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Hughes ES, He Z, Tuck LR, Ballou ER, Wallace EWJ. A trade-off between proliferation and defense in the fungal pathogen Cryptococcus at alkaline pH is controlled by the transcription factor GAT201. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.06.14.543486. [PMID: 37398450 PMCID: PMC10312749 DOI: 10.1101/2023.06.14.543486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Cryptococcus is a fungal pathogen whose virulence relies on proliferation in and dissemination to host sites, and on synthesis of a defensive yet metabolically costly polysaccharide capsule. Regulatory pathways required for Cryptococcus virulence include a GATA-like transcription factor, Gat201, that regulates Cryptococcal virulence in both capsule-dependent and capsule-independent ways. Here we show that Gat201 is part of a negative regulatory pathway that limits fungal survival. RNA-seq analysis found strong induction of GAT201 expression within minutes of transfer to host-like media at alkaline pH. Microscopy, growth curves, and colony forming units to test viability show that in host-like media at alkaline pH wild-type Cryptococcus neoformans yeast cells produce capsule but do not bud or maintain viability, while gat201Δ cells make buds and maintain viability, yet fail to produce capsule. GAT201 is required for transcriptional upregulation of a specific set of genes in host-like media, the majority of which are direct Gat201 targets. Evolutionary analysis shows that Gat201 is conserved within pathogenic fungi but lost in model yeasts. This work identifies the Gat201 pathway as controlling a trade-off between proliferation, which we showed is repressed by GAT201, and production of defensive capsule. The assays established here will allow characterisation of the mechanisms of action of the Gat201 pathway. Together, our findings urge improved understanding of the regulation of proliferation as a driver of fungal pathogenesis.
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Affiliation(s)
- Elizabeth S Hughes
- Institute for Cell Biology, and Centre for Engineering Biology, School of Biological Sciences, The University of Edinburgh
| | - Zhenzhen He
- Institute for Cell Biology, and Centre for Engineering Biology, School of Biological Sciences, The University of Edinburgh
| | - Laura R Tuck
- Institute for Cell Biology, and Centre for Engineering Biology, School of Biological Sciences, The University of Edinburgh
| | | | - Edward W J Wallace
- Institute for Cell Biology, and Centre for Engineering Biology, School of Biological Sciences, The University of Edinburgh
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2
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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, Oliveira LD, de Araújo LS, Fava WS, Bonfietti LX, Paniago AMM, Venturini J, Espinel-Ingroff A. Antifungal Resistance in Cryptococcal Infections. Pathogens 2024; 13:128. [PMID: 38392866 PMCID: PMC10891860 DOI: 10.3390/pathogens13020128] [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: 10/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.
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Affiliation(s)
- Marcia S C Melhem
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | | | - Juliana P F Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | | | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Wellington S Fava
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Lucas X Bonfietti
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Anamaria M M Paniago
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Ana Espinel-Ingroff
- Central Public Health Laboratory-LACEN, Campo Grande 79074-460, MS, Brazil
- VCU Medical Center, Richmond, VA 23284, USA
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3
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Boulware DR, Atukunda M, Kagimu E, Musubire AK, Akampurira A, Tugume L, Ssebambulidde K, Kasibante J, Nsangi L, Mugabi T, Gakuru J, Kimuda S, Kasozi D, Namombwe S, Turyasingura I, Rutakingirwa MK, Mpoza E, Kigozi E, Muzoora C, Ellis J, Skipper CP, Matkovits T, Williamson PR, Williams DA, Fieberg A, Hullsiek KH, Abassi M, Dai B, Meya DB. Oral Lipid Nanocrystal Amphotericin B for Cryptococcal Meningitis: A Randomized Clinical Trial. Clin Infect Dis 2023; 77:1659-1667. [PMID: 37606364 PMCID: PMC10724459 DOI: 10.1093/cid/ciad440] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Amphotericin B is the gold standard treatment for severe mycoses. A new orally delivered, less-toxic formulation of amphotericin has been developed. METHODS In our randomized clinical trial, we tested oral lipid nanocrystal (LNC) amphotericin B (MAT2203, Matinas Biopharma) vs intravenous (IV) amphotericin for human immunodeficiency virus-associated cryptococcal meningitis in 4 sequential cohorts. Two pilot cohorts assessed safety and tolerability (n = 10 each), and 2 cohorts assessed efficacy with/without 2 IV loading doses (n = 40 each). The experimental arm received 1.8 g/d oral LNC amphotericin through 2 weeks with 100 mg/kg/d flucytosine, then 1.2 g/d LNC amphotericin through 6 weeks. The randomized control arm (n = 41) received 7 days of IV amphotericin with flucytosine, then 7 days of fluconazole 1200 mg/d. The primary end point was cerebrospinal fluid (CSF) early fungicidal activity (EFA). RESULTS We randomized 80 participants to oral LNC amphotericin + flucytosine with (n = 40) and without (n = 40) 2 IV loading doses and 41 control participants to IV amphotericin + flucytosine. Mean EFA was 0.40 log10 colony-forming units (CFU)/mL/d for all-oral LNC amphotericin, 0.42 log10 Cryptococcus CFU/mL/d for oral LNC amphotericin with IV loading doses, and 0.46 log10 CFU/mL/d for IV amphotericin controls. LNC amphotericin groups achieved 2-week CSF sterility in 63% (44 of 70) vs 68% (23 of 34) of controls. The 18-week survival was 85% (34 of 40) with all-oral LNC amphotericin, 90% (36 of 40) with oral LNC amphotericin given IV loading doses, and 85% (35 of 41) with IV amphotericin.Grade 3-4 laboratory adverse events occurred less frequently in LNC amphotericin groups (41%) than the IV amphotericin group (61%, P = .05), particularly for anemia (21% vs 44%; P = .01) and potassium (5% vs 17%; P = .04). CONCLUSIONS This new oral amphotericin B LNC formulation appears promising for cryptococcal meningitis with antifungal activity, similar survival, and less toxicity than IV amphotericin. CLINICAL TRIALS REGISTRATION NCT04031833.
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Affiliation(s)
- David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Laura Nsangi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Mugabi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Sarah Kimuda
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Derrick Kasozi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Suzan Namombwe
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Enos Kigozi
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Peter R Williamson
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ann Fieberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kathy H Hullsiek
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Biyue Dai
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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4
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Carvalho JL, Malo ME, Allen KJ, Frank C, Xiao Z, Jiao R, Dadachova E. Radioimmunotherapy as a pathogen-agnostic treatment method for opportunistic mucormycosis infections. Access Microbiol 2023; 5:000671.v4. [PMID: 38188245 PMCID: PMC10765049 DOI: 10.1099/acmi.0.000671.v4] [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: 07/10/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Invasive fungal infections (IFIs) such as mucormycosis are causing devastating morbidity and mortality in immunocompromised patients as anti-fungal agents do not work in the setting of a suppressed immune system. The coronavirus disease 2019 (COVID-19) pandemic has created a novel landscape for IFIs in post-pandemic patients, resulting from severe immune suppression caused by COVID-19 infection, comorbidities (diabetes, obesity) and immunosuppressive treatments such as steroids. The antigen-antibody interaction has been employed in radioimmunotherapy (RIT) to deliver lethal doses of ionizing radiation emitted by radionuclides to targeted cells and has demonstrated efficacy in several cancers. One of the advantages of RIT is its independence of the immune status of a host, which is crucial for immunosuppressed post-COVID-19 patients. In the present work we targeted the fungal pan-antigens 1,3-beta-glucan and melanin pigment, which are present in the majority of pathogenic fungi, with RIT, thus making such targeting pathogen-agnostic. We demonstrated in experimental murine mucormycosis in immunocompetent and immunocompromised mice that lutetium-177 (177Lu)-labelled antibodies to these two antigens effectively decreased the fungal burden in major organs, including the brain. These results are encouraging because they show the effectiveness of pathogen-agnostic RIT in significantly decreasing fungal burden in vivo, while they can also potentially be applied to treat the broad range of invasive fungal infections that express the pan-antigens 1,3-beta-glucan or melanin.
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Affiliation(s)
- Jorge L.C. Carvalho
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Mackenzie E. Malo
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Kevin J.H. Allen
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Connor Frank
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Zhiwen Xiao
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Rubin Jiao
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
| | - Ekaterina Dadachova
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan S7N 5E5, Canada
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5
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Tugume L, Ssebambulidde K, Kasibante J, Ellis J, Wake RM, Gakuru J, Lawrence DS, Abassi M, Rajasingham R, Meya DB, Boulware DR. Cryptococcal meningitis. Nat Rev Dis Primers 2023; 9:62. [PMID: 37945681 DOI: 10.1038/s41572-023-00472-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
Cryptococcus neoformans and Cryptococcus gattii species complexes cause meningoencephalitis with high fatality rates and considerable morbidity, particularly in persons with deficient T cell-mediated immunity, most commonly affecting people living with HIV. Whereas the global incidence of HIV-associated cryptococcal meningitis (HIV-CM) has decreased over the past decade, cryptococcosis still accounts for one in five AIDS-related deaths globally due to the persistent burden of advanced HIV disease. Moreover, mortality remains high (~50%) in low-resource settings. The armamentarium to decrease cryptococcosis-associated mortality is expanding: cryptococcal antigen screening in the serum and pre-emptive azole therapy for cryptococcal antigenaemia are well established, whereas enhanced pre-emptive combination treatment regimens to improve survival of persons with cryptococcal antigenaemia are in clinical trials. Short courses (≤7 days) of amphotericin-based therapy combined with flucytosine are currently the preferred options for induction therapy of cryptococcal meningitis. Whether short-course induction regimens improve long-term morbidity such as depression, reduced neurocognitive performance and physical disability among survivors is the subject of further study. Here, we discuss underlying immunology, changing epidemiology, and updates on the management of cryptococcal meningitis with emphasis on HIV-associated disease.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.
| | - Kenneth Ssebambulidde
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John Kasibante
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jayne Ellis
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David S Lawrence
- Clinical Research Department, Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Radha Rajasingham
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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6
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Giamberardino CD, Tenor JL, Toffaletti DL, Palmucci JR, Schell W, Boua JVK, Marius C, Stott KE, Steele SL, Hope W, Cilla D, Perfect JR. Pharmacodynamics of ATI-2307 in a rabbit model of cryptococcal meningoencephalitis. Antimicrob Agents Chemother 2023; 67:e0081823. [PMID: 37728934 PMCID: PMC10583688 DOI: 10.1128/aac.00818-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 07/22/2023] [Indexed: 09/22/2023] Open
Abstract
Cryptococcal meningoencephalitis (CM) is a devastating fungal disease with high morbidity and mortality. The current regimen that is standard-of-care involves a combination of three different drugs administered for up to one year. There is a critical need for new therapies due to both toxicity and inadequate fungicidal activity of the currently available antifungal drugs. ATI-2307 is a novel aryl amidine that disrupts the mitochondrial membrane potential and inhibits the respiratory chain complexes of fungi-it thus represents a new mechanism for direct antifungal action. Furthermore, ATI-2307 selectively targets fungal mitochondria via a fungal-specific transporter that is not present in mammalian cells. It has very potent in vitro anticryptococcal activity. In this study, the efficacy of ATI-2307 was tested in a rabbit model of CM. ATI-2307 demonstrated significant fungicidal activity at dosages between 1 and 2 mg/kg/d, and these results were superior to fluconazole and similar to amphotericin B treatment. When ATI-2307 was combined with fluconazole, the antifungal effect was greater than either therapy alone. While ATI-2307 has potent anticryptococcal activity in the subarachnoid space, its ability to reduce yeasts in the brain parenchyma was relatively less over the same study period. This new drug, with its unique mechanism of fungicidal action and ability to positively interact with an azole, has demonstrated sufficient anticryptococcal potential in this experimental setting to be further evaluated in clinical studies.
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Affiliation(s)
- Charles D. Giamberardino
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Wiley Schell
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
| | | | - Choiselle Marius
- Department of Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Katharine E. Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | | | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | - Don Cilla
- Appili Therapeutics Inc., Halifax, Nova Scotia, Canada
| | - John R. Perfect
- Department of Medicine, Division of Infectious Diseases, Duke University, Durham, North Carolina, USA
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7
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Liu J, Lu Y, Liu J, Liang J, Zhang Q, Li H, Zhong X, Bu H, Wang Z, Fan L, Liang P, Xie J, Wang Y, Gong J, Chen H, Dai Y, Yang L, Su X, Wang A, Xiong L, Xia H, Jiang Y, Liu Z, Peng F. Development and validation of a machine learning model to predict prognosis in HIV-negative cryptococcal meningitis patients: a multicenter study. Eur J Clin Microbiol Infect Dis 2023; 42:1183-1194. [PMID: 37606868 DOI: 10.1007/s10096-023-04653-2] [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: 06/15/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
PURPOSE To predict prognosis in HIV-negative cryptococcal meningitis (CM) patients by developing and validating a machine learning (ML) model. METHODS This study involved 523 HIV-negative CM patients diagnosed between January 1, 1998, and August 31, 2022, by neurologists from 3 tertiary Chinese centers. Prognosis was evaluated at 10 weeks after the initiation of antifungal therapy. RESULTS The final prediction model for HIV-negative CM patients comprised 8 variables: Cerebrospinal fluid (CSF) cryptococcal count, CSF white blood cell (WBC), altered mental status, hearing impairment, CSF chloride levels, CSF opening pressure (OP), aspartate aminotransferase levels at admission, and decreased rate of CSF cryptococcal count within 2 weeks after admission. The areas under the curve (AUCs) in the internal, temporal, and external validation sets were 0.87 (95% CI 0.794-0.944), 0.92 (95% CI 0.795-1.000), and 0.86 (95% CI 0.744-0.975), respectively. An artificial intelligence (AI) model was trained to detect and count cryptococci, and the mean average precision (mAP) was 0.993. CONCLUSION A ML model for predicting prognosis in HIV-negative CM patients was built and validated, and the model might provide a reference for personalized treatment of HIV-negative CM patients. The change in the CSF cryptococcal count in the early phase of HIV-negative CM treatment can reflect the prognosis of the disease. In addition, utilizing AI to detect and count CSF cryptococci in HIV-negative CM patients can eliminate the interference of human factors in detecting cryptococci in CSF samples and reduce the workload of the examiner.
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Affiliation(s)
- Junyu Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Yaxin Lu
- Big Data and Artificial Intelligence Center, The Third Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jia Liu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jiayin Liang
- Department of Laboratory, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Qilong Zhang
- Department of Neurology, Jiangxi Chest Hospital, Jiangxi, 330000, China
| | - Hua Li
- Department of Neurology, Cangshan Breach of the 900Th Hospital of PLA Joint Service Support Force, Fuzhou, 350000, Fujian, China
| | - Xiufeng Zhong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-Sen University, Guangzhou, China
| | - Hui Bu
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Zhanhang Wang
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Liuxu Fan
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Panpan Liang
- Department of Laboratory, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Jia Xie
- Department of Neurology, Jiangxi Chest Hospital, Jiangxi, 330000, China
| | - Yuan Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Sun Yat-Sen University, Guangzhou, China
| | - Jiayin Gong
- Department of Neurology, Fujian Medical University Union Hospital, Xinquan Road 29#, Fuzhou, 350001, China
| | - Haiying Chen
- Department of Neurology, Jiangxi Chest Hospital, Jiangxi, 330000, China
| | - Yangyang Dai
- Department of Neurology, Guangdong 999 Brain Hospital, Guangzhou, China
| | - Lu Yang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Xiaohong Su
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Anni Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Lei Xiong
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China
| | - Han Xia
- Department of Scientific Affairs, Hugobiotech Co., Ltd, Beijing, China
| | - Ying Jiang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
| | - Zifeng Liu
- Big Data and Artificial Intelligence Center, The Third Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
| | - Fuhua Peng
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, China.
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8
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Bertout S, Laroche L, Roger F, Krasteva D, Drakulovski P, Bellet V. Fluconazole Resistance and Virulence in In Vitro Induced-Fluconazole Resistant Strains and in Clinical Fluconazole Resistant Strain of Cryptococcus deuterogattii. Pathogens 2023; 12:758. [PMID: 37375448 DOI: 10.3390/pathogens12060758] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Neuromeningeal cryptococcosis is a life-threatening infection of the central nervous system, caused by encapsulated yeast belonging to the Cryptococcus neoformans and Cryptococcus gattii species complexes. Recent data showed that virulence and antifungal resistance are variable for yeasts belonging to the C. gattii species complex. There is an increase in resistance to fluconazole for yeasts of the C. gattii species complex and the virulence is variable according to the genotype. In the present study, (i) we explored and compared the mechanisms of resistance to fluconazole between C. deuterogattii clinically resistant strains and induced fluconazole-resistant strains by exposure to fluconazole in vitro, and (ii) we studied their virulence in the Galleria mellonella study model. We demonstrated that the fluconazole resistance mechanisms involved were different between clinically resistant strains and induced resistant strains. We also demonstrated that fluconazole-induced resistant strains are less virulent when compared to the original susceptible strains. On the contrary, the clinically resistant strain tested maintains its virulence compared to fluconazole-susceptible strains of the same sequence type.
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Affiliation(s)
- Sébastien Bertout
- Laboratoire de Parasitologie et Mycologie Médicale, TransVIHMI, University of Montpellier, INSERM, IRD, 15 Avenue Charles Flahaut, 34093 Montpellier, France
| | - Laetitia Laroche
- Laboratoire de Biologie Médicale, Hôpital Lozère, 48000 Mende, France
| | - Frédéric Roger
- Laboratoire de Parasitologie et Mycologie Médicale, TransVIHMI, University of Montpellier, INSERM, IRD, 15 Avenue Charles Flahaut, 34093 Montpellier, France
| | - Donika Krasteva
- Laboratoire de Parasitologie et Mycologie Médicale, TransVIHMI, University of Montpellier, INSERM, IRD, 15 Avenue Charles Flahaut, 34093 Montpellier, France
| | - Pascal Drakulovski
- Laboratoire de Parasitologie et Mycologie Médicale, TransVIHMI, University of Montpellier, INSERM, IRD, 15 Avenue Charles Flahaut, 34093 Montpellier, France
| | - Virginie Bellet
- Laboratoire de Parasitologie et Mycologie Médicale, TransVIHMI, University of Montpellier, INSERM, IRD, 15 Avenue Charles Flahaut, 34093 Montpellier, France
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Harrison TS, Lawrence DS, Mwandumba HC, Boulware DR, Hosseinipour MC, Lortholary O, Meintjes G, Mosepele M, Jarvis JN. How Applicable Is the Single-Dose AMBITION Regimen for Human Immunodeficiency Virus-Associated Cryptococcal Meningitis to High-Income Settings? Clin Infect Dis 2023; 76:944-949. [PMID: 36166405 PMCID: PMC9989135 DOI: 10.1093/cid/ciac792] [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: 07/01/2022] [Revised: 09/05/2022] [Accepted: 09/23/2022] [Indexed: 11/12/2022] Open
Abstract
The AmBisome Therapy Induction Optimization (AMBITION-cm) trial, conducted in eastern and southern Africa, showed that a single, high dose (10 mg/kg) of liposomal amphotericin B, given with an oral backbone of fluconazole and flucytosine, was noninferior to the World Health Organization (WHO)-recommended regimen of 7 days of amphotericin B deoxycholate plus flucytosine for treatment of human immunodeficiency virus (HIV)-associated cryptococcal meningitis and has been incorporated into WHO treatment guidelines. We believe that the trial also has important implications for the treatment of HIV-associated cryptococcal meningitis in high-income settings. We advance the arguments, supported by evidence where available, that the AMBITION-cm trial regimen is likely to be as fungicidal as the currently recommended 14-day liposomal amphotericin-based treatments, better tolerated with fewer adverse effects, and confer significant economic and practical benefits and, therefore, should be included as a treatment option in guidance for HIV-associated cryptococcal treatment in high-income settings.
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Affiliation(s)
- Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, United Kingdom
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Henry C Mwandumba
- Clinical Sciences Department, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Clinical Research Programme, Blantyre, Malawi
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - David R Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mina C Hosseinipour
- Lilongwe Medical Relief Trust (University of North Carolina Project), Lilongwe, Malawi
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Olivier Lortholary
- Institut Pasteur, National Center for Scientific Research, Molecular Mycology Unit and National Reference Center for Invasive Mycoses and Antifungals, Unités Mixtes de Recherche 2000, Paris, France
- Université de Paris-Cité, Necker Pasteur Center for Infectious Diseases and Tropical Medicine, Hôpital Necker Enfants Malades, Assistance Publique–Hôpitaux de Paris, IHU Imagine, Paris, France
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mosepele Mosepele
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
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10
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Skipper CP, Hullsiek KH, Stadelman A, Williams DA, Ssebambulidde K, Okafor E, Tugume L, Nuwagira E, Akampurira A, Musubire AK, Abassi M, Muzoora C, Rhein J, Boulware DR, Meya DB. Sterile Cerebrospinal Fluid Culture at Cryptococcal Meningitis Diagnosis Is Associated with High Mortality. J Fungi (Basel) 2022; 9:46. [PMID: 36675867 PMCID: PMC9866844 DOI: 10.3390/jof9010046] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/21/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cryptococcus is the leading cause of AIDS-related meningitis in sub-Saharan Africa. The clinical implications of a sterile cerebrospinal fluid (CSF) culture among individuals diagnosed with cryptococcal meningitis using CSF cryptococcal antigen (CrAg) are unclear. We prospectively enrolled 765 HIV-positive Ugandans with first-episode cryptococcal meningitis from November 2010 to May 2017. All persons were treated with amphotericin-based induction therapy. We grouped participants by tertile of baseline CSF quantitative Cryptococcus culture burden and compared clinical characteristics, CSF immune profiles, and 18-week mortality. We found 55 (7%) CSF CrAg-positive participants with sterile CSF cultures. Compared to the non-sterile groups, participants with sterile CSF cultures had higher CD4 counts, lower CSF opening pressures, and were more frequently receiving ART. By 18 weeks, 47% [26/55] died in the sterile culture group versus 35% [83/235] in the low culture tertile, 46% [107/234] in the middle tertile, and 56% [135/241] in the high tertile (p < 0.001). The sterile group had higher levels of CSF interferon-gamma (IFN-γ), IFN-α, interleukin (IL)-6, IL-17, G-CSF, GM-CSF, and chemokine CXCL2 compared with non-sterile groups. Despite persons with sterile CSF cultures having higher CD4 counts, lower CSF opening pressures, and CSF cytokine profiles associated with better Cryptococcus control (e.g., IFN-γ predominant), mortality was similar to those with higher fungal burdens. This unexpected finding challenges the traditional paradigm that increasing CSF fungal burdens are associated with increased mortality but is consistent with a damage-response framework model.
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Affiliation(s)
- Caleb P Skipper
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Anna Stadelman
- School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
| | - Darlisha A Williams
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | | | - Elizabeth Okafor
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Andrew Akampurira
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Mahsa Abassi
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara 1410, Uganda
| | - Joshua Rhein
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David B Meya
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
- Infectious Diseases Institute, Makerere University, Kampala 7062, Uganda
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11
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Giamberardino CD, Schell WA, Tenor JL, Toffaletti DL, Palmucci JR, Marius C, Boua JVK, Soltow Q, Mansbach R, Moseley MA, Thompson JW, Dubois LG, Hope W, Perfect JR, Shaw KJ. Efficacy of APX2039 in a Rabbit Model of Cryptococcal Meningitis. mBio 2022; 13:e0234722. [PMID: 36222509 PMCID: PMC9765414 DOI: 10.1128/mbio.02347-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal Meningitis (CM) is uniformly fatal if not treated, and treatment options are limited. We previously reported on the activity of APX2096, the prodrug of the novel Gwt1 inhibitor APX2039, in a mouse model of CM. Here, we investigated the efficacy of APX2039 in mouse and rabbit models of CM. In the mouse model, the controls had a mean lung fungal burden of 5.95 log10 CFU/g, whereas those in the fluconazole-, amphotericin B-, and APX2039-treated mice were 3.56, 4.59, and 1.50 log10 CFU/g, respectively. In the brain, the control mean fungal burden was 7.97 log10 CFU/g, while the burdens were 4.64, 7.16, and 1.44 log10 CFU/g for treatment with fluconazole, amphotericin B, and APX2039, respectively. In the rabbit model of CM, the oral administration of APX2039 at 50 mg/kg of body weight twice a day (BID) resulted in a rapid decrease in the cerebrospinal fluid (CSF) fungal burden, and the burden was below the limit of detection by day 10 postinfection. The effective fungicidal activity (EFA) was -0.66 log10 CFU/mL/day, decreasing from an average of 4.75 log10 CFU/mL to 0 CFU/mL, over 8 days of therapy, comparing favorably with good clinical outcomes in humans associated with reductions of the CSF fungal burden of -0.4 log10 CFU/mL/day, and, remarkably, 2-fold the EFA of amphotericin B deoxycholate in this model (-0.33 log10 CFU/mL/day). A total drug exposure of the area under the concentration-time curve from 0 to 24 h (AUC0-24) of 25 to 50 mg · h/L of APX2039 resulted in near-maximal antifungal activity. These data support the further preclinical and clinical evaluation of APX2039 as a new oral fungicidal monotherapy for the treatment of CM. IMPORTANCE Cryptococcal meningitis (CM) is a fungal disease with significant global morbidity and mortality. The gepix Gwt1 inhibitors are a new class of antifungal drugs. Here, we demonstrated the efficacy of APX2039, the second member of the gepix class, in rabbit and mouse models of cryptococcal meningitis. We also analyzed the drug levels in the blood and cerebrospinal fluid in the highly predictive rabbit model and built a mathematical model to describe the behavior of the drug with respect to the elimination of the fungal pathogen. We demonstrated that the oral administration of APX2039 resulted in a rapid decrease in the CSF fungal burden, with an effective fungicidal activity of -0.66 log10 CFU/mL/day, comparing favorably with good clinical outcomes in humans associated with reductions of -0.4 log10 CFU/mL/day. The drug APX2039 had good penetration of the central nervous system and is an excellent candidate for future clinical testing in humans for the treatment of CM.
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Affiliation(s)
- Charles D. Giamberardino
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Wiley A. Schell
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Jennifer L. Tenor
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Julia R. Palmucci
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
| | - Choiselle Marius
- Duke University School of Medicine, Department of Surgery, Durham, North Carolina, USA
| | - Jane-Valeriane K. Boua
- Duke University School of Medicine, Department of Neurosurgery, Durham, North Carolina, USA
| | | | | | - M. Arthur Moseley
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - J. Will Thompson
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - Laura G. Dubois
- Duke University School of Medicine, Duke Proteomics and Metabolomics Core Facility, Center for Genomic and Computational Biology, Durham, North Carolina, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool, United Kingdom
| | - John R. Perfect
- Duke University School of Medicine, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA
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12
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Sephton-Clark P, Tenor JL, Toffaletti DL, Meyers N, Giamberardino C, Molloy SF, Palmucci JR, Chan A, Chikaonda T, Heyderman R, Hosseinipour M, Kalata N, Kanyama C, Kukacha C, Lupiya D, Mwandumba HC, Harrison T, Bicanic T, Perfect JR, Cuomo CA. Genomic Variation across a Clinical Cryptococcus Population Linked to Disease Outcome. mBio 2022; 13:e0262622. [PMID: 36354332 PMCID: PMC9765290 DOI: 10.1128/mbio.02626-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/13/2022] [Indexed: 11/12/2022] Open
Abstract
Cryptococcus neoformans is the causative agent of cryptococcosis, a disease with poor patient outcomes that accounts for approximately 180,000 deaths each year. Patient outcomes may be impacted by the underlying genetics of the infecting isolate; however, our current understanding of how genetic diversity contributes to clinical outcomes is limited. Here, we leverage clinical, in vitro growth and genomic data for 284 C. neoformans isolates to identify clinically relevant pathogen variants within a population of clinical isolates from patients with human immunodeficiency virus (HIV)-associated cryptococcosis in Malawi. Through a genome-wide association study (GWAS) approach, we identify variants associated with the fungal burden and the growth rate. We also find both small and large-scale variation, including aneuploidy, associated with alternate growth phenotypes, which may impact the course of infection. Genes impacted by these variants are involved in transcriptional regulation, signal transduction, glycosylation, sugar transport, and glycolysis. We show that growth within the central nervous system (CNS) is reliant upon glycolysis in an animal model and likely impacts patient mortality, as the CNS yeast burden likely modulates patient outcome. Additionally, we find that genes with roles in sugar transport are enriched in regions under selection in specific lineages of this clinical population. Further, we demonstrate that genomic variants in two genes identified by GWAS impact virulence in animal models. Our approach identifies links between the genetic variation in C. neoformans and clinically relevant phenotypes and animal model pathogenesis, thereby shedding light on specific survival mechanisms within the CNS and identifying the pathways involved in yeast persistence. IMPORTANCE Infection outcomes for cryptococcosis, most commonly caused by C. neoformans, are influenced by host immune responses as well as by host and pathogen genetics. Infecting yeast isolates are genetically diverse; however, we lack a deep understanding of how this diversity impacts patient outcomes. To better understand both clinical isolate diversity and how diversity contributes to infection outcomes, we utilize a large collection of clinical C. neoformans samples that were isolated from patients enrolled in a clinical trial across 3 hospitals in Malawi. By combining whole-genome sequence data, clinical data, and in vitro growth data, we utilize genome-wide association approaches to examine the genetic basis of virulence. Genes with significant associations display virulence attributes in both murine and rabbit models, demonstrating that our approach can identify potential links between genetic variants and patho-biologically significant phenotypes.
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Affiliation(s)
- Poppy Sephton-Clark
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Jennifer L. Tenor
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dena L. Toffaletti
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nancy Meyers
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Charles Giamberardino
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Síle F. Molloy
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George's University Hospital, London, United Kingdom
| | - Julia R. Palmucci
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adrienne Chan
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tarsizio Chikaonda
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Robert Heyderman
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Mina Hosseinipour
- UNC Project Malawi, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Newton Kalata
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Cecilia Kanyama
- UNC Project Malawi, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher Kukacha
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Duncan Lupiya
- Tisungane Clinic, Zomba Central Hospital, Zomba, Malawi
| | - Henry C. Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Thomas Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George's University Hospital, London, United Kingdom
| | - Tihana Bicanic
- Centre for Global Health, Institute of Infection and Immunity, St George's University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George's University Hospital, London, United Kingdom
| | - John R. Perfect
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina A. Cuomo
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
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13
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Muzazu SGY, Assefa DG, Phiri C, Getinet T, Solomon S, Yismaw G, Manyazewal T. Prevalence of cryptococcal meningitis among people living with human immuno-deficiency virus and predictors of mortality in adults on induction therapy in Africa: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:989265. [PMID: 36160163 PMCID: PMC9494297 DOI: 10.3389/fmed.2022.989265] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cryptococcal meningitis (CM) is a leading cause of adult meningitis in countries with a high burden of HIV. It has remained a significant cause of morbidity and mortality in Africa despite the extensive rollout of HIV antiretroviral therapy (ART). This study aimed to systematically synthesize the evidence on the prevalence of CM among people living with HIV (PLWH) and its predictors of mortality among adults who are on induction antifungal therapy in Africa. Methods PubMed/MEDLINE, Embase, and Google Scholar were searched for randomized clinical trials or observational studies published in Africa from 1995 to April 2021. Pooled prevalence of CM among PLWH was calculated using R-studio Version 1.4.1717 software and the data extracted from eligible studies were pooled as percentage with a 95% confidence interval (CI). Predictors of mortality among adults on induction antifungal therapy were synthesized narratively. Results Out of 364 studies identified, 17 eligible articles were included in the analysis. The prevalence of CM among PLWH in Africa was 5.11% (95% CI 2.71-9.43%; participants = 10,813; studies = 9; I 2 = 97%). In the subgroup analysis, the prevalence was 12.9% (95% CI 4.883-30.0; participants = 533; studies = 3; I 2 = 63%) in the years 1995-2010 and 3.18% (95% CI 1.54-6.45; participants = 10,280; studies = 6; I 2 = 98%) in the years 2011-2021, with the prevalence significantly decreased by 51% (p = 0.02). Predictors of mortality were fluconazole monotherapy, focal neurological signs, low Glasgow coma scale, and delayed diagnosis of CM at varied timepoint. Conclusion Prevalence of CM has significantly decreased from 1996-2010 to 2011-2021 among PLWH on induction therapy in Africa. Fluconazole monotherapy, focal neurological symptoms, diastolic blood pressure < 60 mmHg, and concurrent tuberculosis coinfection were significant predictors of mortality at 2- and 10-weeks timepoints. CM remains a major concern among PLWH despite increases in ART coverage. Improved access to effective antifungal therapies is needed in Africa for timely initiation of combination induction therapy and better treatment outcomes of PLWH. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=254113], identifier [CRD42021254113].
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Affiliation(s)
- Seke G. Y. Muzazu
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Enteric Diseases and Vaccines Research Unit, Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | - Dawit Getachew Assefa
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Christabel Phiri
- Levy Mwanawasa University Teaching Hospital, Department of Internal Medicine, Lusaka, Zambia
| | - Tewodros Getinet
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Samrawit Solomon
- School of Public Health, Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Gizachew Yismaw
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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14
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Diagnostic Accuracy of Point of Care Cryptococcal Antigen Lateral Flow Assay in Fingerprick Whole Blood and Urine Samples for the Detection of Asymptomatic Cryptococcal Disease in Patients with Advanced HIV Disease. Microbiol Spectr 2022; 10:e0107522. [PMID: 35924841 PMCID: PMC9430595 DOI: 10.1128/spectrum.01075-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptococcal disease (CD) is a leading cause of mortality among individuals with advanced HIV disease (AHD). Screening with serum cryptococcal antigen (sCrAg) lateral flow assay (LFA) enables early detection of subclinical disease but requires venipuncture and laboratory processing. Clinic-based point of care (POC) CrAg screening tests using urine or fingerprick whole blood could facilitate early diagnosis of CD. We evaluated the diagnostic performance of POC clinic-based fingerprick whole blood and urine CrAg compared to the gold standard laboratory sCrAg LFA in screening for CD among asymptomatic individuals with CD4 counts of <200 cells/μL in Harare, Zimbabwe. sCrAg positive participants who consented to a lumbar puncture also had cerebrospinal fluid (CSF) CrAg testing and titers for CSF-positive specimens. A total of 1,333 individuals were screened, and over half (56.6%) were males. The median (interquartile range) CD4 count was 27.5 (11–46) cells/μL. We found a sensitivity of 63.8% (95% CI: 54.8–72.1) and specificity of 84.0% (95% CI: 81.7–86.0) for urine CrAg, and a sensitivity of 48.0% (95% CI: 39.1–57.1) and specificity of 99.5% (95% CI: 98.9–99.8) was found for fingerprick whole blood. The sensitivity of both POC CrAg tests increased in individuals with sCrAg titers of ≥1:160, CD4 count of <50 cells/μL and disseminated central nervous system (CNS) disease. Clinic-based POC urine and fingerprick whole blood CrAg testing performed better in screening for CD among AHD patients with CNS disease. More sensitive assays to identify AHD patients with asymptomatic CD are needed. IMPORTANCE Cryptococcal disease (CD) remains a leading cause of morbidity and mortality among individuals with advanced HIV disease (AHD). Identifying point of care (POC) approaches to screening for CD in asymptomatic individuals is important to guide therapeutic management. We evaluated the use of POC fingerprick whole blood and urine testing for cryptococcal disease in patients with AHD as compared with laboratory-based serum antigen testing. POC fingerprick whole blood and urine testing had low sensitivity and specificity in asymptomatic individuals with AHD. Most analysis has focused on evaluating test performance in symptomatic individuals. Here we show that POC testing with whole blood and urine samples should not be used to screen for asymptomatic CD in AHD.
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15
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Alanazi AH, Adil MS, Lin X, Chastain DB, Henao-Martínez AF, Franco-Paredes C, Somanath PR. Elevated Intracranial Pressure in Cryptococcal Meningoencephalitis: Examining Old, New, and Promising Drug Therapies. Pathogens 2022; 11:783. [PMID: 35890028 PMCID: PMC9321092 DOI: 10.3390/pathogens11070783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Despite the availability of effective antifungal therapy, cryptococcal meningoencephalitis (CM) remains associated with elevated mortality. The spectrum of symptoms associated with the central nervous system (CNS) cryptococcosis is directly caused by the high fungal burden in the subarachnoid space and the peri-endothelial space of the CNS vasculature, which results in intracranial hypertension (ICH). Management of intracranial pressure (ICP) through aggressive drainage of cerebrospinal fluid by lumbar puncture is associated with increased survival. Unfortunately, these procedures are invasive and require specialized skills and supplies that are not readily available in resource-limited settings that carry the highest burden of CM. The institution of pharmacologic therapies to reduce the production or increase the resorption of cerebrospinal fluid would likely improve clinical outcomes associated with ICH in patients with CM. Here, we discuss the potential role of multiple pharmacologic drug classes such as diuretics, corticosteroids, and antiepileptic agents used to decrease ICP in various neurological conditions as potential future therapies for CM.
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Affiliation(s)
- Abdulaziz H. Alanazi
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
| | - Mir S. Adil
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
| | - Xiaorong Lin
- Department of Microbiology, University of Georgia, Athens, GA 30602, USA;
| | - Daniel B. Chastain
- Department of Clinical and Administrative Pharmacy, UGA College of Pharmacy, SWGA Clinical Campus, Phoebe Putney Memorial Hospital, Albany, GA 31701, USA;
| | - Andrés F. Henao-Martínez
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (A.F.H.-M.); (C.F.-P.)
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (A.F.H.-M.); (C.F.-P.)
- Hospital Infantil de México, Federico Gómez, Ciudad de México 06720, Mexico
| | - Payaningal R. Somanath
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA 30902, USA; (A.H.A.); (M.S.A.)
- Research Department, Charlie Norwood VA Medical Center, Augusta, GA 30912, USA
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16
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Thompson GR, Boulware DR, Bahr NC, Clancy CJ, Harrison TS, Kauffman CA, Le T, Miceli MH, Mylonakis E, Nguyen MH, Ostrosky-Zeichner L, Patterson TF, Perfect JR, Spec A, Kontoyiannis DP, Pappas PG. Noninvasive Testing and Surrogate Markers in Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac112. [PMID: 35611348 PMCID: PMC9124589 DOI: 10.1093/ofid/ofac112] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/02/2022] [Indexed: 02/04/2023] Open
Abstract
Invasive fungal infections continue to increase as at-risk populations expand. The high associated morbidity and mortality with fungal diseases mandate the continued investigation of novel antifungal agents and diagnostic strategies that include surrogate biomarkers. Biologic markers of disease are useful prognostic indicators during clinical care, and their use in place of traditional survival end points may allow for more rapid conduct of clinical trials requiring fewer participants, decreased trial expense, and limited need for long-term follow-up. A number of fungal biomarkers have been developed and extensively evaluated in prospective clinical trials and small series. We examine the evidence for these surrogate biomarkers in this review and provide recommendations for clinicians and regulatory authorities.
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Affiliation(s)
- George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California-Davis Medical Center, Sacramento California, USA
- Department of Medical Microbiology and Immunology, University of California-Davis, Davis, California, USA
| | - David R Boulware
- Division of Infectious Diseases, Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Medicine, University of Kansas, Kansas City, Kansas, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Thomas S Harrison
- Centre for Global Health, Institute of Infection and Immunity, St George’s University of London, London, United Kingdom
- Clinical Academic Group in Infection, St George’s Hospital NHS Trust, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Thuy Le
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Thomas F Patterson
- Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas, USA
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Infectious Diseases, Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA
| | - Andrej Spec
- Division of Infectious Diseases, Department of Medicine, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
| | - Dimitrios P Kontoyiannis
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter G Pappas
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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17
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Rathore SS, Sathiyamoorthy J, Lalitha C, Ramakrishnan J. A holistic review on Cryptococcus neoformans. Microb Pathog 2022; 166:105521. [DOI: 10.1016/j.micpath.2022.105521] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/06/2022] [Accepted: 04/06/2022] [Indexed: 12/21/2022]
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18
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Ohnishi YDO, Pantoja ASL, Abraão LSDO, Alves NG, Ohnishi MDDO, Libonati RMF, Ventura AMRDS, Palácios VRDCM. Cryptococcal meningitis in patients with and without acquired immunodeficiency. Acta Trop 2022; 227:106228. [PMID: 34864000 DOI: 10.1016/j.actatropica.2021.106228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/12/2021] [Indexed: 11/01/2022]
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19
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Fu C, Beattie SR, Jezewski AJ, Robbins N, Whitesell L, Krysan DJ, Cowen LE. Genetic analysis of Hsp90 function in Cryptococcus neoformans highlights key roles in stress tolerance and virulence. Genetics 2022; 220:iyab164. [PMID: 34849848 PMCID: PMC8733452 DOI: 10.1093/genetics/iyab164] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
The opportunistic human fungal pathogen Cryptococcus neoformans has tremendous impact on global health, causing 181,000 deaths annually. Current treatment options are limited, and the frequent development of drug resistance exacerbates the challenge of managing invasive cryptococcal infections. In diverse fungal pathogens, the essential molecular chaperone Hsp90 governs fungal survival, drug resistance, and virulence. Therefore, targeting this chaperone has emerged as a promising approach to combat fungal infections. However, the role of Hsp90 in supporting C. neoformans pathogenesis remains largely elusive due to a lack of genetic characterization. To help dissect the functions of Hsp90 in C. neoformans, we generated a conditional expression strain in which HSP90 is under control of the copper-repressible promoter CTR4-2. Addition of copper to culture medium depleted Hsp90 transcript and protein levels in this strain, resulting in compromised fungal growth at host temperature; increased sensitivity to stressors, including the azole class of antifungals; altered C. neoformans morphology; and impaired melanin production. Finally, leveraging the fact that copper concentrations vary widely in different mouse tissues, we demonstrated attenuated virulence for the CTR4-2p-HSP90 mutant specifically in an inhalation model of Cryptococcus infection. During invasion and establishment of infection in this mouse model, the pathogen is exposed to the relatively high copper concentrations found in the lung as compared to blood. Overall, this work generates a tractable genetic system to study the role of Hsp90 in supporting the pathogenicity of C. neoformans and provides proof-of-principle that targeting Hsp90 holds great promise as a strategy to control cryptococcal infection.
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Affiliation(s)
- Ci Fu
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
| | - Sarah R Beattie
- Departments of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Andrew J Jezewski
- Departments of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Nicole Robbins
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
| | - Luke Whitesell
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
| | - Damian J Krysan
- Departments of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Microbiology/Immunology, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Leah E Cowen
- Department of Molecular Genetics, University of Toronto, Toronto, ON M5G 1M1, Canada
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20
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Hurt WJ, Harrison TS, Molloy SF, Bicanic TA. Combination Therapy for HIV-Associated Cryptococcal Meningitis-A Success Story. J Fungi (Basel) 2021; 7:1098. [PMID: 34947080 PMCID: PMC8708058 DOI: 10.3390/jof7121098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Cryptococcal meningitis is the leading cause of adult meningitis in patients with HIV, and accounts for 15% of all HIV-related deaths in sub-Saharan Africa. The mainstay of management is effective antifungal therapy, despite a limited arsenal of antifungal drugs, significant progress has been made developing effective treatment strategies by using combination regimens. The introduction of fluconazole as a safe and effective step-down therapy allowed for shorter courses of more fungicidal agents to be given as induction therapy, with higher doses achieving more rapid CSF sterilisation and improved treatment outcomes. The development of early fungicidal activity (EFA), an easily measured surrogate of treatment efficacy, has enabled rapid identification of effective combinations through dose ranging phase II studies, allowing further evaluation of clinical benefit in targeted phase III studies. Recent clinical trials have shown that shorter course induction regimens using one week of amphotericin paired with flucytosine are non-inferior to traditional two-week induction regimens and that the combination of fluconazole and flucytosine offers a viable treatment alternative when amphotericin is unavailable. Access to drugs in many low and middle-income settings remains challenging but is improving, and novel strategies based on single high dose liposomal amphotericin B promise further reduction in treatment complications and toxicities. This review aims to summarise the key findings of the principal clinical trials that have led to the success story of combination therapy thus far.
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Affiliation(s)
- William J. Hurt
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Thomas S. Harrison
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
| | - Síle F. Molloy
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
| | - Tihana A. Bicanic
- Institute of Infection & Immunity, St George’s University London, London SW17 0RE, UK; (T.S.H.); (S.F.M.); (T.A.B.)
- Clinical Academic Group in Infection & Immunity, St George’s University Hospitals NHS Trust, London SW17 0QT, UK
- The MRC Centre of Medical Mycology, University of Exeter, Stocker Road, Exeter EX4 4QD, UK
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21
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Dangarembizi R. Reimagining the future of African brain health: Perspectives for basic research on the pathogenesis of cryptococcal meningitis. Brain Behav Immun Health 2021; 18:100388. [PMID: 34825235 PMCID: PMC8605210 DOI: 10.1016/j.bbih.2021.100388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/24/2022] Open
Abstract
Cryptococcal meningitis is a fatal opportunistic infection of the brain and a leading cause of neurological damage and death in immunocompromised individuals. This neglected fungal disease of the brain is a huge burden on the health systems of developing countries, especially in Sub-Saharan Africa, where up to 25% of people living with HIV/AIDS succumb to it. Cryptococcal fungal cells have a predilection for the brain and they are capable of traversing the blood brain barrier and invade the brain where they cause infection, inflammation and a disruption of normal brain function. A robust host neuroimmune response is critical for pathogen clearance and survival, and a good understanding of the mechanisms underlying its development in the host is critical for the development of effective treatments. However, past basic research studies have been focussed on the characteristics of the fungus and its effect on the peripheral immune system; with little attention paid to how it interacts with brain immune cells. This mini review briefly discusses the paucity of basic research data on the neuroimmune response to cryptococcal infection, raises pertinent questions on how the brain cells respond to the fungal infection, and thereafter discusses models, techniques and advanced technologies that could be useful for carrying out high-throughput research on the pathogenesis of cryptococcal meningitis.
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Affiliation(s)
- R Dangarembizi
- Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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22
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Cell Wall Integrity Pathway Involved in Morphogenesis, Virulence and Antifungal Susceptibility in Cryptococcus neoformans. J Fungi (Basel) 2021; 7:jof7100831. [PMID: 34682253 PMCID: PMC8540506 DOI: 10.3390/jof7100831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/17/2022] Open
Abstract
Due to its location, the fungal cell wall is the compartment that allows the interaction with the environment and/or the host, playing an important role during infection as well as in different biological functions such as cell morphology, cell permeability and protection against stress. All these processes involve the activation of signaling pathways within the cell. The cell wall integrity (CWI) pathway is the main route responsible for maintaining the functionality and proper structure of the cell wall. This pathway is highly conserved in the fungal kingdom and has been extensively characterized in Saccharomyces cerevisiae. However, there are still many unknown aspects of this pathway in the pathogenic fungi, such as Cryptococcus neoformans. This yeast is of particular interest because it is found in the environment, but can also behave as pathogen in multiple organisms, including vertebrates and invertebrates, so it has to adapt to multiple factors to survive in multiple niches. In this review, we summarize the components of the CWI pathway in C. neoformans as well as its involvement in different aspects such as virulence factors, morphological changes, and its role as target for antifungal therapies among others.
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23
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Ngan NTT, Thanh Hoang Le N, Vi Vi NN, Van NTT, Mai NTH, Van Anh D, Trieu PH, Lan NPH, Phu NH, Chau NVV, Lalloo DG, Hope W, Beardsley J, White NJ, Geskus R, Thwaites GE, Krysan D, Tai LTH, Kestelyn E, Binh TQ, Hung LQ, Tung NLN, Day JN. An open label randomized controlled trial of tamoxifen combined with amphotericin B and fluconazole for cryptococcal meningitis. eLife 2021; 10:68929. [PMID: 34581270 PMCID: PMC8547950 DOI: 10.7554/elife.68929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/21/2021] [Indexed: 12/15/2022] Open
Abstract
Background Cryptococcal meningitis has high mortality. Flucytosine is a key treatment but is expensive and rarely available. The anticancer agent tamoxifen has synergistic anti-cryptococcal activity with amphotericin in vitro. It is off-patent, cheap, and widely available. We performed a trial to determine its therapeutic potential. Methods Open label randomized controlled trial. Participants received standard care - amphotericin combined with fluconazole for the first 2 weeks - or standard care plus tamoxifen 300 mg/day. The primary end point was Early Fungicidal Activity (EFA) - the rate of yeast clearance from cerebrospinal fluid (CSF). Trial registration https://clinicaltrials.gov/ct2/show/NCT03112031. Results Fifty patients were enrolled (median age 34 years, 35 male). Tamoxifen had no effect on EFA (-0.48log10 colony-forming units/mL/CSF control arm versus -0.49 tamoxifen arm, difference -0.005log10CFU/ml/day, 95% CI: -0.16, 0.15, p=0.95). Tamoxifen caused QTc prolongation. Conclusions High-dose tamoxifen does not increase the clearance rate of Cryptococcus from CSF. Novel, affordable therapies are needed. Funding The trial was funded through the Wellcome Trust Asia Programme Vietnam Core Grant 106680 and a Wellcome Trust Intermediate Fellowship to JND grant number WT097147MA.
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Affiliation(s)
- Nguyen Thi Thuy Ngan
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam.,Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - Nguyen Ngo Vi Vi
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | | | - Duong Van Anh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Phan Hai Trieu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - Nguyen Hoan Phu
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | | | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - William Hope
- Centre of Excellence in Infectious Disease Research, Institute of Translational Medicine, Liverpool University, Liverpool, United Kingdom
| | - Justin Beardsley
- The University of Sydney, Marie Bashir Institute, NSW, Camperdown, Australia.,Westmead Institute for Medical Research, Westmead, Australia
| | - Nicholas J White
- Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Damian Krysan
- Department of Paediatrics and Microbiology/Immunology, Carver College of Medicine, University of Iowa, Iowa City, United States
| | | | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Tran Quang Binh
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | - Le Quoc Hung
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Viet Nam
| | | | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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24
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Stott KE, Loyse A, Jarvis JN, Alufandika M, Harrison TS, Mwandumba HC, Day JN, Lalloo DG, Bicanic T, Perfect JR, Hope W. Cryptococcal meningoencephalitis: time for action. THE LANCET. INFECTIOUS DISEASES 2021; 21:e259-e271. [PMID: 33872594 DOI: 10.1016/s1473-3099(20)30771-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Cryptococcal meningoencephalitis was first described over a century ago. This fungal infection is preventable and treatable yet continues to be associated with excessive morbidity and mortality. The largest burden of disease resides in people living with HIV in low-income and middle-income countries. In this group, mortality with the best antifungal induction regimen (7 days of amphotericin B deoxycholate [1·0 mg/kg per day] and flucytosine [100·0 mg/kg per day]) in a clinical trial setting was 24% at 10 weeks. The world is now at an inflection point in terms of recognition, research, and action to address the burden of morbidity and mortality from cryptococcal meningoencephalitis. However, the scope of interventional programmes needs to increase, with particular attention to implementation science that is specific to individual countries. This Review summarises causes of excessive mortality, interventions with proven survival benefit, and gaps in knowledge and practice that contribute to the ongoing high death toll from cryptococcal meningoencephalitis. TRANSLATIONS: For the Vietnamese and Chichewa translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Katharine Elizabeth Stott
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Angela Loyse
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - Joe N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University and Hospital, London, UK
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University School of Medicine, Durham, NC, USA
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Translational Medicine, University of Liverpool, Liverpool Health Partners, Liverpool, UK
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25
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Abstract
Cryptococcosis is an invasive fungal infection of global significance caused by yeasts of the genus Cryptococcus. The prevalence of HIV in certain areas of the world and the expanding population of immunocompromised patients contribute to the ongoing global disease burden. Point-of-care serologic testing has allowed for more rapid diagnosis and implementation of screening programs in resource-limited settings. Management involves therapy aimed at reduction in fungal burden, maintenance of intracranial pressure, and optimization of host immunity. Despite diagnostic and therapeutic advances, cryptococcosis continues to be a disease with unacceptably high incidence and mortality, particularly in resource-limited settings.
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Affiliation(s)
- Alexis C Gushiken
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - Kapil K Saharia
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA
| | - John W Baddley
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD 21201, USA.
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26
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Pullen MF, Hullsiek KH, Rhein J, Musubire AK, Tugume L, Nuwagira E, Abassi M, Ssebambulidde K, Mpoza E, Kiggundu R, Akampurira A, Nabeta HW, Schutz C, Evans EE, Rajasingham R, Skipper CP, Pastick KA, Williams DA, Morawski BM, Bangdiwala AS, Meintjes G, Muzoora C, Meya DB, Boulware DR. Cerebrospinal Fluid Early Fungicidal Activity as a Surrogate Endpoint for Cryptococcal Meningitis Survival in Clinical Trials. Clin Infect Dis 2021; 71:e45-e49. [PMID: 31912875 DOI: 10.1093/cid/ciaa016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In cryptococcal meningitis phase 2 clinical trials, early fungicidal activity (EFA) of Cryptococcus clearance from cerebrospinal fluid (CSF) is used as a surrogate endpoint for all-cause mortality. The Food and Drug Administration allows for using surrogate endpoints for accelerated regulatory approval, but EFA as a surrogate endpoint requires further validation. We examined the relationship between rate of CSF Cryptococcus clearance (EFA) and mortality through 18 weeks. METHODS We pooled individual-level CSF data from 3 sequential cryptococcal meningitis clinical trials conducted during 2010-2017. All 738 subjects received amphotericin + fluconazole induction therapy and had serial quantitative CSF cultures. The log10-transformed colony-forming units (CFUs) per mL CSF were analyzed by general linear regression versus day of culture over the first 10 days. RESULTS Mortality through 18 weeks was 37% for EFA > = 0.60 (n = 170), 36% for 0.40-0.59 (n = 182), 39% for 0.30-0.39 (n = 112), 35% for 0.20-0.29 (n = 87), and 50% for those with EFA < 0.20 CFU/mL/day (n = 187). The hazard ratio for 18-week mortality, comparing those with EFA < 0.20 to those with EFA > = 0.20, was 1.60 (95% confidence interval, 1.25, 2.04; P = .002). The lowest EFA group had lower median CD4 T-cell counts (P < .01) and lower proportion of patients with CSF pleocytosis (P < .001). CONCLUSIONS EFA is associated with all-cause mortality in cryptococcal meningitis. An EFA threshold of > = 0.20 log10 CFU/mL/day was associated with similar 18-week mortality (37%) compared to 50% mortality with EFA < 0.20. This EFA threshold may be considered a target for a surrogate endpoint. This builds upon existing studies to validate EFA as a surrogate endpoint.
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Affiliation(s)
- Matthew F Pullen
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katherine Huppler Hullsiek
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joshua Rhein
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Mahsa Abassi
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Ruben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Henry W Nabeta
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Emily E Evans
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Caleb P Skipper
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katelyn A Pastick
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Darlisha A Williams
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Bozena M Morawski
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ananta S Bangdiwala
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, South Africa
| | - Conrad Muzoora
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B Meya
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, MN, USA
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27
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Chen CH, Li H, Chen HM, Chen YM, Chang YJ, Lin PY, Hsu CW, Tseng PT, Lin KH, Tu YK. Efficacy of induction regimens for cryptococcal meningitis in HIV-infected adults: a systematic review and network meta-analysis. Sci Rep 2021; 11:8565. [PMID: 33883566 PMCID: PMC8060388 DOI: 10.1038/s41598-021-87726-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/01/2021] [Indexed: 11/09/2022] Open
Abstract
Cryptococcal meningitis (CM) is the most fatal adult meningitis in patients with human immunodeficiency virus (HIV). There is no conclusive evidence for the superiority of 1-week amphotericin B deoxycholate (AmphB) + flucytosine (5-FC) regimen over other antifungals in the management of HIV patients with CM (HIV-CM patients). We aimed to evaluate the differences in efficacy and tolerability of different antifungal agents in HIV-CM patients by conducting a current network meta-analysis NMA. Overall, 19 randomized controlled trials were included with 2642 participants. A regimen indicated a possibly lower early mortality rate, namely, AmphB + 5-FC + Azole (OR = 1.1E-12, 95% CIs = 1.3E-41 to 0.06) comparing to AmphB + 5-FC. The current NMA provides evidence that AmphB + 5-FC + Azole are superior to all the investigated treatments for induction regimen in HIV-CM patients.
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Affiliation(s)
- Chang-Hua Chen
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Center for Infection Prevention and Control, Changhua Christian Hospital, Changhua, 500, Taiwan
- National Chung Hsing University, Taichung, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Hua Li
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsien-Meng Chen
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Min Chen
- Department of Pharmacy, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Tao Tseng
- WinShine Clinics in Specialty of Psychiatry, Kaohsiung City, Taiwan
| | - Kai-Huang Lin
- Division of Critical Care Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan.
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Vanherp L, Poelmans J, Weerasekera A, Hillen A, Croitor-Sava AR, Sorrell TC, Lagrou K, Vande Velde G, Himmelreich U. Trehalose as quantitative biomarker for in vivo diagnosis and treatment follow-up in cryptococcomas. Transl Res 2021; 230:111-122. [PMID: 33166695 DOI: 10.1016/j.trsl.2020.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022]
Abstract
Brain lesions caused by Cryptococcus neoformans or C. gattii (cryptococcomas) are typically difficult to diagnose correctly and treat effectively, but rapid differential diagnosis and treatment initiation are crucial for good outcomes. In previous studies, cultured cryptococcal isolates and ex vivo lesion material contained high concentrations of the virulence factor and fungal metabolite trehalose. Here, we studied the in vivo metabolic profile of cryptococcomas in the brain using magnetic resonance spectroscopy (MRS) and assessed the relationship between trehalose concentration, fungal burden, and treatment response in order to validate its suitability as marker for early and noninvasive diagnosis and its potential to monitor treatment in vivo. We investigated the metabolites present in early and late stage cryptococcomas using in vivo 1H MRS in a murine model and evaluated changes in trehalose concentrations induced by disease progression and antifungal treatment. Animal data were compared to 1H and 13C MR spectra of Cryptococcus cultures and in vivo data from 2 patients with cryptococcomas in the brain. In vivo MRS allowed the noninvasive detection of high concentrations of trehalose in cryptococcomas and showed a comparable metabolic profile of cryptococcomas in the murine model and human cases. Trehalose concentrations correlated strongly with the fungal burden. Treatment studies in cultures and animal models showed that trehalose concentrations decrease following exposure to effective antifungal therapy. Although further cases need to be studied for clinical validation, this translational study indicates that the noninvasive MRS-based detection of trehalose is a promising marker for diagnosis and therapeutic follow-up of cryptococcomas.
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Affiliation(s)
- Liesbeth Vanherp
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Jennifer Poelmans
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Akila Weerasekera
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium; A.A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School (MGH/HMS), Boston, Massachusetts, USA
| | - Amy Hillen
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Anca R Croitor-Sava
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium; STADIUS, Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, and Westmead Institute for Medical Research, Centre for Infectious Diseases and Microbiology, Sydney, Australia
| | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium; National Reference Centre for Mycosis, Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greetje Vande Velde
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Uwe Himmelreich
- Biomedical MRI, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.
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29
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Zono B, Kamangu E, Situakibanza H, Amaela E, Bepouka B, Mbula M, Kayembe JM, Mvumbi G, Hayette MP. Epidemiological, clinical and biological profile of neuromeningeal cryptococcosis among people living with HIV in Kinshasa, Democratic Republic of Congo. Pan Afr Med J 2021; 37:302. [PMID: 33654521 PMCID: PMC7896526 DOI: 10.11604/pamj.2020.37.302.20521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 11/24/2020] [Indexed: 11/11/2022] Open
Abstract
Neuromeningeal cryptococcosis (NMC) is one of the most frequent opportunistic infections (OI) in Human Immunodeficiency Virus (HIV) infection. In Kinshasa, the latest data on cryptococcosis were published in 1996. The objective was to describe the epidemiological, clinical and biological profiles of NMC in HIV-infected people living in Kinshasa. This is a descriptive study based on the medical records of patients who attended three clinics in Kinshasa between January 1 s t 2011 and December 31st 2014. Only the medical records of HIV-infected people presenting the NMC were reviewed. During the 4 year-period of the study, 261 HIV-positive patients presented to the clinics for neuromeningeal syndrome, including 23 with NMC. The global prevalence of NMC was 8.8% for the three clinics. The mean age was 42.8 ± 9.5 years, with male predominance (65.2%). The main symptoms were headache (73.9%), neck stiffness (60.9%), fever (47.8%), and coma (47.8%). Biological records were as follows: median CD4 cell count was 79 cells/mm3; cerebrospinal fluid (CSF) was clear for 56.5% of the cases with predominance of neutrophils in 73.9%. The outcome was fatal in 34.8% of cases. The prevalence and therapeutic outcome of NMC show that it constitutes a non-negligible OI in Kinshasa, especially in HIV-infected people at the AIDS stage. As HIV-infected people with severe immunosuppression are the most affected by NMC, active preventive measures should benefit this vulnerable category of people.
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Affiliation(s)
- Bive Zono
- Service of Molecular Biology, Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Erick Kamangu
- Service of Molecular Biology, Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Hippolyte Situakibanza
- Service of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Evelyne Amaela
- Service of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Ben Bepouka
- Service of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Mbula
- Service of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Jean-Marie Kayembe
- Service of Pneumology, Department of Internal Medicine, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Georges Mvumbi
- Service of Molecular Biology, Department of Basic Sciences, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marie-Pierre Hayette
- Service of Molecular Biology, Department of Clinical Microbiology, University of Liege, Liege, Belgium
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30
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Song W, Shen YZ, Wang ZY, Qi TK, Liu L, Zhang RF, Wang JR, Tang Y, Chen J, Sun JJ, Lu HZ. Clinical features and treatment outcomes of human immunodeficiency virus-associated cryptococcal meningitis: a 2-year retrospective analysis. Chin Med J (Engl) 2020; 133:2787-2795. [PMID: 33273326 PMCID: PMC7717751 DOI: 10.1097/cm9.0000000000001191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is one of the most common opportunistic infections caused by Cryptococcus neoformans in human immunodeficiency virus (HIV)-infected patients, and is complicated with significant morbidity and mortality. This study retrospectively analyzed the clinical features, characteristics, treatment, and outcomes of first-diagnosed HIV-associated CM after 2-years of follow-up. METHODS Data from all patients (n = 101) of HIV-associated CM hospitalized in Shanghai Public Health Clinical Center from September 2013 to December 2016 were collected and analyzed using logistic regression to identify clinical and microbiological factors associated with mortality. RESULTS Of the 101 patients, 86/99 (86.9%) of patients had CD4 count <50 cells/mm, 57/101 (56.4%) were diagnosed at ≥14 days from the onset to diagnosis, 42/99 (42.4%) had normal cerebrospinal fluid (CSF) cell counts and biochemical examination, 30/101 (29.7%) had concomitant Pneumocystis (carinii) jiroveci pneumonia (PCP) on admission and 37/92 (40.2%) were complicated with cryptococcal pneumonia, 50/74 (67.6%) had abnormalities shown on intracranial imaging, amongst whom 24/50 (48.0%) had more than one lesion. The median time to negative CSF Indian ink staining was 8.50 months (interquartile range, 3.25-12.00 months). Patients who initiated antiretroviral therapy (ART) before admission had a shorter time to negative CSF Indian ink compared with ART-naïve patients (7 vs. 12 months, χ = 15.53, P < 0.001). All-cause mortality at 2 weeks, 8 weeks, and 2 years was 10.1% (10/99), 18.9% (18/95), and 20.7% (19/92), respectively. Coinfection with PCP on admission (adjusted odds ratio [AOR], 3.933; 95% confidence interval [CI], 1.166-13.269, P = 0.027) and altered mental status (AOR, 9.574; 95% CI, 2.548-35.974, P = 0.001) were associated with higher mortality at 8 weeks. CONCLUSION This study described the clinical features and outcomes of first diagnosed HIV-associated CM with 2-year follow-up data. Altered mental status and coinfection with PCP predicted mortality in HIV-associated CM.
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Affiliation(s)
- Wei Song
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
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31
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Beattie SR, Krysan DJ. Antifungal drug screening: thinking outside the box to identify novel antifungal scaffolds. Curr Opin Microbiol 2020; 57:1-6. [PMID: 32339892 PMCID: PMC7652037 DOI: 10.1016/j.mib.2020.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023]
Abstract
Invasive fungal infections are responsible for a significant disease burden worldwide. Drugs to treat these infections are limited to only four unique classes, and despite these available treatments, mortality rates remain unacceptably high. In this review, we will discuss antifungal drug screening and how the approach to identifying novel compounds needs move away from traditional growth-based assays in order to meet the demand for new drugs. We highlight specific examples of creative screening strategies that increase the likelihood of identifying compounds with desired activities and provide perspective to inspire development of novel screens for the identification of first-in-class antifungals.
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Affiliation(s)
- Sarah R Beattie
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Damian J Krysan
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States; Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States.
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32
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Todd RT, Selmecki A. Expandable and reversible copy number amplification drives rapid adaptation to antifungal drugs. eLife 2020; 9:e58349. [PMID: 32687060 PMCID: PMC7371428 DOI: 10.7554/elife.58349] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/09/2020] [Indexed: 12/13/2022] Open
Abstract
Previously, we identified long repeat sequences that are frequently associated with genome rearrangements, including copy number variation (CNV), in many diverse isolates of the human fungal pathogen Candida albicans (Todd et al., 2019). Here, we describe the rapid acquisition of novel, high copy number CNVs during adaptation to azole antifungal drugs. Single-cell karyotype analysis indicates that these CNVs appear to arise via a dicentric chromosome intermediate and breakage-fusion-bridge cycles that are repaired using multiple distinct long inverted repeat sequences. Subsequent removal of the antifungal drug can lead to a dramatic loss of the CNV and reversion to the progenitor genotype and drug susceptibility phenotype. These findings support a novel mechanism for the rapid acquisition of antifungal drug resistance and provide genomic evidence for the heterogeneity frequently observed in clinical settings.
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Affiliation(s)
- Robert T Todd
- Department of Microbiology and Immunology, University of Minnesota Medical SchoolMinneapolis, MinnesotaUnited States
| | - Anna Selmecki
- Department of Microbiology and Immunology, University of Minnesota Medical SchoolMinneapolis, MinnesotaUnited States
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33
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Beardsley J, Hoang NLT, Kibengo FM, Tung NLN, Binh TQ, Hung LQ, Chierakul W, Thwaites GE, Chau NVV, Nguyen TTT, Geskus RB, Day JN. Do Intracerebral Cytokine Responses Explain the Harmful Effects of Dexamethasone in Human Immunodeficiency Virus-associated Cryptococcal Meningitis? Clin Infect Dis 2020; 68:1494-1501. [PMID: 30169607 PMCID: PMC6481995 DOI: 10.1093/cid/ciy725] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
Background The CryptoDex trial showed that dexamethasone caused poorer clinical outcomes and slowed fungal clearance in human immunodeficiency virus–associated cryptococcal meningitis. We analyzed cerebrospinal fluid (CSF) cytokine concentrations from participants over the first week of treatment to investigate mechanisms of harm and test 2 hypotheses: (1) dexamethasone reduced proinflammatory cytokine concentrations, leading to poorer outcomes and (2) leukotriene A4 hydrolase (LTA4H) genotype influenced the clinical impact of dexamethasone, as observed in tuberculous meningitis. Methods We included participants from Vietnam, Thailand, and Uganda. Using the Luminex system, we measured CSF concentrations of the following: interferon γ, tumor necrosis factor (TNF) α, granulocyte-macrophage colony-stimulating factor, monocyte chemoattractant 1, macrophage inflammatory protein 1α, and interleukin 6, 12p70, 8, 4, 10, and 17. We determined the LTA4H genotype based on the promoter region single-nucleotide polymorphism rs17525495. We assessed the impact of dexamethasone on cytokine concentration dynamics and the association between cytokine concentration dynamics and fungal clearance with mixed effect models. We measured the influence of LTA4H genotype on outcomes with Cox regression models. Results Dexamethasone increased the rate TNF-α concentration’s decline in (−0.13 log2pg/mL/d (95% confidence interval, −.22 to −.06 log2pg/mL/d; P = .03), which was associated with slower fungal clearance (correlation, −0.62; 95% confidence interval, −.83 to −.26). LTA4H genotype had no statistically significant impact on outcome or response to dexamethasone therapy. Better clinical outcomes were associated with higher baseline concentrations of interferon γ. Conclusions Dexamethasone may slow fungal clearance and worsen outcomes by increasing TNF-α concentration’s rate of decline.
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Affiliation(s)
- Justin Beardsley
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom.,Marie Bashir Institute, University of Sydney, New South Wales, Australia
| | - Nhat L T Hoang
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | - Tran Q Binh
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Le Q Hung
- Department of Tropical Medicine, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Wirongrong Chierakul
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | | | - Thuong T T Nguyen
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
| | - Jeremy N Day
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford, United Kingdom
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Beattie SR, Schnicker NJ, Murante T, Kettimuthu K, Williams NS, Gakhar L, Krysan DJ. Benzothiourea Derivatives Target the Secretory Pathway of the Human Fungal Pathogen Cryptococcus neoformans. ACS Infect Dis 2020; 6:529-539. [PMID: 32070095 DOI: 10.1021/acsinfecdis.9b00478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cryptococcus neoformans is one of the most important human fungal pathogens and causes life-threatening meningoencephalitis in immunocompromised patients. The current gold standard therapy for C. neoformans meningoencephalitis is based on medications that are over 50 years old and is not readily available in regions with high disease burden. Here, we report the mycologic, mechanistic, and pharmacologic characterization of a set of benzothioureas with highly selective fungicidal activity against C. neoformans. In addition, to direct antifungal activity, benzothioureas inhibit C. neoformans virulence traits. On the basis of a set of phenotypic, biochemical, and biophysical assays, the benzothioureas (BTUs) inhibit the late secretory pathway (post-Golgi), possibly through a direct interaction with Sav1, an orthologue of the Sec4-class small GTPase. Importantly, pharmacological characterization of the BTUs indicates it readily penetrates the blood-brain barrier. Together, our data support the further development of this scaffold as an antifungal agent with a novel mechanism of action against C. neoformans.
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Affiliation(s)
- Sarah R. Beattie
- Department of Pediatrics, Carver College of Medicine, University of Iowa, 25 South Grand Avenue, Iowa City, Iowa 52245, United States
| | - Nicholas J. Schnicker
- Protein and Crystallography Facility, Carver College of Medicine, University of Iowa, 51 Newton Road, Iowa City, Iowa 52245, United States
| | - Thomas Murante
- Department of Pediatrics, University of Rochester, 601 Elmwood Avenue, Rochester, New York 14642, United States
| | - Kavitha Kettimuthu
- Department of Biochemistry, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, Texas 75390, United States
| | - Noelle S. Williams
- Department of Biochemistry, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, Texas 75390, United States
| | - Lokesh Gakhar
- Protein and Crystallography Facility, Carver College of Medicine, University of Iowa, 51 Newton Road, Iowa City, Iowa 52245, United States
- Department of Biochemistry, Carver College of Medicine, University of Iowa, 51 Newton Road, Iowa City, Iowa 52245, United States
| | - Damian J. Krysan
- Department of Pediatrics, Carver College of Medicine, University of Iowa, 25 South Grand Avenue, Iowa City, Iowa 52245, United States
- Department of Microbiology and Immunology, Carver College of Medicine, University of Iowa, 25 South Grand Avenue, Iowa City, Iowa 52245, United States
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Chagas OJ, Buccheri R, de Souza Carvalho Melhem M, Szeszs W, dos Anjos Martins M, de Oliveira L, Marcusso R, Santos DW. Usefulness of Yeast Cell Counting and Lack of Clinical Correlation of the Antifungal Susceptibility Testing Results in Management of Aids-associated Cryptococcal Meningitis. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00368-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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Tugume L, Rhein J, Hullsiek KH, Mpoza E, Kiggundu R, Ssebambulidde K, Schutz C, Taseera K, Williams DA, Abassi M, Muzoora C, Musubire AK, Meintjes G, Meya DB, Boulware DR. HIV-Associated Cryptococcal Meningitis Occurring at Relatively Higher CD4 Counts. J Infect Dis 2020; 219:877-883. [PMID: 30325463 DOI: 10.1093/infdis/jiy602] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 10/10/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Cryptococcal meningitis can occur in persons with less-apparent immunosuppression. We evaluated clinical characteristics and outcomes of persons with HIV-related Cryptococcus presenting with higher CD4 counts. METHODS We enrolled 736 participants from 2 prospective cohorts in Uganda and South Africa from November 2010 to May 2017. We compared participants with CD4 <50, 50-99, or ≥100 cells/μL by clinical characteristics, cerebrospinal fluid (CSF) parameters, and 18-week survival. RESULTS Among first episode of cryptococcosis, 9% presented with CD4 ≥100 cells/μL. Participants with CD4 ≥100 cells/μL presented more often with altered mental status (52% vs 39%; P = .03) despite a 10-fold lower initial median CSF fungal burden of 7850 (interquartile range [IQR] 860-65500) versus 79000 (IQR 7400-380000) colony forming units/mL (P < .001). Participants with CD4 ≥100 cells/μL had higher median CSF levels of interferon-gamma, interleukin (IL)-6, IL-8, and IL-13, and lower monocyte chemokine, CCL2 (P < .01 for each). Death within 18 weeks occurred in 47% with CD4 <50, 35% with CD4 50-99, and 40% with CD4 ≥100 cells/μL (P = .04). CONCLUSION HIV-infected individuals developing cryptococcal meningitis with CD4 ≥100 cells/μL presented more frequently with altered mental status despite having 10-fold lower fungal burden and with greater Th2 (IL-13) immune response. Higher CD4 count was protective despite an increased propensity for immune-mediated damage, consistent with damage-response framework. CLINICAL TRIAL REGISTRATION NCT01075152 and NCT01802385.
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Affiliation(s)
- Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joshua Rhein
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | | | - Darlisha A Williams
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | - Mahsa Abassi
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - Abdu K Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
| | | | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,University of Minnesota, Minneapolis
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Efficacy of ventriculoperitoneal shunting in patients with cryptococcal meningitis with intracranial hypertension. Int J Infect Dis 2019; 88:102-109. [PMID: 31499210 DOI: 10.1016/j.ijid.2019.08.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/14/2019] [Accepted: 08/31/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal (VP) shunting in cryptococcal meningitis (CM) patients with high intracranial pressure (ICP) has been studied extensively. METHODS A total of 74 CM patients with ICP were identified, including 27 patients with or without ventriculomegaly receiving VP shunting. RESULTS Through retrospective analysis, there was an obvious decline in ICP as well as Cryptococcus count after VP shunting. Damage to the cranial nerves was improved after the surgery. For those patients receiving VP shunting, there was an obvious decline in ICP as well as Cryptococcus count, with less usage of mannitol. Hydrocephalus or ventriculomegaly was improved, and both the clearance time of Cryptococcus and the hospitalization time were shortened (p<0.05). The complications of VP shunting were not common. CONCLUSIONS For patients diagnosed with CM and with apparent ICP, VP shunting can be considered regardless of whether there is damage to the cranial nerves or hydrocephaly.
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Ross AJ, Ndayishimiye E. A review of the management and outcome of patients admitted with cryptococcal meningitis at a regional hospital in KwaZulu-Natal province. S Afr Fam Pract (2004) 2019. [DOI: 10.1080/20786190.2019.1607480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Andrew J Ross
- Department of Family Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Egide Ndayishimiye
- Prince Mshiyeni Memorial Hospital, Master of Public Health (MPH), University of KwaZulu-Natal, Durban, South Africa
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Beardsley J, Sorrell TC, Chen SCA. Central Nervous System Cryptococcal Infections in Non-HIV Infected Patients. J Fungi (Basel) 2019; 5:jof5030071. [PMID: 31382367 PMCID: PMC6787755 DOI: 10.3390/jof5030071] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022] Open
Abstract
Central nervous system (CNS) cryptococcosis in non-HIV infected patients affects solid organ transplant (SOT) recipients, patients with malignancy, rheumatic disorders, other immunosuppressive conditions and immunocompetent hosts. More recently described risks include the use of newer biologicals and recreational intravenous drug use. Disease is caused by Cryptococcus neoformans and Cryptococcus gattii species complex; C. gattii is endemic in several geographic regions and has caused outbreaks in North America. Major virulence determinants are the polysaccharide capsule, melanin and several ‘invasins’. Cryptococcal plb1, laccase and urease are essential for dissemination from lung to CNS and crossing the blood–brain barrier. Meningo-encephalitis is common but intracerebral infection or hydrocephalus also occur, and are relatively frequent in C. gattii infection. Complications include neurologic deficits, raised intracranial pressure (ICP) and disseminated disease. Diagnosis relies on culture, phenotypic identification methods, and cryptococcal antigen detection. Molecular methods can assist. Preferred induction antifungal therapy is a lipid amphotericin B formulation (amphotericin B deoxycholate may be used in non-transplant patients) plus 5-flucytosine for 2–6 weeks depending on host type followed by consolidation/maintenance therapy with fluconazole for 12 months or longer. Control of raised ICP is essential. Clinicians should be vigilant for immune reconstitution inflammatory syndrome.
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Affiliation(s)
- Justin Beardsley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia
- Westmead Institute for Medical Research, Westmead, Sydney 2145, Australia
| | - Sharon C-A Chen
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital and the Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney 2145, Australia.
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Rhein J, Huppler Hullsiek K, Tugume L, Nuwagira E, Mpoza E, Evans EE, Kiggundu R, Pastick KA, Ssebambulidde K, Akampurira A, Williams DA, Bangdiwala AS, Abassi M, Musubire AK, Nicol MR, Muzoora C, Meya DB, Boulware DR. Adjunctive sertraline for HIV-associated cryptococcal meningitis: a randomised, placebo-controlled, double-blind phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2019; 19:843-851. [PMID: 31345462 PMCID: PMC7041360 DOI: 10.1016/s1473-3099(19)30127-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Identifying new antifungals for cryptococcal meningitis is a priority given the inadequacy of current therapy. Sertraline has previously shown in vitro and in vivo activity against cryptococcus. We aimed to assess the efficacy and cost-effectiveness of adjunctive sertraline in adults with HIV-associated cryptococcal meningitis compared with placebo. METHODS In this double-blind, randomised, placebo-controlled trial, we recruited HIV-positive adults with cryptococcal meningitis from two hospitals in Uganda. Participants were randomly assigned (1:1) to receive standard therapy with 7-14 days of intravenous amphotericin B (0·7-1·0 mg/kg per day) and oral fluconazole (starting at 800 mg/day) with either adjunctive sertraline or placebo. Sertraline was administered orally or via nasogastric tube at a dose of 400 mg/day for 2 weeks, followed by 200 mg/day for 12 weeks, then tapered off over 3 weeks. The primary endpoint was 18-week survival, analysed by intention-to-treat. This study is registered with ClinicalTrials.gov, number NCT01802385. FINDINGS Between March 9, 2015, and May 29, 2017, we screened 842 patients with suspected meningitis and enrolled 460 of a planned 550 participants, at which point the trial was stopped for futility. Three patients in the sertraline group and three patients in the placebo group were lost to follow-up and therefore discontinued before study end. At 18 weeks, 120 (52%) of 229 patients in the sertraline group and 106 (46%) of 231 patients in the placebo group had died (hazard ratio 1·21, 95% CI 0·93-1·57; p=0·15). The fungal clearance rate from cerebrospinal fluid was similar between groups (0·43 -log10 CFU/mL per day [95% CI 0·37-0·50] in the sertraline group vs 0·47 -log10 CFU/mL per day [0·40-0·54] in the placebo group; p=0·59), as was occurrence of grade 4 or 5 adverse events (72 [31%] of 229 vs 75 [32%] of 231; p=0·98), most of which were associated with amphotericin B toxicity. INTERPRETATION Sertraline did not reduce mortality and should not be used to treat patients with HIV-associated cryptococcal meningitis. The reasons for sertraline inactivity appear to be multifactorial and might be associated with insufficient duration of therapeutic sertraline concentrations. FUNDING National Institutes of Health and Medical Research Council, Wellcome Trust.
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Affiliation(s)
- Joshua Rhein
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Lillian Tugume
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Edwin Nuwagira
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edward Mpoza
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Emily E. Evans
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Reuben Kiggundu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Katelyn A. Pastick
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | | | - Darlisha A. Williams
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Mahsa Abassi
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Abdu K. Musubire
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David B. Meya
- University of Minnesota, Minneapolis, MN, USA,Infectious Diseases Institute, Makerere University, Kampala, Uganda,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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Li Z, Liu Y, Chong Y, Li X, Jie Y, Zheng X, Yan Y. Fluconazole plus flucytosine is a good alternative therapy for non-HIV and non-transplant-associated cryptococcal meningitis: A retrospective cohort study. Mycoses 2019; 62:686-691. [PMID: 31120606 PMCID: PMC6852269 DOI: 10.1111/myc.12944] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 12/29/2022]
Abstract
Cryptococcal meningitis (CM) carries a high risk of mortality with increasing incidences in immune competent hosts. Current treatments are not well tolerated, and evaluation of other treatments is needed. Fluconazole and 5‐flucytosine in treating immune competent hosts have not been characterised. To evaluate the efficacy of fluconazole and 5‐flucytosine in treating non‐HIV‐ and non‐transplant‐associated CM. We performed a retrospective cohort study of the outcomes in immune competent patients with CM treated with fluconazole and 5‐flucytosine or deoxycholate‐amphotericin B and 5‐flucytosine. The primary outcome was treatment response evaluated at the 12th week after initiation of antifungal therapy. A total of 43 and 47 patients received amphotericin B deoxycholate and 5‐flucytosine or fluconazole and 5‐flucytosine, respectively. A total of 38 (88.4%) patients cannot tolerate recommended doses of amphotericin B deoxycholate and 5‐flucytosine (patients needed dose reduction during the treatment). Patients given fluconazole and 5‐flucytosine had higher baseline cryptococcal burdens (median 3632 versus 900 cryptococci/mL, P = 0.008). No significant differences were seen in cryptococcus clearance (74.4% vs 70.2%, P = 0.814), treatment time (39 days, 20‐69 days vs 21 days, 7‐63 days, P = 0.107) and successful response (including complete and partial responses) rates (69.7% vs 72.3%, P = 0.820). Fluconazole and 5‐flucytosine treatment had lower total adverse events (19.1% vs 90.7%, P < 0.001). Fluconazole and 5‐flucytosine had relatively high efficacy with few adverse events in treating CM. Fluconazole and 5‐flucytosine therapy is promising in patients that do not tolerate or are not suited for amphotericin B deoxycholate treatment.
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Affiliation(s)
- Zhanyi Li
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yu Liu
- Department of General Surgery (Thyroid and Breast), Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yutian Chong
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiangyong Li
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yusheng Jie
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Zheng
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Yan
- Department of Infectious Diseases, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Abstract
Cryptococcus neoformans is an encapsulated yeast responsible for approximately a quarter of a million deaths worldwide annually despite therapy, and upwards of 11% of HIV/AIDS-related deaths, rivaling the impact of tuberculosis and malaria. However, the most effective antifungal agent, amphotericin B, requires intravenous delivery and has significant renal and hematopoietic toxicity, making it difficult to utilize, especially in resource-limited settings. The present studies describe a new nanoparticle crystal encapsulated formulation of amphotericin B known as encochleated amphotericin B (CAmB) that seeks to provide an oral formulation that is low in toxicity and cost. Using a 3-day delayed model of murine cryptococcal meningoencephalitis and a large inoculum of a highly virulent strain of serotype A C. neoformans, CAmB, in combination with flucytosine, was found to have efficacy equivalent to parental amphotericin B deoxycholate with flucytosine and superior to oral fluconazole without untoward toxicity. Transport of fluorescent CAmB particles to brain as well as significant brain levels of amphotericin drug was demonstrated in treated mice, and immunological profiles were similar to those of mice treated with conventional amphotericin B. Additional toxicity studies using a standardized rat model showed negligible toxicity after a 28-day treatment schedule. These studies thus offer the potential for an efficacious oral formulation of a known fungicidal drug against intrathecal cryptococcal disease.IMPORTANCE Cryptococcus neoformans is a significant global fungal pathogen that kills an estimated quarter of a million HIV-infected individuals yearly and has poor outcomes despite therapy. The most effective therapy, amphotericin B, is highly effective in killing the fungus but is available only in highly toxic, intravenous formulations that are unavailable in most of the developing world, where cryptococcal disease in most prevalent. For example, in Ethiopia, reliance on the orally available antifungal fluconazole results in high mortality, even when initiated as preemptive therapy at the time of HIV diagnosis. Thus, alternative agents could result in significant saving of lives. Toward this end, the present work describes the development of a new formulation of amphotericin B (CAmB) that encapsulates the drug as a crystal lipid nanoparticle that facilitates oral absorption and prevents toxicity. Successful oral absorption of the drug was demonstrated in a mouse model that, in combination with the antifungal flucytosine, provided efficacy equal to a parental preparation of amphotericin B plus flucytosine. These studies demonstrate the potential for CAmB in combination with flucytosine to provide an effective oral formulation of a well-known, potent fungicidal drug combination.
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The Mouse Inhalation Model of Cryptococcus neoformans Infection Recapitulates Strain Virulence in Humans and Shows that Closely Related Strains Can Possess Differential Virulence. Infect Immun 2019; 87:IAI.00046-19. [PMID: 30833336 DOI: 10.1128/iai.00046-19] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/22/2019] [Indexed: 12/30/2022] Open
Abstract
Cryptococcal meningitis (CM) causes high rates of HIV-related mortality, yet the Cryptococcus factors influencing patient outcome are not well understood. Pathogen-specific traits, such as the strain genotype and degree of antigen shedding, are associated with the clinical outcome, but the underlying biology remains elusive. In this study, we examined factors determining disease outcome in HIV-infected cryptococcal meningitis patients infected with Cryptococcus neoformans strains with the same multilocus sequence type (MLST). Both patient mortality and survival were observed during infections with the same sequence type. Disease outcome was not associated with the patient CD4 count. Patient mortality was associated with higher cryptococcal antigen levels, the cerebrospinal fluid (CSF) fungal burden by quantitative culture, and low CSF fungal clearance. The virulence of a subset of clinical strains with the same sequence type was analyzed using a mouse inhalation model of cryptococcosis. We showed a strong association between human and mouse mortality rates, demonstrating that the mouse inhalation model recapitulates human infection. Similar to human infection, the ability to multiply in vivo, demonstrated by a high fungal burden in lung and brain tissues, was associated with mouse mortality. Mouse survival time was not associated with single C. neoformans virulence factors in vitro or in vivo; rather, a trend in survival time correlated with a suite of traits. These observations show that MLST-derived genotype similarities between C. neoformans strains do not necessarily translate into similar virulence either in the mouse model or in human patients. In addition, our results show that in vitro assays do not fully reproduce in vivo conditions that influence C. neoformans virulence.
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Sood V, Pattanashetti N, Ramachandran R, Gupta KL. Deceptively asymptomatic cryptococcaemia in a renal transplant recipient: the lull before a storm. BMJ Case Rep 2019; 12:12/4/e228115. [PMID: 31005864 DOI: 10.1136/bcr-2018-228115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryptococcal infection constitutes around 3% of opportunistic infections in solid organ transplant recipients. Most common organ affected in renal transplant recipients (RTRs) is central nervous system and usually presents with chronic meningoencephalitis (CME). Ischaemic stroke as a consequence of cryptococcal meningoencephalitisis rare and possibly due to the involvement of intracranial vessel by exudates causing vasculitis-related thrombosis. In this context, we describe an unusual case of asymptomatic cryptococcaemia in an RTR, progressing on to acute ischaemic stroke secondary to acute CME with near complete neurological recovery following timely diagnosis, early and appropriate antifungal treatment. The index case attempts to re-emphasise the significance of mandatory screening required to exclude the possibility of dissemination of cryptococcaemia in RTRs besides highlighting the requirement of prolonged induction phase with combination therapy, particularly in presence of stroke.
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Affiliation(s)
- Vivek Sood
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Navin Pattanashetti
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Krishan Lal Gupta
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Jarvis JN, Leeme TB, Molefi M, Chofle AA, Bidwell G, Tsholo K, Tlhako N, Mawoko N, Patel RKK, Tenforde MW, Muthoga C, Bisson GP, Kidola J, Changalucha J, Lawrence D, Jaffar S, Hope W, Molloy SF, Harrison TS. Short-course High-dose Liposomal Amphotericin B for Human Immunodeficiency Virus-associated Cryptococcal Meningitis: A Phase 2 Randomized Controlled Trial. Clin Infect Dis 2019; 68:393-401. [PMID: 29945252 PMCID: PMC6336908 DOI: 10.1093/cid/ciy515] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 06/18/2018] [Indexed: 01/03/2023] Open
Abstract
Background We performed a phase 2 noninferiority trial examining the early fungicidal activity (EFA) of 3 short-course, high-dose liposomal amphotericin B (L-AmB) regimens for cryptococcal meningitis (CM) in Tanzania and Botswana. Methods Human immunodeficiency virus (HIV)-infected adults with CM were randomized to (i) L-AmB 10 mg/kg on day 1 (single dose); (ii) L-AmB 10 mg/kg on day 1 and 5 mg/kg on day 3 (2 doses); (iii) L-AmB 10 mg/kg on day 1 and 5 mg/kg on days 3 and 7 (3 doses); or (iv) L-AmB 3 mg/kg/day for 14 days (control). All patients also received oral fluconazole 1200 mg/day for 14 days. Primary endpoint was mean rate of clearance of cerebrospinal fluid cryptococcal infection (EFA). Noninferiority was defined as an upper limit of the 2-sided 95% confidence interval (CI) of difference in EFA between intervention and control <0.2 log10 colony-forming units (CFU)/mL/day. Results Eighty participants were enrolled. EFA for daily L-AmB was -0.41 log10 CFU/mL/day (standard deviation, 0.11; n = 17). Difference in mean EFA from control was -0.11 (95% CI, -.29 to .07) log10 CFU/mL/day faster with single dose (n = 16); -0.05 (95% CI, -.20 to .10) log10 CFU/mL/day faster with 2 doses (n = 18); and -0.13 (95% CI, -.35 to .09) log10 CFU/mL/day faster with 3 doses (n = 18). EFA in all short-course arms was noninferior to control. Ten-week mortality was 29% (n = 23) with no statistical difference between arms. All arms were well tolerated. Conclusions Single-dose 10 mg/kg L-AmB was well tolerated and led to noninferior EFA compared to 14 days of 3 mg/kg/day L-AmB in HIV-associated CM. Induction based on a single 10 mg/kg L-AmB dose is being taken forward to a phase 3 clinical endpoint trial. Clinical Trials Registration ISRCTN 10248064.
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Affiliation(s)
- Joseph N Jarvis
- Botswana–University of Pennsylvania Partnership, Gaborone
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
- University of Botswana, Gaborone
| | - Tshepo B Leeme
- Botswana–University of Pennsylvania Partnership, Gaborone
| | | | | | | | - Katlego Tsholo
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Nametso Tlhako
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Norah Mawoko
- Botswana–University of Pennsylvania Partnership, Gaborone
| | - Raju K K Patel
- Botswana–University of Pennsylvania Partnership, Gaborone
| | | | | | - Gregory P Bisson
- Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | - David Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, United Kingdom
| | - Síle F Molloy
- Centre for Global Health, Institute for Infection and Immunity, St George’s University of London, United Kingdom
| | - Thomas S Harrison
- Centre for Global Health, Institute for Infection and Immunity, St George’s University of London, United Kingdom
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Transcriptional Profiling of Patient Isolates Identifies a Novel TOR/Starvation Regulatory Pathway in Cryptococcal Virulence. mBio 2018; 9:mBio.02353-18. [PMID: 30563896 PMCID: PMC6299223 DOI: 10.1128/mbio.02353-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Human infection with Cryptococcus causes up to a quarter of a million AIDS-related deaths annually and is the most common cause of nonviral meningitis in the United States. As an opportunistic fungal pathogen, Cryptococcus neoformans is distinguished by its ability to adapt to diverse host environments, including plants, amoebae, and mammals. In the present study, comparative transcriptomics of the fungus within human cerebrospinal fluid identified expression profiles representative of low-nutrient adaptive responses. Transcriptomics of fungal isolates from a cohort of HIV/AIDS patients identified high expression levels of an alternative carbon nutrient transporter gene, STL1, to be associated with poor early fungicidal activity, an important clinical prognostic marker. Mouse modeling and pathway analysis demonstrated a role for STL1 in mammalian pathogenesis and revealed that STL1 expression is regulated by a novel multigene regulatory mechanism involving the CAC2 subunit of the chromatin assembly complex 1, CAF-1. In this pathway, the global regulator of virulence gene VAD1 was found to transcriptionally regulate a cryptococcal homolog of a cytosolic protein, Ecm15, in turn required for nuclear transport of the Cac2 protein. Derepression of STL1 by the CAC2-containing CAF-1 complex was mediated by Cac2 and modulated binding and suppression of the STL1 enhancer element. Derepression of STL1 resulted in enhanced survival and growth of the fungus in the presence of low-nutrient, alternative carbon sources, facilitating virulence in mice. This study underscores the utility of ex vivo expression profiling of fungal clinical isolates and provides fundamental genetic understanding of saprophyte adaption to the human host.IMPORTANCE Cryptococcus is a fungal pathogen that kills an estimated quarter of a million individuals yearly and is the most common cause of nonviral meningitis in the United States. The fungus is carried in about 10% of the adult population and, after reactivation, causes disease in a wide variety of immunosuppressed individuals, including the HIV infected and patients receiving transplant conditioning, cancer therapy, or corticosteroid therapy for autoimmune diseases. The fungus is widely carried in the soil but can also cause infections in plants and mammals. However, the mechanisms for this widespread ability to infect a variety of hosts are poorly understood. The present study identified adaptation to low nutrients as a key property that allows the fungus to inhabit these diverse environments. Further studies identified a nutrient transporter gene, STL1, to be upregulated under low nutrients and to be associated with early fungicidal activity, a marker of poor clinical outcome in a cohort of HIV/AIDS patients. Understanding molecular mechanisms involved in adaptation to the human host may help to design better methods of control and treatment of widely dispersed fungal pathogens such as Cryptococcus.
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Lawrence DS, Youssouf N, Molloy SLF, Alanio A, Alufandika M, Boulware DR, Boyer-Chammard T, Chen T, Dromer F, Hlupeni A, Hope W, Hosseinipour MC, Kanyama C, Lortholary O, Loyse A, Meya DB, Mosepele M, Muzoora C, Mwandumba HC, Ndhlovu CE, Niessen L, Schutz C, Stott KE, Wang D, Lalloo DG, Meintjes G, Jaffar S, Harrison TS, Jarvis JN. AMBIsome Therapy Induction OptimisatioN (AMBITION): High Dose AmBisome for Cryptococcal Meningitis Induction Therapy in sub-Saharan Africa: Study Protocol for a Phase 3 Randomised Controlled Non-Inferiority Trial. Trials 2018; 19:649. [PMID: 30470259 PMCID: PMC6251219 DOI: 10.1186/s13063-018-3026-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cryptococcal meningitis (CM) is a major cause of mortality in HIV programmes in Africa despite increasing access to antiretroviral therapy (ART). Mortality is driven in part by limited availability of amphotericin-based treatment, drug-induced toxicities of amphotericin B deoxycholate and prolonged hospital admissions. A single, high-dose of liposomal amphotericin (L-AmB, Ambisome) on a fluconazole backbone has been reported as non-inferior to 14 days of standard dose L-AmB in reducing fungal burden. This trial examines whether single, high-dose L-AmB given with high-dose fluconazole and flucytosine is non-inferior to a seven-day course of amphotericin B deoxycholate plus flucytosine (the current World Health Organization [WHO] recommended treatment regimen). METHODS An open-label phase III randomised controlled non-inferiority trial conducted in five countries in sub-Saharan Africa: Botswana, Malawi, South Africa, Uganda and Zimbabwe. The trial will compare CM induction therapy with (1) a single dose (10 mg/kg) of L-AmB given with 14 days of fluconazole (1200 mg/day) and flucytosine (100 mg/kg/day) to (2) seven days amphotericin B deoxycholate (1 mg/kg/day) given alongside seven days of flucytosine (100 mg/kg/day) followed by seven days of fluconazole (1200 mg/day). The primary endpoint is all-cause mortality at ten weeks with a non-inferiority margin of 10% and 90% power. Secondary endpoints are early fungicidal activity, proportion of grade III/IV adverse events, pharmacokinetic parameters and pharmacokinetic/pharmacodynamic associations, health service costs, all-cause mortality within the first two and four weeks, all-cause mortality within the first ten weeks (superiority analysis) and rates of CM relapse, immune reconstitution inflammatory syndrome and disability at ten weeks. A total of 850 patients aged ≥ 18 years with a first episode of HIV-associated CM will be enrolled (425 randomised to each arm). All patients will be followed for 16 weeks. All patients will receive consolidation therapy with fluconazole 800 mg/day to complete ten weeks of treatment, followed by fluconazole maintenance and ART as per local guidance. DISCUSSION A safe, sustainable and easy to administer regimen of L-AmB that is non-inferior to seven days of daily amphotericin B deoxycholate therapy may reduce the number of adverse events seen in patients treated with amphotericin B deoxycholate and shorten hospital admissions, providing a highly favourable and implementable alternative to the current WHO recommended first-line treatment. TRIAL REGISTRATION ISRCTN, ISRCTN72509687 . Registered on 13 July 2017.
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Affiliation(s)
- David S. Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nabila Youssouf
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Síle L. F. Molloy
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Alexandre Alanio
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Melanie Alufandika
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
| | - David R. Boulware
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Timothée Boyer-Chammard
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Tao Chen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Francoise Dromer
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Admire Hlupeni
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | | | - Cecilia Kanyama
- Lilongwe Medical Relief Trust (UNC Project), Lilongwe, Malawi
| | - Oliver Lortholary
- Molecular Mycology Unit and National Reference Centre for Invasive Mycoses, Institut Pasteur, Paris, France
| | - Angela Loyse
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - David B. Meya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Mosepele Mosepele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Internal Medicine, University of Botswana, Gaborone, Botswana
| | - Conrad Muzoora
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henry C. Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chiratidzo E. Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Louis Niessen
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Charlotte Schutz
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Katharine E. Stott
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine, Blantyre, Malawi
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David G. Lalloo
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shabbar Jaffar
- Department of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas S. Harrison
- Research Centre for Infection and Immunity, St George’s University of London, London, UK
| | - Joseph N. Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
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Jiang YK, Wu JQ, Zhao HZ, Wang X, Wang RY, Zhou LH, Yip CW, Huang LP, Cheng JH, Chen YH, Li H, Zhu LP, Weng XH. Genetic influence of Toll-like receptors on non-HIV cryptococcal meningitis: An observational cohort study. EBioMedicine 2018; 37:401-409. [PMID: 30366814 PMCID: PMC6284510 DOI: 10.1016/j.ebiom.2018.10.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 11/28/2022] Open
Abstract
Background Cryptococcal meningitis (CM) is a significant source of mortality, the pathogenesis of which has not been fully understood, especially in non-HIV infected populations. We aimed to explore the potential genetic influence of Toll-like receptor (TLR) on non-HIV CM. Methods This observational cohort study was done in two stages: a discovery stage and a validation stage. A case-control genetic association study was conducted between 159 non-HIV CM patients and 468 healthy controls. TLR SNPs significantly related to susceptibility went further validation in a second cohort of 583 subjects from a certain district. Associations among TLR SNPs, cerebrospinal fluid (CSF) cytokine concentrations, and clinical severity were explored in a third cohort of 99 previously untreated non-HIV CM patients. Logistic regression model was used to determine the independent predictors for disease severity. Findings In the discovery stage, eight TLR SNPs exhibited significant genetic susceptibility to non-HIV CM, one of which was validated in a population validation of HIV-infected cases while none survived in non-HIV cases. CSF cytokine detections showed that 18 cytokines were significantly over-expressed in severely ill patients. Two of the 8 SNPs (rs5743604 and rs3804099) were also significantly associated with disease severity. Specifically, the rs3804099 C/T genotype was further found to be correlated to 12 of the 18 up-regulated cytokines in severe patients. In addition, high levels of interleukin (IL)-10 in CSF (OR 2·97, 95% CI 1·49–5·90; p = 0·002) was suggested as an independent predictor for severity after adjusted for possible confounders. Interpretation TLR participates in both the occurrence and the pathogenesis of non-HIV CM. The in situ immune responses of CM were under genetic influence of TLR and contributed to disease severity. Fund National Natural Science Foundation of China and National Key Basic Research Program of China (973 Program).
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Affiliation(s)
- Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ji-Qin Wu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ching-Wan Yip
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ya-Hong Chen
- Department of Infectious Diseases, Mengchao Hepatobiliary Hospital, Fujian Medical University, Fuzhou, Fujian, China; Fujian HIV/AIDS Diagnosis and Treatment Center, Fuzhou, Fujian, China
| | - Hua Li
- Department of Neurology, No. 476 Hospital of Fuzhou General Hospital, Nanjing Military Region, Chinese People's Liberation Army, Fuzhou, Fujian, China
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.
| | - Xin-Hua Weng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
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Helal M, Dadachova E. Radioimmunotherapy as a Novel Approach in HIV, Bacterial, and Fungal Infectious Diseases. Cancer Biother Radiopharm 2018; 33:330-335. [PMID: 30133305 DOI: 10.1089/cbr.2018.2481] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
In the past several decades, many antimicrobial agents have been used in treating different fungal, bacterial, and viral infections. However, these agents have faced challenges such as pronounced side-effect profiles and pathogen resistance. In addition, a cure for many chronic infections such as human immunodeficiency virus (HIV) has not been achieved, and the incidence of opportunistic infections in immunocompromised patients has increased significantly in the past decades. Therefore, an alternative strategy for combating these infections is needed. Radioimmunotherapy (RIT) has been proposed to be a valuable tool in the management of such infections. The side-effects associated with RIT are minimal as the targeted antigens are only expressed on microbial or infected cells. RIT demonstrated impressive potency in eradicating pathogens in animal models and patient samples. Cryptococcus neoformans, HIV, and Bacillus anthracis are few examples of infections for which RIT has been an effective treatment using radionuclides such as bismuth-213 (213Bi) or rhenium-188 (188Re).
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Affiliation(s)
- Muath Helal
- University of Saskatchewan , Saskatoon, Saskatchewan, Canada
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