Hypersensitivity pneumonitis induced by Penicillium expansum in a home environment

Misalignment between Clinical Mold Antigen Extracts and Airborne Molds Found in Water-Damaged Homes

RATIONALE

Epidemiologic studies have demonstrated that exposure to molds and other fungi can play a role in a variety of allergic and pulmonary diseases in susceptible individuals. Species-specific mold antigen extracts are used in the clinical evaluation of suspected mold-related conditions, however alignment between these extracts and the species of molds identified in the indoor environment of water-damaged homes has not been rigorously evaluated.

OBJECTIVES

To identify the predominant genera and species of mold in the air of homes with water damage, mold growth, and/or occupants with respiratory complaints (complaint homes), and to assess their alignment with the mold antigen extracts used in clinical practice.

METHODS

The genera and species of molds identified in culture-type outdoor and indoor air samples collected from complaint homes throughout the U.S. and Canada from 2002-2017 were examined. Mold antigen extracts available and utilized for skin and serum testing in clinical practice were assessed and alignment between these data were evaluated.

RESULTS

Culture data from 24,455 indoor air samples from 7,547 complaint homes and 29,493 outdoor samples was evaluated. Mean exposure values (CFU/m3) were calculated for each genus and species, and indoor vs outdoor values compared. Penicillium was the predominant genus identified in water-damaged homes, with a mean exposure (233.3 CFU/m3) 2.9 times higher than that of the Aspergillus genus (81.4 CFU/m3). Five Penicillium (P. aurantiogriseum, P. brevicompactum, P. citrinum, P. crustosum, and P. variabile) and three Aspergillus (A. versicolor, A. sydowii, and A. niger) species were identified as the predominant indoor water-damage related fungi. However, none of these Penicillium species and only one of the Aspergillus species is currently available as an antigen extract for use in skin testing or serum testing panels.

CONCLUSIONS

Significant misalignment exists between the currently available mold antigen extracts and the predominant species of molds found in water-damaged homes. Improving alignment has the potential to enhance diagnosis of mold-related diseases including allergic asthma and hypersensitivity pneumonitis and to improve patient outcomes via interventions including antigen avoidance through building remediation and occupant relocation, consistent with the findings of a recent ATS Workshop Report.

Antigen avoidance in people with hypersensitivity pneumonitis: A scoping review

BACKGROUND

Antigen avoidance (AA) is essential for people with hypersensitivity pneumonitis (HP). An intervention programme to promote continuous AA in people with HP will be the focus of future research.

OBJECTIVES

We systematically analysed the AA behaviour of people with HP, interventions of health-care providers to promote AA behaviour, clinical outcomes after AA, and evaluation methods after AA.

METHODS

We conducted a scoping review using six online databases and manual searches. Papers written in English or Japanese that reported cases on AA were selected. The extracted data were classified qualitatively.

RESULTS

In total 205 cases included in 109 eligible papers were examined.

CONCLUSIONS

This review clarified the fundamental evidence of AA in people with HP. These people required the continuous support of health-care providers to continue appropriate AA. This review highlighted four aspects that require further research to design interventions for promoting effective and continuous AA in people with HP.

Blowing in the wind: Bacteria and fungi are spreading from public restroom hand dryers

This study aimed to identify and quantify fungi and bacteria in the airflow of restroom hand dryers in public areas. Airflow from restroom hand dryers in 8 retail locations was tested using three types of culture media, followed by PCR and sequence analysis to identify microbial species. Both bacterial and fungal colonies were detected in all locations. The number of colonies did not vary significantly across different locations, suggesting a similar level of microbial spread by hand dryers between different types of commercial stores. Molecular analysis revealed 24 bacterial species and 40 fungal species. Of these species, 48% (31/64) have been reported to be implicated in various infections in humans, primarily those with underlying medical conditions. This study is the first to demonstrate the spread of fungi by the airflow of restroom hand dryers, and the first to show the prevalence of different fungal and bacterial species spread by restroom hand dryers in common public areas.

Identification of Dermatophyte and Nondermatophyte Molds Isolated from Animal Lesions Suspected to Dermatomycoses

Background:

Dermatomycoses contain superficial fungal infections of keratinized layers of the body such as skin, hair, and nail that affect more than 20%–25% of people and animals worldwide. Some fungi can cause superficial infections in animals after accidental penetration and colonization on injured skin and can be transmitted to humans by exposure. The infection caused mainly by dermatophyte species and may also be caused rarely by yeasts and nondermatophytic molds.

Materials and Methods:

Eighty-two skin scrapings and hair samples were collected from animals (sheep, cow, cat, camel, calf, goat, horse, and dog) in three specialized pet clinics and three livestock and slaughterhouses. The isolates were identified using direct microscopy, culture, and polymerase chain reaction-sequencing of ITS1-5.8SrDNA-ITS2 region.

Results:

Thirteen mold strains out of 82 clinical samples (15.8%) were isolated from animal lesions. Acremonium exuviarum (n = 4; 30.7%), Sarocladium implicatum (n = 2; 15.4%), Arthroderma otae (n = 2; 15.4%), Chaetomium iranianum (n = 1; 7.7%), Trichothecium roseum (n = 1; 7.7%), Lichtheimia ramosa (n = 1; 7.7%), Penicillium chrysogenum (n = 1; 7.7%), and Microsporum equinum (n = 1; 7.7%) were isolated from clinical specimens.

Conclusion:

Since opportunistic fungi are increasing as etiological agents of dermatomycoses, isolation of these molds from wounds can be a warning to veterinarians, and daily cleaning of wounds with a proper disinfectant is recommended for the prevention of fungal colonization.

Expanded cardboard waste sorting and occupational exposure to microbial species

Member states of the European Union have to maximize recycling. The current, Danish cardboard recycling system can be improved by increasing the kinds of cardboard products that can be recycled to include e.g. used beverage cartons and pizza boxes (i.e. an expanded cardboard fraction (ECF)). This study aims to obtain knowledge about exposure to airborne endotoxin and microorganisms at species level at different collection frequencies of ECF, and whether an increase in waste sorted fractions means that each waste fraction is collected less frequently. Bacterial and endotoxin concentrations were associated significantly with temperature inside the waste containers and endotoxin and fungal exposures with collection frequency. The concentration of fungi was highest at the truck back and for reduced collection frequencies. The geometric mean diameters of particles with bacteria were between 3.0 and 5.2 μm and with fungi between 3.8 μm and 6.0 μm. In total, 81 and 25 different bacterial and fungal species were found at the waste receiving plant, respectively. Work with ECF caused exposures to food-related microorganisms (e.g. Arthrobacter arilaitensis and Penicillium camemberti), potential pathogens (e.g. Bacillus cereus, Salmonella sp. and P. expansum), and commensal bacteria. Bacillus cereus and Salmonella were found in the particle size fraction often being swallowed. Workers collecting EFC will be at risk of being exposed to microbial species that normally are related to residual waste. It seems to be advisable with an EFC collection frequency shorter than eight weeks. However, introduction of new waste fractions has generally been associated with reduced collection frequencies.

Fungal Contaminants in Drinking Water Regulation? A Tale of Ecology, Exposure, Purification and Clinical Relevance

Microbiological drinking water safety is traditionally monitored mainly by bacterial parameters that indicate faecal contamination. These parameters correlate with gastro-intestinal illness, despite the fact that viral agents, resulting from faecal contamination, are usually the cause. This leaves behind microbes that can cause illness other than gastro-intestinal and several emerging pathogens, disregarding non-endemic microbial contaminants and those with recent pathogenic activity reported. This white paper focuses on one group of contaminants known to cause allergies, opportunistic infections and intoxications: Fungi. It presents a review on their occurrence, ecology and physiology. Additionally, factors contributing to their presence in water distribution systems, as well as their effect on water quality are discussed. Presence of opportunistic and pathogenic fungi in drinking water can pose a health risk to consumers due to daily contact with water, via several exposure points, such as drinking and showering. The clinical relevance and influence on human health of the most common fungal contaminants in drinking water is discussed. Our goal with this paper is to place fungal contaminants on the roadmap of evidence based and emerging threats for drinking water quality safety regulations.

Sensitization to fungal allergens: Resolved and unresolved issues

Exposure and sensitization to fungal allergens can promote the development and worsening of allergic diseases. Although numerous species of fungi have been associated with allergic diseases in the literature, the significance of fungi from the genera Alternaria, Cladosporium, Penicillium, Aspergillus, and Malassezia has been well documented. However, it should be emphasized that the contribution of different fungal allergens to allergic diseases is not identical, but species-specific. Alternaria and Cladosporium species are considered to be important outdoor allergens, and sensitization and exposure to species of these genera is related to the development of asthma and rhinitis, as well as epidemics of asthma exacerbation, including life-threatening asthma exacerbation. In contrast, xerophilic species of Penicillium and Aspergillus, excluding Aspergillus fumigatus, are implicated in allergic diseases as indoor allergens. A. fumigatus has a high capacity to colonize the bronchial tract of asthmatic patients, causing severe persistent asthma and low lung function, and sometimes leading to allergic bronchopulmonary aspergillosis. Malassezia are common commensals of healthy skin, although they are also associated with atopic dermatitis, especially on the head and neck, but not with respiratory allergies. Despite its importance in the management of allergic diseases, precise recognition of species-specific IgE sensitization to fungal allergens is often challenging because the majority of fungal extracts exhibit broad cross-reactivity with taxonomically unrelated fungi. Recent progress in gene technology has contributed to the identification of specific and cross-reactive allergen components from different fungal sources. However, data demonstrating the clinical relevance of IgE reactivity to these allergen components are still insufficient.

[Moulds in dwellings: health risks and involved species]

INTRODUCTION

In industrialized countries the population spends 90% of its time in enclosed spaces. Since 1973, energy consumption for heating decreased on average by 36% per dwelling. Low-quality insulation, a fall in temperature and inadequate ventilation translated into high humidity in dwellings, which led to proliferation of moulds.

BACKGROUND

The allergenic, toxic and infectious effects of moulds on human health are documented. However, the potential dose/effect relationship between measured concentrations of indoor moulds and respiratory disorders often remains difficult to assess accurately. In several cases, fungi were demonstrated only as a promoter of health disorders. In a few cases (hypersensitivity pneumonitis, invasive fungal infections), the pathogenesis is without doubt due to environmental fungal exposure in a limited number of patients. On the other hand, the role of fungi was suspected but not proven for some well-defined pathologies, and some ill-defined health disorders, affecting large numbers of patients, such as the Sick Building Syndrome, rhinitis, sinusitis and conjunctivitis, as well as asthma and exacerbations of bronchitis. Eighteen fungal species, suspected of playing a role in public health, have been listed by the French Superior Council of Public Health. For each species, the proliferation conditions, type of substrates contaminated and heath effects reported in the literature are described.

VIEWPOINT

The lack of standardization of measurements of concentrations of fungal species, the interactions with chemical compounds (formaldehydes), organic compounds (mycotoxins, endotoxins) and between species, makes the analysis of indoor fungal contamination complicated. The time has come to establish clearly a relationship between exposure to fungi and health disorders, rather than continuing to investigate factors related to the level of indoor fungal contamination.

Hypersensitivity pneumonitis caused by Penicillium citrinum, not Enoki spores

BACKGROUND

Flammulina velutipes is called the Enoki mushroom in Japanese and is cultivated indoors. Mushroom workers face occupational exposure to a tremendous number of fungi and organic antigens capable of causing hypersensitivity pneumonitis (HP). One worker employed at an Enoki farm developed HP due to Penicillium citrinum. This study investigated new cases of HP among the workers cultivating Enoki.

METHODS

Serum Krebs von der Lungen-6 (KL-6), surfactant protein (SP)-A and SP-D were measured. Lymphocyte stimulation tests (LST) and double immunodiffusion tests (DIT) were performed to identify P. citrinum. Workers showing high levels of KL-6, SP-A, or SP-D and a high LST value or positive DIT were identified and then were further examined by chest computed tomography, bronchoalveolar lavage and transbronchial lung biopsy. The initial patient and new HP patients were defined as the HP group and the other participants were defined as the non-HP group.

RESULTS

Forty-eight Enoki workers participated in the study. Four of nine workers who met the criteria for further examinations were diagnosed as having HP due to P. citrinum. In comparison between non-HP group and HP group, KL-6, SP-D and LST values were significantly higher in HP group. There was a strong correlation between KL-6 and SP-D. DIT had high sensitivity and high specificity.

CONCLUSIONS

KL-6, SP-D, LST, and DIT were useful for detecting HP patients. KL-6 was the most useful predictor of HP in this study. DIT was useful not only as a predictor of HP but also as a detector of the causative antigen.

Solvent comparison in the isolation, solubilization, and toxicity of Stachybotrys chartarum spore trichothecene mycotoxins in an established in vitro luminescence protein translation inhibition assay

It is well known that non-viable mold contaminants such as macrocyclic trichothecene mycotoxins of Stachybotrys chartarum are highly toxinigenic to humans. However, the method of recovering native mycotoxin has been without consensus. Inconsistencies occur in the methods of isolation, suspension, preparation, and quantitation of the mycotoxin from the spores. The purpose of this study was to provide quantitatively comparative data on three concurrent preparations of 10(6)S. chartarum spores. The experiments were designed to specifically evaluate a novel method of mycotoxin extraction, solubilization, and the subsequent inhibitory effect in an established in vitro luminescence protein translation assay from 30 day-old spores. The mycotoxin-containing spores swabbed from wallboard cultures were milled with and without glass beads in 100% methanol, 95% ethanol, or water. Milled spore lysates were cleared of cell debris by filter centrifugation followed by a second centrifugation through a 5000 MWCO filter to remove interfering proteins and RNases. Cleared lysate was concentrated by centrivap and suspended in either alcohol or water as described. The suspensions were used immediately in the in vitro luminescence protein translation assay with the trichothecene, T-2 toxin, as a control. Although, mycotoxin is reported to be alcohol soluble, the level of translation inhibition was not reliably satisfactory for either the methanol or ethanol preparations. In fact, the methanol and ethanol control reactions were not significantly different than the alcohol prepared spore samples. In addition, we observed that increasing amounts of either alcohol inhibited the reaction in a dose dependent manner. This suggests that although alcohol isolation of mycotoxin is desirable in terms of time and labor, the presence of alcohol in the luminescence protein translation reaction was not acceptable. Conversely, water extraction of mycotoxin demonstrated a dose dependent response, and there was significant difference between the water controls and the water extracted mycotoxin reactions. In our hands, water was the best extraction agent for mycotoxin when using this specific luminescence protein translation assay kit.

Hypersensitivity pneumonitis induced by spores of Penicillium citrinum in a worker cultivating Enoki mushroom

A 47-year-old Japanese woman was admitted to our hospital with a 2-week history of dry cough and shortness of breath. She had been engaged in Enoki mushroom production for 22 years. Chest X-ray and chest computed tomography (CT) scan showed bilateral fine-nodular shadows and ground glass opacity. Bronchoalveolar lavage fluid demonstrated an increase of total cell counts with predominant lymphocytosis. Pathological specimens obtained by video-assisted thoracoscopic surgery revealed alveolitis and noncaseating granuloma with giant cells. Lymphocyte stimulation test showed positive responses with Enoki mushroom, culture medium, and Penicillium citrinum. On double immunodiffusion test, a precipitation line was observed between patient's serum and Penicillium citrinum antigen. She was found to have hypersensitivity pneumonitis caused by Penicillium citrinum. This is the first report of mushroom worker's lung caused by Penicillium citrinum.

A case of hypersensitivity pneumonitis caused by Penicillium species in a home environment

We report a case of hypersensitivity pneumonitis in a 30-yr-old female housewife caused by Penicillium species found in her home environment. The patient was diagnosed according to history, chest radiograph, spirometry, high-resolution chest CT, and transbronchial lung biopsy. To identify the causative agent, cultured aeromolds were collected by the open-plate method. From the main fungi cultured, fungal antigens were prepared, and immunoblot analysis with the patient's serum and each fungal antigen was performed. A fungal colonies were isolated from the patient's home. Immunoblotting analysis with the patient's sera demonstrated a IgG-binding fractions to Penicillium species extract, while binding was not noted with control subject. This study indicates that the patient had hypersensitivity pneumonitis on exposure to Penicillium species in her home environment.

Purification and preliminary crystallographic analysis of a Penicillium expansum lipase

PF898 is a strain of Penicillium expansum optimized for the high level production of Penicillium expansum lipase (PEL). This PEL is unique compared with other lipases in several aspects, For example, the PEL shows low sequence identities (<30%) to all other known lipases, and high percentage of hydrophobic residues in the N-terminal region. The PEL was purified to homogeneity and shown to be 28 kDa by SDS-PAGE. Crystals suitable for X-ray diffraction analysis were obtained by the sitting-drop method of vapor diffusion with ammonia sulfate as the precipitating agent at 298 K. The crystals have tetragonal lattice and unit-cell parameters of a=b=88.09 A, c=126.54 A. Diffraction data were collected to a resolution of 2.08 A on an in-house rotating-anode generator.

Toxic and other non-IgE-mediated effects of fungal exposures

There are more than 100000 recognized species of fungi, comprising 25% of the biomass of the earth. Allergic, IgE-induced, manifestations of airborne fungi are common, whereas non-IgE manifestations are rare. Recently, much focus has been placed on the non-IgE-mediated effects of various molds, including hypersensitivity pneumonitis, infectious disease, and mycotoxicoses. Hypersensitivity pneumonitis is a clinical syndrome associated with systemic and interstitial lung disease that occurs in susceptible individuals following fungal inhalation. Most fungi are not pathogenic to man; however, certain fungi are capable of infecting immunocompetent individuals. Although mycotoxins and exposure to mycotoxins ("toxic mold syndrome") are implicated in causing numerous, nonspecific, systemic symptoms, currently, there is no scientific evidence to support the allegation that human health is affected by inhaled mycotoxins. However, if mold is discovered in a home, school, or office setting, the source should be investigated and appropriate remediation undertaken to minimize structural damage and potential allergic sensitization.

Invasive infection due to penicillium species other than P. marneffei

Infection caused by Penicillium spp. due to species other than P. marneffei is rare. We present three such cases of invasive disease. The first had chronic granulomatous disorder (CGD) with pulmonary infection caused by Penicillium spp. and he responded to amphotericin B therapy. Cases two and three were not known to be immunocompromised and both failed to respond to therapy. Case two had cerebral disease from an unknown source caused by P. chrysogenum. Case three probably acquired infection caused by P. decumbens peri-operatively and presented with paravertebral infection. The pertinent literature on invasive infections of Penicillium spp. other than P. marneffei is reviewed. From 1951 onwards, 31 reported cases of invasive disease included 12 cases of pulmonary infection (six in non-immunocompromised patients), four cases of prosthetic valve endocarditis, six cases of CAPD peritonitis, five cases of endophthalmitis, individual cases of fungemia and oesophagitis (both in AIDS), upper urinary tract infection and intracranial infection. Trauma, surgery or prosthetic material is commonly implicated in the non-pulmonary cases. Superficial infection (keratitis and otomycosis) is commonly caused by Penicillium spp. Allergic pulmonary disease, often occupational (such as various cheeseworkers' diseases), is also common. Optimal therapy for invasive infection is not established, but surgery may be advisable if possible. Amphotericin B may be the most effective antifungal drug.

Hypersensitivity pneumonitis caused by Fusarium napiforme in a home environment

BACKGROUND

We report a case of hypersensitivity pneumonitis (HP) in a 17-year-old male student caused by Fusarium napiforme found in his home environment.

METHODS

The patient was diagnosed according to history, chest radiograph, spirometry, high-resolution chest CT, and transbronchial lung biopsy. To identify the causative agent, cultured aeromolds were collected by the open-plate method. From the main fungi cultured, fungal antigens were prepared, and immunoblot analysis with the patient's serum and each fungal antigen was performed.

RESULTS

Five fungal species were isolated from the patient's home. Immunoblotting analysis with the patient's serum demonstrated more than 10 IgG-binding fractions to F. napiforme extract only, while little binding was noted with the other fungal antigens.

CONCLUSIONS

We should be aware that HP may be caused by F. napiforme in the home environment.

Reduction of pulmonary toxicity of Stachybotrys chartarum spores by methanol extraction of mycotoxins

The fungus Stachybotrys chartarum has been implicated in cases of nonspecific indoor air quality complaints in adults and in cases of pulmonary hemorrhaging in infants. The effects that have been described have been attributed to mycotoxins. Previous dose-effect studies focused on exposure to a single mycotoxin in a solvent, a strategy which is unlikely to accurately characterize the effects of inhaled spores. In this study we examined the role of mycotoxins in the pulmonary effects caused by S. chartarum spores and the dose dependency of these effects. S. chartarum spores were extracted in methanol to reduce the mycotoxin content of the spores. Then either untreated (toxin-containing) or methanol-extracted S. chartarum spores were intratracheally instilled into male 10-week-old Charles River-Dawley rats. After 24 h, the lungs were lavaged, and the bronchoalveolar lavage fluid was analyzed to determine differences in lactic dehydrogenase, albumin, hemoglobin, myeloperoxidase, and leukocyte differential counts. Weight change was also monitored. Our data show that methanol extraction dramatically reduced the toxicity of S. chartarum spores. No statistically significant effects were observed in the bronchoalveolar lavage fluids of the animals that were treated with methanol-extracted spores at any dose. Conversely, dose-dependent effects of the toxin-containing spores were observed when we examined the lactic dehydrogenase, albumin, and hemoglobin concentrations, the polymorphonuclear leukocyte counts, and weight loss. Our findings show that a single, intense exposure to toxin-containing S. chartarum spores results in pulmonary inflammation and injury in a dose-dependent manner. Importantly, the effects are related to methanol-soluble toxins in the spores.

Molds on house walls and the effect of their chloroform-extractable metabolites on the respiratory cilia movement of one-day-old chicks in vitro

The ciliostatic activity of the chloroform-extractable endo- and exometabolites of 5 strains of filamentous fungi--Alternaria sp., Aspergillus glaucus group, Aspergillus versicolor, Cladosporium sphoerospermum, Penicillium sp. and Ulocladium sp.--isolated from molded walls of a dwelling--on tracheal cilia from 1-d-old chicks in vitro was evaluated. Endometabolites of Alternaria sp. and A. versicolor and exometabolites of Ulocladium sp. were the most active, these extracts stopped the ciliary movement within 1 d. The results are discussed in relation to the health status of people living in "moldy" dwellings.