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Rabacal W, Schweitzer F, Kling HM, Buzzelli L, Rayens E, Norris KA. A therapeutic vaccine strategy to prevent Pneumocystis pneumonia in an immunocompromised host in a non-human primate model of HIV and Pneumocystis co-infection. Front Immunol 2022; 13:1036658. [PMID: 36561749 PMCID: PMC9763597 DOI: 10.3389/fimmu.2022.1036658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Pneumocystis is a ubiquitous fungal pathogen that causes pneumonia (PCP) and pulmonary sequelae in HIV-infected individuals and other immunocompromised populations. With the success of anti-retroviral therapy for HIV-infected individuals the frequency of PCP in that population has decreased, however, PCP remains a significant cause of morbidity and mortality in individuals with hematologic and solid malignancies, and in individuals treated with immunosuppressive therapies for autoimmune diseases, and following bone marrow and solid organ transplantation. Despite the clinical need, there is no approved vaccine to prevent PCP in vulnerable populations. The ultimate goal of the field is to develop an effective vaccine that can overcome immune deficits in at risk populations and induce long-lasting protective immunity to Pneumocystis. Toward this goal, our laboratory has established a model of PCP co-infection in simian immunodeficiency virus (SIV)-infected non-human primates (NHP) and identified a recombinant protein sub-unit vaccine, KEX1, that induces robust anti-Pneumocystis immunity in immune-competent macaques that is durable and prevents PCP following simian immunodeficiency virus (SIV)-induced immunosuppression. Type I, or invariant natural killer T (iNKT) cells have the potential to provide B cell help under conditions of reduced CD4+ T cell help. Methods In the present study, we used the SIV model of HIV infection to address whether therapeutic vaccination with the iNKT cell-activating adjuvant α-galactosylceramide (α-GC) and KEX1 (α-GC+KEX1) can effectively boost anti-Pneumocystis humoral immunity following virus-induced immunosuppression. Results Immunization of antigen-experienced NHPs with α-GC+KEX1 during the early chronic phase of SIV-infection significantly boosted anti-Pneumocystis humoral immunity by increasing memory B cells and antibody titers, and enhanced titer durability during SIV-induced immunosuppression. This therapeutic vaccination strategy boosted anti-Pneumocystis immune responses during SIV-infection and contributed to protection against Pneumocystis co-infection in KEX1-vaccinated macaques. Conclusion These studies present a novel strategy for stimulating durable anti-Pneumocystis humoral immunity in the context of complex, chronic SIV-induced immunosuppression and may be further applied to immunization of other immunosuppressed populations, and toward other common recall antigens.
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Affiliation(s)
- Whitney Rabacal
- Center for Vaccines and Immunology, Department of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - Finja Schweitzer
- Center for Vaccines and Immunology, Department of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - Heather M. Kling
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lizabeth Buzzelli
- Center for Vaccines and Immunology, Department of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - Emily Rayens
- Center for Vaccines and Immunology, Department of Infectious Diseases, University of Georgia, Athens, GA, United States
| | - Karen A. Norris
- Center for Vaccines and Immunology, Department of Infectious Diseases, University of Georgia, Athens, GA, United States
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Martínez-Rodríguez S, Friaza V, Girón-Moreno RM, Gallego EQ, Salcedo-Posadas A, Figuerola-Mulet J, Solé-Jover A, Campano E, Morilla R, Calderón EJ, Medrano FJ, Horra CDL. Fungal microbiota dynamics and its geographical, age and gender variability in patients with cystic fibrosis. Clin Microbiol Infect 2022; 29:539.e1-539.e7. [PMID: 36371030 DOI: 10.1016/j.cmi.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/31/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES In cystic fibrosis (CF), there is a predisposition to bronchial colonization by potentially pathogenic microorganisms, such as fungi. Our aims were to describe the dynamics of respiratory mycobiota in patients with CF and to evaluate the geographic, age and gender variability in its distribution. METHODS Cohort study in which 45 patients with CF from four hospitals in three Spanish cities were followed up during a 1-year period, obtaining spontaneous sputum samples every 3 to 6 months. Fungal microbiota were characterized by Internal Transcribed Spacer sequencing and Pneumocystis jirovecii was identified by nested PCR in a total of 180 samples. RESULTS The presence of fungi were detected in 119 (66.11%) of the 180 samples and in 44 (97.8%) of the 45 patients: 19 were positive and 1 negative throughout all follow-ups and the remaining 25 presented alternation between positive and negative results. A total of 16 different genera were identified, with Candida spp. (50/180, 27.78%) and Pneumocystis spp. (44/180, 24.44%) being the most prevalent ones. The distribution of fungal genera was different among the evaluated centres (p < 0.05), by age (non-adults aged 6-17 years vs. adults aged ≥18 years) (p < 0.05) and by gender (p < 0.05). DISCUSSION A high prevalence of fungal respiratory microbiota in patients with CF was observed, whose dynamics are characterized by the existence of multiple cycles of clearance and colonization, reporting the existence of geographic, age and gender variability in the distribution of fungal genera in this disease.
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Affiliation(s)
- Sara Martínez-Rodríguez
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, Spain
| | - Vicente Friaza
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosa M Girón-Moreno
- Unidad de Fibrosis Quística-Bronquiectasias, Instituto de Investigación Sanitaria de La Princesa, Madrid
| | - Esther Quintana Gallego
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Joan Figuerola-Mulet
- Servicio de Pediatría, Hospital Universitari Son Espases, Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - Amparo Solé-Jover
- Unidad de Trasplante Pulmonar y Fibrosis Quística. Universitat de Valencia, Hospital Universitario La Fe, Valencia, Spain
| | - Elena Campano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain
| | - Ruben Morilla
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain; Departamento de Enfermería, Universidad de Sevilla, Spain
| | - Enrique J Calderón
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain; Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Seville, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, Spain
| | - Francisco J Medrano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain; Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Seville, Spain; Departamento de Medicina, Facultad de Medicina, Universidad de Sevilla, Spain.
| | - Carmen de la Horra
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla), Seville, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
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Rayens E, Norris KA. Prevalence and Healthcare Burden of Fungal Infections in the United States, 2018. Open Forum Infect Dis 2022; 9:ofab593. [PMID: 35036461 PMCID: PMC8754384 DOI: 10.1093/ofid/ofab593] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/18/2021] [Indexed: 12/17/2022] Open
Abstract
Background Fungal infections are responsible for >1.5 million deaths globally per year, primarily in those with compromised immune function. This is concerning as the number of immunocompromised patients, especially in those without human immunodeficiency virus (HIV), has risen in the past decade. The purpose of this analysis was to provide the current prevalence and impact of fungal disease in the United States. Methods We analyzed hospital discharge data from the most recent (2018) Healthcare Cost and Utilization Project National Inpatient Sample, and outpatient visit data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Costs are presented in 2018 United States (US) dollars. Results In the 35.5 million inpatient visits documented in 2018 in the US, approximately 666 235 fungal infections were diagnosed, with an estimated attributable cost of $6.7 billion. Aspergillus, Pneumocystis, and Candida infections accounted for 76.3% of fungal infections diagnosed, and 81.1% of associated costs. Most fungal disease occurred in patients with elevated risk of infection. The visit costs, lengths of stay, and risks of mortality in this population were more than twice that of those without fungal diagnoses. A further 6.6 million fungal infections were diagnosed during outpatient visits. Conclusions Fungal disease is a serious clinical concern with substantial healthcare costs and significant increases in morbidity and mortality, particularly among predisposed patients. Increased surveillance, standardized treatment guidelines, and improvement in diagnostics and therapeutics are needed to support the rising numbers of at-risk patients.
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Affiliation(s)
- Emily Rayens
- Center for Vaccines and Immunology, Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Karen A Norris
- Center for Vaccines and Immunology, Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
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Rayens E, Norris KA, Cordero JF. Mortality Trends in Risk Conditions and Invasive Mycotic Disease in the United States, 1999-2018. Clin Infect Dis 2021; 74:309-318. [PMID: 33876235 DOI: 10.1093/cid/ciab336] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Invasive fungal infections (IFIs) in the United States are chronically underdiagnosed and a lack of coordinated surveillance makes the true burden of disease difficult to determine. The purpose of this analysis was to capture mortality-associated burden of risk conditions and fungal infections. METHODS We analyzed data from the National Vital Statistics System from 1999-2018 to estimate the mortality attributed to risk conditions and related fungal disease. RESULTS The number of risk conditions associated with fungal disease is steadily rising in the United States with 1,047,422 diagnoses at time of death in 2018. While fungal disease decreased substantially from 1999 to 2010, primarily due to the control of HIV infection, the number deaths with fungal diagnosis has increased in the non-HIV cohort, with significant increases in patients with diabetes, cancer, immunosuppressive disorders, or sepsis. CONCLUSION The landscape of individuals at risk for serious fungal diseases is changing, with a continued decline in HIV-associated incidence, but increased diagnoses in patients with cancer, sepsis, immunosuppressive disorders, and influenza. Additionally, there is an overall increase in the number of fungal infections in recent years, indicating a failure to control fungal disease mortality in these new immunocompromised cohorts. Improvement in prevention and management of fungal diseases is needed to control morbidity and mortality in the rising number of immunocompromised and at-risk patients in the United States.
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Affiliation(s)
- Emily Rayens
- Center for Vaccines and Immunology, Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, Georgia USA.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia USA
| | - Karen A Norris
- Center for Vaccines and Immunology, Department of Infectious Diseases, College of Veterinary Medicine, University of Georgia, Athens, Georgia USA
| | - José F Cordero
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, Georgia USA
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Morilla R, Medrano FJ, Calzada A, Quintana E, Campano E, Friaza V, Calderón EJ, de la Horra C. Pneumocystis jirovecii among patients with cystic fibrosis and their household members. Med Mycol 2021; 59:849-854. [PMID: 33693837 PMCID: PMC8754488 DOI: 10.1093/mmy/myab010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 12/16/2022] Open
Abstract
We conducted a pilot study of patients with cystic fibrosis (CF) to assess intra-family transmission of P. jirovecii and compare it with data on other prevalent pathogens such as P. aeruginosa and S. pneumoniae, in which respiratory transmission has already been documented. Oral swab samples from 10 patients with CF and 15 household members were collected at baseline and 2 weeks later. P. aeruginosa and S. pneumoniae were assessed using standardized culture methods and PCR, and P. jirovecii was assessed using real and nested PCR, genotyping the positive samples by direct sequencing. P. aeruginosa cultures were positive for 7/10 (70%) of patients with CF at baseline and was identified by PCR in 8/10 (80%) of cases at baseline and 2 weeks later. S. pneumoniae cultures were negative for all patients, but the microorganism was identified by PCR in two cases. P. jirovecii was detected by real time and nested PCR in 5/10 (50%) of the patients at the two time points. In the household members, P. aeruginosa and P. jirovecii were identified in 7/15 (46.7%), and S. pneumoniae was identified in 8/15 (53,3%). The concordance of positive or negative pairs of patients with CF and their household members was 33.3% (5/15) for P. aeruginosa, 46.7% (7/15) for S. pneumonia and 93.3% (14/15) for P. jirovecii. The concordance for P. jirovecii genotypes among five pairs with available genotype was 100%. This study suggests for the first time the possible transmission of Pneumocystis in the home of patients with CF, indicating that patients and their household members are reservoirs and possible sources of infection.
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Affiliation(s)
- Ruben Morilla
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Department of Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain.,Department of Nursing, Universidad de Sevilla, Seville, Spain
| | - Francisco J Medrano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Department of Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain.,Department of Medicine, Universidad de Sevilla, 41013 Seville, Spain
| | - Ana Calzada
- Hospital Virgen de las Montañas de Villamartín, 11650 Cadiz, Spain
| | - Esther Quintana
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Campano
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain
| | - Vicente Friaza
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
| | - Enrique J Calderón
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Department of Internal Medicine, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain.,Department of Medicine, Universidad de Sevilla, 41013 Seville, Spain
| | - Carmen de la Horra
- Instituto de Biomedicina de Sevilla (Hospital Universitario Virgen del Rocío/ CSIC/ Universidad de Sevilla), 41013 Seville, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain.,Department of Microbiology and Parasitology, School of Pharmacy, University of Seville, 41013 Seville, Spain
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Bonnet P, Le Gal S, Calderon E, Delhaes L, Quinio D, Robert-Gangneux F, Ramel S, Nevez G. Pneumocystis jirovecii in Patients With Cystic Fibrosis: A Review. Front Cell Infect Microbiol 2020; 10:571253. [PMID: 33117730 PMCID: PMC7553083 DOI: 10.3389/fcimb.2020.571253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/14/2020] [Indexed: 12/12/2022] Open
Abstract
Pneumocystis pneumonia (PCP) remains the most frequent AIDS-defining illness in developed countries. This infection also occurs in non-AIDS immunosuppressed patients, e.g., those who have undergone an organ transplantation. Moreover, mild Pneumocystis jirovecii infections related to low pulmonary fungal burden, frequently designated as pulmonary colonization, occurs in patients with chronic pulmonary diseases, e.g., cystic fibrosis (CF). Indeed, this autosomal recessive disorder alters mucociliary clearance leading to bacterial and fungal colonization of the airways. This mini-review compiles and discusses available information on P. jirovecii and CF. It highlights significant differences in the prevalence of P. jirovecii pulmonary colonization in European and Brazilian CF patients. It also describes the microbiota associated with P. jirovecii in CF patients colonized by P. jirovecii. Furthermore, we have described P. jirovecii genomic diversity in colonized CF patients. In addition of pulmonary colonization, it appears that PCP can occur in CF patients specifically after lung transplantation, thus requiring preventive strategies. In other respects, Pneumocystis primary infection is a worldwide phenomenon occurring in non-immunosuppressed infants within their first months. The primary infection is mostly asymptomatic but it can also present as a benign self-limiting infection. It probably occurs in the same manner in CF infants. Nonetheless, two cases of severe Pneumocystis primary infection mimicking PCP in CF infants have been reported, the genetic disease appearing in these circumstances as a risk factor of PCP while the host-pathogen interaction in older children and adults with pulmonary colonization remains to be clarified.
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Affiliation(s)
- Pierre Bonnet
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France
| | - Solène Le Gal
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France.,Groupe d'Etude des Interactions Hôte-Pathogène (ER, GEIHP), Université d'Angers, Université de Brest, Brest, France
| | - Enrique Calderon
- CIBER de Epidemiologia y Salud Publica and Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - Laurence Delhaes
- Laboratory of Parasitology and Mycology, Bordeaux University Hospital, Bordeaux, France Inserm U1045 - University of Bordeaux, Bordeaux, France
| | - Dorothée Quinio
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France
| | - Florence Robert-Gangneux
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé Environnement Travail), UMR_S 1085, Rennes, France
| | - Sophie Ramel
- Centre de Ressources et de Compétences de la Mucoviscidose, Fondation Ildys, Roscoff, France
| | - Gilles Nevez
- Laboratoire de Parasitologie et Mycologie, Hôpital de La Cavale Blanche, CHU de Brest, Brest, France.,Groupe d'Etude des Interactions Hôte-Pathogène (ER, GEIHP), Université d'Angers, Université de Brest, Brest, France
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Fungal Pathogens in CF Airways: Leave or Treat? Mycopathologia 2017; 183:119-137. [PMID: 28770417 DOI: 10.1007/s11046-017-0184-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/22/2017] [Indexed: 02/07/2023]
Abstract
Chronic airway infection plays an essential role in the progress of cystic fibrosis (CF) lung disease. In the past decades, mainly bacterial pathogens, such as Pseudomonas aeruginosa, have been the focus of researchers and clinicians. However, fungi are frequently detected in CF airways and there is an increasing body of evidence that fungal pathogens might play a role in CF lung disease. Several studies have shown an association of fungi, particularly Aspergillus fumigatus and Candida albicans, with the course of lung disease in CF patients. Mechanistically, in vitro and in vivo studies suggest that an impaired immune response to fungal pathogens in CF airways renders them more susceptible to fungi. However, it remains elusive whether fungi are actively involved in CF lung disease pathologies or whether they rather reflect a dysregulated airway colonization and act as microbial bystanders. A key issue for dissecting the role of fungi in CF lung disease is the distinction of dynamic fungal-host interaction entities, namely colonization, sensitization or infection. This review summarizes key findings on pathophysiological mechanisms and the clinical impact of fungi in CF lung disease.
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Nevez G, Robert-Gangneux F, Pougnet L, Virmaux M, Belleguic C, Deneuville E, Rault G, Chevrier S, Ramel S, Le Bihan J, Guillaud-Saumur T, Calderon E, Le Govic Y, Gangneux JP, Le Gal S. Pneumocystis jirovecii and Cystic Fibrosis in Brittany, France. Mycopathologia 2017; 183:81-87. [DOI: 10.1007/s11046-017-0172-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/27/2017] [Indexed: 11/30/2022]
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