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Earle K, Valero C, Conn DP, Vere G, Cook PC, Bromley MJ, Bowyer P, Gago S. Pathogenicity and virulence of Aspergillus fumigatus. Virulence 2023; 14:2172264. [PMID: 36752587 PMCID: PMC10732619 DOI: 10.1080/21505594.2023.2172264] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/16/2022] [Indexed: 02/09/2023] Open
Abstract
Pulmonary infections caused by the mould pathogen Aspergillus fumigatus are a major cause of morbidity and mortality globally. Compromised lung defences arising from immunosuppression, chronic respiratory conditions or more recently, concomitant viral or bacterial pulmonary infections are recognised risks factors for the development of pulmonary aspergillosis. In this review, we will summarise our current knowledge of the mechanistic basis of pulmonary aspergillosis with a focus on emerging at-risk populations.
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Affiliation(s)
- Kayleigh Earle
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Clara Valero
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Daniel P. Conn
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - George Vere
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Peter C. Cook
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Michael J. Bromley
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Paul Bowyer
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Sara Gago
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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2
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Hokken MWJ, Coolen JPM, Steenbreker H, Zoll J, Baltussen TJH, Verweij PE, Melchers WJG. The Transcriptome Response to Azole Compounds in Aspergillus fumigatus Shows Differential Gene Expression across Pathways Essential for Azole Resistance and Cell Survival. J Fungi (Basel) 2023; 9:807. [PMID: 37623579 PMCID: PMC10455693 DOI: 10.3390/jof9080807] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
The opportunistic pathogen Aspergillus fumigatus is found on all continents and thrives in soil and agricultural environments. Its ability to readily adapt to novel environments and to produce billions of spores led to the spread of azole-resistant A. fumigatus across the globe, posing a threat to many immunocompromised patients, including critically ill patients with severe influenza or COVID-19. In our study, we sought to compare the adaptational response to azoles from A. fumigatus isolates that differ in azole susceptibility and genetic background. To gain more insight into how short-term adaptation to stressful azole compounds is managed through gene expression, we conducted an RNA-sequencing study on the response of A. fumigatus to itraconazole and the newest clinically approved azole, isavuconazole. We observed many similarities in ergosterol biosynthesis up-regulation across isolates, with the exception of the pan-azole-resistant isolate, which showed very little differential regulation in comparison to other isolates. Additionally, we found differential regulation of membrane efflux transporters, secondary metabolites, iron metabolism, and various stress response and cell signaling mechanisms.
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Affiliation(s)
- Margriet W. J. Hokken
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Jordy P. M. Coolen
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Hilbert Steenbreker
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
| | - Jan Zoll
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Tim J. H. Baltussen
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
| | - Willem J. G. Melchers
- Department of Medical Microbiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands (T.J.H.B.)
- Center of Expertise in Mycology Radboudumc/CWZ, 6500 HB Nijmegen, The Netherlands
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3
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O'Dea AL, Feng R, Glaser LJ, Kubrak C, Rubenstein RC, Dorgan DJ, Hadjiliadis D, Kawut SM, Hong G. The Clinical Association between Aspergillus fumigatus and Respiratory Outcomes in Adolescents and Adults with Cystic Fibrosis. Ann Am Thorac Soc 2023; 20:984-992. [PMID: 36800434 DOI: 10.1513/annalsats.202210-852oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/17/2023] [Indexed: 02/19/2023] Open
Abstract
Rationale: The clinical significance of Aspergillus fumigatus (Af) detection in the absence of allergic bronchopulmonary aspergillosis in cystic fibrosis (CF) airways remains unclear. Yet, some clinicians initiate antifungal therapy for Af-positive respiratory cultures out of concern for infection in people with CF. Objectives: To determine the association between the presence of Af and respiratory outcomes in individuals with CF. Methods: We conducted a prospective longitudinal cohort study of 206 adults and adolescents (age 14 yr and older) with CF and collected sputum for selective fungus culture. We assessed clinical outcome measurements, including patient-reported outcomes (measured by the Cystic Fibrosis Questionnaire-Revised), spirometry, and number of pulmonary exacerbations (PEx) for a 1-year period. We used mixed-effects linear models to determine the association between positive Af culture results, defined as Af detection in sputum culture at the study visit, with both respiratory domain score and forced expiratory volume in 1 second (FEV1) percent predicted, adjusted for confounders. Mixed-effects Poisson regression models were employed to examine the association between positive Af culture results and PEx events. We explored the association between Af history, defined as Af detection at baseline or within 2 years of enrollment, and respiratory outcomes. Results: Af prevalence was 10.3% (95% confidence interval [CI], 6.8, 15.7) at baseline. Forty-eight (23.3%; 95% CI, 17.7, 29.7) participants had at least one Af-positive culture result during the study period. Positive Af culture result was not associated with lower respiratory domain score. However, Af history was associated with a 6.48-point lower respiratory domain score, reflective of worse respiratory quality of life (95% CI, -11.96, -0.99; P = 0.02). Positive Af culture result was associated with a 2.54% lower FEV1 percent predicted (95% CI, -4.64, -0.44; P = 0.02) and a 1.71-fold increase in severe PEx incidence (95% CI, 1.05, 2.76; P = 0.03). Conclusions: Positive Af culture result was not associated with lower patient-reported, respiratory-related quality of life. Yet, positive Af culture result was associated with both lower FEV1 percent predicted and increased frequency of severe PEx warranting intravenous antibiotics in adolescents and adults with CF. Future studies are required to better understand the direct role of Af in lung disease progression in CF.
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Affiliation(s)
- Anna L O'Dea
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, and
| | - Laurel J Glaser
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina Kubrak
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri; and
| | - Ronald C Rubenstein
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri; and
| | - Daniel J Dorgan
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
| | - Denis Hadjiliadis
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
- Center for Clinical Epidemiology and Biostatistics, and
| | - Gina Hong
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine
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Dunne K, Reece E, McClean S, Doyle S, Rogers TR, Murphy P, Renwick J. Aspergillus fumigatus Supernatants Disrupt Bronchial Epithelial Monolayers: Potential Role for Enhanced Invasion in Cystic Fibrosis. J Fungi (Basel) 2023; 9:jof9040490. [PMID: 37108944 PMCID: PMC10141846 DOI: 10.3390/jof9040490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Aspergillus fumigatus is the most commonly isolated fungus in chronic lung diseases, with a prevalence of up to 60% in cystic fibrosis patients. Despite this, the impact of A. fumigatus colonisation on lung epithelia has not been thoroughly explored. We investigated the influence of A. fumigatus supernatants and the secondary metabolite, gliotoxin, on human bronchial epithelial cells (HBE) and CF bronchial epithelial (CFBE) cells. CFBE (F508del CFBE41o-) and HBE (16HBE14o-) trans-epithelial electrical resistance (TEER) was measured following exposure to A. fumigatus reference and clinical isolates, a gliotoxin-deficient mutant (ΔgliG) and pure gliotoxin. The impact on tight junction (TJ) proteins, zonula occludens-1 (ZO-1) and junctional adhesion molecule-A (JAM-A) were determined by western blot analysis and confocal microscopy. A. fumigatus conidia and supernatants caused significant disruption to CFBE and HBE TJs within 24 h. Supernatants from later cultures (72 h) caused the greatest disruption while ΔgliG mutant supernatants caused no disruption to TJ integrity. The ZO-1 and JAM-A distribution in epithelial monolayers were altered by A. fumigatus supernatants but not by ΔgliG supernatants, suggesting that gliotoxin is involved in this process. The fact that ΔgliG conidia were still capable of disrupting epithelial monolayers indicates that direct cell-cell contact also plays a role, independently of gliotoxin production. Gliotoxin is capable of disrupting TJ integrity which has the potential to contribute to airway damage, and enhance microbial invasion and sensitisation in CF.
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Affiliation(s)
- Katie Dunne
- Discipline of Clinical Microbiology, School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Emma Reece
- Discipline of Clinical Microbiology, School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Siobhán McClean
- School of Biomolecular and Biomedical Science, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland
| | - Sean Doyle
- Department of Biology, Maynooth University, Maynooth, W23 F2K8 Kildare, Ireland
| | - Thomas R Rogers
- Discipline of Clinical Microbiology, School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Philip Murphy
- Discipline of Clinical Microbiology, School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
| | - Julie Renwick
- Discipline of Clinical Microbiology, School of Medicine, Trinity College Dublin, D02 PN40 Dublin, Ireland
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Tiew PY, Narayana JK, Quek MSL, Ang YY, Ko FWS, Poh ME, Jaggi TK, Xu H, Thng KX, Koh MS, Tee A, Hui DSC, Abisheganaden JA, Tsaneva-Atanasova K, Chew FT, Chotirmall SH. Sensitisation to recombinant Aspergillus fumigatus allergens and clinical outcomes in COPD. Eur Respir J 2023; 61:13993003.00507-2022. [PMID: 35926878 PMCID: PMC9816419 DOI: 10.1183/13993003.00507-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/24/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Variable clinical outcomes are reported with fungal sensitisation in chronic obstructive pulmonary disease (COPD), and it remains unclear which fungi and what allergens associate with the poorest outcomes. The use of recombinant as opposed to crude allergens for such assessment is unknown. METHODS A prospective multicentre assessment of stable COPD (n=614) was undertaken in five hospitals across three countries: Singapore, Malaysia and Hong Kong. Clinical and serological assessment was performed against a panel of 35 fungal allergens including crude and recombinant Aspergillus and non-Aspergillus allergens. Unsupervised clustering and topological data analysis (TDA) approaches were employed using the measured sensitisation responses to elucidate if sensitisation subgroups exist and their related clinical outcomes. RESULTS Aspergillus fumigatus sensitisation was associated with increased exacerbations in COPD. Unsupervised cluster analyses revealed two "fungal sensitisation" groups. The first was characterised by Aspergillus sensitisation and increased exacerbations, poorer lung function and worse prognosis. Polysensitisation in this group conferred even poorer outcome. The second group, characterised by Cladosporium sensitisation, was more symptomatic. Significant numbers of individuals demonstrated sensitisation responses to only recombinant (as opposed to crude) A. fumigatus allergens f 1, 3, 5 and 6, and exhibited increased exacerbations, poorer lung function and an overall worse prognosis. TDA validated these findings and additionally identified a subgroup within Aspergillus-sensitised COPD of patients with frequent exacerbations. CONCLUSION Aspergillus sensitisation is a treatable trait in COPD. Measuring sensitisation responses to recombinant Aspergillus allergens identifies an important patient subgroup with poor COPD outcomes that remains overlooked by assessment of only crude Aspergillus allergens.
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Affiliation(s)
- Pei Yee Tiew
- Dept of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | | | | | - Yan Ying Ang
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Fanny Wai San Ko
- Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - Mau Ern Poh
- Dept of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Tavleen Kaur Jaggi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Huiying Xu
- Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Kai Xian Thng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Mariko Siyue Koh
- Dept of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Augustine Tee
- Dept of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - David Shu Cheong Hui
- Dept of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - John Arputhan Abisheganaden
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Krasimira Tsaneva-Atanasova
- Living Systems Institute and Department of Mathematics, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
- EPSRC Hub for Quantitative Modelling in Healthcare, University of Exeter, Exeter, UK
| | - Fook Tim Chew
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
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6
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Hong G. Progress and challenges in fungal lung disease in cystic fibrosis. Curr Opin Pulm Med 2022; 28:584-590. [PMID: 36101907 PMCID: PMC9547960 DOI: 10.1097/mcp.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review is an overview of the recent progress made for the diagnosis and understanding of fungal lung disease in people with cystic fibrosis (CF), with a focus on Aspergillus fumigatus , the most common filamentous fungus in the CF airway. Currently, the longstanding question of the clinical significance of Aspergillus fumigatus and other fungi in CF respiratory cultures, in the absence of allergy, remains. Clinical criteria and biomarkers are needed to classify fungal lung disease and determine who may warrant therapy. RECENT FINDINGS Several retrospective and prospective studies have described the prevalence of A. fumigatus and other fungi in the CF lung and factors contributing to the changes in fungal epidemiology. Selective fungus culture testing for the detection of fungi in CF sputa has been well studied, yet a standardized fungus culture protocol has yet to be defined. Culture-independent molecular studies and other fungal diagnostic testing have been conducted in the CF population, leading to efforts to better understand the clinical role of these tests. Recent works have aimed to determine whether chronic A. fumigatus colonization is associated with lung disease progression measured by FEV 1 percentage predicted, structural lung disease, lung clearance index and respiratory quality-of-life. However, the existing knowledge gaps remain: definition of a fungal respiratory infection, the association between fungal infection and clinical outcomes, and indications for antifungal therapy. SUMMARY Significant progress has been made for the detection and diagnosis of fungal lung disease. Yet, the role and impact of A. fumigatus and other fungal infections on respiratory health in people with CF remains to be determined.
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Affiliation(s)
- Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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7
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Li L, Mac Aogáin M, Xu T, Jaggi TK, Chan LLY, Qu J, Wei L, Liao S, Cheng HS, Keir HR, Dicker AJ, Tan KS, De Yun W, Koh MS, Ong TH, Lim AYH, Abisheganaden JA, Low TB, Hassan TM, Long X, Wark PAB, Oliver B, Drautz-Moses DI, Schuster SC, Tan NS, Fang M, Chalmers JD, Chotirmall SH. Neisseria species as pathobionts in bronchiectasis. Cell Host Microbe 2022; 30:1311-1327.e8. [PMID: 36108613 DOI: 10.1016/j.chom.2022.08.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/30/2022] [Accepted: 07/18/2022] [Indexed: 02/07/2023]
Abstract
Neisseria species are frequently identified in the bronchiectasis microbiome, but they are regarded as respiratory commensals. Using a combination of human cohorts, next-generation sequencing, systems biology, and animal models, we show that bronchiectasis bacteriomes defined by the presence of Neisseria spp. associate with poor clinical outcomes, including exacerbations. Neisseria subflava cultivated from bronchiectasis patients promotes the loss of epithelial integrity and inflammation in primary epithelial cells. In vivo animal models of Neisseria subflava infection and metabolipidome analysis highlight immunoinflammatory functional gene clusters and provide evidence for pulmonary inflammation. The murine metabolipidomic data were validated with human Neisseria-dominant bronchiectasis samples and compared with disease in which Pseudomonas-, an established bronchiectasis pathogen, is dominant. Metagenomic surveillance of Neisseria across various respiratory disorders reveals broader importance, and the assessment of the home environment in bronchiectasis implies potential environmental sources of exposure. Thus, we identify Neisseria species as pathobionts in bronchiectasis, allowing for improved risk stratification in this high-risk group.
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Affiliation(s)
- Liang Li
- Department of Pharmacology, School of Medicine, Southern University of Science and Technology, Shenzhen, China; Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Biochemical Genetics Laboratory, Department of Biochemistry, St. James's Hospital, Dublin, Ireland; Clinical Biochemistry Unit, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Tengfei Xu
- School of Civil and Environmental Engineering, Nanyang Technological University, Singapore, Singapore; College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, PRC
| | - Tavleen Kaur Jaggi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Louisa L Y Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jing Qu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lan Wei
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Shumin Liao
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hong Sheng Cheng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Holly R Keir
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Alison J Dicker
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Kai Sen Tan
- Department of Otolaryngology, Infectious Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wang De Yun
- Department of Otolaryngology, Infectious Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Albert Yick Hou Lim
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - John A Abisheganaden
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Teck Boon Low
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Xiang Long
- Department of Respiratory Medicine and Critical Care, Peking University Shenzhen Hospital, Shenzhen, China
| | - Peter A B Wark
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Brian Oliver
- Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia; School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Daniela I Drautz-Moses
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore, Singapore
| | - Stephan C Schuster
- Singapore Centre for Environmental Life Sciences Engineering (SCELSE), Nanyang Technological University, Singapore, Singapore
| | - Nguan Soon Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
| | - Mingliang Fang
- School of Civil and Environmental Engineering, Nanyang Technological University, Singapore, Singapore; Department of Environmental Science and Engineering, Fudan University, Shanghai 200433, China
| | - James D Chalmers
- University of Dundee, Ninewells Hospital, Medical School, Dundee, Scotland
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore.
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Hughes DA, Rosenthal M, Cuthbertson L, Ramadan N, Felton I, Simmonds NJ, Loebinger MR, Price H, Armstrong-James D, Elborn JS, Cookson WO, Moffatt MF, Davies JC. An invisible threat? Aspergillus positive cultures and co-infecting bacteria in airway samples. J Cyst Fibros 2022; 22:320-326. [PMID: 35871975 DOI: 10.1016/j.jcf.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aspergillus fumigatus (Af) infection is associated with poor lung health in chronic suppurative lung diseases but often goes undetected. We hypothesised that inhibition of Af growth by Pseudomonas aeruginosa (Pa) increases the frequency of false-negative Af culture in co-infected people. Using a substantial group of cystic fibrosis (CF) airway samples, we assessed the relationship between Af and bacterial pathogens, additionally comparing fungal culture with next-generation sequencing. METHODS Frequency of co-culture was assessed for 44,554 sputum/BAL cultures, from 1,367 CF patients between the years 2010-2020. In a subgroup, Internal Transcribed Spacer-2 (ITS2) fungal sequencing was used to determine sequencing-positive, culture-negative (S+/C-) rates. RESULTS Pa+ samples were nearly 40% less likely (P<0.0001) than Pa- samples to culture Af, an effect that was also seen with some other Gram-negative isolates. This impact varied with Pa density and appeared to be moderated by Staphylococcus aureus co-infection. Sequencing identified Af-S+/C- for 40.1% of tested sputa. Samples with Pa had higher rates of Af-S+/C- (49.3%) than those without (35.7%; RR 1.38 [1.02-1.93], P<0.05). Af-S+/C- rate was not changed by other common bacterial infections. Pa did not affect the S+/C- rates of Candida, Exophiala or Scedosporium. CONCLUSIONS Pa/ Af co-positive cultures are less common than expected in CF. Our findings suggest an Af-positive culture is less likely in the presence of Pa. Interpretation of negative cultures should be cautious, particularly in Pa-positive samples, and a companion molecular diagnostic could be useful. Further work investigating mechanisms, alternative detection techniques and other chronic suppurative lung diseases is needed.
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Affiliation(s)
- Dominic A Hughes
- King's College Hospital NHS Foundation Trust, London, UK; National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK.
| | - Mark Rosenthal
- Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | - Leah Cuthbertson
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK
| | - Newara Ramadan
- Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | - Imogen Felton
- Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | - Nicholas J Simmonds
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK; Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | - Michael R Loebinger
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK; Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
| | - Henry Price
- Department of Physics, Imperial College London, UK
| | - Darius Armstrong-James
- Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK; Department of Infectious Diseases, Imperial College London, UK
| | | | - William O Cookson
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK
| | - Miriam F Moffatt
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK
| | - Jane C Davies
- National Heart & Lung Institute, Imperial College London, Emmanuel Kaye Building, 1B Manresa Road, London SW3 6LR, UK; Royal Brompton Hospital, Guy's & St Thomas' Trust, London, UK
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9
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Blomquist A, Inghammar M, Al Shakirchi M, Ericson P, Krantz C, Svedberg M, Lindblad A, Påhlman LI. Persistent Aspergillus fumigatus infection in cystic fibrosis: impact on lung function and role of treatment of asymptomatic colonization-a registry-based case-control study. BMC Pulm Med 2022; 22:263. [PMID: 35790954 PMCID: PMC9258124 DOI: 10.1186/s12890-022-02054-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Aspergillus fumigatus is the most common filamentous fungus isolated from the airways of people with cystic fibrosis (CF). The aim of this study was to investigate how chronic A. fumigatus colonization affects lung function in people with CF, to identify risk factors for colonization, and to evaluate antifungal treatment of asymptomatic Aspergillus colonization.
Methods Data from 2014–2018 was collected from the Swedish CF registry and medical records. Baseline data before the start of A. fumigatus colonization was compared with the two succeeding years to evaluate how colonization and treatment affected lung function and other clinical aspects.
Results A total of 437 patients were included, of which 64 (14.6%) became colonized with A. fumigatus during the study period. Inhaled antibiotics was associated with A. fumigatus colonization (adjusted OR 3.1, 95% CI 1.6–5.9, p < 0.05). Fungal colonization was not associated with a more rapid lung function decline or increased use of IV-antibiotics compared to the non-colonized group, but patients with A. fumigatus had more hospital days, a higher increase of total IgE, and higher eosinophil counts. In the Aspergillus group, 42 patients were considered to be asymptomatic. Of these, 19 patients received antifungal treatment. Over the follow up period, the treated group had a more pronounced decrease in percent predicted Forced Expiratory Volume in one second (ppFEV1) compared to untreated patients (− 8.7 vs − 1.4 percentage points, p < 0.05). Conclusion Inhaled antibiotics was associated with A. fumigatus colonization, but no association was found between persistent A. fumigatus and subsequent lung function decline. No obvious benefits of treating asymptomatic A. fumigatus colonization were demonstrated.
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Affiliation(s)
- Axel Blomquist
- Department of Clinical Sciences Lund, Section for Infection Medicine, Skåne University Hospital, Lund University, BMC B14, 221 84, Lund, Sweden
| | - Malin Inghammar
- Department of Clinical Sciences Lund, Section for Infection Medicine, Skåne University Hospital, Lund University, BMC B14, 221 84, Lund, Sweden
| | - Mahasin Al Shakirchi
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institute, Stockholm, Sweden
| | - Petrea Ericson
- Department of Respiratory Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Christina Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Marcus Svedberg
- Department of Paediatrics, Institute of Clinical Science at The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Lindblad
- Department of Paediatrics, Institute of Clinical Science at The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lisa I Påhlman
- Department of Clinical Sciences Lund, Section for Infection Medicine, Skåne University Hospital, Lund University, BMC B14, 221 84, Lund, Sweden. .,Wallenberg Centre for Molecular Medicine, Lund University, Lund, Sweden.
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10
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Tiew PY, Thng KX, Chotirmall SH. Clinical Aspergillus Signatures in COPD and Bronchiectasis. J Fungi (Basel) 2022; 8:jof8050480. [PMID: 35628736 PMCID: PMC9146266 DOI: 10.3390/jof8050480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 12/21/2022] Open
Abstract
Pulmonary mycoses remain a global threat, causing significant morbidity and mortality. Patients with airways disease, including COPD and bronchiectasis, are at increased risks of pulmonary mycoses and its associated complications. Frequent use of antibiotics and corticosteroids coupled with impaired host defenses predispose patients to fungal colonization and airway persistence, which are associated with negative clinical consequences. Notably, Aspergillus species remain the best-studied fungal pathogen and induce a broad spectrum of clinical manifestations in COPD and bronchiectasis ranging from colonization and sensitization to more invasive disease. Next-generation sequencing (NGS) has gained prominence in the field of respiratory infection, and in some cases is beginning to act as a viable alternative to traditional culture. NGS has revolutionized our understanding of airway microbiota and in particular fungi. In this context, it permits the identification of the previously unculturable, fungal composition, and dynamic change within microbial communities of the airway, including potential roles in chronic respiratory disease. Furthermore, inter-kingdom microbial interactions, including fungi, in conjunction with host immunity have recently been shown to have important clinical roles in COPD and bronchiectasis. In this review, we provide an overview of clinical Aspergillus signatures in COPD and bronchiectasis and cover the current advances in the understanding of the mycobiome in these disease states. The challenges and limitations of NGS will be addressed.
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Affiliation(s)
- Pei Yee Tiew
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore 168753, Singapore;
- Duke-NUS Medical School, Singapore 169857, Singapore
| | - Kai Xian Thng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore;
| | - Sanjay H. Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore;
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore 308433, Singapore
- Correspondence:
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11
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Sass G, Nazik H, Chatterjee P, Shrestha P, Groleau MC, Déziel E, Stevens DA. Altered Pseudomonas Strategies to Inhibit Surface Aspergillus Colonies. Front Cell Infect Microbiol 2021; 11:734296. [PMID: 34746024 PMCID: PMC8570168 DOI: 10.3389/fcimb.2021.734296] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/17/2021] [Indexed: 01/23/2023] Open
Abstract
Pseudomonas aeruginosa and Aspergillus fumigatus infections frequently co-localize in lungs of immunocompromised patients and individuals with cystic fibrosis (CF). The antifungal activity of P. aeruginosa has been described for its filtrates. Pyoverdine and pyocyanin are the principal antifungal P. aeruginosa molecules active against A. fumigatus biofilm metabolism present in iron-limited or iron-replete planktonic P. aeruginosa culture filtrates, respectively. Using various P. aeruginosa laboratory wild-type strains (PA14, PAO1, PAK), we found antifungal activity against Aspergillus colonies on agar. Comparing 36 PA14 and 7 PAO1 mutants, we found that mutants lacking both major siderophores, pyoverdine and pyochelin, display higher antifungal activity on agar than their wild types, while quorum sensing mutants lost antifungal activity. Addition of ferric iron, but not calcium or magnesium, reduced the antifungal effects of P. aeruginosa on agar, whereas iron-poor agar enhanced antifungal effects. Antifungal activity on agar was mediated by PQS and HHQ, via MvfR. Among the MvfR downstream factors, rhamnolipids and elastase were produced in larger quantities by pyoverdine–pyochelin double mutants and showed antifungal activity on agar. In summary, antifungal factors produced by P. aeruginosa on agar differ from those produced by bacteria grown in liquid cultures, are dependent on quorum sensing, and are downregulated by the availability of ferric iron. Rhamnolipids and elastase seem to be major mediators of Pseudomonas’ antifungal activity on a solid surface.
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Affiliation(s)
- Gabriele Sass
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | - Hasan Nazik
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | | | - Pallabi Shrestha
- Infectious Disease Research Laboratory, San Jose, CA, United States
| | - Marie-Christine Groleau
- Centre Armand-Frappier Santé Biotechnologie, Institute National de la Recherche Scientifique (INRS), Laval, QC, Canada
| | - Eric Déziel
- Centre Armand-Frappier Santé Biotechnologie, Institute National de la Recherche Scientifique (INRS), Laval, QC, Canada
| | - David A Stevens
- Infectious Disease Research Laboratory, San Jose, CA, United States.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States
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12
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Al Shakirchi M, Sorjonen K, Klingspor L, Bergman P, Hjelte L, de Monestrol I. The Effects of Aspergillus fumigatus Colonization on Lung Function in Patients with Cystic Fibrosis. J Fungi (Basel) 2021; 7:jof7110944. [PMID: 34829231 PMCID: PMC8618016 DOI: 10.3390/jof7110944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022] Open
Abstract
Aspergillus fumigatus is commonly isolated from CF airways. However, the impact on CF lung progression is not completely understood. In this study, using a 16-year retrospective observational cohort study (2000–2015) that included 132 patients, we determined the annual lung function, measured as percent predicted forced expiratory volume in the first second (ppFEV1), decline before and after the first colonization with A. fumigatus. Further, in the same individual, the ratios of lung function when patients were colonized with A. fumigatus and when they were not were calculated. The impact of eradication, with antifungal treatment or spontaneously, was assessed. The annual ppFEV1 was significantly lower after the first colonization with A. fumigatus. Furthermore, within the same individual, colonization with A. fumigatus for two and three years in a row was associated with 4.3% and 7.9% lower ppFEV1, respectively, compared to when not colonized. Finally, patients who eradicated A. fumigatus the following two years after colonization exhibited 9.9% and 14.5% higher ppFEV1 compared to patients who continued to produce cultures with A. fumigatus for two and three years. Our study demonstrated that A. fumigatus colonization was associated with a negative impact on lung function in the long term and eradication, spontaneously or with treatment, was associated with a better pulmonary outcome.
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Affiliation(s)
- Mahasin Al Shakirchi
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
- Correspondence:
| | - Kimmo Sorjonen
- Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, 171 77 Stockholm, Sweden;
| | - Lena Klingspor
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, 171 77 Stockholm, Sweden; (L.K.); (P.B.)
- Department of Infectious Diseases, The Immunodeficiency Unit, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden
| | - Lena Hjelte
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Isabelle de Monestrol
- Stockholm Cystic Fibrosis Centre, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (L.H.); (I.d.M.)
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, 171 77 Stockholm, Sweden
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13
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Hong G, Desai S, Moss RB, Eschenhagen P, Quon BS, Schwarz C. Clinician variability in the diagnosis and treatment of aspergillus fumigatus-related conditions in cystic fibrosis: An international survey. J Cyst Fibros 2021; 21:136-142. [PMID: 34332906 DOI: 10.1016/j.jcf.2021.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/07/2021] [Accepted: 07/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The diagnosis and treatment of Aspergillus fumigatus (Af)-related conditions remain a challenge in cystic fibrosis (CF) due to overlapping features of disease and absence of clinical guidelines for Af-related conditions outside of ABPA. OBJECTIVE To investigate the differences of clinical practice in the diagnosis and management of Af-related conditions in CF. METHODS We conducted an international survey to CF clinicians to ascertain the screening, diagnostic, and treatment practices for Af-related conditions in CF. Respondents were grouped into geographical regions and regional comparisons using chi-square tests of independence or Fisher's tests were performed. RESULTS A total of 319 survey responses from 35 countries were analyzed. We observed differences in use and frequency of fungus culture, Aspergillus-specific IgE and IgG, skin prick testing, and pulmonary function testing as screening for Af-related conditions between the geographical regions. ABPA and Aspergillus bronchitis diagnostic criteria selection differed by region; significantly greater proportion of United States (US) and Canadian clinicians were unable to define Aspergillus bronchitis compared to Europe and other regions. Decision to treat ABPA was uniform across regions, but the consideration of Aspergillus bronchitis as a clinical disease warranting therapy differed between regions. The use of glucocorticoid and itraconazole was the first-line treatment of ABPA among clinicians; however, prednisone monotherapy was more common in US and Canada. CONCLUSIONS Significant variability in the diagnosis and management of Aspergillus-related conditions in CF was observed. Future studies are necessary to better harmonize the approach to Af-related disease in CF.
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Affiliation(s)
- Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sameer Desai
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Richard B Moss
- Center of Excellence in Pulmonary Biology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Patience Eschenhagen
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Bradley S Quon
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany; Centre for Heart Lung Innovation, University of British Columbia and St. Paul's Hospital; Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Carsten Schwarz
- Department of Pediatric Pneumology, Immunology and Intensive Care Medicine, CF Center, Charité-Universitätsmedizin Berlin, Berlin, Germany
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14
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Reece E, Bettio PHDA, Renwick J. Polymicrobial Interactions in the Cystic Fibrosis Airway Microbiome Impact the Antimicrobial Susceptibility of Pseudomonas aeruginosa. Antibiotics (Basel) 2021; 10:antibiotics10070827. [PMID: 34356747 PMCID: PMC8300716 DOI: 10.3390/antibiotics10070827] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/01/2021] [Accepted: 07/01/2021] [Indexed: 12/19/2022] Open
Abstract
Pseudomonas aeruginosa is one of the most dominant pathogens in cystic fibrosis (CF) airway disease and contributes to significant inflammation, airway damage, and poorer disease outcomes. The CF airway is now known to be host to a complex community of microorganisms, and polymicrobial interactions have been shown to play an important role in shaping P. aeruginosa pathogenicity and resistance. P. aeruginosa can cause chronic infections that once established are almost impossible to eradicate with antibiotics. CF patients that develop chronic P. aeruginosa infection have poorer lung function, higher morbidity, and a reduced life expectancy. P. aeruginosa adapts to the CF airway and quickly develops resistance to several antibiotics. A perplexing phenomenon is the disparity between in vitro antimicrobial sensitivity testing and clinical response. Considering the CF airway is host to a diverse community of microorganisms or 'microbiome' and that these microorganisms are known to interact, the antimicrobial resistance and progression of P. aeruginosa infection is likely influenced by these microbial relationships. This review combines the literature to date on interactions between P. aeruginosa and other airway microorganisms and the influence of these interactions on P. aeruginosa tolerance to antimicrobials.
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15
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Fungal Infection and Inflammation in Cystic Fibrosis. Pathogens 2021; 10:pathogens10050618. [PMID: 34069863 PMCID: PMC8157353 DOI: 10.3390/pathogens10050618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022] Open
Abstract
Fungi are frequently recovered from lower airway samples from people with cystic fibrosis (CF), yet the role of fungi in the progression of lung disease is debated. Recent studies suggest worsening clinical outcomes associated with airway fungal detection, although most studies to date are retrospective or observational. The presence of fungi can elicit a T helper cell type 2 (Th-2) mediated inflammatory reaction known as allergic bronchopulmonary aspergillosis (ABPA), particularly in those with a genetic atopic predisposition. In this review, we discuss the epidemiology of fungal infections in people with CF, risk factors associated with development of fungal infections, and microbiologic approaches for isolation and identification of fungi. We review the spectrum of fungal disease presentations, clinical outcomes after isolation of fungi from airway samples, and the importance of considering airway co-infections. Finally, we discuss the association between fungi and airway inflammation highlighting gaps in knowledge and future research questions that may further elucidate the role of fungus in lung disease progression.
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16
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Mac Aogáin M, Narayana JK, Tiew PY, Ali NABM, Yong VFL, Jaggi TK, Lim AYH, Keir HR, Dicker AJ, Thng KX, Tsang A, Ivan FX, Poh ME, Oriano M, Aliberti S, Blasi F, Low TB, Ong TH, Oliver B, Giam YH, Tee A, Koh MS, Abisheganaden JA, Tsaneva-Atanasova K, Chalmers JD, Chotirmall SH. Integrative microbiomics in bronchiectasis exacerbations. Nat Med 2021; 27:688-699. [PMID: 33820995 DOI: 10.1038/s41591-021-01289-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 02/16/2021] [Indexed: 02/01/2023]
Abstract
Bronchiectasis, a progressive chronic airway disease, is characterized by microbial colonization and infection. We present an approach to the multi-biome that integrates bacterial, viral and fungal communities in bronchiectasis through weighted similarity network fusion ( https://integrative-microbiomics.ntu.edu.sg ). Patients at greatest risk of exacerbation have less complex microbial co-occurrence networks, reduced diversity and a higher degree of antagonistic interactions in their airway microbiome. Furthermore, longitudinal interactome dynamics reveals microbial antagonism during exacerbation, which resolves following treatment in an otherwise stable multi-biome. Assessment of the Pseudomonas interactome shows that interaction networks, rather than abundance alone, are associated with exacerbation risk, and that incorporation of microbial interaction data improves clinical prediction models. Shotgun metagenomic sequencing of an independent cohort validated the multi-biome interactions detected in targeted analysis and confirmed the association with exacerbation. Integrative microbiomics captures microbial interactions to determine exacerbation risk, which cannot be appreciated by the study of a single microbial group. Antibiotic strategies probably target the interaction networks rather than individual microbes, providing a fresh approach to the understanding of respiratory infection.
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Affiliation(s)
- Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jayanth Kumar Narayana
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Pei Yee Tiew
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Valerie Fei Lee Yong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Tavleen Kaur Jaggi
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Albert Yick Hou Lim
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Holly R Keir
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alison J Dicker
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Kai Xian Thng
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Akina Tsang
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | | | - Mau Ern Poh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Martina Oriano
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Stefano Aliberti
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Blasi
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Teck Boon Low
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Brian Oliver
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Yan Hui Giam
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Augustine Tee
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Krasimira Tsaneva-Atanasova
- Department of Mathematics and Living Systems Institute, College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - James D Chalmers
- School of Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
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17
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Respiratory Mycoses in COPD and Bronchiectasis. Mycopathologia 2021; 186:623-638. [PMID: 33709335 DOI: 10.1007/s11046-021-00539-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) and bronchiectasis represent chronic airway diseases associated with significant morbidity and mortality. Bacteria and viruses are commonly implicated in acute exacerbations; however the significance of fungi in these airways remains poorly defined. While COPD and bronchiectasis remain recognized risk factors for the occurrence of Aspergillus-associated disease including chronic and invasive aspergillosis, underlying mechanisms that lead to the progression from colonization to invasive disease remain uncertain. Nonetheless, advances in molecular technologies have improved our detection, identification and understanding of resident fungi characterizing these airways. Mycobiome sequencing has revealed the complex varied and myriad profile of airway fungi in COPD and bronchiectasis, including their association with disease presentation, progression, and mortality. In this review, we outline the emerging evidence for the clinical importance of fungi in COPD and bronchiectasis, available diagnostic modalities, mycobiome sequencing approaches and association with clinical outcomes.
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18
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Abreu SC, Hampton TH, Hoffman E, Dearborn J, Ashare A, Singh Sidhu K, Matthews DE, McKenna DH, Amiel E, Barua J, Krasnodembskaya A, English K, Mahon B, Dos Santos C, Cruz FF, Chambers DC, Liu KD, Matthay MA, Cramer RA, Stanton BA, Rocco PRM, Wargo MJ, Weiss DJ, Rolandsson Enes S. Differential effects of the cystic fibrosis lung inflammatory environment on mesenchymal stromal cells. Am J Physiol Lung Cell Mol Physiol 2020; 319:L908-L925. [PMID: 32901521 PMCID: PMC7792680 DOI: 10.1152/ajplung.00218.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/14/2020] [Accepted: 08/23/2020] [Indexed: 12/23/2022] Open
Abstract
Growing evidence demonstrates that human mesenchymal stromal cells (MSCs) modify their in vivo anti-inflammatory actions depending on the specific inflammatory environment encountered. Understanding this better is crucial to refine MSC-based cell therapies for lung and other diseases. Using acute exacerbations of cystic fibrosis (CF) lung disease as a model, the effects of ex vivo MSC exposure to clinical bronchoalveolar lavage fluid (BALF) samples, as a surrogate for the in vivo clinical lung environment, on MSC viability, gene expression, secreted cytokines, and mitochondrial function were compared with effects of BALF collected from healthy volunteers. CF BALF samples that cultured positive for Aspergillus sp. (Asp) induced rapid MSC death, usually within several hours of exposure. Further analyses suggested the fungal toxin gliotoxin as a potential mediator contributing to CF BALF-induced MSC death. RNA sequencing analyses of MSCs exposed to either Asp+ or Asp- CF BALF samples identified a number of differentially expressed transcripts, including those involved in interferon signaling, antimicrobial gene expression, and cell death. Toxicity did not correlate with bacterial lung infections. These results suggest that the potential use of MSC-based cell therapies for CF or other lung diseases may not be warranted in the presence of Aspergillus.
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Affiliation(s)
- Soraia C Abreu
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Thomas H Hampton
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Evan Hoffman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Jacob Dearborn
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alix Ashare
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Dwight E Matthews
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
- Department of Chemistry, University of Vermont, Burlington, Vermont
| | - David H McKenna
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Eyal Amiel
- Department of Biomedical and Health Sciences, College of Nursing and Health Sciences, University of Vermont, Burlington, Vermont
| | - Jayita Barua
- Division of Pulmonary Disease and Critical Care, University of Vermont, and The Vermont Lung Center, Burlington, Vermont
| | - Anna Krasnodembskaya
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University of Belfast, Belfast, United Kingdom
| | - Karen English
- Cellular Immunology Laboratory, Biology Department, Human Health Research Institute, Maynooth University, Maynooth, Ireland
| | - Bernard Mahon
- Immunology & Cell Biology Laboratory, Biology Department, Human Health Research Institute, Maynooth University, Maynooth, Ireland
| | - Claudia Dos Santos
- Departments of Medicine and Critical Care Medicine and the Keenan Research Center for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fernanda F Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Brazil
| | - Daniel C Chambers
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Queenland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Kathleen D Liu
- Departments of Medicine and Anesthesiology and the Cardiovascular Research Institute, University of California, San Francisco, California
| | - Michael A Matthay
- Departments of Medicine and Anesthesiology and the Cardiovascular Research Institute, University of California, San Francisco, California
| | - Robert A Cramer
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Bruce A Stanton
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Brazil
| | - Matthew J Wargo
- Department of Microbiology & Molecular Genetics, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Daniel J Weiss
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Sara Rolandsson Enes
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
- Department of Experimental Medical Science, Lung Biology Unit, Lund University, Lund, Sweden
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19
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Keown K, Reid A, Moore JE, Taggart CC, Downey DG. Coinfection with Pseudomonas aeruginosa and Aspergillus fumigatus in cystic fibrosis. Eur Respir Rev 2020; 29:29/158/200011. [PMID: 33208485 DOI: 10.1183/16000617.0011-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Cystic fibrosis (CF) lung disease is characterised by mucus stasis, chronic infection and inflammation, causing progressive structural lung disease and eventual respiratory failure. CF airways are inhabited by an ecologically diverse polymicrobial environment with vast potential for interspecies interactions, which may be a contributing factor to disease progression. Pseudomonas aeruginosa and Aspergillus fumigatus are the most common bacterial and fungal species present in CF airways respectively and coinfection results in a worse disease phenotype. METHODS In this review we examine existing expert knowledge of chronic co-infection with P. aeruginosa and A. fumigatus in CF patients. We summarise the mechanisms of interaction and evaluate the clinical and inflammatory impacts of this co-infection. RESULTS P. aeruginosa inhibits A. fumigatus through multiple mechanisms: phenazine secretion, iron competition, quorum sensing and through diffusible small molecules. A. fumigatus reciprocates inhibition through gliotoxin release and phenotypic adaptations enabling evasion of P. aeruginosa inhibition. Volatile organic compounds secreted by P. aeruginosa stimulate A. fumigatus growth, while A. fumigatus stimulates P. aeruginosa production of cytotoxic elastase. CONCLUSION A complex bi-directional relationship exists between P. aeruginosa and A. fumigatus, exhibiting both mutually antagonistic and cooperative facets. Cross-sectional data indicate a worsened disease state in coinfected patients; however, robust longitudinal studies are required to derive causality and to determine whether interspecies interaction contributes to disease progression.
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Affiliation(s)
- Karen Keown
- Royal Belfast Hospital for Sick Children, Belfast Health and Social Care Trust, Belfast, UK.,Wellcome Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Alastair Reid
- Royal Belfast Hospital for Sick Children, Belfast Health and Social Care Trust, Belfast, UK
| | - John E Moore
- Northern Ireland Public Health Laboratory, Dept of Bacteriology, Belfast City Hospital, Belfast, UK
| | - Clifford C Taggart
- Wellcome Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Damian G Downey
- Wellcome Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
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20
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Sass G, Nazik H, Chatterjee P, Stevens DA. Under nonlimiting iron conditions pyocyanin is a major antifungal molecule, and differences between prototypic Pseudomonas aeruginosa strains. Med Mycol 2020; 59:453-464. [PMID: 32827431 DOI: 10.1093/mmy/myaa066] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 01/09/2023] Open
Abstract
Airways of immunocompromised patients, or individuals with cystic fibrosis (CF), are common ground for Pseudomonas aeruginosa and Aspergillus fumigatus infections. Hence, in such a microenvironment both pathogens compete for resources. While under limiting iron conditions the siderophore pyoverdine is the most effective antifungal P. aeruginosa product, we now provide evidence that under nonlimiting iron conditions P. aeruginosa supernatants lack pyoverdine but still possess considerable antifungal activity. Spectrometric analyses of P. aeruginosa supernatants revealed the presence of phenazines, such as pyocyanin, only under nonlimiting iron conditions. Supernatants of quorum sensing mutants of strain PA14, defective in phenazine production, as well as supernatants of the P. aeruginosa strain PAO1, lacked pyocyanin, and were less inhibitory toward A. fumigatus biofilms under nonlimiting iron conditions. When blood as a natural source of iron was present during P. aeruginosa supernatant production, pyoverdine was absent, and phenazines, including pyocyanin, appeared, resulting in an antifungal effect on A. fumigatus biofilms. Pure pyocyanin reduced A. fumigatus biofilm metabolism. In summary, P. aeruginosa has mechanisms to compete with A. fumigatus under limiting and non-limiting iron conditions, and can switch from iron-denial-based to toxin-based antifungal activity. This has implications for the evolution of the microbiome in clinical settings where the two pathogens co-exist. Important differences in the iron response of P. aeruginosa laboratory strains PA14 and PAO1 were also uncovered.
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Affiliation(s)
- Gabriele Sass
- California Institute for Medical Research, San Jose, California, USA
| | - Hasan Nazik
- California Institute for Medical Research, San Jose, California, USA
| | | | - David A Stevens
- California Institute for Medical Research, San Jose, California, USA.,Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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21
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Schrumpf JA, van der Does AM, Hiemstra PS. Impact of the Local Inflammatory Environment on Mucosal Vitamin D Metabolism and Signaling in Chronic Inflammatory Lung Diseases. Front Immunol 2020; 11:1433. [PMID: 32754156 PMCID: PMC7366846 DOI: 10.3389/fimmu.2020.01433] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023] Open
Abstract
Vitamin D plays an active role in the modulation of innate and adaptive immune responses as well as in the protection against respiratory pathogens. Evidence for this immunomodulatory and protective role is derived from observational studies showing an association between vitamin D deficiency, chronic airway diseases and respiratory infections, and is supported by a range of experimental studies using cell culture and animal models. Furthermore, recent intervention studies have now shown that vitamin D supplementation reduces exacerbation rates in vitamin D-deficient patients with chronic obstructive pulmonary disease (COPD) or asthma and decreases the incidence of acute respiratory tract infections. The active vitamin D metabolite, 1,25-dihydroxy-vitamin D (1,25(OH)2D), is known to contribute to the integrity of the mucosal barrier, promote killing of pathogens (via the induction of antimicrobial peptides), and to modulate inflammation and immune responses. These mechanisms may partly explain its protective role against infections and exacerbations in COPD and asthma patients. The respiratory mucosa is an important site of local 1,25(OH)2D synthesis, degradation and signaling, a process that can be affected by exposure to inflammatory mediators. As a consequence, mucosal inflammation and other disease-associated factors, as observed in e.g., COPD and asthma, may modulate the protective actions of 1,25(OH)2D. Here, we discuss the potential consequences of various disease-associated processes such as inflammation and exposure to pathogens and inhaled toxicants on vitamin D metabolism and local responses to 1,25(OH)2D in both immune- and epithelial cells. We furthermore discuss potential consequences of disturbed local levels of 25(OH)D and 1,25(OH)2D for chronic lung diseases. Additional insight into the relationship between disease-associated mechanisms and local effects of 1,25(OH)2D is expected to contribute to the design of future strategies aimed at improving local levels of 1,25(OH)2D and signaling in chronic inflammatory lung diseases.
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Affiliation(s)
- Jasmijn A Schrumpf
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
| | - Anne M van der Does
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
| | - Pieter S Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, Netherlands
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22
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Nichols DP, Moss RB. Early Aspergillosis in Cystic Fibrosis and Air Trapping: Guilt by Association? Am J Respir Crit Care Med 2020; 201:644-645. [PMID: 31904998 PMCID: PMC7068827 DOI: 10.1164/rccm.201912-2309ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Dave P Nichols
- Seattle Children's HospitalUniversity of Washington School of MedicineSeattle, Washingtonand
| | - Richard B Moss
- Department of PediatricsStanford University School of MedicinePalo Alto, California
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23
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Postolache TT, Akram F, Lee EE, Lowry CA, Stiller JW, Brenner LA, Streeten EA, Turecki G, Dwivedi Y. Increased brain vitamin D receptor expression and decreased expression of cathelicidin antimicrobial peptide in individuals who died by suicide. J Psychiatr Res 2020; 125:75-84. [PMID: 32213352 DOI: 10.1016/j.jpsychires.2020.02.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/01/2020] [Accepted: 02/24/2020] [Indexed: 01/22/2023]
Abstract
Vitamin D deficiency is associated with immune dysregulation, increased vulnerability to infections, depression, and suicidal behavior. One mediator of vitamin D-dependent immune regulation and antimicrobial defense is the cathelicidin antimicrobial peptide (LL-37), encoded by the cathelicidin-related antimicrobial peptide (CRAMP) gene. We compared the mRNA expression of the CRAMP gene, the vitamin D receptor (VDR) gene, as well as the CYP27B1 and CYP24A1 genes (involved in vitamin D metabolism) in the dorsolateral prefrontal cortex (dlPFC) and anterior cingulate cortex (ACC) between depressed individuals who died by suicide (n = 15) and matched (age, gender, and post-mortem interval) non-psychiatric controls (n = 15). Gene expression was measured through qRT-PCR with TaqMan® primers and probes, with GAPDH and β-actin genes as endogenous controls. Statistical analyses included t-tests and Pearson correlations. CRAMP mRNA expression was downregulated and VDR mRNA expression was upregulated in both dlPFC and ACC in suicides relative to controls, with no significant differences in expression of CYP24A1 and CYP27B1. To our knowledge, this is the first study on brain cathelicidin expression in the human brain in relationship to suicide. Increased VDR and decreased CRAMP expression are consistent with previously reported associations between vitamin D deficiency, immune dysregulation, and suicidal behavior, and should lead to future studies uncovering novel interactive targets for suicide prevention.
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Affiliation(s)
- Teodor T Postolache
- Mood and Anxiety Program, University of Maryland School of Medicine, Baltimore, MD, USA; Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA; Veterans Health Administration, Capitol MIRECC, Baltimore VA Medical Center, Baltimore MD, USA.
| | - Faisal Akram
- Mood and Anxiety Program, University of Maryland School of Medicine, Baltimore, MD, USA; Saint Elizabeths Hospital, DC Department of Behavioral Health, Washington, DC, USA
| | - Ellen E Lee
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA, USA; Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Christopher A Lowry
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA; Department of Integrative Physiology, Center for Neuroscience, And Center for Microbial Exploration, University of Colorado Boulder, Boulder, CO, USA; Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - John W Stiller
- Mood and Anxiety Program, University of Maryland School of Medicine, Baltimore, MD, USA; Saint Elizabeths Hospital, DC Department of Behavioral Health, Washington, DC, USA; Maryland State Athletic Commission, Baltimore, MD, USA
| | - Lisa A Brenner
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Rocky Mountain Regional Veterans Affairs Medical Center (RMRVAMC), Aurora, CO, USA; Military and Veteran Microbiome: Consortium for Research and Education (MVM-CoRE), Aurora, CO, USA; Department of Physical Medicine & Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Elizabeth A Streeten
- Program for Personalized and Genomic Medicine, Department of Medicine, Endocrinology, Diabetes & Metabolism, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gustavo Turecki
- McGill Group for Suicide Studies, Douglas Mental Health University Institute, McGill University, Montreal, QC, Canada
| | - Yogesh Dwivedi
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
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24
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Chen JJ, He YS, Zhong XJ, Cai ZL, Lyu YS, Zhao ZF, Ji K. Ribonuclease T2 from Aspergillus fumigatus promotes T helper type 2 responses through M2 polarization of macrophages. Int J Mol Med 2020; 46:718-728. [PMID: 32468025 PMCID: PMC7307867 DOI: 10.3892/ijmm.2020.4613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022] Open
Abstract
Allergic bronchopulmonary aspergillosis (ABPA) is an allergic immunological response to Aspergillus fumigatus (Af) exposure, which induces a strong T helper 2 (Th2) response via mechanisms that have yet to be elucidated. The aim of the present study was to investigate the hypothesis that T2 ribonuclease from Af (Af RNASET2) induces M2‑type macrophage polarization to produce a T helper 2 (Th2) immune response. Recombinant Af RNASET2 (rAf RNASET2) was expressed and purified in a prokaryotic pET system and BALB/c mice were immunized with rAf RNASET2 for in vivo analyses. Expression levels of M2 polarization factors were evaluated in RAW264.7 macrophages treated with rAf RNASET2 in vitro using flow cytometry, reverse transcription‑quantitative PCR, and western blot analysis. The results predicted that the mature Af RNASET2 protein (382 amino acids; GenBank no. MN593022) contained two conserved amino acid sequence (CAS) domains, termed CAS‑1 and CAS‑2, which are also characteristic of the RNASET2 family proteins. The protein expression levels of the Th2‑related cytokines interleukin (IL)‑4, IL‑10, and IL‑13 were upregulated in mice immunized with rAf RNASET2. RAW264.7 macrophages treated with rAf RNASET2 showed increased mRNA expression levels of M2 factors [arginase 1, Il‑10, and Il‑13]; however, there was no difference in cells treated with rAf RNASET2 that had been inactivated with a ribonuclease inhibitor (RNasin). The protein expression levels of IL‑10 in macrophage culture supernatant were also increased following stimulation with rAf RNASET2. In addition, rAf RNASET2 upregulated the expression of phosphorylated mitogen activated protein kinases (MAPKs) in RAW264.7 cells, whereas MAPK inhibitors attenuated rAf RNASET2‑induced IL‑10 expression in RAW264.7 cells. In conclusion, the present study reveals that high rAf RNASET2 activity is required for rAf RNASET2‑induced M2 polarization of macrophages and suggests an important immune regulatory role for Af RNASET2 in ABPA pathogenesis.
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Affiliation(s)
- Jia-Jie Chen
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Yong-Shen He
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Xiao-Jun Zhong
- Central Laboratory, Shenzhen Nanshan Hospital, Shenzhen, Guangdong 518083, P.R. China
| | - Ze-Lang Cai
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Yan-Si Lyu
- Department of Dermatology, Shenzhen University General Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Zhen-Fu Zhao
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Kunmei Ji
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
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25
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Evaluation of Droplet Digital Polymerase Chain Reaction (ddPCR) for the Absolute Quantification of Aspergillus species in the Human Airway. Int J Mol Sci 2020; 21:ijms21093043. [PMID: 32357408 PMCID: PMC7247686 DOI: 10.3390/ijms21093043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prior studies illustrate the presence and clinical importance of detecting Aspergillus species in the airways of patients with chronic respiratory disease. Despite this, a low fungal biomass and the presence of PCR inhibitors limits the usefulness of quantitative PCR (qPCR) for accurate absolute quantification of Aspergillus in specimens from the human airway. Droplet digital PCR (ddPCR) however, presents an alternative methodology allowing higher sensitivity and accuracy of such quantification but remains to be evaluated in head-to-head fashion using specimens from the human airway. Here, we implement a standard duplex TaqMan PCR protocol, and assess if ddPCR is superior in quantifying airway Aspergillus when compared to standard qPCR. METHODS The molecular approaches of qPCR and ddPCR were applied to DNA fungal extracts in n = 20 sputum specimens obtained from non-diseased (n = 4), chronic obstructive pulmonary disease (COPD; n = 8) and non-cystic fibrosis bronchiectasis (n = 8) patients where Aspergillus status was known. DNA was extracted and qPCR and ddPCR performed on all specimens with appropriate controls and head-to-head comparisons performed. RESULTS Standard qPCR and ddPCR were both able to detect, even at low abundance, Aspergillus species (Aspergillus fumigatus - A. fumigatus and Aspergillus terreus - A. terreus) from specimens known to contain the respective fungi. Importantly, however, ddPCR was superior for the detection of A. terreus particularly when present at very low abundance and demonstrates greater resistance to PCR inhibition compared to qPCR. CONCLUSION ddPCR has greater sensitivity for A. terreus detection from respiratory specimens, and is more resistant to PCR inhibition, important attributes considering the importance of A. terreus species in chronic respiratory disease states such as bronchiectasis.
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26
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Breuer O, Schultz A, Garratt LW, Turkovic L, Rosenow T, Murray CP, Karpievitch YV, Akesson L, Dalton S, Sly PD, Ranganathan S, Stick SM, Caudri D. Aspergillus Infections and Progression of Structural Lung Disease in Children with Cystic Fibrosis. Am J Respir Crit Care Med 2020; 201:688-696. [DOI: 10.1164/rccm.201908-1585oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Oded Breuer
- Telethon Kids Institute and
- Department of Pediatrics, Pediatric Pulmonary Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
- Department of Respiratory and Sleep Medicine and
| | - Andre Schultz
- Telethon Kids Institute and
- Division of Child Health, Faculty of Medicine and Dentistry, University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine and
| | | | | | - Tim Rosenow
- Telethon Kids Institute and
- Division of Child Health, Faculty of Medicine and Dentistry, University of Western Australia, Perth, Western Australia, Australia
| | - Conor P. Murray
- Department of Diagnostic Imaging, Perth Children’s Hospital, Perth, Western Australia, Australia
| | | | - Lauren Akesson
- Telethon Kids Institute and
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Victorian Clinical Genetics Services, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Samuel Dalton
- Department of Respiratory Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia
| | - Peter D. Sly
- Children’s Health and Environment Program, Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Sarath Ranganathan
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory Medicine, Royal Children’s Hospital, Parkville, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia; and
| | - Stephen M. Stick
- Telethon Kids Institute and
- Division of Child Health, Faculty of Medicine and Dentistry, University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine and
| | - Daan Caudri
- Telethon Kids Institute and
- Department of Respiratory and Sleep Medicine and
- Department of Pediatrics/Respiratory Medicine, Erasmus Medical Center–Sophia, Rotterdam, the Netherlands
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27
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Mac Aogáin M, Tiew PY, Lim AYH, Low TB, Tan GL, Hassan T, Ong TH, Pang SL, Lee ZY, Gwee XW, Martinus C, Sio YY, Matta SA, Ong TC, Tiong YS, Wong KN, Narayanan S, Au VB, Marlier D, Keir HR, Tee A, Abisheganaden JA, Koh MS, Wang DY, Connolly JE, Chew FT, Chalmers JD, Chotirmall SH. Distinct "Immunoallertypes" of Disease and High Frequencies of Sensitization in Non-Cystic Fibrosis Bronchiectasis. Am J Respir Crit Care Med 2020; 199:842-853. [PMID: 30265843 DOI: 10.1164/rccm.201807-1355oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Allergic sensitization is associated with poor clinical outcomes in asthma, chronic obstructive pulmonary disease, and cystic fibrosis; however, its presence, frequency, and clinical significance in non-cystic fibrosis bronchiectasis remain unclear. OBJECTIVES To determine the frequency and geographic variability that exists in a sensitization pattern to common and specific allergens, including house dust mite and fungi, and to correlate such patterns to airway immune-inflammatory status and clinical outcomes in bronchiectasis. METHODS Patients with bronchiectasis were recruited in Asia (Singapore and Malaysia) and the United Kingdom (Scotland) (n = 238), forming the Cohort of Asian and Matched European Bronchiectasis, which matched recruited patients on age, sex, and bronchiectasis severity. Specific IgE response against a range of common allergens was determined, combined with airway immune-inflammatory status and correlated to clinical outcomes. Clinically relevant patient clusters, based on sensitization pattern and airway immune profiles ("immunoallertypes"), were determined. MEASUREMENTS AND MAIN RESULTS A high frequency of sensitization to multiple allergens was detected in bronchiectasis, exceeding that in a comparator cohort with allergic rhinitis (n = 149). Sensitization was associated with poor clinical outcomes, including decreased pulmonary function and more severe disease. "Sensitized bronchiectasis" was classified into two immunoallertypes: one fungal driven and proinflammatory, the other house dust mite driven and chemokine dominant, with the former demonstrating poorer clinical outcome. CONCLUSIONS Allergic sensitization occurs at high frequency in patients with bronchiectasis recruited from different global centers. Improving endophenotyping of sensitized bronchiectasis, a clinically significant state, and a "treatable trait" permits therapeutic intervention in appropriate patients, and may allow improved stratification in future bronchiectasis research and clinical trials.
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Affiliation(s)
- Micheál Mac Aogáin
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Pei Yee Tiew
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Albert Yick Hou Lim
- 3 Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Teck Boon Low
- 4 Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Gan Liang Tan
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Tidi Hassan
- 5 Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Thun How Ong
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Sze Lei Pang
- 6 Department of Biological Sciences, National University of Singapore, Singapore.,7 Institute of Systems Biology, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Zi Yang Lee
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Xiao Wei Gwee
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Christopher Martinus
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Yang Yie Sio
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Sri Anusha Matta
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Tan Ching Ong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Yuen Seng Tiong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - Kang Ning Wong
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | | | | | - Damien Marlier
- 8 Institute of Molecular and Cell Biology, A*STAR, Singapore
| | - Holly R Keir
- 9 University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland; and
| | - Augustine Tee
- 4 Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | | | - Mariko Siyue Koh
- 2 Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - De Yun Wang
- 10 Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - John E Connolly
- 8 Institute of Molecular and Cell Biology, A*STAR, Singapore
| | - Fook Tim Chew
- 6 Department of Biological Sciences, National University of Singapore, Singapore
| | - James D Chalmers
- 9 University of Dundee, Ninewells Hospital and Medical School, Dundee, Scotland; and
| | - Sanjay H Chotirmall
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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28
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Fungal Infections and ABPA. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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29
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Nazik H, Sass G, Ansari SR, Ertekin R, Haas H, Déziel E, Stevens DA. Novel intermicrobial molecular interaction: Pseudomonas aeruginosa Quinolone Signal (PQS) modulates Aspergillus fumigatus response to iron. MICROBIOLOGY-SGM 2019; 166:44-55. [PMID: 31778108 DOI: 10.1099/mic.0.000858] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Pseudomonas aeruginosa (Pa) and Aspergillus fumigatus (Af), the commonest bacterium and fungus in compromised host airways, compete for iron (Fe). The Pseudomonas quinolone signal (PQS), a Pa quorum sensing molecule, also chelates Fe, and delivers Fe to the Pa cell membrane using Pa siderophores. In models of Af biofilm formation or preformed biofilms, PQS inhibited Af in a low Fe environment. AfΔsidA (mutant unable to produce siderophores) biofilm was more sensitive to PQS inhibition than wild-type (WT), as was planktonic AfΔsidA growth. PQS decreased WT Af growth on agar. All these inhibitory actions were reversed by Fe. The Pa siderophore pyoverdin, or Af siderophore inhibitor celastrol, act cooperatively with PQS in Af inhibition. These findings all indicate PQS inhibition is owing to Fe chelation. Remarkably, in high Fe environments, PQS enhanced Af biofilm at 1/100 to 1/2000 Fe concentration required for Fe alone to enhance. Planktonic Af growth, and on agar, Af conidiation, were also enhanced by PQS+Fe compared to Fe alone. In contrast, neither AfΔsidA biofilm, nor planktonic AfΔsidA, were enhanced by PQS-Fe compared to Fe. When Af siderophore ferricrocin (FC),+PQS, were added to AfΔsidA, Af was then boosted more than by FC alone. Moreover, FC+PQS+Fe boosted AfΔsidA more than Fe, FC, FC+Fe, PQS+FC or PQS+Fe. Thus PQS-Fe maximal stimulation requires Af siderophores. PQS inhibits Af via chelation under low Fe conditions. In a high Fe environment, PQS paradoxically stimulates Af efficiently, and this involves Af siderophores. PQS production by Pa could stimulate Af in cystic fibrosis airways, where Fe homeostasis is altered and Fe levels increase, supporting fungal growth.
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Affiliation(s)
- Hasan Nazik
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,California Institute for Medical Research, San Jose, CA, USA
| | - Gabriele Sass
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,California Institute for Medical Research, San Jose, CA, USA
| | - Shajia R Ansari
- California Institute for Medical Research, San Jose, CA, USA
| | - Reyhan Ertekin
- California Institute for Medical Research, San Jose, CA, USA
| | - Hubertus Haas
- Division of Molecular Biology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Eric Déziel
- INRS-Institut Armand-Frappier, Laval, Quebec, Canada
| | - David A Stevens
- California Institute for Medical Research, San Jose, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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30
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Hong G, Alby K, Ng SCW, Fleck V, Kubrak C, Rubenstein RC, Dorgan DJ, Kawut SM, Hadjiliadis D. The presence of Aspergillus fumigatus is associated with worse respiratory quality of life in cystic fibrosis. J Cyst Fibros 2019; 19:125-130. [PMID: 31446018 DOI: 10.1016/j.jcf.2019.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/09/2019] [Accepted: 08/12/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The clinical effects of Aspergillus fumigatus in the cystic fibrosis (CF) airway, with the exception of allergic bronchopulmonary aspergillosis, is unclear. METHODS CF adolescents and adults (age 14 years and older) underwent bacterial and semi-selective fungal culture testing to determine the prevalence of fungi in the CF respiratory tract and the independent association between the presence of Aspergillus fumigatus and clinical characteristics. RESULTS Aspergillus fumigatus (10.3%) and Candida species (57.8%) were the most common filamentous fungi and yeast seen respectively in the sputa of 206 individuals with CF. Inhaled corticosteroid (ICS) use was more common in Aspergillus fumigatus-positive than Aspergillus fumigatusnegative (100% versus 75.8%, p = .01). Aspergillus fumigatus was significantly associated with lower respiratory domain score (β -8.74, 95% CI -16.6, -0.88, p = .03), representing worse respiratory-related quality of life, accounting for demographics, disease characteristics, and the presence of a pulmonary exacerbation. CONCLUSION The presence of Aspergillus fumigatus in CF sputum was associated with worse respiratory quality of life in CF in a crosssectional, single center study. Longitudinal analysis examining the clinical implications of Aspergillus fumigatus on respiratory health over time is needed.
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Affiliation(s)
- Gina Hong
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Kevin Alby
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Sharon C W Ng
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Victoria Fleck
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Christina Kubrak
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ronald C Rubenstein
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Dorgan
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Steven M Kawut
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Denis Hadjiliadis
- Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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31
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Reece E, McClean S, Greally P, Renwick J. The prevalence of Aspergillus fumigatus in early cystic fibrosis disease is underestimated by culture-based diagnostic methods. J Microbiol Methods 2019; 164:105683. [PMID: 31386863 DOI: 10.1016/j.mimet.2019.105683] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 11/28/2022]
Abstract
Aspergillus fumigatus is the most common fungus infecting/colonising people with cystic fibrosis (CF) and can negatively impact clinical status. Diagnostic laboratories rely on culture to detect A. fumigatus which is known to be less sensitive than molecular approaches. Therefore, A. fumigatus colonisation in the CF population may be underestimated. Sputum (n = 60) from 25 children with CF were collected and A. fumigatus was detected using routine culture (CM1), enhanced culture (CM2) and ITS1 qPCR. The prevalence of A. fumigatus in this young CF population was 68% by qPCR and only 16% by CM1. CM1, CM2 and qPCR detected A. fumigatus in 8%, 22% and 53% of samples, respectively. qPCR had a 94.2% and 77.4% increased odds of detecting A. fumigatus over CM1 and CM2, respectively. Molecular methods proved superior for detecting A. fumigatus in CF sputum. A. fumigatus is likely more prevalent in early CF disease than is currently reported.
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Affiliation(s)
- Emma Reece
- Department of Clinical Microbiology, Trinity College Dublin, Trinity Centre for Health Science, Tallaght University Hospital, Dublin 24, Ireland
| | - Siobhán McClean
- School of Biomolecular and Biomedical Sciences, University College Dublin, Ireland
| | - Peter Greally
- Department of Respiratory Medicine, The National Children's Hospital, Tallaght University Hospital, Dublin 24, Ireland
| | - Julie Renwick
- Department of Clinical Microbiology, Trinity College Dublin, Trinity Centre for Health Science, Tallaght University Hospital, Dublin 24, Ireland.
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32
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Zhang C, Chen F, Liu X, Han X, Hu Y, Su X, Chen Y, Sun Y, Han L. Gliotoxin Induces Cofilin Phosphorylation to Promote Actin Cytoskeleton Dynamics and Internalization of Aspergillus fumigatus Into Type II Human Pneumocyte Cells. Front Microbiol 2019; 10:1345. [PMID: 31275272 PMCID: PMC6591310 DOI: 10.3389/fmicb.2019.01345] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/29/2019] [Indexed: 01/27/2023] Open
Abstract
Aspergillus fumigatus is able to internalize into lung epithelial cells to escape from immune attack for further dissemination. We previously reported that gliotoxin, a major mycotoxin of A. fumigatus, promotes this internalization; however, the mechanism remained unclear. Here, we report that gliotoxin is able to induce cofilin phosphorylation in A549 type II human pneumocytes. Either too high or too low a level of cofilin phosphorylation blocked the gliotoxin-induced actin cytoskeleton rearrangement and A. fumigatus internalization. LIM domain kinase 1 (LIMK1) and its upstream small GTPases (Cdc42 and RhoA, but not Rac1) predominantly mediated the gliotoxin-induced cofilin phosphorylation and A. fumigatus internalization. Simultaneously, gliotoxin significantly stimulated an increase in cAMP; however, adding an antagonist of PKA did not block gliotoxin-induced A. fumigatus internalization. In vivo, exogenous gliotoxin helped gliotoxin synthesis deficient strain gliPΔ invade into the lung tissue and the lung fungal burden increased markedly in immunosuppressed mice. In conclusion, these data revealed a novel role of gliotoxin in inducing cofilin phosphorylation mostly through the Cdc42/RhoA-LIMK1 signaling pathway to promote actin cytoskeleton rearrangement and internalization of A. fumigatus into type II human pneumocytes.
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Affiliation(s)
- Changjian Zhang
- Chinese PLA Center for Disease Control and Prevention, Beijing, China.,Academy of Military Medical Sciences, Beijing, China
| | - Fangyan Chen
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Xiaoyu Liu
- Chinese PLA Center for Disease Control and Prevention, Beijing, China.,Academy of Military Medical Sciences, Beijing, China
| | - Xuelin Han
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Yingsong Hu
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Xueting Su
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Yong Chen
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
| | - Yansong Sun
- Academy of Military Medical Sciences, Beijing, China
| | - Li Han
- Chinese PLA Center for Disease Control and Prevention, Beijing, China
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33
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Sass G, Ansari SR, Dietl AM, Déziel E, Haas H, Stevens DA. Intermicrobial interaction: Aspergillus fumigatus siderophores protect against competition by Pseudomonas aeruginosa. PLoS One 2019; 14:e0216085. [PMID: 31067259 PMCID: PMC6505954 DOI: 10.1371/journal.pone.0216085] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/12/2019] [Indexed: 12/27/2022] Open
Abstract
Pseudomonas aeruginosa and Aspergillus fumigatus are pathogens frequently co-inhabiting immunocompromised patient airways, particularly in people with cystic fibrosis. Both microbes depend on the availability of iron, and compete for iron in their microenvironment. We showed previously that the P. aeruginosa siderophore pyoverdine is the main instrument in battling A. fumigatus biofilms, by iron chelation and denial of iron to the fungus. Here we show that A. fumigatus siderophores defend against anti-fungal P. aeruginosa effects. P. aeruginosa supernatants produced in the presence of wildtype A. fumigatus planktonic supernatants (Afsup) showed less activity against A. fumigatus biofilms than P. aeruginosa supernatants without Afsup, despite higher production of pyoverdine by P. aeruginosa. Supernatants of A. fumigatus cultures lacking the sidA gene (AfΔsidA), unable to produce hydroxamate siderophores, were less capable of protecting A. fumigatus biofilms from P. aeruginosa supernatants and pyoverdine. AfΔsidA biofilm was more sensitive towards inhibitory effects of pyoverdine, the iron chelator deferiprone (DFP), or amphothericin B than wildtype A. fumigatus biofilm. Supplementation of sidA-deficient A. fumigatus biofilm with A. fumigatus siderophores restored resistance to pyoverdine. The A. fumigatus siderophore production inhibitor celastrol sensitized wildtype A. fumigatus biofilms towards the anti-fungal activity of DFP. In conclusion, A. fumigatus hydroxamate siderophores play a pivotal role in A. fumigatus competition for iron against P. aeruginosa.
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Affiliation(s)
- Gabriele Sass
- California Institute for Medical Research, San Jose, California, United States of America
- * E-mail:
| | - Shajia R. Ansari
- California Institute for Medical Research, San Jose, California, United States of America
| | - Anna-Maria Dietl
- Division of Molecular Biology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Eric Déziel
- INRS-Institut Armand-Frappier, Laval, Quebec, Canada
| | - Hubertus Haas
- Division of Molecular Biology, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - David A. Stevens
- California Institute for Medical Research, San Jose, California, United States of America
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
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34
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Proal A, Marshall T. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in the Era of the Human Microbiome: Persistent Pathogens Drive Chronic Symptoms by Interfering With Host Metabolism, Gene Expression, and Immunity. Front Pediatr 2018; 6:373. [PMID: 30564562 PMCID: PMC6288442 DOI: 10.3389/fped.2018.00373] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/14/2018] [Indexed: 12/16/2022] Open
Abstract
The illness ME/CFS has been repeatedly tied to infectious agents such as Epstein Barr Virus. Expanding research on the human microbiome now allows ME/CFS-associated pathogens to be studied as interacting members of human microbiome communities. Humans harbor these vast ecosystems of bacteria, viruses and fungi in nearly all tissue and blood. Most well-studied inflammatory conditions are tied to dysbiosis or imbalance of the human microbiome. While gut microbiome dysbiosis has been identified in ME/CFS, microbes and viruses outside the gut can also contribute to the illness. Pathobionts, and their associated proteins/metabolites, often control human metabolism and gene expression in a manner that pushes the body toward a state of illness. Intracellular pathogens, including many associated with ME/CFS, drive microbiome dysbiosis by directly interfering with human transcription, translation, and DNA repair processes. Molecular mimicry between host and pathogen proteins/metabolites further complicates this interference. Other human pathogens disable mitochondria or dysregulate host nervous system signaling. Antibodies and/or clonal T cells identified in patients with ME/CFS are likely activated in response to these persistent microbiome pathogens. Different human pathogens have evolved similar survival mechanisms to disable the host immune response and host metabolic pathways. The metabolic dysfunction driven by these organisms can result in similar clusters of inflammatory symptoms. ME/CFS may be driven by this pathogen-induced dysfunction, with the nature of dysbiosis and symptom presentation varying based on a patient's unique infectious and environmental history. Under such conditions, patients would benefit from treatments that support the human immune system in an effort to reverse the infectious disease process.
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Affiliation(s)
- Amy Proal
- Autoimmunity Research Foundation, Thousand Oaks, CA, United States
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35
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Tracy MC, Moss RB. The myriad challenges of respiratory fungal infection in cystic fibrosis. Pediatr Pulmonol 2018; 53:S75-S85. [PMID: 29992775 DOI: 10.1002/ppul.24126] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/21/2018] [Indexed: 12/27/2022]
Abstract
Fungal infection in cystic fibrosis (CF) is a recognized challenge, with many areas requiring further investigation. Consensus definitions exist for allergic bronchopulmonary aspergillus in CF, but the full scope of clinically relevant non-allergic fungal disease in CF-asymptomatic colonization, transient or chronic infection localized to endobronchial mucus plugs or airway tissue, and invasive disease-is yet to be clearly defined. Recent advances in mycological culture and non-culture identification have expanded the list of both potential pathogens and community commensals in the lower respiratory tract. Here we aim to outline the current understanding of fungal presence in the CF respiratory tract, risk factors for acquiring fungi, host-pathogen interactions that influence the role of fungi from bystander to pathogen, advances in the diagnostic approaches to isolating and identifying fungi in CF respiratory samples, challenges of classifying clinical phenotypes of CF patients with fungi, and current treatment approaches. Development and validation of biomarkers characteristic of different fungal clinical phenotypes, and controlled trials of antifungal agents in well-characterized target populations, remain central challenges to surmount and goals to be achieved.
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Affiliation(s)
- Michael C Tracy
- Center for Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
| | - Richard B Moss
- Center for Excellence in Pulmonary Biology, Division of Pulmonary, Asthma and Sleep Medicine, Department of Pediatrics, Stanford University Medical School, Palo Alto, California
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36
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Mac Aogáin M, Chandrasekaran R, Lim AYH, Low TB, Tan GL, Hassan T, Ong TH, Hui Qi Ng A, Bertrand D, Koh JY, Pang SL, Lee ZY, Gwee XW, Martinus C, Sio YY, Matta SA, Chew FT, Keir HR, Connolly JE, Abisheganaden JA, Koh MS, Nagarajan N, Chalmers JD, Chotirmall SH. Immunological corollary of the pulmonary mycobiome in bronchiectasis: the CAMEB study. Eur Respir J 2018; 52:13993003.00766-2018. [PMID: 29880655 PMCID: PMC6092680 DOI: 10.1183/13993003.00766-2018] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 05/26/2018] [Indexed: 01/05/2023]
Abstract
Understanding the composition and clinical importance of the fungal mycobiome was recently identified as a key topic in a “research priorities” consensus statement for bronchiectasis. Patients were recruited as part of the CAMEB study: an international multicentre cross-sectional Cohort of Asian and Matched European Bronchiectasis patients. The mycobiome was determined in 238 patients by targeted amplicon shotgun sequencing of the 18S–28S rRNA internally transcribed spacer regions ITS1 and ITS2. Specific quantitative PCR for detection of and conidial quantification for a range of airway Aspergillus species was performed. Sputum galactomannan, Aspergillus specific IgE, IgG and TARC (thymus and activation regulated chemokine) levels were measured systemically and associated to clinical outcomes. The bronchiectasis mycobiome is distinct and characterised by specific fungal genera, including Aspergillus, Cryptococcus and Clavispora. Aspergillus fumigatus (in Singapore/Kuala Lumpur) and Aspergillus terreus (in Dundee) dominated profiles, the latter associating with exacerbations. High frequencies of Aspergillus-associated disease including sensitisation and allergic bronchopulmonary aspergillosis were detected. Each revealed distinct mycobiome profiles, and associated with more severe disease, poorer pulmonary function and increased exacerbations. The pulmonary mycobiome is of clinical relevance in bronchiectasis. Screening for Aspergillus-associated disease should be considered even in apparently stable patients. The airway mycobiome in bronchiectasis is associated with clinically significant diseasehttp://ow.ly/MCKj30knVrn
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Affiliation(s)
- Micheál Mac Aogáin
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,These two authors contributed equally to this work
| | - Ravishankar Chandrasekaran
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,These two authors contributed equally to this work
| | - Albert Yick Hou Lim
- Dept of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
| | - Teck Boon Low
- Dept of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Gan Liang Tan
- Dept of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Tidi Hassan
- Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Thun How Ong
- Dept of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | | | | | - Jia Yu Koh
- Genome Institute of Singapore, A*STAR, Singapore
| | - Sze Lei Pang
- Dept of Biological Sciences, National University of Singapore, Singapore.,Institute of Systems Biology, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | - Zi Yang Lee
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Xiao Wei Gwee
- Dept of Biological Sciences, National University of Singapore, Singapore
| | | | - Yang Yie Sio
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Sri Anusha Matta
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Fook Tim Chew
- Dept of Biological Sciences, National University of Singapore, Singapore
| | - Holly R Keir
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | | | | | - Mariko Siyue Koh
- Dept of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | | | - James D Chalmers
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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37
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The Human Cathelicidin Antimicrobial Peptide LL-37 Promotes the Growth of the Pulmonary Pathogen Aspergillus fumigatus. Infect Immun 2018; 86:IAI.00097-18. [PMID: 29712727 DOI: 10.1128/iai.00097-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 04/20/2018] [Indexed: 12/14/2022] Open
Abstract
The pulmonary mucus of cystic fibrosis (CF) patients displays elevated levels of the cathelicidin antimicrobial peptide LL-37, and the aim of this work was to assess the effect of LL-37 on the growth of Aspergillus fumigatus, a common pathogen of CF patients. Exposure of A. fumigatus to LL-37 and its derived fragment RK-31 (1.95 μg/ml) for 24 h had a positive effect on growth (199.94% ± 6.172% [P < 0.05] and 218.20% ± 4.63% [P < 0.05], respectively), whereas scrambled LL-37 peptide did not (85.12% ± 2.92%). Exposure of mycelium (preformed for 24 h) to 5 μg/ml intact LL-37 for 48 h increased hyphal wet weight (4.37 ± 0.23 g, P < 0.001) compared to the control (2.67 ± 0.05 g) and scrambled LL-37 (2.23 ± 0.09 g) treatments. Gliotoxin secretion from LL-37 exposed hyphae (169.1 ± 6.36 ng/mg hyphae, P < 0.05) was increased at 24 h compared to the results seen with the control treatment (102 ± 18.81 ng/mg hyphae) and the scrambled LL-37 treatment (96.09 ± 15.15 ng/mg hyphae). Shotgun proteomic analysis of 24-h LL-37-treated hyphae revealed an increase in the abundance of proteins associated with growth (eukaryotic translation initiation factor 5A [eIF-5A] [16.3-fold increased]), tissue degradation (aspartic endopeptidase [4.7-fold increased]), and allergic reactions (Asp F13 [10-fold increased]). By 48 h, there was an increase in protein levels indicative of cellular stress (glutathione peroxidase [9-fold increased]), growth (eIF-5A [6-fold increased]), and virulence (RNase mitogillin [3.7-fold increased]). These results indicate that LL-37 stimulates A. fumigatus growth and that this stimulation can result in increased fungal growth and secretion of toxins in the lungs of CF patients.
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38
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Abhimanyu, Coussens AK. The role of UV radiation and vitamin D in the seasonality and outcomes of infectious disease. Photochem Photobiol Sci 2018; 16:314-338. [PMID: 28078341 DOI: 10.1039/c6pp00355a] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The seasonality of infectious disease outbreaks suggests that environmental conditions have a significant effect on disease risk. One of the major environmental factors that can affect this is solar radiation, primarily acting through ultraviolet radiation (UVR), and its subsequent control of vitamin D production. Here we show how UVR and vitamin D, which are modified by latitude and season, can affect host and pathogen fitness and relate them to the outcomes of bacterial, viral and vector-borne infections. We conducted a thorough comparison of the molecular and cellular mechanisms of action of UVR and vitamin D on pathogen fitness and host immunity and related these to the effects observed in animal models and clinical trials to understand their independent and complementary effects on infectious disease outcome. UVR and vitamin D share common pathways of innate immune activation primarily via antimicrobial peptide production, and adaptive immune suppression. Whilst UVR can induce vitamin D-independent effects in the skin, such as the generation of photoproducts activating interferon signaling, vitamin D has a larger systemic effect due to its autocrine and paracrine modulation of cellular responses in a range of tissues. However, the seasonal patterns in infectious disease prevalence are not solely driven by variation in UVR and vitamin D levels across latitudes. Vector-borne pathogens show a strong seasonality of infection correlated to climatic conditions favoring their replication. Conversely, pathogens, such as influenza A virus, Mycobacterium tuberculosis and human immunodeficiency virus type 1, have strong evidence to support their interaction with vitamin D. Thus, UVR has both vitamin D-dependent and independent effects on infectious diseases; these effects vary depending on the pathogen of interest and the effects can be complementary or antagonistic.
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Affiliation(s)
- Abhimanyu
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Western Cape, South Africa.
| | - Anna K Coussens
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Western Cape, South Africa. and Division of Medical Microbiology, Department of Pathology, University of Cape Town, Anzio Rd, Observatory, 7925, Western Cape, South Africa
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39
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Reece E, Doyle S, Greally P, Renwick J, McClean S. Aspergillus fumigatus Inhibits Pseudomonas aeruginosa in Co-culture: Implications of a Mutually Antagonistic Relationship on Virulence and Inflammation in the CF Airway. Front Microbiol 2018; 9:1205. [PMID: 29922270 PMCID: PMC5996130 DOI: 10.3389/fmicb.2018.01205] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/17/2018] [Indexed: 11/26/2022] Open
Abstract
Many cystic fibrosis (CF) airway infections are considered to be polymicrobial and microbe–microbe interactions may play an important role in disease pathology. Pseudomonas aeruginosa and Aspergillus fumigatus are the most prevalent bacterial and fungal pathogens isolated from the CF airway, respectively. We have previously shown that patients co-colonized with these pathogens had comparable outcomes to those chronically colonized with P. aeruginosa. Our objective was to examine the interactions between A. fumigatus and P. aeruginosa, specifically the effects of co-colonization on biofilm formation, virulence and host pro-inflammatory responses. Our findings suggest that co-infections of A. fumigatus and P. aeruginosa in the Galleria mellonella acute infection model showed that pre-exposure of larvae to sub-lethal inocula of A. fumigatus increased the mortality caused by subsequent P. aeruginosa infection. Co-infection of human bronchial epithelial cells (CFBE41o-) with both pathogens did not enhance IL-6 and IL-8 production beyond the levels observed following single infections. In addition, both pathogens stimulated cytokine secretion via the same two mitogen-activated protein kinases (MAPKs) signaling pathways, ERK and p38. Mixed species biofilms showed overall reduced biofilm development with crystal violet staining. Quantification by species-specific qPCR revealed that both pathogens had mutually antagonistic effects on each other. A. fumigatus supernatants showed strong anti-Pseudomonal activity and gliotoxin was the main active agent. Gliotoxin resulted in varying levels of anti-biofilm activity toward other bacteria commonly found in the CF airways. Gliotoxin produced by A. fumigatus colonizing the CF airways may have a significant impact on the CF airway microbiome composition with potential clinical implications.
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Affiliation(s)
- Emma Reece
- Department of Clinical Microbiology, Trinity College Dublin - Trinity Centre for Health Science, Tallaght Hospital, Dublin, Ireland
| | - Sean Doyle
- Department of Biology, Maynooth University, Maynooth, Ireland
| | - Peter Greally
- Department of Respiratory Medicine, The National Children's Hospital, Tallaght Hospital, Dublin, Ireland
| | - Julie Renwick
- Department of Clinical Microbiology, Trinity College Dublin - Trinity Centre for Health Science, Tallaght Hospital, Dublin, Ireland
| | - Siobhán McClean
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
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40
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Studies of Pseudomonas aeruginosa Mutants Indicate Pyoverdine as the Central Factor in Inhibition of Aspergillus fumigatus Biofilm. J Bacteriol 2017; 200:JB.00345-17. [PMID: 29038255 DOI: 10.1128/jb.00345-17] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/02/2017] [Indexed: 01/05/2023] Open
Abstract
Pseudomonas aeruginosa and Aspergillus fumigatus are common opportunistic bacterial and fungal pathogens, respectively. They often coexist in airways of immunocompromised patients and individuals with cystic fibrosis, where they form biofilms and cause acute and chronic illnesses. Hence, the interactions between them have long been of interest and it is known that P. aeruginosa can inhibit A. fumigatusin vitro We have approached the definition of the inhibitory P. aeruginosa molecules by studying 24 P. aeruginosa mutants with various virulence genes deleted for the ability to inhibit A. fumigatus biofilms. The ability of P. aeruginosa cells or their extracellular products produced during planktonic or biofilm growth to affect A. fumigatus biofilm metabolism or planktonic A. fumigatus growth was studied in agar and liquid assays using conidia or hyphae. Four mutants, the pvdD pchE, pvdD, lasR rhlR, and lasR mutants, were shown to be defective in various assays. This suggested the P. aeruginosa siderophore pyoverdine as the key inhibitory molecule, although additional quorum sensing-regulated factors likely contribute to the deficiency of the latter two mutants. Studies of pure pyoverdine substantiated these conclusions and included the restoration of inhibition by the pyoverdine deletion mutants. A correlation between the concentration of pyoverdine produced and antifungal activity was also observed in clinical P. aeruginosa isolates derived from lungs of cystic fibrosis patients. The key inhibitory mechanism of pyoverdine was chelation of iron and denial of iron to A. fumigatusIMPORTANCE Interactions between human pathogens found in the same body locale are of vast interest. These interactions could result in exacerbation or amelioration of diseases. The bacterium Pseudomonas aeruginosa affects the growth of the fungus Aspergillus fumigatus Both pathogens form biofilms that are resistant to therapeutic drugs and host immunity. P. aeruginosa and A. fumigatus biofilms are found in vivo, e.g., in the lungs of cystic fibrosis patients. Studying 24 P. aeruginosa mutants, we identified pyoverdine as the major anti-A. fumigatus compound produced by P. aeruginosa Pyoverdine captures iron from the environment, thus depriving A. fumigatus of a nutrient essential for its growth and metabolism. We show how microbes of different kingdoms compete for essential resources. Iron deprivation could be a therapeutic approach to the control of pathogen growth.
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41
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Dietary vitamin D3 deficiency exacerbates sinonasal inflammation and alters local 25(OH)D3 metabolism. PLoS One 2017; 12:e0186374. [PMID: 29045457 PMCID: PMC5646812 DOI: 10.1371/journal.pone.0186374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/30/2017] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have been shown to be vitamin D3 (VD3) deficient, which is associated with more severe disease and increased polyp size. To gain mechanistic insights into these observational studies, we examined the impact of VD3 deficiency on inflammation and VD3 metabolism in an Aspergillus fumigatus (Af) mouse model of chronic rhinosinusitis (Af-CRS). METHODS Balb/c mice were fed control or VD3 deficient diet for 4 weeks. Mice were then sensitized with intraperitoneal Af, and one week later given Af intranasally every three days for four weeks while being maintained on control or VD3 deficient diet. Airway function, sinonasal immune cell infiltrate and sinonasal VD3 metabolism profiles were then examined. RESULTS Mice with VD3 deficiency had increased Penh and sRaw values as compared to controls as well as exacerbated changes in sRaw when coupled with Af-CRS. As compared to controls, VD3 deficient and Af-CRS mice had reduced sinonasal 1α-hydroxylase and the active VD3 metabolite, 1,25(OH)2D3. Differential analysis of nasal lavage samples showed that VD3 deficiency alone and in combination with Af-CRS profoundly upregulated eosinophil, neutrophil and lymphocyte numbers. VD3 deficiency exacerbated increases in monocyte-derived dendritic cell (DC) associated with Af-CRS. Conversely, T-regulatory cells were decreased in both Af-CRS mice and VD3 deficient mice, though coupling VD3 deficiency with Af-CRS did not exacerbate CD4 or T-regulatory cells numbers. Lastly, VD3 deficiency had a modifying or exacerbating impact on nasal lavage levels of IFN-γ, IL-6, IL-10 and TNF-α, but had no impact on IL-17A. CONCLUSIONS VD3 deficiency causes changes in sinonasal immunity, which in many ways mirrors the changes observed in Af-CRS mice, while selectively exacerbating inflammation. Furthermore, both VD3 deficiency and Af-CRS were associated with altered sinonasal VD3 metabolism causing reductions in local levels of the active VD3 metabolite, 1,25(OH)2D3, even with adequate circulating levels.
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Vitamin D deficiency is a risk factor for infections in patients affected by HCV-related liver cirrhosis. Int J Infect Dis 2017; 63:23-29. [DOI: 10.1016/j.ijid.2017.07.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/11/2017] [Accepted: 07/31/2017] [Indexed: 02/07/2023] Open
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Everaerts S, Lagrou K, Dubbeldam A, Lorent N, Vermeersch K, Van Hoeyveld E, Bossuyt X, Dupont LJ, Vanaudenaerde BM, Janssens W. Sensitization to Aspergillus fumigatus as a risk factor for bronchiectasis in COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:2629-2638. [PMID: 28919731 PMCID: PMC5587018 DOI: 10.2147/copd.s141695] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Bronchiectasis-chronic obstructive pulmonary disease (COPD) overlap presents a possible clinical phenotype of COPD, but it is unclear why it develops in a subset of patients. We hypothesized that sensitization to Aspergillus fumigatus (A fum) is associated with bronchiectasis in COPD and occurs more frequently in vitamin D-deficient patients. METHODS This observational study investigated sensitization to A fum in an outpatient clinical cohort of 300 COPD patients and 50 (ex-) smoking controls. Total IgE, A fum-specific IgE against the crude extract and against the recombinant antigens and A fum IgG were measured using ImmunoCAP fluoroenzyme immunoassay. Vitamin D was measured by radioimmunoassay, and computed tomography images of the lungs were scored using the modified Reiff score. RESULTS Sensitization to A fum occurred in 18% of COPD patients compared to 4% of controls (P=0.0110). In all, 31 COPD patients (10%) were sensitized to the crude extract and 24 patients (8%) had only IgE against recombinant antigens. A fum IgG levels were significantly higher in the COPD group (P=0.0473). Within COPD, A fum-sensitized patients were more often male (P=0.0293) and more often had bronchiectasis (P=0.0297). Pseudomonas aeruginosa and Serratia marcescens were more prevalent in historical sputum samples of A fum-sensitized COPD patients compared to A fum-non-sensitized COPD patients (P=0.0436). Vitamin D levels were comparable (P=0.2057). Multivariate analysis demonstrated that sensitization to recombinant f1 or f3 had a 2.8-fold increased risk for bronchiectasis (P=0.0030). CONCLUSION These results highlight a potential role for sensitization to A fum in COPD-related bronchiectasis.
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Affiliation(s)
- Stephanie Everaerts
- Department of Respiratory Diseases, University Hospitals Leuven
- Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, KU Leuven
| | - Katrien Lagrou
- Department of Laboratory Medicine, University Hospitals Leuven
- Department of Microbiology and Immunology, KU Leuven
| | - Adriana Dubbeldam
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Natalie Lorent
- Department of Respiratory Diseases, University Hospitals Leuven
| | - Kristina Vermeersch
- Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, KU Leuven
| | | | - Xavier Bossuyt
- Department of Laboratory Medicine, University Hospitals Leuven
- Department of Microbiology and Immunology, KU Leuven
| | - Lieven J Dupont
- Department of Respiratory Diseases, University Hospitals Leuven
- Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, KU Leuven
| | - Bart M Vanaudenaerde
- Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, KU Leuven
| | - Wim Janssens
- Department of Respiratory Diseases, University Hospitals Leuven
- Laboratory of Respiratory Diseases, Department of Clinical and Experimental Medicine, KU Leuven
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Moustaki M, Loukou I, Priftis KN, Douros K. Role of vitamin D in cystic fibrosis and non-cystic fibrosis bronchiectasis. World J Clin Pediatr 2017; 6:132-142. [PMID: 28828295 PMCID: PMC5547424 DOI: 10.5409/wjcp.v6.i3.132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/27/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023] Open
Abstract
Bronchiectasis is usually classified as cystic fibrosis (CF) related or CF unrelated (non-CF); the latter is not considered an orphan disease any more, even in developed countries. Irrespective of the underlying etiology, bronchiectasis is the result of interaction between host, pathogens, and environment. Vitamin D is known to be involved in a wide spectrum of significant immunomodulatory effects such as down-regulation of pro-inflammatory cytokines and chemokines. Respiratory epithelial cells constitutively express 1α-hydroxylase leading to the local transformation of the inactive 25(OH)-vitamin D to the active 1,25(OH)2-vitamin D. The latter through its autocrine and paracrine functions up-regulates vitamin D dependent genes with important consequences in the local immunity of lungs. Despite the scarcity of direct evidence on the involvement of vitamin D deficiency states in the development of bronchiectasis in either CF or non-CF patients, it is reasonable to postulate that vitamin D may play some role in the pathogenesis of lung diseases and especially bronchiectasis. The potential contribution of vitamin D deficiency in the process of bronchiectasis is of particular clinical importance, taking into consideration the increasing prevalence of vitamin D deficiency worldwide and the significant morbidity of bronchiectasis. Given the well-established association of vitamin D deficiency with increased inflammation, and the indicative evidence for harmful consequences in lungs, it is intriguing to speculate that the administration of vitamin D supplementation could be a reasonable and cost effective supplementary therapeutic approach for children with non-CF bronchiectasis. Regarding CF patients, maybe in the future as more data become available, we have to re-evaluate our policy on the most appropriate dosage scheme for vitamin D.
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Fungal Pathogens in CF Airways: Leave or Treat? Mycopathologia 2017; 183:119-137. [PMID: 28770417 DOI: 10.1007/s11046-017-0184-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/22/2017] [Indexed: 02/07/2023]
Abstract
Chronic airway infection plays an essential role in the progress of cystic fibrosis (CF) lung disease. In the past decades, mainly bacterial pathogens, such as Pseudomonas aeruginosa, have been the focus of researchers and clinicians. However, fungi are frequently detected in CF airways and there is an increasing body of evidence that fungal pathogens might play a role in CF lung disease. Several studies have shown an association of fungi, particularly Aspergillus fumigatus and Candida albicans, with the course of lung disease in CF patients. Mechanistically, in vitro and in vivo studies suggest that an impaired immune response to fungal pathogens in CF airways renders them more susceptible to fungi. However, it remains elusive whether fungi are actively involved in CF lung disease pathologies or whether they rather reflect a dysregulated airway colonization and act as microbial bystanders. A key issue for dissecting the role of fungi in CF lung disease is the distinction of dynamic fungal-host interaction entities, namely colonization, sensitization or infection. This review summarizes key findings on pathophysiological mechanisms and the clinical impact of fungi in CF lung disease.
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Saadoon A, Ambalavanan N, Zinn K, Ashraf AP, MacEwen M, Nicola T, Fanucchi MV, Harris WT. Effect of Prenatal versus Postnatal Vitamin D Deficiency on Pulmonary Structure and Function in Mice. Am J Respir Cell Mol Biol 2017; 56:383-392. [PMID: 27870560 DOI: 10.1165/rcmb.2014-0482oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Epidemiologic studies have linked gestational vitamin D deficiency to respiratory diseases, although mechanisms have not been defined. We hypothesized that antenatal vitamin D deficiency would impair airway development and alveolarization in a mouse model. We studied the effect of antenatal vitamin D deficiency by inducing it in pregnant mice and then compared lung development and function in their offspring to littermate controls. Postnatal vitamin D deficiency and sufficiency models from each group were also studied. We developed a novel tracheal ultrasound imaging technique to measure tracheal diameter in vivo. Histological analysis estimated tracheal cartilage total area and thickness. We found that vitamin D-deficient pups had reduced tracheal diameter with decreased tracheal cartilage minimal width. Vitamin D deficiency increased airway resistance and reduced lung compliance, and led to alveolar simplification. Postnatal vitamin D supplementation improved lung function and radial alveolar count, a parameter of alveolar development, but did not correct tracheal narrowing. We conclude that antenatal vitamin D deficiency impairs airway and alveolar development and limits lung function. Reduced tracheal diameter, cartilage irregularity, and alveolar simplification in vitamin D-deficient mice may contribute to increased airways resistance and diminished lung compliance. Vitamin D supplementation after birth improved lung function and, potentially, alveolar simplification, but did not improve defective tracheal structure. This mouse model offers insight into the mechanisms of vitamin D deficiency-associated lung disease and provides an in vivo model for investigating preclinical preventive and therapeutic strategies.
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Affiliation(s)
| | | | | | | | | | | | - Michelle V Fanucchi
- 3 Environmental Health Sciences, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
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Muldoon EG, Strek ME, Patterson KC. Allergic and Noninvasive Infectious Pulmonary Aspergillosis Syndromes. Clin Chest Med 2017; 38:521-534. [PMID: 28797493 DOI: 10.1016/j.ccm.2017.04.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Aspergillus spp are ubiquitous in the environment, and inhalation of Aspergillus spores is unavoidable. An intact immune system, with normal airway function, protects most people from disease. Globally, however, the toll from aspergillosis is high. The literature has largely focused on invasive aspergillosis, yet the burden in terms of chronicity and prevalence is higher for noninvasive Aspergillus conditions. This article discusses allergic aspergilloses and provides an update on the diagnosis and management of allergic bronchopulmonary aspergillosis, including in patients with cystic fibrosis, and an update on severe asthma with fungal sensitization. In addition, the presentation, investigation, and management of noninvasive infectious aspergilloses are reviewed.
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Affiliation(s)
- Eavan G Muldoon
- National Aspergillosis Centre, University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK; Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, 5481 South Maryland Avenue, Chicago, IL 60637, USA
| | - Karen C Patterson
- Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, 3400 Spruce Street, 828 West Gates Building, Philadelphia, PA 19104, USA
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Aspergillus Species in Bronchiectasis: Challenges in the Cystic Fibrosis and Non-cystic Fibrosis Airways. Mycopathologia 2017; 183:45-59. [DOI: 10.1007/s11046-017-0143-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/08/2017] [Indexed: 12/26/2022]
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Goh KJ, Yii ACA, Lapperre TS, Chan AK, Chew FT, Chotirmall SH, Koh MS. Sensitization to Aspergillus species is associated with frequent exacerbations in severe asthma. J Asthma Allergy 2017; 10:131-140. [PMID: 28461762 PMCID: PMC5407445 DOI: 10.2147/jaa.s130459] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Severe asthma is a largely heterogeneous disease with varying phenotypic profiles. The relationship between specific allergen sensitization and asthma severity, particularly in Asia, remains unclear. We aim to study the prevalence of specific allergen sensitization patterns and investigate their association with outcomes in a severe asthma cohort in an Asian setting. Methods We conducted a cross-sectional study of patients receiving step 4 or 5 Global Initiative for Asthma treatment. Univariate and multivariate analyses were performed to assess the association between sensitization to a specific identifiable allergen by skin prick test (SPT) and uncontrolled asthma (defined in our study as the use of ≥2 steroid bursts or hospitalization in the past year, a history of near-fatal asthma or evidence of airflow obstruction on spirometry). Results Two hundred and six severe asthma patients (mean age 45±17 years, 99 [48.1%] male) were evaluated. Of them, 78.2% had a positive SPT to one or more allergens. The most common allergen to which patients were sensitized was house dust mites (Blomia tropicalis, Dermatophagoides pteronyssinus and Dermatophagoides farinae). Also, 11.7% were sensitized to Aspergillus species. On multivariate analysis, Aspergillus sensitization was associated with uncontrolled asthma (odds ratio 6.07, 95% confidence interval 1.80–20.51). In particular, Aspergillus sensitization was independently associated with the use of ≥2 steroid bursts in the past year (odds ratio 3.05, 95% confidence interval 1.04–8.95). No similar associations of uncontrolled asthma with sensitization to any other allergens were found. Conclusion High allergen, specifically Aspergillus sensitization was observed in the Asian population with severe asthma by SPT. Aspergillus sensitization was specifically associated with frequent exacerbations and a greater corticosteroid requirement. An improved understanding of the severe asthma with Aspergillus sensitization phenotype is warranted, which is likely a subgroup of severe asthma with fungal sensitization.
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Affiliation(s)
- Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital
| | - Anthony Chau Ang Yii
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital.,Duke-National University of Singapore Medical School
| | - Therese Sophie Lapperre
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital.,Duke-National University of Singapore Medical School
| | - Adrian Kw Chan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital.,Duke-National University of Singapore Medical School.,Allergy Centre, Singapore General Hospital
| | - Fook Tim Chew
- Department of Biological Sciences, Faculty of Science, National University of Singapore
| | - Sanjay H Chotirmall
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital.,Duke-National University of Singapore Medical School.,Allergy Centre, Singapore General Hospital
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Reece E, Segurado R, Jackson A, McClean S, Renwick J, Greally P. Co-colonisation with Aspergillus fumigatus and Pseudomonas aeruginosa is associated with poorer health in cystic fibrosis patients: an Irish registry analysis. BMC Pulm Med 2017; 17:70. [PMID: 28431569 PMCID: PMC5401475 DOI: 10.1186/s12890-017-0416-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary infection is the main cause of death in cystic fibrosis (CF). Aspergillus fumigatus (AF) and Pseudomonas aeruginosa (PA) are the most prevalent fungal and bacterial pathogens isolated from the CF airway, respectively. Our aim was to determine the effect of different colonisation profiles of AF and PA on the clinical status of patients with CF. METHODS A retrospective analysis of data from the Cystic Fibrosis Registry of Ireland from 2013 was performed to determine the effect of intermittent and persistent colonisation with AF or PA or co-colonisation with both microorganisms on clinical outcome measures in patients with CF. Key outcomes measured included forced expiratory volume in one second (FEV1), number of hospitalisations, respiratory exacerbations and antimicrobials prescribed, and complications of CF, including CF related diabetes (CFRD) and allergic bronchopulmonary aspergillosis (ABPA). RESULTS The prevalence of AF and PA colonisation were 11% (5% persistent, 6% intermittent) and 31% (19% persistent, 12% intermittent) in the Irish CF population, respectively. Co-colonisation with both pathogens was associated with a 13.8% reduction in FEV1 (p = 0.016), higher levels of exacerbations (p = 0.042), hospitalisations (p = 0.023) and antimicrobial usage (p = 0.014) compared to non-colonised patients and these clinical outcomes were comparable to those persistently colonised with PA. Intermittent and persistent AF colonisation were not associated with poorer clinical outcomes or ABPA. Patients with persistent PA had a higher prevalence of CFRD diagnosis (p = 0.012). CONCLUSIONS CF patients co-colonised with AF and PA had poor clinical outcomes comparable to patients persistently colonised with PA, emphasising the clinical significance of co-colonisation with these microorganisms.
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Affiliation(s)
- Emma Reece
- Department of Clinical Microbiology, School of Medicine, Trinity College Dublin, Trinity Centre for Health Science, Tallaght Hospital, Dublin 24, Ireland
| | - Ricardo Segurado
- UCD CSTAR, School of Public Health, Physiotherapy and Sports Science, UCD, Dublin 4, Ireland
| | - Abaigeal Jackson
- Cystic Fibrosis Registry of Ireland, Woodview house, UCD Belfield, Dublin 4, Ireland
| | - Siobhán McClean
- Centre of Microbial Host Interactions, Institute of Technology Tallaght, Dublin 24, Ireland.,School of Biomolecular and Biomedical Sciences, University College Dublin, Dublin 24, Ireland
| | - Julie Renwick
- Department of Clinical Microbiology, School of Medicine, Trinity College Dublin, Trinity Centre for Health Science, Tallaght Hospital, Dublin 24, Ireland.
| | - Peter Greally
- Cystic Fibrosis Registry of Ireland, Woodview house, UCD Belfield, Dublin 4, Ireland.,Department of Respiratory Medicine, The National Children's Hospital, Tallaght hospital, Dublin 24, Ireland
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