Striving for Perfection: Experience from the Laboratory Foundation Training Course

By Rukumani Devi Velayuthan

What were your initial thoughts on the AFWG Laboratory Foundation Training course?

I felt that the course was a great platform to learn extensively, especially because I felt I needed more training and mentorship in my field, beyond my experience in University Malaya, Malaysia. The Asia Fungal Working Group (AFWG) provided such a good opportunity for me to be an observer in a premier medical and research institution for fungal studies, the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, India.

It was a blessing to have been mentored and taught by brilliant and humble experts, such as Professor Arunaloke Chakrabarti, President-elect of the International Society for Human and Animal Mycology (ISHAM), and co-mentor Professor Shivaprakash Rudramurthy, ISHAM Vice President. Associate Professor Dr Anup Kumar Ghosh and Assistant Professor Dr Harsimran Kaur were also extremely helpful. At the start of the 3-month laboratory course, I was a bit nervous and apprehensive, as PGIMER was highly ranked and renowned in the world.

What did you observe during the course?

I began my course at the clinical microbiology laboratory around the third week of April 2018 under the close supervision of Dr Harsimran, who is the youngest mycologist in the center and is passionate about mycology diagnostic work.

At PGIMER, I was exposed to: their clinical and diagnostic work; the wide culture collection in the WHO Collaborating Centre on Reference and Research on Fungi of Medical Importance (at the Mycology Division of the Department of Medical Microbiology); and their advanced research center.

Relative to the samples I usually receive in my lab in Malaysia, the samples the PGIMER microbiology laboratory receives are so much more, at least 50 to 100 samples daily. These are handled by their hardworking and dedicated team members, who process the samples for diagnosis and reporting throughout the day until late in the evening. Because PGIMER is a large mycology reference center that uses advanced diagnostic techniques, samples are received from all over India. Samples that have been processed elsewhere may still be sent to PGIMER for a second opinion from their mycology experts. I was so impressed by the dedication of the staff to diagnosing fungal infections.

After initial examinations, yeasts and molds are identified by their phenotypic checklists. Yeasts are identified mainly by phenotypic identification (using assimilation tests, corn meal agar, ascospore production tests, etc). The center widely uses matrix-assisted laser desorption/ionization (MALDI) for more efficient identification and quick turnaround times. Molds are mainly identified by slide culture. This center uses a lot of specialized media, like corn meal agar and potato dextrose agar (PDA), to enhance sporulation. Because of their well-trained staff’s massive effort and energy, even difficult non-sporulating organisms could be identified. Other molds that are hard to identify are subjected to polymerase chain reaction (PCR) methods. Serologic tests such as galactomannan, (1→3)-β-D-glucan, Aspergillus-specific IgG and IgE/total IgE, cryptococcal antigen and skin tests also aid the team in diagnosing fungal infection. They also practice therapeutic drug monitoring (for voriconazole, itraconazole and posaconazole) and antifungal susceptibility testing for yeasts and molds.

I was happy to witness the use of advanced molecular techniques at PGIMER, where they are experts in conventional and real-time PCR. In particular, Dr Anup is dedicated to working on updating their MALDI software. It was obvious that their staff is continuously improving and striving to achieve perfection in the fungal diagnostics field.

I was very impressed by the culture collection, which was the largest I’ve seen. With precious help from Sunitha Gupta, a senior medical technologist who taught me many skills in identifying fungi, I took the opportunity to observe very rare fungal pathogens, such as Aspergillus tetrazonus, Rhizopus homothallicus, Saksenaea vasiformis, Rhinocladiella mackenziei (formerly Ramichloridium mackenziei), Dactylaria gallopava, Chaetomium globosum, and many more.

The WHO Collaborating Centre on Reference and Research on Fungi of Medical Importance provides services for identification and characterization of emerging fungal infections to other institutions and countries upon the request of WHO. This Centre also standardizes new diagnostic technology and disseminates these to national laboratories. The experts from this Centre also provide technical support to member countries in establishing and managing fungal diagnostic services, including training the national trainers as and when required by WHO.

What important lessons did you learn from the course?

At PGIMER, I learned that having a good organizational setup is crucial. Clinical, research and molecular work were distinctly under specific experts. The medical lab technician, research assistant, clerks, PhD students, etc, were given jobs in specialized areas. This ensures that each one clearly knows what his/her given tasks are and can work accordingly. In the working environment, the staff exhibits a close bond and was in good spirits, which helps boost productivity. Despite their busy schedule, I was treated like family – I was even fed home cooking! I definitely felt the closeness among the staff.

Communication, another key element that made the team successful, is important, not only among consultants, but among staff members as well. Relevant cases are discussed with their respective clinicians for fast action. I noted excellent clinical ethics while visiting the wards and outpatient departments to observe sample collections.

I learned that collaboration between clinicians and mycologists, and with national and international experts, is essential as well. Being willing to teach and listen, and having a good attitude are indispensable to being a good mycology professional.

How would you apply what you have learned back to your home country?

After my 3-month experience, I’m determined to organize my lab by giving the staff members clearer work lists and job descriptions. I’ve had discussions with my colleagues on proper methods of collecting clinical samples for better yields. Based on what I’ve learned from PGIMER, I’ve introduced storage methods and sporulation methods using special media, and new techniques involving slide cultures, preservation techniques and identifying clinically relevant dermatophytes in culture plates. We’ve also purchased new primers to improve PCR techniques for fungal diagnostics. Our lab should be able to use serology testing (like galactomannan) and MALDI soon. I will also be involved in collecting data on yeasts and yeast-like fungi for the WHO Collaborating Centre for Surveillance of Antimicrobial Resistance through WHONET. I also plan to commence antifungal sensitivity testing for clinically important molds and for a few clinically relevant pathogenic yeasts. As for research, I’ve applied for some grants to investigate antifungal resistant patterns in sterile samples.

Any final thoughts on the course?

I’m very grateful that I was given this once-in-a-lifetime chance, and for the mentorship of Professors Arunaloke and Shivaprakash, and Drs Anup and Harsimran who have all selflessly dedicated some of their valuable time to my training. Thank you for accepting me as a life member of the Society for Indian Human and Animal Mycology in India. I am also thankful for all the staff and students of PGIMER who were kind enough to teach me and treat me as part of their team. A very special ‘thank you’ goes out to Betty Lin, AFWG secretariat, for her constant support. I hope to continuously grow and improve the fungal diagnostic field in my own laboratory.