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Chen TK, Batra JS, Michalik DE, Casillas J, Patel R, Ruiz ME, Hara H, Patel B, Kadapakkam M, Ch'Ng J, Small CB, Zagaliotis P, Ragsdale CE, Leal LO, Roilides E, Walsh TJ. Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor (rhu GM-CSF) as Adjuvant Therapy for Invasive Fungal Diseases. Open Forum Infect Dis 2022; 9:ofac535. [PMID: 36381625 PMCID: PMC9645583 DOI: 10.1093/ofid/ofac535] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/07/2022] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Sargramostim (yeast-derived, glycosylated recombinant human granulocyte-macrophage colony-stimulating factor [rhu GM-CSF]) augments innate and adaptive immune responses and accelerates hematopoietic recovery of chemotherapy-induced neutropenia. However, considerably less is known about its efficacy as adjunctive immunotherapy against invasive fungal diseases (IFDs). METHODS The clinical courses of 15 patients with pediatric malignancies and IFDs treated adjunctively with sargramostim at a single institution were analyzed in a retrospective cohort review. Further, a systematic review of published reports of rhu GM-CSF for IFDs was also conducted. RESULTS Among 65 cases, 15 were newly described pediatric patients and 50 were previously published cases of IFDs treated with rhu GM-CSF. Among the newly reported pediatric patients, IFDs were caused by Candida spp., Trichosporon sp., and molds (Aspergillus spp., Rhizopus sp., Lichtheimia sp., and Scedosporium sp). Twelve (80%) were neutropenic at baseline, and 12 (80%) were refractory to antifungal therapy. Among 12 evaluable patients, the overall response rate was 92% (8 [67%] complete responses, 3 [25%] partial responses, and 1 [8%] stable). Treatment is ongoing in the remaining 3 patients. Among 50 published cases (15 Candida spp., 13 Mucorales, 11 Aspergillus spp., 11 other organisms), 20 (40%) had baseline neutropenia and 36 (72%) were refractory to standard therapy before rhu GM-CSF administration. Consistent with responses in the newly reported patients, the overall response rate in the literature review was 82% (40 [80%] complete responses, 1 [2%] partial response, and 9 [18%] no response). CONCLUSIONS Sargramostim may be a potential adjunctive immunomodulator for selected patients with hematological malignancies and refractory IFDs.
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Affiliation(s)
- Tempe K Chen
- Department of Pediatric Infectious Diseases, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Department of Pediatrics, Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, USA
| | - Jagmohan S Batra
- Department of Pediatric Infectious Diseases, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Department of Pediatrics, Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, USA
| | - David E Michalik
- Department of Pediatric Infectious Diseases, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Department of Pediatrics, Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California, USA
| | - Jacqueline Casillas
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Ramesh Patel
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Maritza E Ruiz
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Harneet Hara
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Bhavita Patel
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Meena Kadapakkam
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - James Ch'Ng
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children's & Women's Hospital Long Beach, Long Beach, California, USA
- Division of Hematology/Oncology, Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Catherine B Small
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
| | - Panagiotis Zagaliotis
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
- Department of Pharmacology and Therapeutics, School of Pharmacy, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Luis O Leal
- Partner Therapeutics, Inc., Lexington, Massachusetts, USA
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York, USA
- Center for Innovative Therapeutics and Diagnostics, Richmond, Virginia, USA
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The Host Immune Response to Scedosporium/ Lomentospora. J Fungi (Basel) 2021; 7:jof7020075. [PMID: 33499053 PMCID: PMC7912657 DOI: 10.3390/jof7020075] [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: 12/22/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 12/14/2022] Open
Abstract
Infections caused by the opportunistic pathogens Scedosporium/Lomentospora are on the rise. This causes problems in the clinic due to the difficulty in diagnosing and treating them. This review collates information published on immune response against these fungi, since an understanding of the mechanisms involved is of great interest in developing more effective strategies against them. Scedosporium/Lomentospora cell wall components, including peptidorhamnomannans (PRMs), α-glucans and glucosylceramides, are important immune response activators following their recognition by TLR2, TLR4 and Dectin-1 and through receptors that are yet unknown. After recognition, cytokine synthesis and antifungal activity of different phagocytes and epithelial cells is species-specific, highlighting the poor response by microglial cells against L. prolificans. Moreover, a great number of Scedosporium/Lomentospora antigens have been identified, most notably catalase, PRM and Hsp70 for their potential medical applicability. Against host immune response, these fungi contain evasion mechanisms, inducing host non-protective response, masking fungal molecular patterns, destructing host defense proteins and decreasing oxidative killing. In conclusion, although many advances have been made, many aspects remain to be elucidated and more research is necessary to shed light on the immune response to Scedosporium/Lomentospora.
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Duarte-Oliveira C, Rodrigues F, Gonçalves SM, Goldman GH, Carvalho A, Cunha C. The Cell Biology of the Trichosporon-Host Interaction. Front Cell Infect Microbiol 2017; 7:118. [PMID: 28439501 PMCID: PMC5383668 DOI: 10.3389/fcimb.2017.00118] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/23/2017] [Indexed: 11/13/2022] Open
Abstract
Fungi of the genus Trichosporon are increasingly recognized as causative agents of superficial and invasive fungal disease in humans. Although most species are considered commensals of the human skin and gastrointestinal tract, these basidiomycetes are an increasing cause of fungal disease among immunocompromised hosts, such as hematological patients and solid organ transplant recipients. The initiation of commensal or pathogenic programs by Trichosporon spp. involves the adaptation to the host microenvironment and its immune system. However, the exact virulence factors activated upon the transition to a pathogenic lifestyle, including the intricate biology of the cell wall, and how these interact with and subvert the host immune responses remain largely unknown. Here, we revisit our current understanding of the virulence attributes of Trichosporon spp., particularly T. asahii, and their interaction with the host immune system, and accommodate this knowledge within novel perspectives on fungal diagnostics and therapeutics.
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Affiliation(s)
- Cláudio Duarte-Oliveira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal.,ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Fernando Rodrigues
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal.,ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Samuel M Gonçalves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal.,ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Gustavo H Goldman
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São PauloSão Paulo, Brazil
| | - Agostinho Carvalho
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal.,ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Cristina Cunha
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal.,ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
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Montoya AM, González GM, Martinez-Castilla AM, Aguilar SA, Franco-Molina MA, Coronado-Cerda E, Rosas-Taraco AG. Cytokines profile in immunocompetent mice during Trichosporon asahii infection. Med Mycol 2017; 56:103-109. [DOI: 10.1093/mmy/myx018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 01/04/2017] [Indexed: 01/25/2023] Open
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Liao Y, Lu X, Yang S, Luo Y, Chen Q, Yang R. Epidemiology and Outcome of Trichosporon Fungemia: A Review of 185 Reported Cases From 1975 to 2014. Open Forum Infect Dis 2015; 2:ofv141. [PMID: 26566536 PMCID: PMC4630454 DOI: 10.1093/ofid/ofv141] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 09/16/2015] [Indexed: 12/20/2022] Open
Abstract
We first reviewed the English-language literature for reported cases of Trichosporon fungemia over the past four decades, and did comprehensive analysis in order to guide our understanding of epidemiology and outcome-related aspects, especially the antifungal treatment and CVC management. Background. Trichosporon species have emerged as an important non-Candida spp yeast pathogen in immunocompromised patients in recent decades; however, the systemic analysis of Trichosporon epidemiology has seldom been reported. Methods. We reviewed 185 reported cases of Trichosporon fungemia from 1975 to 2014 in the English-language literature, and the epidemiology and prognostic factors of the included cases are described. Results. The number of cases reported has increased with time, especially over the past decade. During the 3 decades from 1975 to 2004, the most commonly used antifungal compounds were amphotericin B/liposomal amphotericin B; however, in recent decades (2005–2014), triazoles (especially voriconazole) have become the most widely used agents, significantly improving outcome in the reported cases. Correlation analysis revealed that negative outcome is associated with several prognostic factors, including a history of antimicrobial use, bacterial bloodstream coinfection, prophylactic/empirical antifungal therapy, Trichosporon beigelii infection, and receiving the antifungal regimen of amphotericin B/liposomal amphotericin B. In addition, a significantly greater proportion of patients with a positive outcome had fungemia without invasive tissue infection and received a voriconazole regimen or an AmB-triazole combined regimen. Significant positive outcome was also associated with patients who had recovered from neutropenia or after central venous catheter removal. Conclusions. Voriconazole can be recommended as a first-line antifungal compound to treat Trichosporon fungemia; the immune status of the host plays a crucial role in the outcome of this infection, and the removal of vascular catheters should be considered if feasible.
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Affiliation(s)
- Yong Liao
- Department of Dermatology , General Hospital of Beijing Military Command ; The Clinical Medical College in the Beijing Military Region of Second Military Medical University of People's Liberation Army
| | - Xuelian Lu
- Department of Dermatology , General Hospital of Beijing Military Command
| | - Suteng Yang
- Department of Dermatology , General Hospital of Beijing Military Command ; The Clinical Medical College in the Beijing Military Region of Second Military Medical University of People's Liberation Army
| | - Yi Luo
- Medical Clinic, General Political Department of People's Liberation Army, Beijing
| | - Qi Chen
- Department of Statistics , Second Military Medical University , Shanghai , China
| | - Rongya Yang
- Department of Dermatology , General Hospital of Beijing Military Command
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6
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Cong L, Liao Y, Lu X, Xia Z, Li H, Yang R. Early transcriptional response of human monocyte-like THP-1 cells in response to Trichosporon asahii infection. Mycopathologia 2014; 179:11-20. [PMID: 25179349 DOI: 10.1007/s11046-014-9784-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 06/28/2014] [Indexed: 11/30/2022]
Abstract
Trichosporon asahii is the major cause of invasive trichosporonosis, but little is known about the host immune response to this pathogen. In this study, the early transcriptional response of human monocyte-like THP-1 cells to T. asahii infection was evaluated using cDNA microarray and 1,315 differentially expressed genes were identified. The up-regulated genes were mostly involved in both innate and adaptive immune responses, as well as apoptosis and anti-apoptosis processes. Genes encoding the pro-inflammatory cytokines TNF-α, IL-1β, IL18 and IL-23α, along with the both C-C motif and C-X-C motif chemokines were strongly up-regulated, suggesting that THP-1 cells can mount a powerful inflammatory response to T. asahii infection. Genes encoding pattern recognition receptors were found up-regulated, such as dendritic cell-specific intercellular adhesion molecule 3-grabbing nonintegrin, cluster of differentiation 36 and the long pentraxin 3. Genes encoding members of the dual-spasticity phosphates family were up-regulated, and these genes were considered as a negative feedback mechanism to prevent excessive inflammatory response. The down-regulated genes in T. asahii-infected THP-1 cells were predominantly associated with cell cycle, mitosis, cell division and DNA repair. Thus, our study defines the early transcriptional response of monocyte-like THP-1 cells to T. asahii infection and provides a foundation for further investigations into the pathogenesis of T. asahii infection.
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Affiliation(s)
- Lin Cong
- Department of Dermatology, General Hospital of Beijing Military Command, 5 Nanmencang, Dongcheng District, Beijing, 100700, China
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7
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Abstract
Invasive yeast infections are a significant cause of morbidity and mortality in patients with defective immune response, such as those with cancer-related immunosuppression, organ transplantation or other immunodeficiencies, and neonates. Hospitalization in the intensive care unit may increase the risk for such infections. Despite the advent of new antifungal agents, the problem is escalating as the number of susceptible hosts increase and virulent, more resistant fungal strains emerge. Over the past few years, advances in immunology and molecular biology have greatly contributed to a better understanding of the pathogenesis of yeast infections. There is evidence that reconstitution of the host immune function is a major contributor to the resolution of yeast infections. Strategies aiming to increase the phagocyte number (e.g., granulocyte transfusions), to stimulate immune response (e.g., administration of hematopoietic growth factors and other proinflammatory cytokines) and to stimulate antigen-specific immunity (e.g., antibody therapy or vaccination) benefit patients at risk of, or suffering from, yeast infections. Further preclinical and clinical studies, as well as improving our understanding of immune system functions and dysfunctions, remain a future challenge.
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Affiliation(s)
- Jorge Garbino
- University Hospitals of Geneva, Infectious Diseases Division (Clinical Research), 24 Rue Micheli du Crest, 1211 Geneva 14, Switzerland.
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8
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de Oliveira Silva RB, Fusco-Almeida AM, Matsumoto MT, Baeza LC, Benaducci T, Mendes-Giannini MJS. Genetic diversity and antifungal susceptibility testing of Trichosporon asahii isolated of Intensive Care Units patients. Braz J Microbiol 2008; 39:585-92. [PMID: 24031270 PMCID: PMC3768427 DOI: 10.1590/s1517-838220080003000033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Revised: 02/08/2007] [Accepted: 07/05/2008] [Indexed: 11/21/2022] Open
Abstract
Trichosporon asahii is an opportunistic pathogen, associated with a high mortality rate in immunocompromised patients. In this study, ten isolates, recovered from oral cavity and urine of patients in Intensive Care Units (ICU) over six months, were identified by classical and molecular methods, typed by RAPD and tested in vitro for susceptibility to fluconazole, itraconazole, 5-flucytosine and amphotericin B. A total agreement between the identification of Trichosporon sp by PCR based on sequences of the Internal Transcribed Spacer Regions (ITS) and on the sequences of small-subunit (SSU) ribosomal DNA (rDNA) was found. Randomly amplified of polymorphic DNA (RAPD), with primers P6 and M13, was used to determine the genomic profiles. The dendogram analysis indicated that almost all strains showed similarity >0.9 among them and all strains were multidrug-resistant. This study brings new results on the identification and genotyping of T. asahii isolated from Brazilian ICU patients and information about their antifungal drugs susceptibility.
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Affiliation(s)
- Rosana Bellan de Oliveira Silva
- Instituto Adolfo Lutz , Rio Claro, SP , Brasil ; Departamento de Análises Clínicas, Faculdade de Ciências Farmacêuticas, Universidade Estadual Paulista , Araraquara, SP , Brasil
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Abstract
Many microbial pathogens evolved to circumvent the attack of neutrophils, which are essential effector cells of the innate immune system. Here we review six major strategies that pathogenic bacteria and fungi use to evade neutrophil defences: (i) turning on survival and stress responses, (ii) avoiding contact, (iii) preventing phagocytosis, (iv) surviving intracellularly, (v) inducing cell death and (vi) evading killing by neutrophil extracellular traps. For each category we give examples and further focus on one particular pathogenic microbe in more detail. Pathogens include Candida albicans, Cryptococcus neoformans, Yersinia ssp., Helicobacter pylori, Staphylococcus aureus, Streptococcus pyogenes and Streptococcus pneumoniae.
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Affiliation(s)
- Constantin F Urban
- Department of Cellular Microbiology, Max Planck Institute for Infection Biology, Charitéplatz 1, 10117 Berlin, Germany
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Walsh TJ, Roilides E, Cortez K, Kottilil S, Bailey J, Lyman CA. Control, immunoregulation, and expression of innate pulmonary host defenses against Aspergillus fumigatus. Med Mycol 2005; 43 Suppl 1:S165-72. [PMID: 16114132 DOI: 10.1080/13693780500064672] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The innate host defense system (IHDS) against Aspergillus fumigatus includes dedicated phagocytic cells (peripheral blood monocytes, monocyte derived macrophages, pulmonary alveolar macrophages, neutrophils, myeloid dendritic cells and natural killer cells), cytokines, chemokines, toll-like receptors, and antimicrobial peptides. During the past decade, the advances in the field of the IHDS have been enormous, allowing a better understanding of the immunopharmacological control, immunoregulation, and expression of innate host defense molecules against Aspergillus fumigatus.
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Affiliation(s)
- T J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bldg. 10, Rm 13N-240, 10 Center Drive, Bethesda, MD 20892, USA.
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Abstract
The very poor outcome of invasive fungal infections (IFI) in patients with haematological malignancies or recipients of haematopoietic stem cell transplantation is largely attributed to their compromised host defence mechanisms. The restoration or augmentation of immune responses in these patients is now considered as one of the cornerstones of effective antifungal therapy. Major advances in the field of experimental immunology have provided insight on the important regulatory role of cytokines in both innate and adaptive immunity to fungal pathogens. Preclinical studies have convincingly demonstrated that immunomodulation with cytokines can enhance the antifungal activity of neutrophils and monocytes/macrophages as well as upregulate protective T-helper type 1 adaptive immune responses. Evidence on the clinical use of cytokines in immunocompromised hosts with IFI is, however, still scant and inconclusive. The present review summarizes experimental and clinical data on the role of cytokines in the immune response to fungal pathogens and on their potential use for prevention or treatment of fungal infections. Implications for future research are also briefly discussed.
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Abstract
During the past two decades, invasive fungal infections have emerged as a major threat to immunocompromised hosts. Patients with neoplastic diseases are at significant risk for such infections as a result of their underlying illness and its therapy. Aspergillus, Candida, Cryptococcus and emerging pathogens, such as the zygomycetes, dark walled fungi, Trichosporon and Fusarium, are largely opportunists, causing infection when host defences are breached. The immune response varies with respect to the fungal species and morphotype encountered. The risk for particular infections differs, depending upon which aspect of immunity is impaired. This article reviews the current understanding of the role and relative importance of innate and adaptive immunity to common and emerging fungal pathogens. An understanding of the host response to these organisms is important in decisions regarding use of currently available antifungal therapies and in the design of new therapeutic modalities.
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Affiliation(s)
- Shmuel Shoham
- Section of Infectious Diseases, Washington Hospital Center, Washington, DC, USA
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Wynne SM, Kwon-Chung KJ, Shea YR, Filie AC, Varma A, Lupo P, Holland SM. Invasive infection with Trichosporon inkin in 2 siblings with chronic granulomatous disease. J Allergy Clin Immunol 2005; 114:1418-24. [PMID: 15577847 DOI: 10.1016/j.jaci.2004.07.066] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 9-year-old girl with autosomal recessive chronic granulomatous disease (CGD) presented with asymptomatic bilateral pulmonary infiltrates on routine computed tomography. Fine-needle aspirate of the infiltrates was obtained and showed fungal cells resembling Trichosporon inkin . The specimen grew in culture, and testing by means of both API 20C and PCR amplification confirmed the diagnosis of T inkin . The infiltrates increased in size, despite sequential therapy with voriconazole, liposomal amphotericin B, caspofungin, and posaconazole. The patient required resection of the infected lung tissue, after which she recovered completely. While she was undergoing therapy, her 13-year-old brother, also with CGD, was given a diagnosis of bilateral T inkin -induced pulmonary infection. He also required bilateral pulmonary resection for cure. These cases demonstrate the predisposition of patients with CGD to have invasive infections with unusual fungal organisms, such as T inkin . They also illustrate the difficulty of treating invasive T inkin infections with antifungal agents alone. There are 9 previously reported cases of invasive infections caused by T inkin , 3 of which are in patients with CGD. All patients required removal of infected prosthetic devices or surgical resection of infected tissue for cure.
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Gil-Lamaignere C, Winn RM, Simitsopoulou M, Maloukou A, Walsh TJ, Roilides E. Inteferon gamma and granulocyte–macrophage colony-stimulating factor augment the antifungal activity of human polymorphonuclear leukocytes againstScedosporiumspp.: comparison withAspergillusspp. Med Mycol 2005; 43:253-60. [PMID: 16010852 DOI: 10.1080/13693780412331271072] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
While Aspergillus spp. have been the most frequent filamentous fungi causing infections in immunocompromised patients, Scedosporium spp. are emerging as life-threatening pathogens. We studied the effects of interferon gamma (IFN-gamma) and granulocyte-macrophage colony-stimulating factor (GM-CSF) alone or combined on the antifungal activities of human polymorphonuclear leukocytes (PMN) against Scedosporium apiospermum and Scedosporium prolificans. We paralleled these activities to those against Aspergillus fumigatus and Aspergillus flavus. Incubation of PMN with IFN-gamma and GM-CSF for 22 h enhanced PMN-induced hyphal damage of both Aspergillus spp. and S. prolificans (p < 0.05) but not of S. apiospermum. However, hyphae of S. apiospermum were damaged significantly more after incubation with PMN that had been treated with IFN-gamma and GM-CSF for 2 h. In addition, incubation of PMN with GM-CSF for 2 h enhanced PMN oxidative burst measured as superoxide anion (O2-) production in response to nonopsonized hyphae of A. flavus and Scedosporium spp. (p < 0.05). In contrast, after 2 h, IFN-gamma and GM-CSF alone did not enhance PMN O2- in response to opsonized hyphae of A. flavus and Scedosporium spp.; however, the combination of IFN-gamma and GM-CSF showed significant enhancement against these species. Thus, IFN-gamma and GM-CSF, particularly in combination, demonstrate a species- and time-dependent augmentation of PMN responses to Scedosporium spp.
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Affiliation(s)
- Cristina Gil-Lamaignere
- Third Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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Ichikawa T, Sugita T, Wang L, Yokoyama K, Nishimura K, Nishikawa A. Phenotypic switching and beta-N-acetylhexosaminidase activity of the pathogenic yeast Trichosporon asahii. Microbiol Immunol 2004; 48:237-42. [PMID: 15107533 DOI: 10.1111/j.1348-0421.2004.tb03519.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The pathogenic yeast Trichosporon asahii is the major causative agent of deep-seated trichosporonosis in immunocompromised patients. Although infection by this microorganism is becoming increasingly frequent, information related to its pathogenicity and virulence factors is still limited. Therefore, we investigated phenotypic switching in colony morphology, and the production of extracellular enzymes as a virulence factor. Sixty-one clinical isolates of T. asahii produced four different morphological types on Sabouraud dextrose agar (SDA): 69% WF (white farinose), 18% WP (white pustular), 10% Y (yellowish white), and 3% WC (white cerebriform). Strains of the three major types (WF, WP, and Y) produced two to five colony types when cultured on SDA at 37 C. The frequency of switching between colony types was 10(-2) to 10(-4), as in Candida albicans and Cryptococcus neoformans. Notably, most of the colonies switched to the smooth (S) type irreversibly, at frequencies of 10(-2) to 10(-3). No secreted aspartic proteinase or phospholipase activity was detected in T. asahii, while beta-N-acetylhexosaminidase activity, which catalyzes the hydrolysis of terminal nonreducing N-acetyl-D-hexosamine residues in N-acetyl-beta-D-hexosaminides, was found. Furthermore, enzymatic activity of the S type was significantly greater than that of the parent type in all strains. No other clinically relevant Trichosporon species (T. mucoides, T. inkin, and T. ovoides ) produced this enzyme. These results provide basal information for understanding the pathogenic potential of T. asahii.
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Affiliation(s)
- Tomoe Ichikawa
- Department of Microbiology, Meiji Pharmaceutical University, Tokyo, Japan
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Walsh TJ, Groll A, Hiemenz J, Fleming R, Roilides E, Anaissie E. Infections due to emerging and uncommon medically important fungal pathogens. Clin Microbiol Infect 2004; 10 Suppl 1:48-66. [PMID: 14748802 DOI: 10.1111/j.1470-9465.2004.00839.x] [Citation(s) in RCA: 374] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The emergence of less common but medically important fungal pathogens contributes to the rate of morbidity and mortality, especially in the increasingly expanding population of immunocompromised patients. These pathogens include septate filamentous fungi (e.g., Fusarium spp., Scedosporium spp., Trichoderma spp.), nonseptate Zygomycetes, the endemic dimorphic pathogen Penicillium marneffei, and non-Cryptococcus, non-Candida pathogenic yeast (e.g., Trichosporon spp.). The medical community is thus called upon to acquire an understanding of the microbiology, epidemiology and pathogenesis of these previously uncommon pathogens in order to become familiar with the options for prevention and treatment.
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Affiliation(s)
- T J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, The National Cancer Institute, Bethesda, MD 20892-1928, USA.
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Moylett EH, Chinen J, Shearer WT. Trichosporon pullulans infection in 2 patients with chronic granulomatous disease: an emerging pathogen and review of the literature. J Allergy Clin Immunol 2003; 111:1370-4. [PMID: 12789241 DOI: 10.1067/mai.2003.1522] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Chronic granulomatous disease is a genetically determined primary immunodeficiency disease in which phagocytic cells are unable to kill certain bacteria and fungi after ingestion. Manifestations include recurrent pyogenic infections caused by catalase-positive microbes. Trichosporon species are emerging as opportunistic agents that cause systemic disease in immunocompromised patients. Typically disease has been described in association with T beigelii in patients with secondary immunodeficiency, such as underlying malignancy. OBJECTIVE The objective was to report the first 2 cases of T pullulans infection in 2 male children with chronic granulomatous disease. METHODS The records of the 2 patients were reviewed. In addition, all cases of T pullulans infection reported in the English language literature are presented. RESULTS This report brings to 7 the total number of cases of T pullulans reported and the first in patients with chronic granulomatous disease, one with invasive pneumonia and the other with an infected paronychium and localized cellulitis. In the 5 additional cases malignancy was the principal risk factor. CONCLUSION T pullulans has rarely been reported as a fungal pathogen. The most prominent risk factor for the development of trichosporonosis is immunocompromise, most notably with neutropenia. Abnormally functioning neutrophils, such as with chronic granulomatous disease, may also predispose individuals to this opportunistic pathogen.
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Affiliation(s)
- Edina H Moylett
- Section of Allergy and Immunology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, MC:FC330.01, Houston, TX 77030, USA
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Roilides E, Lyman CA, Panagopoulou P, Chanock S. Immunomodulation of invasive fungal infections. Infect Dis Clin North Am 2003; 17:193-219. [PMID: 12751266 DOI: 10.1016/s0891-5520(02)00070-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Genetic and acquired (disease- or therapy- related) host immune factors increase the risk for IFIs. In addition to antifungal drug therapy, modulation of host defenses by the use of HGFs and IFN-gamma has been supported by extensive in vitro and in vivo preclinical data. Clinical studies on the prevention or the adjunctive therapy of IFIs in combination with antifungal agents are limited, however, and do not allow specific recommendations for their cost-effective use in most of the immunodeficient settings. There is an urgent need to push forward with well-structured, randomized clinical trials to determine optimal dose, duration, and timing for different combinations of immunotherapy and antifungal agents in high-risk patients.
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Affiliation(s)
- Emmanuel Roilides
- Third Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Konstantinoupoleos 49, GR-54642 Thessaloniki, Greece.
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Abstract
Less common and emerging fungal pathogens are often resistant to conventional antifungal therapy and may cause severe morbidity and mortality in immunocompromised hosts. Some Scedosporium species may be completely resistant to antifungal therapy. Hyaline septated filamentous fungi, such as Fusarium species, Acremonium species, Paecilomyces species, and Trichoderma species, are increasingly reported as causing invasive mycoses refractory to amphotericin B therapy. Dematiaceous septated filamentous fungi, such as Bipolaris species may cause pneumonia, sinusitis, and CNS infections that are unresponsive to current medical interventions. Trichosporon spp are resistant to the fungicidal effects of amphotericin B. An increasing number of different members of the class Zygomycetes are reported as causing lethal infections, despite aggressive medical and surgical interventions. Infections due to these and other less common and emergent fungal pathogens will likely continue to develop in the settings of selective anti-fungal pressure, permissive environmental conditions, and an expanding population of immunocompromised hosts.
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Affiliation(s)
- Rhonda V Fleming
- Division of Infectious Diseases, Boston University Medical Center, Boston, MA, USA
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Roilides E, Lamaignere CG, Farmaki E. Cytokines in immunodeficient patients with invasive fungal infections: an emerging therapy. Int J Infect Dis 2002; 6:154-63. [PMID: 12718828 DOI: 10.1016/s1201-9712(02)90104-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Immune response is the major contributor to host defense against opportunistic fungal infections such as candidiasis, aspergillosis and other rare infections. A number of cytokines have been developed and studied in vitro for activity against fungal pathogens. The most studied among them in relation to fungal infections are granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), macrophage colony-stimulating factor (M-CSF) and interferon-gamma (IFN-gamma). The fields where these cytokines have been predominantly studied or where they may need more study are primary immunodeficiencies of the phagocytic cells, neonatal age, human immunodeficiency virus infection and cancer-related conditions such as neutropenia and hemopoietic cell transplantation. In this review, the in vitro, experimental animal and clinical data of cytokines are summarized in relation to invasive candidiasis, aspergillosis and emerging fungal infections. Cytokine administration to patients together with antifungal agents, as well as transfusion of cytokine-upgraded phagocytes, are promising immunotherapeutic modalities for further research.
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Affiliation(s)
- Emmanuel Roilides
- 3rd Department of Pediatrics, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
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21
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Abstract
During the past two decades opportunistic fungal infections have emerged as important causes of morbidity and mortality in patients with severe underlying illnesses and compromised host defenses. While Aspergillus and Candida spp. collectively account for the majority of these infections, recent epidemiological trends indicate a shift towards infections by Aspergillus spp., nonalbicans Candida spp., as well as previously uncommon opportunistic fungi. Apart from an expanding number of different Zygomycetes, previously uncommon hyaline filamentous fungi (such as Fusarium species, Acremonium species, Paecilomyces species, Pseudallescheria boydii, and Scedosporium prolificans), dematiaceous filamentous fungi (such as Bipolaris species, Cladophialophora bantiana, Dactylaria gallopava, Exophiala species, and Alternaria species) and yeast-like pathogens (such as Trichosporon species, Blastoschizomyces capitatus, Malassezia species, Rhodotorula rubra and others) are increasingly encountered as causing life threatening invasive infections that are often refractory to conventional therapies. On the basis of past and current trends, the spectrum of fungal pathogens will continue to evolve in the settings of an expanding population of immunocompromised hosts, selective antifungal pressures, and shifting conditions in hospitals and the environment. An expanded and refined drug arsenal, further elucidation of pathogenesis and resistance mechanisms, establishment of in vitro/in vivo correlations, incorporation of pharmacodynamics, combination- and immunotherapies offer hope for substantial progress in prevention and treatment.
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Affiliation(s)
- A H Groll
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, MD 20892, USA.
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Wolf DG, Falk R, Hacham M, Theelen B, Boekhout T, Scorzetti G, Shapiro M, Block C, Salkin IF, Polacheck I. Multidrug-resistant Trichosporon asahii infection of nongranulocytopenic patients in three intensive care units. J Clin Microbiol 2001; 39:4420-5. [PMID: 11724855 PMCID: PMC88559 DOI: 10.1128/jcm.39.12.4420-4425.2001] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Trichosporon asahii (Trichosporon beigelii) infections are rare but have been associated with a wide spectrum of clinical manifestations, ranging from superficial involvement in immunocompetent individuals to severe systemic disease in immunocompromised patients. We report on the recent recovery of T. asahii isolates with reduced susceptibility in vitro to amphotericin B (AMB), flucytosine, and azoles from six nongranulocytopenic patients who exhibited risk factors and who developed either superficial infections (four individuals) or invasive infections (two individuals) while in intensive care units. The latter two patients responded clinically and microbiologically to AMB treatment. All six isolates were closely related according to random amplified polymorphic DNA studies and showed 71% similarity by amplified fragment length polymorphism analysis, suggesting a common nosocomial origin. We also review the literature pertaining to T. asahii infections and discuss the salient characteristics of this fungus and recent taxonomic proposals for the genus.
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Affiliation(s)
- D G Wolf
- Department of Clinical Microbiology and Infectious Diseases, The Hebrew University-Hadassah Medical Center, Jerusalem, Israel
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Piwoz JA, Stadtmauer GJ, Bottone EJ, Weitzman I, Shlasko E, Cummingham-Rundles C. Trichosporon inkin lung abscesses presenting as a penetrating chest wall mass. Pediatr Infect Dis J 2000; 19:1025-7. [PMID: 11055614 DOI: 10.1097/00006454-200010000-00023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J A Piwoz
- Mount Sinai School of Medicine, New York, NY, USA
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Sasaki E, Tashiro T, Kuroki M, Seki M, Miyazaki Y, Maesaki S, Tomono K, Kadota J, Kohno S. Effects of macrophage colony-stimulating factor (M-CSF) on anti-fungal activity of mononuclear phagocytes against Trichosporon asahii. Clin Exp Immunol 2000; 119:293-8. [PMID: 10632665 PMCID: PMC1905513 DOI: 10.1046/j.1365-2249.2000.01134.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Trichosporon asahii is an emerging opportunistic pathogen in immunocompromised patients. Little is known about the mechanisms of host defence against T. asahii. We investigated the fungicidal activity of human peripheral blood monocytes and murine peritoneal macrophages against T. asahii isolates, and the effects of M-CSF on the anti-fungal activity of mononuclear phagocytes. We also established a neutropenic mouse model of disseminated trichosporonosis with T. asahii. M-CSF enhanced the phagocytic fungicidal activity of mononuclear cells, and infected mice treated with human M-CSF at 10 x 106 U/kg showed a significant improvement in survival rate, with fewer fungal colony counts in the lung compared with control mice. Mice treated with human M-CSF showed higher concentrations of tumour necrosis factor-alpha (TNF-alpha) in the lung and plasma compared with control mice. The survival rate was significantly reduced in mice treated with anti-mouse TNF-alpha. Our results showed that M-CSF enhanced the fungicidal activity of mononuclear phagocytes partly by production of TNF-alpha, and suggest that the administration of M-CSF to patients with disseminated trichosporonosis may be a useful adjunct to conventional anti-microbial therapy and prophylaxis.
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Affiliation(s)
- E Sasaki
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan
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Walsh TJ, Groll AH. Emerging fungal pathogens: evolving challenges to immunocompromised patients for the twenty-first century. Transpl Infect Dis 1999; 1:247-61. [PMID: 11428996 DOI: 10.1034/j.1399-3062.1999.010404.x] [Citation(s) in RCA: 223] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Opportunistic fungi have emerged during the past decade as important causes of morbidity and mortality in immunocompromised patients. Candida species constitute the third to fourth most common causes of nosocomial blood stream infections, and Aspergillus species have emerged as the most common infectious cause of pneumonic mortality in bone marrow/stem cell transplant recipients. Among HIV-infected patients, meningoencephalitis due to Cryptococcus neoformans ranks among the most common AIDS-defining infections. Hyaline septated filamentous fungi, such as Fusarium species, Acremonium species, Paecilomyces species, and Trichoderma species, are increasingly reported as causing invasive mycoses refractory to conventional therapy. Dematiaceous septated filamentous fungi, such as Pseudallescheria boydii, Bipolaris species, and Cladophialophora bantiana cause pneumonia, sinusitis, and CNS infection unresponsive to current therapy. An increasing number of different members of the class of Zygomycetes are reported as causing lethal infections, despite aggressive medical and surgical interventions. Yet the treatment for zygomycosis has not changed in approximately 40 years. The prevalence of the endemic mycoses, such as those due to Penicillium marneffei, Coccidioides immitis, and Histoplasma capsulatum, has been reported to expand rapidly in response to environmental exposures and increased numbers of vulnerable hosts in endemic regions of the world. Dermatophytoses are occurring with increasing prevalence and morbidity in elderly and immunocompromised patients. As we enter the next millennium, we may anticipate that emergent fungal infections will continue to develop in the settings of permissive environmental conditions, selective antifungal pressure, and an expanding population of immunocompromised hosts.
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Affiliation(s)
- T J Walsh
- Immunocompromised Host Section, Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland 20892, USA.
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Kataoka-Nishimura S, Akiyama H, Saku K, Kashiwa M, Mori S, Tanikawa S, Sakamaki H, Onozawa Y. Invasive infection due toTrichosporon cutaneum in patients with hematologic malignancies. Cancer 1998. [DOI: 10.1002/(sici)1097-0142(19980201)82:3<484::aid-cncr9>3.0.co;2-p] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Muranaka H, Suga M, Nakagawa K, Sato K, Gushima Y, Ando M. Effects of granulocyte and granulocyte-macrophage colony-stimulating factors in a neutropenic murine model of trichosporonosis. Infect Immun 1997; 65:3422-9. [PMID: 9234807 PMCID: PMC175484 DOI: 10.1128/iai.65.8.3422-3429.1997] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
We produced disseminated trichosporonosis in a neutropenic murine model with Trichosporon asahii, which was identified by DNA relatedness analysis. We then assessed the efficacy of granulocyte colony-stimulating factor (G-CSF) (30 to 100 microg/kg of body weight per day) and granulocyte-macrophage colony-stimulating factor (GM-CSF) (0.8 to 2 microg/kg x day). The administration of G-CSF either before or after infection improved the survival rate from less than 25% up to 100% (P < 0.05). The effects of G-CSF on organ clearance and histological examinations were most remarkable in the lungs. The levels of tumor necrosis factor alpha (TNF-alpha) in bronchoalveolar lavage fluid (BALF) of neutropenic and G-CSF-pretreated mice were 60 +/- 6 ng/ml and 18 +/- 6 pg/ml, respectively, at 24 h after infection. Immunohistologically, alveolar macrophages proved to be the main source of TNF-alpha in BALF. GM-CSF increased neutrophil counts less significantly than did G-CSF and increased the lethality (P < 0.05) with a high level of TNF-alpha in BALF. Expecting to inhibit TNF-alpha, we administered anti-TNF-alpha intraperitoneally at the dose completely inhibiting TNF-alpha in plasma (2 x 10(4) U), but the TNF-alpha level in BALF and the lethality increased. Though the number of neutrophils at the early stage of infection appeared to be the most critical, the results suggest that other host defense mechanisms, such as TNF-alpha overproduction in the lungs, have an important role in the prognosis of trichosporonosis.
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Affiliation(s)
- H Muranaka
- First Department of Internal Medicine, Kumamoto University School of Medicine, Japan
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Walsh TJ, Hiemenz JW, Anaissie E. Recent progress and current problems in treatment of invasive fungal infections in neutropenic patients. Infect Dis Clin North Am 1996; 10:365-400. [PMID: 8803625 DOI: 10.1016/s0891-5520(05)70303-2] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Invasive fungal infections, including disseminated candidiasis and invasive pulmonary aspergillosis, are important causes of morbidity and mortality in neutropenic patients. The recent development of fluconazole, itraconazole, lipid formulations of amphotericin B, and recombinant cytokines have expanded our therapeutic armamentarium. Clinical trials have elucidated new strategies for utilizing these compounds in the prevention and treatment of opportunistic mycoses. The population of more severely immunocompromised patients, however, continues to expand and the spectrum of drug-resistant fungi, including but not limited to Candida spp, Fusarium spp, Zygomycetes, and dematiaceous moulds, continues to evolve, thus presenting new challenges to recent therapeutic advances. Development of new antifungal chemotherapeutic agents and novel approaches for augmentation of host response will be required to meet these new mycologic challenges.
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Affiliation(s)
- T J Walsh
- Infectious Diseases Section, National Cancer Institute, Bethesda, Maryland, USA
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Guého E, Faergemann J, Lyman C, Anaissie E. MalasseziaandTrichosporon: two emerging pathogenic basidiomycetous yeast-like fungi. Med Mycol 1994. [DOI: 10.1080/02681219480000971] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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