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Yang L, Su J, Zhuo C. A case of intracranial infection caused by Aspergillus flavus originating from chronic otitis media. Med Mycol Case Rep 2024; 44:100637. [PMID: 38585188 PMCID: PMC10997898 DOI: 10.1016/j.mmcr.2024.100637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 04/09/2024] Open
Abstract
Central nervous system (CNS) aspergillosis is uncommon in immunocompetent patients. We present a 64-year-old man with chronic otitis media and uncontrolled diabetes. Aspergillus flavus was identified in cerebrospinal fluid via metagenomics next-generation sequencing technology. Initial voriconazole treatment offered limited relief, but personalized dosage adjustments, guided by drug concentration, led to remission. This case underscores the importance of diverse diagnostic approaches and tailored therapy for CNS Aspergillus infections.
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Affiliation(s)
- Ling Yang
- Department of Infection, The First Hospital of Guangzhou Medical University, Guangzhou, 510000, China
| | - Jiacun Su
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Chao Zhuo
- Department of Infection, The First Hospital of Guangzhou Medical University, Guangzhou, 510000, China
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2
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Hasan MS, Sundberg C, Gilotte E, Ge X, Kostov Y, Rao G. Bioburden detection on surface and water samples in a rapid, ultra-sensitive and high-throughput manner. Biotechnol Prog 2024:e3457. [PMID: 38494865 DOI: 10.1002/btpr.3457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 03/02/2024] [Accepted: 03/05/2024] [Indexed: 03/19/2024]
Abstract
Bioburden detection is crucial for food, water, and biopharmaceutical applications as it can directly impact public health. The objective of this study is to develop and validate an assay and protocol for detecting bioburden on solid surfaces, as well as in water, with high sensitivity and accuracy in a rapid manner. Henceforth, a resazurin-based assay optimized for detecting bioburden has been integrated with a previously developed portable multichannel fluorometer. The microbes were isolated from solid surfaces in different laboratory settings by swabbing technique, and stream water was collected for contamination analysis. Based on the results, the assay and protocol can successfully detect bioburden as low as 20 CFU/cm2 and 10 CFU/mL present in both surface and water samples, respectively.
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Affiliation(s)
- Md Sadique Hasan
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
- Department of Computer Science and Electrical Engineering, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Chad Sundberg
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Elias Gilotte
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Xudong Ge
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Yordan Kostov
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Govind Rao
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, Maryland, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, Maryland, USA
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3
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Hasan MS, Sundberg C, Tolosa M, Andar A, Ge X, Kostov Y, Rao G. A novel, low-cost microfluidic device with an integrated filter for rapid, ultrasensitive, and high-throughput bioburden detection. Sci Rep 2023; 13:12084. [PMID: 37495652 PMCID: PMC10372024 DOI: 10.1038/s41598-023-38770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Rapid and accurate bioburden detection has become increasingly necessary for food, health, pharmaceutical and environmental applications. To detect bioburden accurately, and in a highly sensitive manner, we have fabricated a novel microfluidic device with an integrated filter to trap the cells. Bioburden is detected on the filter paper in situ using the redox reaction of fluorescent label resorufin and a portable multichannel fluorometer is used for fluorescence measurement. The microfluidic device was fabricated in a facile, low-cost, and rapid way with microwave-induced thermally assisted bonding. To characterize the bonding quality of the microfluidic cassettes, different tests were performed, and the filter paper material and size were optimized. Primary Bacillus subtilis culture bacterial samples were filtered through the device to validate and investigate the performance parameters. Our results show that a limit of detection (LOD) of 0.037 CFU/mL can be achieved through this microfluidic device whereas the LOD in a normal microfluidic cassette in the fluorometer and the golden standard spectrophotometer are 0.378 and 0.128 CFU/mL respectively. The results depict that three to ten times LOD improvement is possible through this microfluidic cassette and more sensitive detection is possible depending on the volume filtered within a rapid 3 min. This novel microfluidic device along with the fluorometer can be used as a rapid portable tool for highly sensitive, accurate and high-throughput bacterial detection for different applications.
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Affiliation(s)
- Md Sadique Hasan
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
- Department of Computer Science and Electrical Engineering, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Chad Sundberg
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Michael Tolosa
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Abhay Andar
- Champions Oncology Inc, 855 N Wolfe St, Baltimore, MD, 21205, USA
| | - Xudong Ge
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Yordan Kostov
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Govind Rao
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, Baltimore, MD, 21250, USA.
- Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, Baltimore, MD, 21250, USA.
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4
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Bao MY, Li M, Bu QR, Yang Y, Song H, Wang CZ, Wang TM, Li N. The effect of herbal medicine in innate immunity to Candida albicans. Front Immunol 2023; 14:1096383. [PMID: 37483621 PMCID: PMC10359817 DOI: 10.3389/fimmu.2023.1096383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/06/2023] [Indexed: 07/25/2023] Open
Abstract
Candida albicans (C. albicans) is an opportunistic pathogenic fungus that often causes mucosal and systemic infections. Several pattern recognition receptors (PRRs), such as Toll-like receptors (TLRs) and C-type lectin receptors (CLRs), have been implicated in the host recognition of C. albicans. These PRRs recognize the pathogen-associated molecular patterns (PAMPs) of C. albicans to activate innate immune cells, thereby rapidly inducing various inflammatory responses by activating intracellular signaling cascades. Herbal medicine and its active components deserve priority development due to their low toxicity and high antibacterial, antiviral and antifungal activities. This review discussed the activities of herbal compounds against C. albicans and their related mechanisms, especially their regulatory role on innate immune cells such as neutrophils, macrophages, and dendritic cells (DCs) implicated in C. albicans infections. Our work aims to find new therapeutic drugs and targets to prevent and treat diseases caused by C. albicans infection with the mechanisms by which this fungus interacts with the innate immune response.
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Affiliation(s)
- Meng-Yuan Bao
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Ming Li
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, China
| | - Qing-Ru Bu
- School of Pharmacy, Anhui University of Chinese Medicine, Hefei, China
| | - Yue Yang
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, China
| | - Hang Song
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, China
| | - Chang-Zhong Wang
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, China
| | - Tian-Ming Wang
- School of Integrated Chinese and Western Medicine, Anhui University of Chinese Medicine, Hefei, China
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, School of Pharmacy, Anhui Medical University, Hefei, China
| | - Ning Li
- Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, School of Pharmacy, Anhui Medical University, Hefei, China
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5
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Hasan MS, Marsafari M, Tolosa M, Andar A, Ramamurthy SS, Ge X, Kostov Y, Rao G. Rapid Ultrasensitive and High-Throughput Bioburden Detection: Microfluidics and Instrumentation. Anal Chem 2022; 94:8683-8692. [PMID: 35666619 DOI: 10.1021/acs.analchem.2c00980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Contamination detection often requires lengthy culturing steps to detect low-level bioburden. To increase the rate of detection and decrease the limit of detection (LOD), a system featuring microfluidics and a multichannel fluorometer has been developed. The eight-channel fluorometer enables parallel testing of multiple samples with the LOD as low as <1 cfu/mL. This low-cost system utilizes the slope of fluorescence intensity that serves as the criterion for bioburden detection. The redox indicator dye resazurin is used to monitor the presence of viable cells in this study and is reduced to resorufin with a high quantum yield at 585 nm. The sample under investigation is spiked with resazurin and loaded in a special-design microfluidic cassette, and the rate of change is observed via the fluorometer. The method was validated using primary Escherichia coli culture in comparison with a spectrophotometer which served as the gold standard. An optimized assay based on Luria-Bertani medium was developed. The impact on the assay sensitivity based on incubation and filtration steps was also explored. The assay is shown to pick up inadvertent contamination from test tubes and pipette tips showing its applicability in real-world settings. The data analysis demonstrated a comparable performance of the multichannel fluorometer vis-a-vis the conventional plate reader. The multichannel system is shown to detect bioburden presence in as low as 20 s for bacterial concentrations ≥5 cfu/mL after 6 h of incubation. Considering its portability, low cost, simplicity of operation, and relevant assay sensitivity, the system is well positioned to detect low-level bioburden in the laboratory, pharmaceutical, and field settings.
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Affiliation(s)
- Md Sadique Hasan
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Department of Computer Science and Electrical Engineering, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Monireh Marsafari
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Michael Tolosa
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Abhay Andar
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Potomac Photonics Inc., Process and Product Technologies, 1450 South Rolling Road, Baltimore, Maryland 21227, United States
| | - Sai Sathish Ramamurthy
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,STAR Laboratory, Department of Chemistry, Sri Sathya Sai Institute of Higher Learning, Prasanthi Nilayam, Puttaparthi, Anantapur 515134, Andhra Pradesh, India
| | - Xudong Ge
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Yordan Kostov
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
| | - Govind Rao
- Center for Advanced Sensor Technology, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States.,Department of Chemical, Biochemical and Environmental Engineering, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, Maryland 21250, United States
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7
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Ma Y, Li W, Ao R, Lan X, Li Y, Zhang J, Yu S. Central nervous system aspergillosis in immunocompetent patients: Case series and literature review. Medicine (Baltimore) 2020; 99:e22911. [PMID: 33126348 PMCID: PMC7598844 DOI: 10.1097/md.0000000000022911] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
The aim of this study was to investigate the clinical characteristics of central nervous system (CNS) aspergillosis in immunocompetent patients.This study enrolled six immunocompetent patients diagnosed with CNS aspergillosis. Additionally, we reviewed the clinical profiles for 28 cases reported in the literature. The age, gender, etiology of Aspergillus infection, clinical manifestations, location of the lesion, treatment, and prognosis were analyzed.There were 19 men (average age, 54.6 ± 14.3 years) and 15 women (average age, 47.0 ± 19.4 years). The clinical manifestations included headache (55.9%; n = 19), visual impairment (32.4%; n = 11), diplopia (32.4%; n = 11), hemiplegia (20.6%; n = 7), fever (17.6%; n = 6), and epilepsy (8.8%; n = 3). According to the radiological features, CNS aspergillosis lesions were divided into two subtypes: parenchymal lesions in the cerebral lobes (n = 11), and meningeal lesions in the meninges (n = 23). The patients with meningeal lesions are easy to be complicated with more serious cerebrovascular diseases, such as subarachnoid hemorrhage and massive infarction. Most of the lesions in brain parenchyma were abscess formation, and magnetic resonance imaging showed ring enhancement. The clinical diagnosis of Aspergillus infection was mainly based on brain biopsy (n = 14), autopsy (n = 8), pathological examination of adjacent brain tissues (n = 7), cerebrospinal fluid (CSF) or tissue culture (n = 3), and second-generation sequencing analysis of the CSF (n = 3). Clinical improvement was achieved in 23 cases, and 11 patients succumbed to the disease. Voriconazole treatment was effective in 24 (70.6%) cases.Immunocompetent subjects are also at risk for Aspergillus infections. Concomitant cerebrovascular diseases are common in patients with CNS aspergillosis, especially in patients with meningeal aspergillosis. Parenchymal aspergillosis lesions are usually localized and manifest as brain abscesses with annular enhancement on magnetic resonance imaging. Biopsy, CSF culture, and next-generation sequencing are mainstream diagnostic modalities. Voriconazole is an effective treatment for Aspergillus infection, and early diagnosis and treatment should be highlighted.
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8
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Firacative C. Invasive fungal disease in humans: are we aware of the real impact? Mem Inst Oswaldo Cruz 2020; 115:e200430. [PMID: 33053052 PMCID: PMC7546207 DOI: 10.1590/0074-02760200430] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/24/2020] [Indexed: 01/08/2023] Open
Abstract
Despite the medical advances and interventions to improve the quality of life of those in intensive care, people with cancer or severely immunocompromised or other susceptible hosts, invasive fungal diseases (IFD) remain severe and underappreciated causes of illness and death worldwide. Therefore, IFD continue to be a public health threat and a major hindrance to the success of otherwise life-saving treatments and procedures. Globally, hundreds of thousands of people are affected every year with Candida albicans, Aspergillus fumigatus, Cryptococcus neoformans, Pneumocystis jirovecii, endemic dimorphic fungi and Mucormycetes, the most common fungal species causing invasive diseases in humans. These infections result in morbidity and mortality rates that are unacceptable and represent a considerable socioeconomic burden. Raising the general awareness of the significance and impact of IFD in human health, in both the hospital and the community, is hence critical to understand the scale of the problem and to raise interest to help fighting these devastating diseases.
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Affiliation(s)
- Carolina Firacative
- Universidad del Rosario, School of Medicine and Health Sciences, Studies in Translational Microbiology and Emerging Diseases (MICROS) Research Group, Bogota, Colombia
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9
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Duszynski B. Spine Intervention Society Position Statement on Best Practices for Epidural Steroid Injections in the Setting of a Preservative-Free Dexamethasone Shortage. PAIN MEDICINE 2020; 20:1277-1280. [PMID: 31034052 DOI: 10.1093/pm/pnz063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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10
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Malani AN, Kauffman CA, Latham R, Peglow S, Ledtke CS, Kerkering TM, Kaufman DH, Triplett PF, Wright PW, Bloch KC, McCotter O, Toda M, Jackson BR, Pappas PG, Chiller TM. Long-term Outcomes of Patients With Fungal Infections Associated With Contaminated Methylprednisolone Injections. Open Forum Infect Dis 2020; 7:ofaa164. [PMID: 32528999 PMCID: PMC7275232 DOI: 10.1093/ofid/ofaa164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022] Open
Abstract
Background The largest health care–associated infection outbreak in the United States occurred during 2012–2013. Following injection of contaminated methylprednisolone, 753 patients developed infection with a dematiaceous mold, Exserohilum rostratum. The long-term outcomes of these infections have not been described. Methods This retrospective cohort study of 440 of a total of 753 patients with proven or probable Exserohilum infection evaluated clinical and radiographic findings, antifungal therapy and associated adverse effects, and outcomes at 6 weeks, 3, 6, 9, and 12 months after diagnosis. Patients were grouped into 4 disease categories: meningitis with/without stroke, spinal or paraspinal infections, meningitis/stroke plus spinal/paraspinal infections, and osteoarticular infections. Results Among the 440 patients, 223 (51%) had spinal/paraspinal infection, 82 (19%) meningitis/stroke, 123 (28%) both, and 12 (3%) osteoarticular infection. Of 82 patients with meningitis/stroke, 18 (22%) died; among those surviving, 87% were cured at 12 months. Only 7 (3%) of 223 patients with spinal/paraspinal infection died, but at 12 months, 68% had persistent or worsening pain and only 47% were cured. For the 123 patients with both meningitis/stroke and spinal/paraspinal infection, 10 (8%) died, pain persisted in 72%, and 52% were cured at 12 months. Only 37% of those with osteoarticular infection were cured at 12 months. Adverse events from antifungal therapy were noted at 6 weeks in 71% of patients on voriconazole and 81% on amphotericin B. Conclusions Fungal infections related to contaminated methylprednisolone injections culminated in death in 8% of patients. Persistent pain and disability were seen at 12 months in most patients with spinal/paraspinal infections.
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Affiliation(s)
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert Latham
- St. Thomas Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | | | | | | - Patty W Wright
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karen C Bloch
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Orion McCotter
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mitsuru Toda
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Peter G Pappas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom M Chiller
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Fungal Endophthalmitis after Intravitreal Injections of Triamcinolone Contaminated by a Compounding Pharmacy: Five-Year Follow-up of 23 Patients. ACTA ACUST UNITED AC 2019; 3:133-139. [DOI: 10.1016/j.oret.2018.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/04/2018] [Accepted: 09/11/2018] [Indexed: 11/22/2022]
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12
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Knezevic NN, Jovanovic F, Voronov D, Candido KD. Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain? Front Pharmacol 2018; 9:1229. [PMID: 30443214 PMCID: PMC6221932 DOI: 10.3389/fphar.2018.01229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/08/2018] [Indexed: 12/31/2022] Open
Abstract
Corticosteroids have played a standard role in the multimodal pain management in the treatment of chronic spinal pain (cervical and lumbar) and osteoarthritis pain over the past three decades. In this review we discuss different types of injectable steroids that are mainly used for injection into the epidural space (for the treatment of radicular back and neck pain), and as intra-articular injections for different types of osteoarthritis related pain conditions. Furthermore, we discuss different approaches taken for epidural corticosteroid injections and spinal surgical rates when injections fail to resolve painful conditions, as well as the possibility of using local anesthetics alone for neuraxial injections, instead of in combination with corticosteroids. While we present some beneficial effects of newly available treatment options for low back pain and osteoarthritis pain, such as use of PRP and hyaluronic acid, corticosteroids remain important considerations in the management of these chronic pain conditions.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, University of Illinois, Chicago, IL, United States.,Department of Surgery, University of Illinois, Chicago, IL, United States
| | - Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Dimitry Voronov
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, University of Illinois, Chicago, IL, United States
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13
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Ashu EE, Xu J. Strengthening the One Health Agenda: The Role of Molecular Epidemiology in Aspergillus Threat Management. Genes (Basel) 2018; 9:genes9070359. [PMID: 30029491 PMCID: PMC6071254 DOI: 10.3390/genes9070359] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 07/14/2018] [Accepted: 07/16/2018] [Indexed: 12/17/2022] Open
Abstract
The United Nations’ One Health initiative advocates the collaboration of multiple sectors within the global and local health authorities toward the goal of better public health management outcomes. The emerging global health threat posed by Aspergillus species is an example of a management challenge that would benefit from the One Health approach. In this paper, we explore the potential role of molecular epidemiology in Aspergillus threat management and strengthening of the One Health initiative. Effective management of Aspergillus at a public health level requires the development of rapid and accurate diagnostic tools to not only identify the infecting pathogen to species level, but also to the level of individual genotype, including drug susceptibility patterns. While a variety of molecular methods have been developed for Aspergillus diagnosis, their use at below-species level in clinical settings has been very limited, especially in resource-poor countries and regions. Here we provide a framework for Aspergillus threat management and describe how molecular epidemiology and experimental evolution methods could be used for predicting resistance through drug exposure. Our analyses highlight the need for standardization of loci and methods used for molecular diagnostics, and surveillance across Aspergillus species and geographic regions. Such standardization will enable comparisons at national and global levels and through the One Health approach, strengthen Aspergillus threat management efforts.
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Affiliation(s)
- Eta E Ashu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, Ontario, ON L8S 4K1, Canada.
| | - Jianping Xu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, Ontario, ON L8S 4K1, Canada.
- Public Research Laboratory, Hainan Medical University, Haikou, Hainan 571199, China.
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14
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Fill MMA, Murphree R, Pettit AC. Health Care Provider Knowledge and Attitudes Regarding Reporting Diseases and Events to Public Health Authorities in Tennessee. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 23:581-588. [PMID: 27997480 PMCID: PMC5474221 DOI: 10.1097/phh.0000000000000492] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT In the United States, state laws require health care providers to report specific diseases and events to public health authorities, a fundamental facet of disease surveillance. However, reporting by providers is often inconsistent, infrequent, and delayed. OBJECTIVE To examine knowledge, attitudes, and practices regarding provider disease reporting and to understand current barriers to provider disease reporting. DESIGN A cross-sectional study was conducted via an anonymous, standardized electronic survey. SETTING The survey was conducted at Vanderbilt University Medical Center, a large, tertiary academic medical center in Nashville, Tennessee. PARTICIPANTS Health care providers in 4 specialties (internal medicine, pediatrics, obstetrics-gynecology, and emergency medicine). MAIN OUTCOME MEASURE(S) Knowledge of and attitudes regarding provider reporting of diseases to public health authorities in Tennessee. RESULTS The majority of providers acknowledged they cared for patients with reportable diseases (362/435, 83.2%) and believed that it was their responsibility to report to public health authorities (429/436, 98.4%); however, less than half had ever reported a case (206/436, 47.2%). The median percent correct on the knowledge assessment of Tennessee reportable diseases and conditions was 81.3% (interquartile range = 68.8-87.5). Providers cited a lack of knowledge of which diseases are reportable (186/429, 43.3%) and the logistics of reporting (153/429, 35.7%) as the primary barriers for compliance. CONCLUSION Most providers acknowledged they cared for patients with reportable diseases and believed they had an obligation to report to public health authorities. However, a lack of knowledge about reporting was frequently described as a limitation to report effectively. Many knowledge deficits were significantly greater among residents than other providers.The policy and practice implications of these findings include a demonstrated need for education of providers about disease reporting as well as development of more convenient reporting mechanisms. Fundamental knowledge of reportable disease requirements and procedures is critical for participation in the broader public health system.
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Affiliation(s)
- Mary-Margaret A Fill
- Departments of Internal Medicine and Pediatrics (Dr Fill) and Division of Infectious Diseases, Department of Internal Medicine (Dr Pettit), Vanderbilt University Medical Center, Nashville, Tennessee; Tennessee Department of Health, Nashville, Tennessee (Dr Murphree); and Career Epidemiology Field Officer Program, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia (Dr Murphree)
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15
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Richards PG, Dang KM, Kauffman CA, Stalker KL, Sudekum D, Kerr L, Brinker-Bodley M, Cheriyan B, West N, Collins CD, Polega S, Malani AN. Therapeutic drug monitoring and use of an adjusted body weight strategy for high-dose voriconazole therapy. J Antimicrob Chemother 2017; 72:1178-1183. [PMID: 28108679 DOI: 10.1093/jac/dkw550] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 11/22/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives A high-dose 12 mg/kg/day (6 mg/kg twice daily) voriconazole regimen was recommended by the CDC to treat patients injected with contaminated methylprednisolone acetate that caused a multi-state fungal outbreak in 2012-13. Therapeutic drug monitoring results of this unique regimen are unknown, as is the most appropriate dosing weight for obese patients. We evaluated voriconazole trough measurements for this dosing scheme, as well as the use of adjusted body weight dosing for obese patients. Methods Voriconazole trough levels were analysed in obese (BMI ≥35 kg/m 2 ) and non-obese (BMI <35 kg/m 2 ) patients who were given initial therapy with 12 mg/kg/day. Results Of 138 patients, the first steady-state voriconazole troughs were supratherapeutic (>5 mg/L) in 65 (47%) patients, therapeutic (2-5 mg/L) in 57 (41%) patients and subtherapeutic (<2 mg/L) in 16 (12%) patients. Twenty-three patients had pre-steady-state dose decreases due to supratherapeutic levels, with subsequent first steady-state troughs in the therapeutic ( n = 17) and subtherapeutic ( n = 6) categories. Voriconazole doses >11 and >8 mg/kg/day produced mainly first steady-state supratherapeutic troughs in 44 obese and 94 non-obese patients, respectively. An initial 12 mg/kg/day was progressively lowered to a median maintenance dose of 8.5 mg/kg/day in the obese and 8.6 mg/kg/day in the non-obese. Conclusions A high-dose voriconazole regimen produced initial supratherapeutic troughs that required dose adjustment downward by nearly 30%. Adjusted body weight dosing in obese patients resulted in a similar maintenance dose to total body weight dosing in the non-obese, and appears to be a sensible dosing strategy for these patients.
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Affiliation(s)
| | | | - Carol A Kauffman
- Division of Infectious Diseases, Veterans Affairs Ann Arbor Healthcare System, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kay Lyn Stalker
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - David Sudekum
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Lisa Kerr
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | | | - Beena Cheriyan
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Nina West
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Curtis D Collins
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Shikha Polega
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, MI, USA
| | - Anurag N Malani
- Department of Internal Medicine, Division of Infectious Diseases, St Joseph Mercy Hospital, Ann Arbor, MI, USA.,Department of Infection Prevention and Control, St Joseph Mercy Hospital, Ann Arbor, MI, USA
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Abstract
In mid-September 2012, the largest healthcare-associated outbreak in U.S. history began. Before it was over, 751 patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 (8.5%) died. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center (NECC). The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cases manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection at the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or paraspinal infection required surgical intervention. Recommendations for treatment evolved over the first few weeks of the outbreak. Initially, combination therapy with liposomal amphotericin B and voriconazole was recommended for all patients; later, combination therapy was recommended only for those who were most ill, and voriconazole monotherapy was recommended for most patients. Among those patients who continued antifungal therapy for at least 6 months, outcomes for most appeared to be successful, although a few patients remain on therapy.
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Cabrera-Gaytán D, Pérez-Pérez G, Arriaga-Nieto L, Vallejos-Parás A, Padilla-Velázquez R, Grajales-Muñiz C. Epidemiological surveillance of meningeal and encephalic syndrome in the Mexican Social Security Institute, 2012–2014. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2017. [DOI: 10.1016/j.hgmx.2016.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kerkering TM. An Iatrogenic Outbreak of Central Nervous System Fungal Infections Due To Contaminated Steroids: a Review of the Framework of Its Control and Management. What Did We Learn? CURRENT CLINICAL MICROBIOLOGY REPORTS 2017. [DOI: 10.1007/s40588-017-0060-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
A portable kinetics fluorometer is developed to detect viable cells which may be contaminating various samples. The portable device acts as a single-excitation, single-emission photometer that continuously measures fluorescence intensity of an indicator dye and plots it. The slope of the plot depends on the number of colony forming units per milliliter. The device uses resazurin as the indicator dye. Viable cells reduce resazurin to resorufin, which is more fluorescent. Photodiode is used to detect fluorescence change. The photodiode generated current proportional to the intensity of the light that reached it, and an op-amp is used in a transimpedance differential configuration to ensure amplification of the photodiode's signal. A microfluidic chip is designed specifically for the device. It acts as a fully enclosed cuvette, which enhances the resazurin reduction rate. In tests, the E. coli-containing media are injected into the microfluidic chip and the device is able to detect the presence of E. coli in LB media based on the fluorescence change that occurred in the indicator dye. The device provides fast, accurate, and inexpensive means to optical detection of the presence of viable cells and could be used in the field in place of more complex methods, i.e., loop-meditated isothermal amplification of DNA (LAMP) to detect bacteria in pharmaceutical samples (Jimenez et al., J Microbiol Methods 41(3):259-265, 2000) or measuring the intrinsic fluorescence of the bacterial or yeast chromophores (Estes et al., Biosens Bioelectron 18(5):511-519, 2003).
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McCarthy MW, Walsh TJ. Molecular diagnosis of invasive mycoses of the central nervous system. Expert Rev Mol Diagn 2016; 17:129-139. [PMID: 27936983 DOI: 10.1080/14737159.2017.1271716] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In September 2012, the Centers for Disease Control and Prevention (CDC) began investigating an outbreak of fungal meningitis among patients who had received contaminated preservative-free methyl prednisolone acetate injections from the New England Compounding Center in Framingham, Massachusetts. Thousands of patients were potentially exposed to tainted corticosteroids, but establishing the diagnosis of fungal meningitis during the nationwide outbreak was difficult because little was known about the natural history of the disease. Areas covered: The challenges associated with this outbreak highlighted the need for rapid and reliable methodologies to assist in the diagnosis of invasive mycoses of the central nervous system (IMCNS), which may be devastating and difficult to treat. In this paper, we review the causative agents of these potentially-lethal infections, which include cryptococcal meningitis, cerebral aspergillosis, and hematogenous Candida meningoencephalitis. Expert commentary: While microscopy, culture, and histopathologic identification of fungal pathogens remain the gold standard for diagnosis, new platforms and species-specific assays have recently emerged, including lateral flow immunoassays (LFA), matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS), and multiplex PCR in conjunction with magnetic resonance (MR) to potentially aid in the diagnosis of IMCNS.
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Affiliation(s)
- Matthew William McCarthy
- a Hospital Medicine , Joan and Sanford I Weill Medical College of Cornell University , New York , NY , USA
| | - Thomas J Walsh
- b Transplantation-Oncology Infectious Diseases Program , Weill Cornell Medical Center , New York , NY , USA
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21
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Murrell D, Bossaer JB, Carico R, Harirforoosh S, Cluck D. Isavuconazonium sulfate: a triazole prodrug for invasive fungal infections. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:18-30. [DOI: 10.1111/ijpp.12302] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 07/27/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Derek Murrell
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - John B. Bossaer
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Ronald Carico
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Sam Harirforoosh
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - David Cluck
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
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Smith RM, Derado G, Wise M, Harris JR, Chiller T, Meltzer MI, Park BJ. Estimated deaths and illnesses averted during fungal meningitis outbreak associated with contaminated steroid injections, United States, 2012-2013. Emerg Infect Dis 2015; 21:933-40. [PMID: 25989264 PMCID: PMC4451895 DOI: 10.3201/eid2106.141558] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Public health response to the outbreak likely resulted fewer injections, cases, and deaths. Deaths, Illnesses Averted in Meningitis Outbreak During 2012–2013, the US Centers for Disease Control and Prevention and partners responded to a multistate outbreak of fungal infections linked to methylprednisolone acetate (MPA) injections produced by a compounding pharmacy. We evaluated the effects of public health actions on the scope of this outbreak. A comparison of 60-day case-fatality rates and clinical characteristics of patients given a diagnosis on or before October 4, the date the outbreak was widely publicized, with those of patients given a diagnosis after October 4 showed that an estimated 3,150 MPA injections, 153 cases of meningitis or stroke, and 124 deaths were averted. Compared with diagnosis after October 4, diagnosis on or before October 4 was significantly associated with a higher 60-day case-fatality rate (28% vs. 5%; p<0.0001). Aggressive public health action resulted in a substantially reduced estimated number of persons affected by this outbreak and improved survival of affected patients.
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Elsawy A, Faidah H, Ahmed A, Mostafa A, Mohamed F. Aspergillus terreus Meningitis in Immunocompetent Patient: A Case Report. Front Microbiol 2015; 6:1353. [PMID: 26648927 PMCID: PMC4664626 DOI: 10.3389/fmicb.2015.01353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 11/16/2015] [Indexed: 11/13/2022] Open
Abstract
We present a description of a rare but dangerous case of fungal meningitis caused by Aspergillus terreus in an immunocompetent patient with a history of sinus disease.
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Affiliation(s)
- Abdelrahman Elsawy
- Medical Microbiology Department, Al-Noor Specialist Hospital, Ministry of Health Makkah, Saudi Arabia ; Department of Microbiology, Al-Azhar Faculty of Medicine, Al-Azhar University Cairo, Egypt
| | - Hani Faidah
- Medical Microbiology Department, Al-Noor Specialist Hospital, Ministry of Health Makkah, Saudi Arabia ; Department of Microbiology, College of Medicine, Umm Al-Qura University Makkah, Saudi Arabia
| | - Abdalla Ahmed
- Department of Microbiology, College of Medicine, Umm Al-Qura University Makkah, Saudi Arabia
| | - Asmaa Mostafa
- Medical Microbiology Department, Al-Noor Specialist Hospital, Ministry of Health Makkah, Saudi Arabia ; Department of Microbiology, Tanta Faculty of Medicine, Tanta University Tanta, Egypt
| | - Farah Mohamed
- Department of Medicine, Al-Noor Specialist Hospital, Ministry of Health Makkah, Saudi Arabia
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Tang X, Liang Y, Zhu Y, Xie C, Yao A, Chen L, Jiang Q, Liu T, Wang X, Qian Y, Wei J, Ni W, Dai J, Jiang Z, Hou W. Anti-transferrin receptor-modified amphotericin B-loaded PLA-PEG nanoparticles cure Candidal meningitis and reduce drug toxicity. Int J Nanomedicine 2015; 10:6227-41. [PMID: 26491294 PMCID: PMC4599718 DOI: 10.2147/ijn.s84656] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fatal fungal infections in central nervous system (CNS) can occur through hematogenous spread or direct extension. At present, hydrophobic amphotericin B (AMB) is the most effective antifungal drug in clinical trials. However, AMB is hydrophobic and therefore penetrates poorly into the CNS, and therapeutic levels of AMB are hard to achieve. The transferrin receptor (TfR/CD71) located at the blood-brain barrier mediates transferrin transcytosis. In order to enhance the receptor-mediated delivery of AMB into CNS with therapeutic level, an anti-TfR antibody (OX26)-modified AMB-loaded PLA (poly[lactic acid])-PEG (polyethylene glycol)-based micellar drug delivery system was constructed. The prepared OX26-modified AMB-loaded nanoparticles (OX26-AMB-NPs) showed significant reduction of CNS fungal burden and an increase of mouse survival time. In conclusion, OX26-AMB-NPs represent a promising novel drug delivery system for intracerebral fungal infection.
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Affiliation(s)
- Xiaolong Tang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China ; State Key Laboratory of Virology/Institute of Medical Virology, School of Basic Medical Sciences, Wuhan University, Wuhan, People's Republic of China
| | - Yong Liang
- Clinical Laboratory, Huai'an Hospital Affiliated of Xuzhou Medical College, Huaian, People's Republic of China
| | - Yongqiang Zhu
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China ; Department of Medical Genetics, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Chunmei Xie
- School of Biotechnology, Southern Medical University, Guangzhou, People's Republic of China
| | - Aixia Yao
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Li Chen
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Qinglin Jiang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Tingting Liu
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Xiaoyu Wang
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Yunyun Qian
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Jia Wei
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Wenxuan Ni
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Jingjing Dai
- Clinical Laboratory, Huainan First People's Hospital and First Affiliated Hospital of Medical College, Anhui University of Science & Technology, Huainan, People's Republic of China
| | - Zhenyou Jiang
- Department of Microbiology and Immunology, School of Medicine, Jinan University, Guangzhou, People's Republic of China ; Guangdong Key Laboratory of Molecular Immunology and Antibody Engineering, Jinan University, Guangzhou, People's Republic of China
| | - Wei Hou
- State Key Laboratory of Virology/Institute of Medical Virology, School of Basic Medical Sciences, Wuhan University, Wuhan, People's Republic of China
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Ashu EE, Xu J. The roles of sexual and asexual reproduction in the origin and dissemination of strains causing fungal infectious disease outbreaks. INFECTION GENETICS AND EVOLUTION 2015; 36:199-209. [PMID: 26394109 DOI: 10.1016/j.meegid.2015.09.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 12/15/2022]
Abstract
Sexual reproduction commonly refers to the reproductive process in which genomes from two sources are combined into a single cell through mating and then the zygote genomes are partitioned to progeny cells through meiosis. Reproduction in the absence of mating and meiosis is referred to as asexual or clonal reproduction. One major advantage of sexual reproduction is that it generates genetic variation among progeny which may allow for faster adaptation of the population to novel and/or stressful environments. However, adaptation to stressful or new environments can still occur through mutation, in the absence of sex. In this review, we analyzed the relative contributions of sexual and asexual reproduction in the origin and spread of strains causing fungal infectious diseases outbreaks. The necessity of sex and the ability of asexual fungi to initiate outbreaks are discussed. We propose a framework that relates the modes of reproduction to the origin and propagation of fungal disease outbreaks. Our analyses suggest that both sexual and asexual reproduction can play critical roles in the origin of outbreak strains and that the rapid spread of outbreak strains is often accomplished through asexual expansion.
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Affiliation(s)
- Eta Ebasi Ashu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, ON L8S 4K1, Canada
| | - Jianping Xu
- Department of Biology, McMaster University, 1280 Main St. W, Hamilton, ON L8S 4K1, Canada.
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McCarty TP, Baddley JW, Walsh TJ, Alexander BD, Kontoyiannis DP, Perl TM, Walker R, Patterson TF, Schuster MG, Lyon GM, Wingard JR, Andes DR, Park BJ, Brandt ME, Pappas PG. Phaeohyphomycosis in transplant recipients: Results from the Transplant Associated Infection Surveillance Network (TRANSNET). Med Mycol 2015; 53:440-6. [DOI: 10.1093/mmy/myv018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/16/2015] [Indexed: 11/14/2022] Open
Affiliation(s)
- Todd P. McCarty
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - John W. Baddley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Thomas J. Walsh
- Departments of Medicine, Pediatrics, and Microbiology and Immunology, New York-Presbyterian Hospital -Weill Cornell Medical Center, New York, USA
| | | | | | - Trish M. Perl
- Departments of Medicine, Pathology, and Epidemiology, The Johns Hopkins Hospital, Baltimore, USA
| | | | - Thomas F. Patterson
- Department of Medicine, University of Texas Health Science Center and South Texas Veterans Health Care System, San Antonio, USA
| | - Mindy G. Schuster
- Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, USA
| | - G. Marshall Lyon
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - John R. Wingard
- Department of Medicine, University of Florida, Gainesville, USA
| | - David R. Andes
- Department of Medicine, University of Wisconsin, Madison, USA
| | | | - Mary E. Brandt
- Centers for Disease Control and Prevention, Atlanta, USA
| | - Peter G. Pappas
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
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Not over yet: fungal infections following methyl prednisolone injections smoulder on. J Clin Microbiol 2015; 52:3506-7. [PMID: 25143420 DOI: 10.1128/jcm.01634-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Utility of real-time PCR for detection of Exserohilum rostratum in body and tissue fluids during the multistate outbreak of fungal meningitis and other infections. J Clin Microbiol 2014; 53:618-25. [PMID: 25520443 DOI: 10.1128/jcm.02443-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Exserohilum rostratum was the major cause of the multistate outbreak of fungal meningitis linked to contaminated injections of methylprednisolone acetate produced by the New England Compounding Center. Previously, we developed a fungal DNA extraction procedure and broad-range and E. rostratum-specific PCR assays and confirmed the presence of fungal DNA in 28% of the case patients. Here, we report the development and validation of a TaqMan real-time PCR assay for the detection of E. rostratum in body fluids, which we used to confirm infections in 57 additional case patients, bringing the total number of case patients with PCR results positive for E. rostratum to 171 (37% of the 461 case patients with available specimens). Compared to fungal culture and the previous PCR assays, this real-time PCR assay was more sensitive. Of the 139 identical specimens from case patients tested by all three methods, 19 (14%) were positive by culture, 41 (29%) were positive by the conventional PCR assay, and 65 (47%) were positive by the real-time PCR assay. We also compared the utility of the real-time PCR assay with that of the previously described beta-d-glucan (BDG) detection assay for monitoring response to treatment in case patients with serially collected CSF. Only the incident CSF specimens from most of the case patients were positive by real-time PCR, while most of the subsequently collected specimens were negative, confirming our previous observations that the BDG assay was more appropriate than the real-time PCR assay for monitoring the response to treatment. Our results also demonstrate that the real-time PCR assay is extremely susceptible to contamination and its results should be used only in conjunction with clinical and epidemiological data.
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Outbreak of fungal infections associated with contaminated methylprednisolone acetate: an update. Curr Infect Dis Rep 2014; 17:441. [PMID: 25416847 DOI: 10.1007/s11908-014-0441-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.
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Fungi associated with drug recalls and rare disease outbreaks. ACTA ACUST UNITED AC 2014; 41:1591-7. [DOI: 10.1007/s10295-014-1503-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
Abstract
Fungi rarely cause disease outbreaks associated with use of microbe-contaminated drugs. These rare episodes typically involve a restricted spectrum of common environmental species with relatively low virulence, rather than classical pathogens. Review of data involving over-the-counter contact lens solutions and prescription drug-related recalls revealed six episodes during the past decade with significant adverse health and financial impact (including loss of vision and death). Contaminations involved fungi mostly identified with the genera Aspergillus, Exserohilum, Fusarium, Paecilomyces, and Rhizopus. These organisms are noted for their capacity to produce resistant morphotypes (chlamydoconidia, ascospores) under various adverse conditions, generally with temperature survival/tolerances markedly in excess of maximal growth temperatures. High constituent levels of melanin, trehalose and heat-shock proteins facilitate differential survival of morphotypes following exposures to toxic chemicals and temperatures above 80 °C. Adverse environmental factors that induce resistant morphotypes are suggested to occur more readily in situ than during in vitro testing. Rare unexplained, sporadic drug contamination episodes with select thermotolerant fungi may relate, in part, to resistant dormant stages.
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Rivera A. Protective immune responses to fungal infections. Parasite Immunol 2014; 36:453-62. [DOI: 10.1111/pim.12098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/10/2014] [Indexed: 02/06/2023]
Affiliation(s)
- A. Rivera
- Department of Pediatrics and Center for Immunity and Inflammation; Rutgers; Rutgers Biomedical and Health Sciences; New Jersey Medical School; Newark NJ USA
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Abstract
The recent outbreak of exserohilum rostratum meningitis linked to epidural injections of methylprednisolone acetate has brought renewed attention to mold infections of the central nervous system (CNS). Although uncommon, these infections are often devastating and difficult to treat. This focused review of the epidemiologic aspects, clinical characteristics, and treatment of mold infections of the CNS covers a group of common pathogens: aspergillus, fusarium, and scedosporium species, molds in the order Mucorales, and dematiaceous molds. Infections caused by these pathogen groups have distinctive epidemiologic profiles, clinical manifestations, microbiologic characteristics, and therapeutic implications, all of which clinicians should understand.
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Affiliation(s)
- Matthew McCarthy
- From the Transplantation-Oncology Infectious Diseases Program, Departments of Medicine, Pediatrics, and Microbiology and Immunology (M.M., T.J.W.), and the Departments of Neurology, Neuroscience, and Neurosurgery (A.R.) and Pathology and Laboratory Medicine (A.N.S.), Weill Cornell Medical Center of Cornell University, New York; and the Infectious Diseases Department and Division of Internal Medicine, University of Texas M.D. Anderson Cancer Center, Houston (D.P.K.)
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Whole-genome analysis of Exserohilum rostratum from an outbreak of fungal meningitis and other infections. J Clin Microbiol 2014; 52:3216-22. [PMID: 24951807 DOI: 10.1128/jcm.00936-14] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Exserohilum rostratum was the cause of most cases of fungal meningitis and other infections associated with the injection of contaminated methylprednisolone acetate produced by the New England Compounding Center (NECC). Until this outbreak, very few human cases of Exserohilum infection had been reported, and very little was known about this dematiaceous fungus, which usually infects plants. Here, we report using whole-genome sequencing (WGS) for the detection of single nucleotide polymorphisms (SNPs) and phylogenetic analysis to investigate the molecular origin of the outbreak using 22 isolates of E. rostratum retrieved from 19 case patients with meningitis or epidural/spinal abscesses, 6 isolates from contaminated NECC vials, and 7 isolates unrelated to the outbreak. Our analysis indicates that all 28 isolates associated with the outbreak had nearly identical genomes of 33.8 Mb. A total of 8 SNPs were detected among the outbreak genomes, with no more than 2 SNPs separating any 2 of the 28 genomes. The outbreak genomes were separated from the next most closely related control strain by ∼136,000 SNPs. We also observed significant genomic variability among strains unrelated to the outbreak, which may suggest the possibility of cryptic speciation in E. rostratum.
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Nelson G, Fermo O, Thakur K, Felton E, Bang J, Wilson L, Rhee S, Llinas R, Johnson K, Sullivan D. Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report. BMC Res Notes 2014; 7:327. [PMID: 24885172 PMCID: PMC4057927 DOI: 10.1186/1756-0500-7-327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 05/28/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality. CASE PRESENTATION We report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment. CONCLUSIONS This is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.
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Affiliation(s)
- George Nelson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olga Fermo
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kiran Thakur
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Felton
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jee Bang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland, USA
| | - Susan Rhee
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristine Johnson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Sullivan
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- W. Harry Feinstone Department of Microbiology and Immunology, Room E5628, The Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe St, Baltimore, Maryland 21205, USA
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Malani AN, Kerr L, Obear J, Singal B, Kauffman CA. Alopecia and Nail Changes Associated With Voriconazole Therapy. Clin Infect Dis 2014; 59:e61-5. [DOI: 10.1093/cid/ciu275] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
PURPOSE OF REVIEW The recent outbreak of fungal meningitis related to contaminated methylprednisolone acetate injections represents an important cause of morbidity and continues to be a significant public health problem in the United States. RECENT FINDINGS As of August 2013, there have been 749 cases and 63 deaths in 20 states associated with epidemic fungal meningitis, most of these because of Exserohilum rostratum. Clinical experience in managing these cases has grown dramatically in the last several months; most patients require at least 6 months of antifungal therapy for complicated disease. Most patients are treated with voriconazole, with or without liposomal amphotericin B, for central nervous system and paraspinal complications of the disease. For disease involving the sacroiliac and peripheral joints, voriconazole alone has been preferred. MRI spine imaging has identified several cases of asymptomatic disease, suggesting an aggressive diagnostic approach to exposed asymptomatic patients. Mortality remains low (<10%), but morbidity relating to persistent symptoms and treatment-associated toxicity is high. SUMMARY The ongoing fungal meningitis epidemic demonstrates an important achievement for the public health community. Important questions remain relating to the diagnosis, management, and long-term outcomes of these patients. Important research questions pertaining to specific risks influencing disease manifestations remain unanswered.
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Espinosa V, Jhingran A, Dutta O, Kasahara S, Donnelly R, Du P, Rosenfeld J, Leiner I, Chen CC, Ron Y, Hohl TM, Rivera A. Inflammatory monocytes orchestrate innate antifungal immunity in the lung. PLoS Pathog 2014; 10:e1003940. [PMID: 24586155 PMCID: PMC3930594 DOI: 10.1371/journal.ppat.1003940] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/08/2014] [Indexed: 12/19/2022] Open
Abstract
Aspergillus fumigatus is an environmental fungus that causes invasive aspergillosis (IA) in immunocompromised patients. Although -CC-chemokine receptor-2 (CCR2) and Ly6C-expressing inflammatory monocytes (CCR2+Mo) and their derivatives initiate adaptive pulmonary immune responses, their role in coordinating innate immune responses in the lung remain poorly defined. Using conditional and antibody-mediated cell ablation strategies, we found that CCR2+Mo and monocyte-derived dendritic cells (Mo-DCs) are essential for innate defense against inhaled conidia. By harnessing fluorescent Aspergillus reporter (FLARE) conidia that report fungal cell association and viability in vivo, we identify two mechanisms by which CCR2+Mo and Mo-DCs exert innate antifungal activity. First, CCR2+Mo and Mo-DCs condition the lung inflammatory milieu to augment neutrophil conidiacidal activity. Second, conidial uptake by CCR2+Mo temporally coincided with their differentiation into Mo-DCs, a process that resulted in direct conidial killing. Our findings illustrate both indirect and direct functions for CCR2+Mo and their derivatives in innate antifungal immunity in the lung. Despite the significant impact of fungal infections to human health our understanding of immunity to these pathogens remains incomplete. Human mycoses are associated with high morbidity and mortality, even with modern antifungal therapies. Aspergillus fumigatus is the most common etiologic agent of invasive aspergillosis (IA), a serious infection that develops in immunodeficient patients. In this study we employ a combination of cell ablation strategies to examine the role of CCR2+Ly6C+ inflammatory monocytes (CCR2+Mo) in innate responses against a pulmonary infection with A.fumigatus conidia. We find that CCR2+Mo and their derivative dendritic cells (Mo-DCs) are required for defense against IA and that mice lacking these cells succumb to infection with A.fumigatus. Our studies indicate that CCR2+Mo and Mo-DCs exert crucial innate antifungal defense by two main mechanisms: 1) CCR2+Mo and Mo-DCs are a significant source of inflammatory mediators that augment the killing capacity of neutrophils and 2) conidial uptake by CCR2+Mo is coincident with their differentiation into Mo-DCs that directly kill fungal conidia via partially NADPH oxidase-dependent mechanisms. In aggregate, our studies find a novel essential function for CCR2+Mo in innate defense against a pulmonary fungal pathogen by mediating indirect and direct containment of fungal cells at the portal of infection.
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Affiliation(s)
- Vanessa Espinosa
- Rutgers, New Jersey Medical School, Department of Pediatrics, Center for Immunity and Inflammation, Newark, New Jersey, United States of America
- Rutgers, Graduate School of Biomedical Sciences, Newark, New Jersey, United States of America
| | - Anupam Jhingran
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, Washington, United States of America
| | - Orchi Dutta
- Rutgers, New Jersey Medical School, Department of Pediatrics, Center for Immunity and Inflammation, Newark, New Jersey, United States of America
- Rutgers, Graduate School of Biomedical Sciences, Newark, New Jersey, United States of America
| | - Shinji Kasahara
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, Washington, United States of America
| | - Robert Donnelly
- Rutgers, New Jersey Medical School, Molecular Resource Facility and High Performance and Research Computing Group, Office of Information Technology, Rutgers University, Newark, New Jersey, United States of America
| | - Peicheng Du
- Rutgers, New Jersey Medical School, Molecular Resource Facility and High Performance and Research Computing Group, Office of Information Technology, Rutgers University, Newark, New Jersey, United States of America
| | - Jeffrey Rosenfeld
- Rutgers, New Jersey Medical School, Molecular Resource Facility and High Performance and Research Computing Group, Office of Information Technology, Rutgers University, Newark, New Jersey, United States of America
| | - Ingrid Leiner
- Memorial Sloan Kettering Cancer Center, Sloan Kettering Institute, New York, New York, United States of America
| | - Chiann-Chyi Chen
- Rutgers, Robert Wood Johnson Medical School, Department of Pharmacology, Piscataway, New Jersey, United States of America
| | - Yacov Ron
- Rutgers, Robert Wood Johnson Medical School, Department of Pharmacology, Piscataway, New Jersey, United States of America
| | - Tobias M. Hohl
- Fred Hutchinson Cancer Research Center, Vaccine and Infectious Disease Division, Seattle, Washington, United States of America
- * E-mail: (TMH); (AR)
| | - Amariliz Rivera
- Rutgers, New Jersey Medical School, Department of Pediatrics, Center for Immunity and Inflammation, Newark, New Jersey, United States of America
- * E-mail: (TMH); (AR)
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Larone DH, Walsh TJ. Exserohilum rostratum: Anatomy of a national outbreak of fungal meningitis. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clinmicnews.2013.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gupta M, Barrett TW, Schriger DL. Annals of Emergency Medicine Journal Club. Every peddler praises his own needle: have clinical rules in the diagnosis of subarachnoid hemorrhage supplanted lumbar punctures yet?: Answers to the July 2013 Journal Club questions. Ann Emerg Med 2013; 62:633-40. [PMID: 24262362 PMCID: PMC7124249 DOI: 10.1016/j.annemergmed.2013.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kleinfeld K, Jones P, Riebau D, Beck A, Paueksakon P, Abel T, Claassen DO. Vascular complications of fungal meningitis attributed to injections of contaminated methylprednisolone acetate. JAMA Neurol 2013; 70:1173-6. [PMID: 23877880 DOI: 10.1001/jamaneurol.2013.3586] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Fungal meningitis due to injections of contaminated methylprednisolone acetate can present with vascular sequelae in immunocompetent individuals. This is particularly germane to neurologists because better recognition of the clinical characteristics of patients with fungal meningitis and ischemic stroke will provide more timely and efficient care. OBSERVATIONS In a case series, 3 patients presented to Vanderbilt University Medical Center in Nashville, Tennessee, with acute ischemic stroke and later received a diagnosis of fungal meningitis attributed to epidural injections of contaminated methylprednisolone. Of these 3 patients, 2 were women, and the mean age for all 3 was 75.3 years. Their medical records and imaging scans were reviewed. All 3 patients presented with acute ischemic strokes and had a history of epidural spinal injections of methylprednisolone for low back pain. All 3 patients had 1 or more traditional risk factors for stroke. There were differing vascular patterns of presentation: 2 patients presented with small-vessel (lacunar) infarctions, whereas 1 patient presented with a large-vessel infarct. Of these 3 patients, 2 died and underwent an autopsy, which revealed Exserohilum rostratum as the presumed cause of death. For 2 cases, fever and meningeal signs were absent at presentation. CONCLUSIONS AND RELEVANCE Patients with fungal meningitis may present with ischemic stroke detected on initial imaging scans. A definitive diagnosis should not delay early antifungal treatment.
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Smith RM, Schaefer MK, Kainer MA, Wise M, Finks J, Duwve J, Fontaine E, Chu A, Carothers B, Reilly A, Fiedler J, Wiese AD, Feaster C, Gibson L, Griese S, Purfield A, Cleveland AA, Benedict K, Harris JR, Brandt ME, Blau D, Jernigan J, Weber JT, Park BJ. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med 2013; 369:1598-609. [PMID: 23252499 DOI: 10.1056/nejmoa1213978] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fungal infections are rare complications of injections for treatment of chronic pain. In September 2012, we initiated an investigation into fungal infections associated with injections of preservative-free methylprednisolone acetate that was purchased from a single compounding pharmacy. METHODS Three lots of methylprednisolone acetate were recalled by the pharmacy; examination of unopened vials later revealed fungus. Notification of all persons potentially exposed to implicated methylprednisolone acetate was conducted by federal, state, and local public health officials and by staff at clinical facilities that administered the drug. We collected clinical data on standardized case-report forms, and we tested for the presence of fungi in isolates and specimens by examining cultures and performing polymerase-chain-reaction assays and histopathological and immunohistochemical testing. RESULTS By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke. CONCLUSIONS Analysis of data from a large, multistate outbreak of fungal infections showed substantial morbidity and mortality. The infections were associated with injection of a contaminated glucocorticoid medication from a single compounding pharmacy. Rapid public health actions included prompt recall of the implicated product, notification of exposed persons, and early outreach to clinicians.
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Affiliation(s)
- Rachel M Smith
- From the Epidemic Intelligence Service, Scientific Education and Professional Development Program Office (R.M.S., S.G., A.P.), Division of Foodborne, Waterborne, and Environmental Diseases (R.M.S., A.P., A.A.C., K.B., J.R.H., M.E.B., B.J.P.), Division of Healthcare Quality Promotion (M.K.S., M.W., J.J., J.T.W.), and Division of High-Consequence Pathogens and Pathology (D.B.), Centers for Disease Control and Prevention, Atlanta; the Tennessee Department of Health, Nashville (M.A.K., A.D.W.); the Michigan Department of Community Health, Bureau of Epidemiology, Lansing (J. Finks, J. Fiedler); the Indiana State Department of Health, Indianapolis (J.D., C.F.); the Virginia Department of Health, Richmond (E.F., L.G.); the Maryland Department of Health and Mental Hygiene, Baltimore (A.C.); the New Jersey Department of Health, Trenton (B.C.); the Florida Department of Health, Tallahassee (A.R.); and the North Carolina Division of Public Health, Raleigh (S.G.)
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Lyons JL. CNS Mold Infections. Curr Infect Dis Rep 2013; 15:569-575. [PMID: 24122369 DOI: 10.1007/s11908-013-0376-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Mold infections of the central nervous system (CNS) present as abscesses, infarcts, hemorrhages, and, less commonly, meningitis. These invasive infections are difficult both to identify and to eradicate given low-sensitivity diagnostics and high-toxicity, low-efficacy antifungal therapies, hence resulting in high rates of morbidity and mortality. Herein, the recent literature on CNS mold infections is reviewed, and updates in diagnosis and management are discussed.
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Affiliation(s)
- Jennifer L Lyons
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA,
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Parize P, Angebault C, de Fonbrune F, Suarez F, Lecuit M, Lortholary O, Bougnoux M. Naturotherapy as a potential source of mould infections in patients with haematological malignancies. J Hosp Infect 2013; 85:163-4. [DOI: 10.1016/j.jhin.2013.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 06/16/2013] [Indexed: 10/26/2022]
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Lockhart SR, Pham CD, Gade L, Iqbal N, Scheel CM, Cleveland AA, Whitney AM, Noble-Wang J, Chiller TM, Park BJ, Litvintseva AP, Brandt ME. Preliminary laboratory report of fungal infections associated with contaminated methylprednisolone injections. J Clin Microbiol 2013; 51:2654-61. [PMID: 23761142 PMCID: PMC3719655 DOI: 10.1128/jcm.01000-13] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 06/03/2013] [Indexed: 11/20/2022] Open
Abstract
In September 2012, the Centers for Disease Control and Prevention (CDC) initiated an outbreak investigation of fungal infections linked to injection of contaminated methylprednisolone acetate (MPA). Between 2 October 2012 and 14 February 2013, the CDC laboratory received 799 fungal isolates or human specimens, including cerebrospinal fluid (CSF), synovial fluid, and abscess tissue, from 469 case patients in 19 states. A novel broad-range PCR assay and DNA sequencing were used to evaluate these specimens. Although Aspergillus fumigatus was recovered from the index case, Exserohilum rostratum was the primary pathogen in this outbreak and was also confirmed from unopened MPA vials. Exserohilum rostratum was detected or confirmed in 191 specimens or isolates from 150 case patients, primarily from Michigan (n=67 patients), Tennessee (n=26), Virginia (n=20), and Indiana (n=16). Positive specimens from Michigan were primarily abscess tissues, while positive specimens from Tennessee, Virginia, and Indiana were primarily CSF. E. rostratum antifungal susceptibility MIC50 and MIC90 values were determined for voriconazole (1 and 2 μg/ml, respectively), itraconazole (0.5 and 1 μg/ml), posaconazole (0.5 and 1 μg/ml), isavuconazole (4 and 4 μg/ml), and amphotericin B (0.25 and 0.5 μg/ml). Thirteen other mold species were identified among case patients, and four other fungal genera were isolated from the implicated MPA vials. The clinical significance of these other fungal species remains under investigation. The laboratory response provided significant support to case confirmation, enabled linkage between clinical isolates and injected vials of MPA, and described significant features of the fungal agents involved in this large multistate outbreak.
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Affiliation(s)
- Shawn R Lockhart
- Mycotic Diseases Branch, National Center for Emerging, Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Badiee P. Evaluation of human body fluids for the diagnosis of fungal infections. BIOMED RESEARCH INTERNATIONAL 2013; 2013:698325. [PMID: 23984401 PMCID: PMC3747334 DOI: 10.1155/2013/698325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 07/09/2013] [Accepted: 07/18/2013] [Indexed: 01/01/2023]
Abstract
Invasive fungal infections are a major cause of morbidity and mortality in immunocompromised patients. Because the etiologic agents of these infections are abundant in nature, their isolation from biopsy material or sterile body fluids is needed to document infection. This review evaluates and discusses different human body fluids used to diagnose fungal infections.
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Affiliation(s)
- Parisa Badiee
- Alborzi Clinical Microbiology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Zand Avenue, Shiraz 7193711351, Iran.
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Casadevall A, Pirofski LA. Exserohilum rostratum fungal meningitis associated with methylprednisolone injections. Future Microbiol 2013; 8:135-7. [PMID: 23374119 DOI: 10.2217/fmb.12.138] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Guharoy R, Noviasky J, Haydar Z, Fakih MG, Hartman C. Compounding pharmacy conundrum: "we cannot live without them but we cannot live with them" according to the present paradigm. Chest 2013; 143:896-900. [PMID: 23412546 DOI: 10.1378/chest.13-0212] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Compounding pharmacies serve a critical role in modern health care to meet special patient care needs. Although the US Food and Drug Administration (FDA) has clearly delineated jurisdiction over drug companies and products manufactured under Good Manufacturing Practice (GMP) regulations to ensure quality, potency, and purity, compounding pharmacies are regulated by the State Boards and are not registered by the FDA. In recent years, some compounding pharmacies acted like a manufacturer, preparing large amounts of injectable drugs with interstate activities. Multiple outbreaks have been linked to compounding pharmacies, including a recent outbreak of fungal meningitis related to contaminated methylprednisolone, exposing > 14,000 patients in multiple states. This tragedy underscores the urgency of addressing safety related to compounding pharmacies. There is a call for action at the federal and state levels to set minimum production standards, impose new labeling conditions on compounded drugs, and require large-scale compounders be regulated by the FDA. "Industrial" compounding must come under FDA oversight, require those pharmacies to meet GMP standards, and ensure quality and safe products for patient use. Moreover, compliance with the Institute for Safe Medication Practices 2011 recommendations that any type of sterile compounding must be in compliance with the United States Pharmacopoeia chapter 797 guidelines will reduce the risk of patient harm from microbial contamination. Finally, other critical factors that require close attention include addressing injectable products compounded in hospitals and other outpatient health-care centers. The FDA and State Boards of Pharmacy must be adequately funded to exercise the oversight effectively.
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Affiliation(s)
- Roy Guharoy
- Ascension Health, St. Louis, MO; University of Massachusetts Medical School, Worcester, MA.
| | - John Noviasky
- SUNY-Upstate Medical University Hospital at Community General, Syracuse, NY
| | | | - Mohamad G Fakih
- Department of Infection Prevention and Control, St. John Hospital and Medical Center, Detroit, MI; Wayne State University School of Medicine, Detroit, MI
| | - Christian Hartman
- University of Massachusetts Medical School, Worcester, MA; Wolters Kluwer Health, Minneapolis, MN
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Surveillance of Health care–Associated Infections. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2013; 19:286-8. [DOI: 10.1097/phh.0b013e3182888276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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