
authors: N
authors: Worasilchai
authors: Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
authors: Rongpong
authors: R
authors: Plongla
authors: Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand.
authors: Sikarin
authors: S
authors: Upala
authors: Department of Medicine, Bassett Medical Center and Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA Department of Preventive and Social Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand.
authors: Anawin
authors: A
authors: Sanguankeo
authors: Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
authors: Leilani
authors: L
authors: Paitoonpong
authors: Microbiology and Molecular Genetics, Biomedical Laboratory Diagnostics, Michigan State University, East Lansing, MI, USA.
authors: Leonel
authors: L
authors: Mendoza
authors: Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand cariya@chula.ac.th.
authors: Ariya
authors: A
authors: Chindamporn
mesh_terms: D000328:Adult; D000935:Antifungal Agents / Q000627:therapeutic use*; D003646:Debridement; D005128:Eye Diseases / Q000188:drug therapy / Q000601:surgery; D005260:Female; D006801:Humans; D007167:Immunotherapy / Q000379:methods*; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D058968:Pythiosis / Q000188:drug therapy* / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome; D014652:Vascular Diseases / Q000188:drug therapy / Q000601:surgery; D055815:Young Adult
chemical_list: D000935:Antifungal Agents
keywords: Pythium; immunotherapy; keratitis; pythiosis; vasculitis