Posaconazole therapy for systemic coccidioidomycosis in a chimpanzee (Pan troglodytes): a case report

Development of a rapid lateral flow assay for detection of anti-coccidioidal antibodies

Coccidioides spp. are dimorphic fungi that are capable of infecting human and non-human mammals and can cause diverse manifestations of coccidioidomycosis or Valley fever (VF). In combination with clinical symptoms and radiographic findings, antibody-based diagnostic tests are often used to diagnose and monitor patients with VF. Chitinase 1 (CTS1) has previously been identified as the seroreactive antigen used in these diagnostic assays to detect anticoccidial IgG. Here, an indirect enzyme-linked immunosorbent assay to detect IgG to CTS1 demonstrated 165 of 178 (92.7%) patients with a positive result by immunodiffusion (ID) and/or complement fixation (CF) had antibodies to the single antigen CTS1. We then developed a rapid antibody lateral flow assay (LFA) to detect anti-CTS1 antibodies. Out of 143 samples tested, the LFA showed 92.9% positive percent agreement [95% confidence interval (CI), 84.3%-96.9%] and 97.7% negative percent agreement (95% CI, 87.9%-99.6%) with ID and CF assays. Serum or plasma from canines, macaques, and dolphins was also tested by the CTS1 LFA. Test line densities of the CTS1 LFA correlated in a linear manner with the reported CF and ID titers for human and non-human samples, respectively. This 10-min point-of-care test for the rapid detection of anti-coccidioidal antibodies could help to inform healthcare providers in real-time, potentially improving the efficiency of healthcare delivery.

Coccidioidomycosis in Nonhuman Primates: Pathologic and Clinical Findings

Coccidioidomycosis in nonhuman primates has been sporadically reported in the literature. This study describes 22 cases of coccidioidomycosis in nonhuman primates within an endemic region, and 79 cases of coccidioidomycosis from the veterinary literature are also reviewed. The 22 cases included baboons ( n = 10), macaques ( n = 9), and chimpanzees ( n = 3). The majority died or were euthanized following episodes of dyspnea, lethargy, or neurologic and locomotion abnormalities. The lungs were most frequently involved followed by the vertebral column and abdominal organs. Microscopic examination revealed granulomatous inflammation accompanied by fungal spherules variably undergoing endosporulation. Baboons represented a large number of cases presented here and had a unique presentation with lesions in bone or thoracic organs, but none had both intrathoracic and extrathoracic lesions. Although noted in 3 cases in the literature, cutaneous infections were not observed among the 22 contemporaneous cases. Similarly, subclinical infections were only rarely observed (2 cases). This case series and review of the literature illustrates that coccidioidomycosis in nonhuman primates reflects human disease with a varied spectrum of presentations from localized lesions to disseminated disease.

Natural pathology of the captive chimpanzee (Pan troglodytes): A 35-year review

We present the spontaneous pathological lesions identified as a result of necropsy or biopsy for 245 chimpanzees (Pan troglodytes) over a 35-year period. A review of the pathology database was performed for all diagnoses on chimpanzees from 1980 to 2014. All morphologic diagnoses, associated system, organ, etiology, and demographic information were reviewed and analyzed. Cardiomyopathy was the most frequent lesion observed followed by hemosiderosis, hyperplasia, nematodiasis, edema, and hemorrhage. The most frequently affected systems were the gastrointestinal, cardiovascular, urogenital, respiratory, and lymphatic/hematopoietic systems. The most common etiology was undetermined, followed by degenerative, physiologic, neoplastic, parasitic, and bacterial. Perinatal and infant animals were mostly affected by physiologic etiologies and chimpanzee-induced trauma. Bacterial and physiologic etiologies were more common in juvenile animals. Degenerative and physiologic (and neoplastic in geriatric animals) etiologies predominated in adult, middle aged, and geriatric chimpanzees.

A SYSTEMATIC REVIEW OF THE LITERATURE RELATING TO CAPTIVE GREAT APE MORBIDITY AND MORTALITY

Wild bonobos (Pan paniscus), chimpanzees (Pan troglodytes), Western gorillas (Gorilla gorilla), and orangutans (Pongo pygmaeus, Pongo abelii) are threatened with extinction. In order to help maintain a self-sustaining zoo population, clinicians require a sound understanding of the diseases with which they might be presented. To provide an up-to-date perspective on great ape morbidity and mortality, a systematic review of the zoological and veterinary literature of great apes from 1990 to 2014 was conducted. This is the first review of the great ape literature published since 1990 and the first-ever systematic literature review of great ape morbidity and mortality. The following databases were searched for relevant articles: CAB Abstracts, Web of Science Core Collection, BIOSIS Citation Index, BIOSIS Previews, Current Contents Connect, Data Citation Index, Derwent Innovations Index, MEDLINE, SciELO Citation Index, and Zoological Record. A total of 189 articles reporting on the causes of morbidity and mortality among captive great apes were selected and divided into comparative morbidity-mortality studies and case reports-series or single-disease prevalence studies. The content and main findings of the morbidity-mortality studies were reviewed and the main limitations identified. The case reports-case series and single-disease prevalence studies were categorized and coded according to taxa, etiology, and body system. Subsequent analysis allowed the amount of literature coverage afforded to each category to be calculated and the main diseases and disorders reported within the literature to be identified. This review concludes that reports of idiopathic and infectious diseases along with disorders of the cardiovascular, respiratory, and gastrointestinal body systems were particularly prominent within the great ape literature during 1990-2014. However, recent and accurate prevalence figures are lacking and there are flaws in those reviews that do exist. There is therefore a critical need for a robust, widespread, and more up-to-date review of mortality among captive great apes.

The habitat of Coccidioides spp. and the role of animals as reservoirs and disseminators in nature

BACKGROUND

Coccidioidomycosis, a potentially fatal fungal infection, is considered an emergent mycotic disease because of the increased incidence of fungal infections registered over recent years. Infection occurs through the inhalation of arthroconidia from two main species of Coccidioides: Coccidioides immitis and C. posadasii, which are both endemic to arid and semi-arid regions of North America. Coccidioides species not only infect humans but can also infect other mammals (land, aquatic, wild or domestic), reptiles and birds.

OBJECTIVE

To obtain information regarding the habitat of Coccidioides spp. and the animals infected by this fungus and to identify the role that infected animals play as reservoirs and disseminators of this fungus in nature.

MATERIALS

A literature review was conducted to identify the habitat of Coccidioides spp. and the infected non-human animal species targeted by this fungus.

RESULTS AND CONCLUSIONS

This review allows us to suggest that Coccidioides spp. may be classified as halotolerant organisms; nevertheless, to perpetuate their life cycle, these organisms depend on different animal species (reservoirs) that serve as a link with the environment, by acting as disseminators of the fungi in nature.

Pharmacokinetics of nikkomycin Z after single rising oral doses

Nikkomycin Z is an antifungal drug that inhibits chitin synthase. This agent is under development as an orphan product for treatment of coccidioidomycosis. Safety and pharmacokinetics of nikkomycin Z were evaluated in healthy male subjects following single, rising oral doses ranging from 250 mg to 2,000 mg. A total of 12 subjects were recruited and divided into two groups. Group 1 (n = 6) received two out of three doses of 250 mg, 1,000 mg, or 1,750 mg and a placebo randomly in place of one of the doses. Group 2 (n = 6) received two out of three doses of 500 mg, 1,500 mg, or 2,000 mg and a placebo in place of one of the doses. Subjects were confined to the study unit overnight prior to dosing, and 12 blood samples were collected over 24 h postdosing while subjects were confined. Subjects returned for additional blood samples and safety evaluations at 48 h and 72 h after each dose. There was a 2-week washout period between doses. Plasma drug concentrations were determined using a validated high-performance liquid chromatography method. Nikkomycin Z was absorbed after oral administration, reaching a maximum concentration in serum of 2.21 microg/ml at 2 h postdose and an area under the concentration-time curve from 0 h to infinity of 11.3 microg x h/ml for the 250-mg dose. Pharmacokinetics appeared linear over the range of 250 to 500 mg; however, relative bioavailability was about 62 to 70% for the 1,000-mg dose and 42 to 47% for doses between 1,500 and 2,000 mg. The mean terminal half-life ranged from 2.1 to 2.5 h and was independent of dose. No serious or dose-related adverse events were observed. This study provides a basis for pharmacokinetic simulations and continued studies of nikkomycin Z administered in multiple doses.

Diagnosis and treatment of ocular coccidioidomycosis in a female captive chimpanzee (Pan troglodytes): a case study

We report here the first documented case of ocular coccidioidomycosis in a chimpanzee (Pan troglodytes). In 1996, a 12-year-old female chimpanzee was undergoing treatment with an experimental triazole, BayR3783, for coccidioidomycosis when she was diagnosed with severe conjunctivitis in the right eye. Subsequent development of a coccidioidal granuloma of the ventral conjunctiva and anterior uvea was noted over the next several months, distorting the lens, iris, pupil, and sclera and progressing to uveitis. Treatment with BayR3783 and subconjunctival injections of triamcinolone were successful in reducing the ocular mass, but extensive damage was done to the lens and cornea. This case study provides an interesting comparison to ocular coccidioidomycosis cases observed in both humans and canines.

Salvage treatment of histoplasmosis with posaconazole

Six patients received salvage treatment with posaconazole oral suspension (800 mg/day in divided doses) for severe forms of histoplasmosis. One patient had pulmonary disease and 5 had disseminated disease. Previous antifungal therapy consisted of amphotericin B, itraconazole, fluconazole, or voriconazole. Posaconazole treatment duration for individual patients ranged from 6 weeks to 34 weeks. All patients had successful clinical outcomes with significant clinical improvements noted during the first month of therapy. Although the number of patients evaluated in this case series is small, the findings are encouraging and provide preliminary evidence that posaconazole may be a useful salvage treatment option for histoplasmosis involving a variety of infected tissues and organs.

Activity of posaconazole in the treatment of central nervous system fungal infections

OBJECTIVES

A multinational, multicentre, open-label clinical trial was conducted to evaluate the safety and efficacy of posaconazole, an extended-spectrum triazole antifungal agent, in subjects with invasive fungal infections who had refractory disease or who were intolerant of standard antifungal therapy. In this subanalysis, we report on those subjects in this trial who had a fungal infection that involved the CNS.

METHODS

Subjects received posaconazole oral suspension 800 mg/day in divided doses for up to 1 year; however, subjects could receive additional therapy as part of a treatment-use extension protocol. A blinded, third-party data review committee determined subject eligibility and outcome.

RESULTS

Of the 330 subjects who enrolled in the study, 53 had infections of the CNS, of which 39 were considered evaluable for efficacy. Most had refractory disease (37 of 39) and underlying HIV infection (29 of 39). Twenty-nine subjects had cryptococcal infections, and 10 had infections caused by other fungal pathogens [Aspergillus spp. (four), Pseudallescheria boydii (two), Coccidioides immitis (one), Histoplasma capsulatum (one), Ramichloridium mackenziei (one), and Apophysomyces elegans plus a Basidiomycetes sp. (one)]. Successful outcomes were observed in 14 of 29 (48%) subjects with cryptococcal meningitis and five of 10 (50%) subjects with CNS infections due to other fungal pathogens. Posaconazole was well tolerated.

CONCLUSIONS

These data suggest that posaconazole, as an oral medication, has clinical activity against fungal infections of the CNS and may provide a valuable alternative to parenteral therapy in patients failing existing antifungal agents.