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Pontes L, Reichert-Lima F, Perini Leme Giordano AL, Moretti ML, Zaninelli Schreiber A. Challenging fungal infections in cystic fibrosis: a case of mixed Aspergillus species infection and antifungal combination testing. Access Microbiol 2024; 6:000758.v3. [PMID: 38737802 PMCID: PMC11083386 DOI: 10.1099/acmi.0.000758.v3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/29/2024] [Indexed: 05/14/2024] Open
Abstract
Aspergillus stands as the predominant fungal genus in the airways of cystic fibrosis (CF) patients, significantly contributing to their morbidity and mortality. Aspergillus fumigatus represents the primary causative species for infections, though the emergence of rare species within the Aspergillus section Fumigati has become noteworthy. Among these, Aspergillus lentulus is particularly significant due to its frequent misidentification and intrinsic resistance to azole antifungal agents. In the management of invasive aspergillosis and resistant infections, combination antifungal therapy has proven to be an effective approach. This report documents a case involving the death of a CF patient due to a pulmonary exacerbation linked to the colonization of multiple Aspergillus species, including A. lentulus, A. fumigatus, and A. terreus, and treated with Itraconazole (ITC) monotherapy. We delineated the procedures used to characterize the Aspergillus isolates in clinical settings and simulated in vitro the impact of the combination antifungal therapy on the isolates obtained from the patient. We evaluated three different combinations: Amphotericin B (AMB)+Voriconazole (VRC), AMB+Anidulafungin (AND), and VRC+AND. Notably, all strains isolated from the patient exhibited a significant decrease in their minimum inhibitory concentration (MIC) or minimum effective concentration (MEC) values when treated with all antifungal combinations. The VRC+AMB combination demonstrated the most synergistic effects. This case report emphasizes the critical importance of susceptibility testing and precise identification of Aspergillus species to enhance patient prognosis. It also underscores the potential benefits of combined antifungal treatment, which, in this case, could have led to a more favourable patient outcome.
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Affiliation(s)
- Laís Pontes
- School of Medical Sciences - University of Campinas, Campinas, São Paulo, Brazil
| | - Franqueline Reichert-Lima
- School of Medical Sciences in São José dos Campos – Humanitas, São José dos Campos – São Paulo, Brazil
| | | | - Maria Luiza Moretti
- School of Medical Sciences - University of Campinas, Campinas, São Paulo, Brazil
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Schwarz C, Eschenhagen PN, Mainz JG, Schmidergall T, Schuette H, Romanowska E. Pulmonary Aspergillosis in People with Cystic Fibrosis. Semin Respir Crit Care Med 2024; 45:128-140. [PMID: 38286138 DOI: 10.1055/s-0043-1777267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
In the last decade, fungal respiratory diseases have been increasingly investigated for their impact on the clinical course of people with cystic fibrosis (CF), with a particular focus on infections caused by Aspergillus spp. The most common organisms from this genus detected from respiratory cultures are Aspergillus fumigatus and Aspergillus terreus, followed by Aspergillus flavus, Aspergillus niger, and Aspergillus nidulans. These species have been identified to be both chronic colonizers and sources of active infection and may negatively impact lung function in people with CF. This review article discusses definitions of aspergillosis, challenges in clinical practice, and current literature available for laboratory findings, clinical diagnosis, and treatment options for pulmonary diseases caused by Aspergillus spp. in people with CF.
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Affiliation(s)
- C Schwarz
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - P N Eschenhagen
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - J G Mainz
- Department of Paediatric Pneumology, Allergology, Cystic Fibrosis Center, Klinikum Westbrandenburg, Brandenburg a. d. Havel, Germany
- University Hospital of the Brandenburg Medical School, Brandenburg a. d. Havel, Germany
| | - T Schmidergall
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
| | - H Schuette
- Pneumology and Respiratory Medicine, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - E Romanowska
- HMU-Health and Medical University, Potsdam, Germany
- Division Cystic Fibrosis, Clinic Westbrandenburg, Potsdam, Germany
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Poore TS, Zemanick ET. Infection, Allergy, and Inflammation: The Role of Aspergillus fumigatus in Cystic Fibrosis. Microorganisms 2023; 11:2013. [PMID: 37630573 PMCID: PMC10458351 DOI: 10.3390/microorganisms11082013] [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: 06/28/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Aspergillus fumigatus (Af) is a mold frequently detected in airway samples from people with cystic fibrosis (pwCF). Abnormal airway mucus may allow Af to germinate, resulting in airway infection or an allergic response. While Af is known to increase morbidity in pwCF, individual responses and the degree of impact on lung disease vary. Improved approaches to diagnosis, treatment, and prevention of Af, particularly the persistent Af infection, are needed. This update highlights our current understanding of Af pathophysiology in the CF airway, the effects of Af on pwCF, and areas of research needed to improve clinical outcomes.
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Affiliation(s)
- T. Spencer Poore
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35223, USA
- UAB Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, AL 35223, USA
| | - Edith T. Zemanick
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
- Breathing Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
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Nayir Buyuksahin H, Dogru D, Emiralioglu N, Ademhan Tural D, Özsezen B, Sunman B, Guzelkaş I, Alboğa D, Arikan-Akdagli S, Sarıbaş Z, Gulmez D, Alp A, Hazırolan G, Soyer Ö, Şekerel BE, İnam G, Irmak İ, Damadoğlu E, Kalyoncu F, Yalçın E, Ozcelik U, Kiper N. A case-control study of the effects of Aspergillus clinical phenotypes on pulmonary functions in patients with cystic fibrosis. Pediatr Pulmonol 2023; 58:1185-1193. [PMID: 36651101 DOI: 10.1002/ppul.26319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/21/2022] [Accepted: 01/15/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION There are no precise data about the effect of Aspergillus infection on lung function other than allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis (pwCF). Here, we aimed to determine clinical phenotypes caused by Aspergillus spp. using laboratory and immunologic parameters and to compare Aspergillus phenotypes in terms of pulmonary function tests (PFT) prospectively. METHODS Twenty-three pwCF who had Aspergillus isolation from respiratory cultures in the last year (case group) and 20 pwCF without Aspergillus isolation in sputum (control group) were included. Aspergillus immunoglobulin (Ig)-G, Aspergillus IgE, Aspergillus polymerase chain reaction (PCR), galactomannan, total IgE from blood samples, and Aspergillus PCR and galactomannan from sputum, and skin prick test reactivity to Aspergillus antigen were used to distinguish different Aspergillus phenotypes. Pulmonary functions and frequency of pulmonary exacerbations were evaluated during a 1-year follow-up. RESULTS Of 23 pwCF, 11 (47.8%) had Aspergillus colonization, nine (39.1%) had Aspergillus bronchitis, and three (13%) had ABPA. Aspergillus infection was not associated with worse z-scores of forced expiratory volume in the first second (FEV1) (p = 0.612), forced vital capacity (p = 0.939), and the median FEV 1% decline (0.0%/year vs. -4.7%/year, p = 0.626). The frequency of pulmonary exacerbations in the Aspergillus infected and noninfected groups was similar. CONCLUSION Although Aspergillus spp. Isolation in pwCF was not associated with decreased lung function, a further decline was seen in the ABPA subgroup, and frequent pulmonary exacerbations during the 1-year follow-up.
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Affiliation(s)
- Halime Nayir Buyuksahin
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Deniz Dogru
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nagehan Emiralioglu
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dilber Ademhan Tural
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Beste Özsezen
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Birce Sunman
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ismail Guzelkaş
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Didem Alboğa
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sevtap Arikan-Akdagli
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Sarıbaş
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Dolunay Gulmez
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Alpaslan Alp
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gülşen Hazırolan
- Department of Medical Microbiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Özge Soyer
- Department of Pediatrics, Division of Allergy and Asthma, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bülent Enis Şekerel
- Department of Pediatrics, Division of Allergy and Asthma, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gözde İnam
- Department of Chest Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - İlim Irmak
- Department of Chest Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Damadoğlu
- Department of Chest Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Fuat Kalyoncu
- Department of Chest Diseases, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ebru Yalçın
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Ozcelik
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nural Kiper
- Department of Pediatrics, Division of Pulmonology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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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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