This correspondence clarifies that DOOR incorporates, rather than causally accounts for, post-randomization treatment modification. In the voriconazole-amphotericin B trial, frequent treatment switching means the reported DOOR probability reflects treatment strategies as implemented, not sustained randomized monotherapy throughout the original trial.

This case report describes the challenging diagnosis and management of cerebral aspergillosis in a patient with chronic lymphocytic leukaemia undergoing treatment with a BTK inhibitor. The initial presentation was deceptively unspecific, comprising cognitive changes, receptive aphasia, gait instability and mild neurological deficits without fever or significant systemic inflammation. The combination of a muted and non-indicative clinical picture and a broad differential diagnosis reflects the evolving complexity of CNS infections in patients treated with targeted haematological therapies. Neuroimaging played a central role in directing attention toward an intracranial pathological process but did not resolve the ambiguity. CT suggested a space-occupying lesion, while MRI revealed multiple enhancing foci with mixed signal characteristics that could represent fungal, bacterial or neoplastic processes. Diagnosis was only established after neurosurgical intervention, when resection of the dominant lesion provided tissue for definitive identification of Aspergillus fumigatus. Once the diagnosis was confirmed, long-term voriconazole therapy was initiated and adjusted with therapeutic drug monitoring, while ibrutinib was discontinued to prevent interactions and further immunosuppression. The patient's clinical trajectory gradually stabilised, with radiological follow-up showing resolution of lesions and no recurrence. Overall, this case illustrates the importance of maintaining a high index of suspicion for fungal CNS infections in patients receiving modern immunomodulatory treatments. The interplay between subtle and non-specific neurological clinical signs, atypical imaging and altered immune responses can delay diagnosis unless the clinical team actively integrates therapeutic background and invasive modalities into its reasoning. The favourable outcome achieved here underscores the value of early multidisciplinary involvement, timely pursuit of tissue diagnosis and careful coordination of antifungal therapy.

Background and objective Candidemia remains a major cause of bloodstream infections, associated with substantial morbidity and mortality. Ongoing surveillance is needed because the distribution of Candida species and patterns of antifungal resistance continue to evolve. This study aimed to characterize the epidemiology and antifungal susceptibility profiles of Candida species isolated from blood cultures at a tertiary academic medical center from 2018 to 2025. Methods We conducted a retrospective laboratory-based analysis of non-duplicate Candida isolates recovered from positive blood cultures between January 2018 and December 2025. Species identification was performed using MALDI-TOF (matrix-assisted laser desorption/ionization time-of-flight) mass spectrometry. Antifungal susceptibility testing was conducted using Sensititre™ YeastOne™ (Thermo Fisher Scientific, Cleveland, OH) panels and interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Results A total of 717 Candida bloodstream isolates were identified. The most common species were Candida albicans (C. albicans) (242/717; 33.8%), Nakaseomyces glabratus (N. glabratus) (230/717; 32.1%), C. parapsilosis (122/717; 17.0%), C. tropicalis (56/717; 7.8%), C. dubliniensis (30/717; 4.2%), Pichia kudriavzevii (P. kudriavzevii) (15/717; 2.1%), and Clavispora lusitaniae (C. lusitaniae) (13/717; 1.8%). Overall, non-albicans species accounted for 475 of 717 cases (66.2%). Antifungal susceptibility remained largely preserved during most of the study period. C. albicans showed low resistance to fluconazole (5/242; 2.1%) and voriconazole (1/242; 0.4%), with no echinocandin resistance detected. Among N. glabratus, 23 (10%) of 230 isolates were fluconazole-resistant, and echinocandin resistance was uncommon. C. parapsilosis and C. tropicalis demonstrated moderate fluconazole resistance. Resistance increased in 2025, particularly to fluconazole (13/79; 16.5%) and caspofungin (9/79; 11.4%). Conclusions Non-albicans species caused most candidemia cases, with N. glabratus occurring nearly as often as C. albicans. Emerging resistance underscores the importance of species-level identification, susceptibility testing, and ongoing surveillance to guide therapy and antifungal stewardship.

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder characterized by nonspecific acute neurological signs and symptoms combined with typical imaging findings. It usually has a favorable prognosis but can occasionally be complicated by severe and life-threatening manifestations. Malignant PRES is the most severe form of this condition, defined by coma, refractory intracranial hypertension, and radiological evidence of cerebral edema or hemorrhage associated with a mass effect. We report a case of a 53-year-old woman with high-risk myelodysplastic neoplasm with increased blasts-2 who underwent allogeneic hematopoietic stem cell transplantation. The post-allograft period was complicated by grade III acute graft-versus-host disease, which required intensified immunosuppression with high-dose prednisolone and therapeutic doses of cyclosporine. Eighty-three days after transplantation, the patient was admitted to the emergency department with acute neurological symptoms. Rapid development of coma and clinical signs of intracranial hypertension, refractory to osmotic therapy with mannitol and hypertonic saline, prompted an emergency decompressive craniectomy. Magnetic resonance imaging confirmed the diagnosis of malignant PRES. Withdrawal of cyclosporine, mycophenolate mofetil, and voriconazole, along with intensive supportive management in the neurocritical care unit, resulted in complete neurological recovery.

Scedosporium boydii spinal infection is rare and often mimics tuberculosis. We report a 54-year-old immunocompetent man with post-traumatic thoracic vertebral infection initially misdiagnosed as spinal tuberculosis. A multi-platform approach combining culture, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), and targeted next-generation sequencing (tNGS) identified S. boydii. Surgical debridement and voriconazole resulted in complete recovery. A high index of suspicion and integrated diagnostics are essential to avoid mismanagement.

In immunocompromised patients, particularly those with indwelling central venous catheters or hematological disorders, Rhodotorula spp. is increasingly implicated in nosocomial infections. We report a series of four cases of Rhodotorula mucilaginosa Fungemia. Two cases involved in adult patients from the intensive care unit with neurological conditions, while the other were pediatric patients with hematological diseases. Rhodotorula mucilaginosa. was identified. In vitro antifungal susceptibility testing revealed that fluconazole, voriconazole, and caspofungin exhibited intermediate to complete resistance.