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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, Oliveira LD, de Araújo LS, Fava WS, Bonfietti LX, Paniago AMM, Venturini J, Espinel-Ingroff A. Antifungal Resistance in Cryptococcal Infections. Pathogens 2024; 13:128. [PMID: 38392866 PMCID: PMC10891860 DOI: 10.3390/pathogens13020128] [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: 10/23/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Antifungal therapy, especially with the azoles, could promote the incidence of less susceptible isolates of Cryptococcus neoformans and C. gattii species complexes (SC), mostly in developing countries. Given that these species affect mostly the immunocompromised host, the infections are severe and difficult to treat. This review encompasses the following topics: 1. infecting species and their virulence, 2. treatment, 3. antifungal susceptibility methods and available categorical endpoints, 4. genetic mechanisms of resistance, 5. clinical resistance, 6. fluconazole minimal inhibitory concentrations (MICs), clinical outcome, 7. environmental influences, and 8. the relevance of host factors, including pharmacokinetic/pharmacodynamic (PK/PD) parameters, in predicting the clinical outcome to therapy. As of now, epidemiologic cutoff endpoints (ECVs/ECOFFs) are the most reliable antifungal resistance detectors for these species, as only one clinical breakpoint (amphotericin B and C. neoformans VNI) is available.
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Affiliation(s)
- Marcia S C Melhem
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | | | - Juliana P F Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | | | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Wellington S Fava
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Lucas X Bonfietti
- Central Public Health Laboratory-LACEN, Mycology Unit, Adolfo Lutz Institut, São Paulo 01246-002, SP, Brazil
| | - Anamaria M M Paniago
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil
| | - Ana Espinel-Ingroff
- Central Public Health Laboratory-LACEN, Campo Grande 79074-460, MS, Brazil
- VCU Medical Center, Richmond, VA 23284, USA
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Glushakova A, Kachalkin A. Wild and partially synanthropic bird yeast diversity, in vitro virulence, and antifungal susceptibility of Candida parapsilosis and Candida tropicalis strains isolated from feces. Int Microbiol 2023:10.1007/s10123-023-00437-y. [PMID: 37874524 DOI: 10.1007/s10123-023-00437-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/20/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
Yeast complexes in the fecal samples of wild (Dendrocopos major, Picus viridis) and partially synanthropic (Bombycilla garrulus, Garrulus glandarius, Pica pica, and Pyrrhula pyrrhula) birds were studied in a forest ecosystem during winter. A total of 18 yeast species were identified: 16 ascomycetes and two basidiomycetes belonging to five subphyla of fungi: Saccharomycotina (15), Pezizomycotina (1), Agaricomycotina (1), and Pucciniomycotina (1). Most yeast species were found in the fecal samples of P. pyrrhula (Candida parapsilosis, C. zeylanoides, Debaryomyces hansenii, Hanseniaspora uvarum, Metschnikowia pulcherrima, Meyerozyma carpophila, M. guilliermondii, Rhodotorula mucilaginosa); the lowest number of yeast species was observed in the feces of B. garrulus (C. parapsilosis, C. zeylanoides, Met. pulcherrima, and Rh. mucilaginosa). The opportunistic species of the genus Candida were found only in feces of partially synanthropic birds: C. parapsilosis was observed in the feces of B. garrulus, G. glandarius, P. pica, and P. pyrrhula; its relative abundance was 69.3%, 49.1%, 10.5%, and 1.1%, respectively; C. tropicalis was observed in the feces of P. pica and G. glandarius; its relative abundance was 54.6% and 7.1%, respectively. Strains of C. parapsilosis and C. tropicalis isolated from the feces of partially synanthropic birds were evaluated for their susceptibility to conventional antifungal agents (fluconazole, voriconazole, amphotericin B) and hydrolytic activity. A total of 160 strains were studied. Resistance to fluconazole was detected in 86.8% of C. parapsilosis strains and in 87% of C. tropicalis strains; resistance to voriconazole was detected in 71.7% of C. parapsilosis and in 66.7% of C. tropicalis strains, and the lowest percentage of resistant strains was detected to amphotericin B, 2.8% and 3.7% in C. parapsilosis and C. tropicalis strains, respectively. Multiresistance was detected in one strain of C. parapsilosis isolated from P. pica feces and in one strain of C. tropicalis isolated from G. glandarius feces. Phospholipase and hemolysin activities in the strains of C. parapsilosis were low (mean Pz values of 0.93 and 0.91, respectively); protease activity was moderate (mean Pz value of 0.53). The ability to produce hydrolytic enzymes was higher in the isolated strains of C. tropicalis. The mean Pz values of phospholipase and hemolysin activities were moderate (mean Pz values of 0.63 and 0.60, respectively), whereas protease activity was high (mean Pz value of 0.32). Thus, wild and partially synanthropic birds play an important role in disseminating of various yeast species. These yeasts can enter the topsoil via feces and contribute to the formation of allochthonous and uneven soil yeast diversity in natural ecosystems. In addition, partially synanthropic birds can be vectors of virulent strains of opportunistic Candida species from urban environments to natural biotopes.
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Affiliation(s)
- Anna Glushakova
- Soil Science Faculty, Lomonosov Moscow State University, 119991, Moscow, Russia.
- I.I. Mechnikov Research Institute of Vaccines and Sera, Moscow, 105064, Russia.
| | - Aleksey Kachalkin
- Soil Science Faculty, Lomonosov Moscow State University, 119991, Moscow, Russia
- G.K. Skryabin Institute of Biochemistry and Physiology of Microorganisms of RAS, Pushchino, 142290, Russia
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Nualmalang R, Thanomsridetchai N, Teethaisong Y, Sukphopetch P, Tangwattanachuleeporn M. Identification of Pathogenic and Opportunistic Yeasts in Pigeon Excreta by MALDI-TOF Mass Spectrometry and Their Prevalence in Chon Buri Province, Thailand. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3191. [PMID: 36833884 PMCID: PMC9967633 DOI: 10.3390/ijerph20043191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 06/18/2023]
Abstract
Pigeon excreta can cause environmental and public health issues, particularly in urban and public areas. They are reservoirs of several human pathogens including fungi, bacteria, and viruses. Epidemiological data of pathogenic and opportunistic yeasts in pigeon droppings in Chon Buri, one of the most reputable tourist cities of Thailand, are scarce. The present study aimed to identify yeasts in pigeon droppings by MALDI-TOF mass spectrometry, and to study their prevalence in Chon Buri, Thailand. A total of 200 pigeon fecal samples were collected randomly from all 11 districts of Chon Buri. A sum of 393 yeast-like colonies were isolated on Sabourand's dextrose agar and CHROMagar media. These isolates were further confirmed for their species by MALDI-TOF MS. Twenty-four yeast species belonging to 11 different genera were identified in pigeon fecal samples. Candida spp., predominantly C. krusei (14.32%), were the most prevalent yeast species. Other yeast species, including C. glabrata (12.73%), C. metapsilosis (11.93%), Lodderomyces elongisporus (10.87%), C. tropicalis (7.16%), C. albicans (5.83%), and Cryptococcus neoformans (4.77%) were identified. This study provides valuable epidemiological data and diversity of yeasts in pigeon droppings in Chon Buri, Thailand, and also supports the use of MALDI-TOF MS for yeast identification and epidemiological surveillance.
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Affiliation(s)
- Rungnapa Nualmalang
- Department of Medical Sciences, Faculty of Allied Health Sciences, Burapha University, Mueang, Chonburi 20131, Thailand
| | - Natthapaninee Thanomsridetchai
- Department of Medical Technology, Faculty of Allied Health Sciences, Burapha University, Mueang, Chonburi 20131, Thailand
| | - Yothin Teethaisong
- Department of Medical Sciences, Faculty of Allied Health Sciences, Burapha University, Mueang, Chonburi 20131, Thailand
- Research Unit for Sensor Innovation (RUSI), Burapha University, Mueang, Chonburi 20131, Thailand
| | - Passanesh Sukphopetch
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Marut Tangwattanachuleeporn
- Department of Medical Sciences, Faculty of Allied Health Sciences, Burapha University, Mueang, Chonburi 20131, Thailand
- Research Unit for Sensor Innovation (RUSI), Burapha University, Mueang, Chonburi 20131, Thailand
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Chrobak-Chmiel D, Kwiecień E, Golke A, Dolka B, Adamczyk K, Biegańska MJ, Spinu M, Binek M, Rzewuska M. Pigeons as Carriers of Clinically Relevant Multidrug-Resistant Pathogens-A Clinical Case Report and Literature Review. Front Vet Sci 2021; 8:664226. [PMID: 34109235 PMCID: PMC8180574 DOI: 10.3389/fvets.2021.664226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/09/2021] [Indexed: 11/13/2022] Open
Abstract
Pigeons are widespread bird species in urban regions (Columba livia forma urbana) and may carry pathogens with zoonotic potential. In recent years, more and more data indicate that these zoonotic pathogens are multidrug resistant. Our results confirmed that global trend. Three different multidrug-resistant pathogens were isolated from an oral cavity of a racing pigeon with lesions typical for pigeon pox virus infection. Staphylococcus aureus was recognized as methicillin resistant, thus resistant to all beta-lactams. Additionally, it was also resistant to many other classes of antibiotics, namely: aminoglycosides, tetracyclines, phenicols, lincosamides, and macrolides. Escherichia coli showed resistance to all antimicrobials tested, and it was classified as intermediate to amikacin. Moreover, Candida albicans resistant to clotrimazole, natamycin, flucytosine, and amphotericin and intermediate to ketoconazole, nystatin, and econazole was also isolated. This raises the question how pigeons acquire such highly resistant strains. Therefore, more data are needed concerning the resistance to antibiotics in strains from domestic and wild pigeons in Poland. Until the problem is fully understood, it will be challenging to implement adequate planning of any control measures and check their effectiveness.
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Affiliation(s)
- Dorota Chrobak-Chmiel
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Ewelina Kwiecień
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Anna Golke
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Beata Dolka
- Department of Pathology and Veterinary Diagnostics, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Krzysztof Adamczyk
- Department of Pathology and Veterinary Diagnostics, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Małgorzata J Biegańska
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Marina Spinu
- Department of Infectious Diseases and Preventive Medicine, Law and Ethics, University of Agricultural Sciences and Veterinary Medicine, Cluj-Napoca, Romania
| | - Marian Binek
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Magdalena Rzewuska
- Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
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Wu HH, Chen YX, Fang SY. Clinicopathological features of isolated pulmonary cryptococcosis in HIV-negative patients. J Int Med Res 2021; 48:300060520927877. [PMID: 32527202 PMCID: PMC7294504 DOI: 10.1177/0300060520927877] [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] [Indexed: 12/24/2022] Open
Abstract
Objective To analyse the clinicopathological features of isolated pulmonary cryptococcosis in human immunodeficiency virus (HIV)-negative patients. Methods This retrospective study analysed the following data from HIV-negative patients diagnosed with pulmonary cryptococcosis: demographics, underlying diseases, clinical manifestations on admission, laboratory tests, imaging data, results of histopathology, treatment options and outcomes. Sputum samples from all patients were collected and assessed for the presence of yeast or fungi. Cryptococcal antigen testing was performed for some patients. Histopathological analysis was also undertaken for some samples of lung tissue. Results The study analysed 37 patients (22 males). Thirteen (35.14%) patients were asymptomatic, 24 (64.86%) were symptomatic and 17 (45.95%) patients had no underlying disease. Out of 25 tested patients, 23 (92.00%) tested positive on the serum cryptococcal capsular polysaccharide antigen test. During 6 to 24 months of follow-up, all 37 patients that were either treated with or without antifungal therapy alone or combined with surgical resection showed complete recovery. One patient made a full recovery without any treatment. Conclusion Early identification of pulmonary cryptococcosis in HIV-negative patients and timely detection of cryptococcal antigens in serum or respiratory specimens may help to improve diagnosis, prognosis and treatment of the disease.
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Affiliation(s)
- Huan-Huan Wu
- Department of Respiratory Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang, Zhejiang Province, China
| | - Yan-Xiao Chen
- Department of Evidence-based Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang, Zhejiang Province, China
| | - Shuang-Yan Fang
- Department of Respiratory Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang, Zhejiang Province, China
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Florek M, Nawrot U, Korzeniowska-Kowal A, Włodarczyk K, Wzorek A, Woźniak-Biel A, Brzozowska M, Galli J, Bogucka A, Król J. An analysis of the population of Cryptococcus neoformans strains isolated from animals in Poland, in the years 2015-2019. Sci Rep 2021; 11:6639. [PMID: 33758319 PMCID: PMC7987961 DOI: 10.1038/s41598-021-86169-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/11/2021] [Indexed: 02/07/2023] Open
Abstract
Fungi belonging to the Cryptococcus neoformans/C. gattii species complex (CNGSC) are pathogens causing severe infections in humans and animals, that for humans may result in a mortality rate ranging up to 70%. The CNGSC is divided into eight major molecular types, that may differ in their virulence and susceptibility. In order to fully understand the epidemiology of cryptococcosis, it is important to study the world distribution and population structure of these pathogens. The present study is the first presenting a population of strains isolated in Poland and one of the few using a multi-species animal group as a source of the specimen. The pathogen was present in 2.375% of the tested animals. The URA5-RFLP and MALDI-TOF MS analyses have revealed that the population consisted exclusively of C. neoformans strains, with a predominance of major molecular type VNIV (C. neoformans var. neoformans). The MALDI-TOF MS was used to perform the CNGSC strains identification on both the species and sub-species level. Despite the fact that the animals providing the specimens were not treated with 5-fluorocytosine, around 10% of the tested population presented MIC values exceeding 64 mg/L, indicating the existence of the 5-fluorocytosine-resistant strains in the environment.
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Affiliation(s)
- Magdalena Florek
- Department of Pathology, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Norwida 31, 50-375, Wrocław, Poland.
| | - Urszula Nawrot
- Department of Pharmaceutical Microbiology and Parasitology, Wrocław Medical University, Borowska 211a, 50-556, Wrocław, Poland
| | - Agnieszka Korzeniowska-Kowal
- Department of Immunology of Infectious Diseases, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114, Wrocław, Poland
| | - Katarzyna Włodarczyk
- Department of Pharmaceutical Microbiology and Parasitology, Wrocław Medical University, Borowska 211a, 50-556, Wrocław, Poland
| | - Anna Wzorek
- Department of Immunology of Infectious Diseases, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Weigla 12, 53-114, Wrocław, Poland
| | - Anna Woźniak-Biel
- Department of Epizootiology and Clinic of Birds and Exotic Animals, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, pl. Grunwaldzki 45, 50-366, Wrocław, Poland
| | - Magdalena Brzozowska
- Referral Animal Hospital Strömsholm, Djursjukhusvägen 11, 73494, Strömsholm, Sweden
| | - Józef Galli
- Veterinary Laboratory Vetlab, Wodzisławska 6, 52-017, Wrocław, Poland
| | - Anna Bogucka
- Veterinary Laboratory Vetlab, Wodzisławska 6, 52-017, Wrocław, Poland
| | - Jarosław Król
- Department of Pathology, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Norwida 31, 50-375, Wrocław, Poland
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Unconventional Yeasts Are Tolerant to Common Antifungals, and Aureobasidium pullulans Has Low Baseline Sensitivity to Captan, Cyprodinil, and Difenoconazole. Antibiotics (Basel) 2020; 9:antibiotics9090602. [PMID: 32942551 PMCID: PMC7557980 DOI: 10.3390/antibiotics9090602] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 01/16/2023] Open
Abstract
Many yeasts have demonstrated intrinsic insensitivity to certain antifungal agents. Unlike the fungicide resistance of medically relevant yeasts, which is highly undesirable, intrinsic insensitivity to fungicides in antagonistic yeasts intended for use as biocontrol agents may be of great value. Understanding how frequently tolerance exists in naturally occurring yeasts and their underlying molecular mechanisms is important for exploring the potential of biocontrol yeasts and fungicide combinations for plant protection. Here, yeasts were isolated from various environmental samples in the presence of different fungicides (or without fungicide as a control) and identified by sequencing the internal transcribed spacer (ITS) region or through matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry. Among 376 isolates, 47 taxa were identified, and Aureobasidium pullulans was the most frequently isolated yeast. The baseline sensitivity of this yeast was established for 30 isolates from different environmental samples in vitro to captan, cyprodinil, and difenoconazole. For these isolates, the baseline minimum inhibitory concentration (MIC50) values for all the fungicides were higher than the concentrations used for the control of plant pathogenic fungi. For some isolates, there was no growth inhibition at concentrations as high as 300 µg/mL for captan and 128 µg/mL for cyprodinil. This information provides insight into the presence of resistance among naturally occurring yeasts and allows the choice of strains for further mechanistic analyses and the assessment of A. pullulans for novel applications in combination with chemical agents and as part of integrated plant-protection strategies.
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Ghaderi Z, Eidi S, Razmyar J. High Prevalence of Cryptococcus neoformans and Isolation of Other Opportunistic Fungi From Pigeon ( Columba livia) Droppings in Northeast Iran. J Avian Med Surg 2020; 33:335-339. [PMID: 31833301 DOI: 10.1647/2018-370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cryptococcus neoformans is an opportunistic human pathogen that causes cryptococcosis, a life-threatening infection that usually manifests as meningoencephalitis in immunocompromised patients. Pigeon (Columba livia) droppings can spread pathogenic yeasts and mold fungi, such as C neoformans, in the environment. The objective of this study was to isolate C neoformans and other opportunistic fungi from feral pigeon droppings. One hundred twenty samples of feral pigeon droppings were suspended 1:10 in saline solution and then cultured. The fungi were identified by standard mycological techniques. Fungal contamination was detected in all examined samples. Yeast and mold fungi were isolated from 114 samples (95%) and 103 samples (85.8%), respectively, out of 120 samples. The highest frequency of yeast and mold fungi isolated from collected samples was C neoformans 77.5% and Rhizopus species 38.3%, respectively. Several types of fungi exist in pigeon droppings that can be spread in the environment and transmitted to children and elderly, as well as immunocompromised patients who are at increased risk of contracting opportunistic diseases.
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Affiliation(s)
- Zahra Ghaderi
- Faculty of Veterinary Medicine, Ferdowsi University of Mashhad, 9177948974-1793 Mashhad, Iran
| | - Samaneh Eidi
- Department of Pathobiology, Ferdowsi University of Mashhad, 9177948974-1793 Mashhad, Iran
| | - Jamshid Razmyar
- Department of Avian Diseases, Ferdowsi University of Mashhad, 9177948974-1793 Mashhad, Iran
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Could Fungicides Lead to Azole Drug Resistance in a Cross-Resistance Manner among Environmental Cryptococcus Strains? CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00373-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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10
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ABULREESH HUSSEINH, ORGANJI SAMEERR, ELBANNA KHALED, OSMAN GAMALE, ALMALKI MESHALH, ABDEL-MALEK AHMEDY, GHYATHUDDIN ABDULLAHA, AHMAD IQBAL. Diversity, Virulence Factors, and Antifungal Susceptibility Patterns of Pathogenic and Opportunistic Yeast Species in Rock Pigeon ( Columba livia) Fecal Droppings in Western Saudi Arabia. Pol J Microbiol 2019; 68:493-504. [PMID: 31880893 PMCID: PMC7260702 DOI: 10.33073/pjm-2019-049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/28/2019] [Accepted: 09/29/2019] [Indexed: 12/18/2022] Open
Abstract
Bird fecal matter is considered a potential source of pathogenic microbes such as yeast species that contaminate the environment. Therefore, it needs to be scrutinized to assess potential environmental health risks. The aim of this study was to investigate the diversity of the yeasts in pigeon fecal droppings, their antifungal susceptibility patterns, and virulence factors. We used culturing techniques to detect the yeasts in pigeon fecal droppings. The isolates were then characterized based on colony morphologies, microscopic examinations, and biochemical reactions. The molecular identification of all yeast isolates was performed by sequencing of the amplified ITS gene. Genes encoding virulence factors CAP1, CAP59, and PLB were also detected. Antifungal susceptibility patterns were examined by the disk diffusion method. A total of 46 yeast-like isolates were recovered, and they belonged to nine different genera, namely, Cryptococcus, Saccharomyces, Rhodotorula, Candida, Meyerozyma, Cyberlindnera, Rhodosporidium, Millerozyma, and Lodderomyces. The prevalence of two genera Cryptococcus and Rhodotorula was high. None of the yeast isolates exhibited any resistance to the antifungal drugs tested; however, all pathogenic Cryptococcus species were positive for virulence determinants like urease activity, growth at 37°C, melanin production, the PLB and CAP genes. This is the first report on the molecular diversity of yeast species, particularly, Cryptococcus species and their virulence attributes in pigeon fecal droppings in Saudi Arabia. Bird fecal matter is considered a potential source of pathogenic microbes such as yeast species that contaminate the environment. Therefore, it needs to be scrutinized to assess potential environmental health risks. The aim of this study was to investigate the diversity of the yeasts in pigeon fecal droppings, their antifungal susceptibility patterns, and virulence factors. We used culturing techniques to detect the yeasts in pigeon fecal droppings. The isolates were then characterized based on colony morphologies, microscopic examinations, and biochemical reactions. The molecular identification of all yeast isolates was performed by sequencing of the amplified ITS gene. Genes encoding virulence factors CAP1, CAP59, and PLB were also detected. Antifungal susceptibility patterns were examined by the disk diffusion method. A total of 46 yeast-like isolates were recovered, and they belonged to nine different genera, namely, Cryptococcus, Saccharomyces, Rhodotorula, Candida, Meyerozyma, Cyberlindnera, Rhodosporidium, Millerozyma, and Lodderomyces. The prevalence of two genera Cryptococcus and Rhodotorula was high. None of the yeast isolates exhibited any resistance to the antifungal drugs tested; however, all pathogenic Cryptococcus species were positive for virulence determinants like urease activity, growth at 37°C, melanin production, the PLB and CAP genes. This is the first report on the molecular diversity of yeast species, particularly, Cryptococcus species and their virulence attributes in pigeon fecal droppings in Saudi Arabia.
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Affiliation(s)
- HUSSEIN H. ABULREESH
- Department of Biology, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Research Laboratories Center, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
| | - SAMEER R. ORGANJI
- Department of Biology, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Research Laboratories Center, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
| | - KHALED ELBANNA
- Department of Biology, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Research Laboratories Center, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Department of Agricultural Microbiology, Faculty of Agriculture, Fayoum University, Fayoum, Egypt
| | - GAMAL E.H. OSMAN
- Department of Biology, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Research Laboratories Center, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Microbial Genetics Department, Agricultural Genetic Engineering Research Institute (AGERI), Giza, Egypt
| | - MESHAL H.K. ALMALKI
- Department of Biology, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
- Research Laboratories Center, Faculty of Applied Science, Umm Al-Qura University, Makkah, Saudi Arabia
| | - AHMED Y. ABDEL-MALEK
- Botany and Microbiology Department, Faculty of Science, Assiut University, Assiut, Egypt
| | - ABDULLAH A.K. GHYATHUDDIN
- Fakieh Poultry Farms, Makkah, Saudi Arabia
- Department of Biological Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - IQBAL AHMAD
- Department of Agricultural Microbiology, Faculty of Agricultural Sciences, Aligarh Muslim University, Aligarh, India
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Magalhães Pinto L, de Assis Bezerra Neto F, Araújo Paulo de Medeiros M, Zuza Alves DL, Maranhão Chaves G. Candida species isolated from pigeon (Columbia livia) droppings may express virulence factors and resistance to azoles. Vet Microbiol 2019; 235:43-52. [PMID: 31282378 DOI: 10.1016/j.vetmic.2019.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
Even though it is widely known that Cryptococcus spp. may transmit cryptococcosis trough aerosol formed when dried birds (mainly pigeons) droppings are dispersed and become airborne, little is known about the role of these birds in harboring other pathogenic yeasts in their gastrointestinal tract, feathers and beaks, specifically because these animals often stay and reproduce close or even above air conditioner units. Here we evaluated the prevalence of pathogenic yeasts isolated from pigeon droppings collected in the outside area of a University Hospital in Brazil. We also aimed to investigate the pathogenic potential and antifungal susceptibility of Candida species of medical interest isolated from these samples. Therefore, we performed the evaluation of virulence factors attributes expression in vitro, including the ability to adhere to human buccal epithelial cells and biofilm formation and to produce lytic enzymes, such as phospholipases, proteinases and hemolysins. Antifungal susceptibility testing against fluconazole, itraconazole, amphotericin and micafungin was also performed. The Candida genus was the most prevalent in our study, with several medically important species being isolated. Of note, these strains were able to express several virulence factors in vitro, clearly showing their pathogenic potential. Our study was able to demonstrate that Candida spp. isolated from pigeon droppings may express virulence factors in the same manner of clinical isolates, suggesting a pathogenic potential for these yeasts. The fact these strains were collected from the outside area of a tertiary hospital may be of interest, because they may be a source of infection, specifically to immunocompromised hosts.
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Affiliation(s)
- Luciana Magalhães Pinto
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Rua. Gal. Gustavo Cordeiro de Faria S/N, Petrópolis, CEP: 59012-570. Natal, Rio Grande do Norte, Brazil.
| | - Francisco de Assis Bezerra Neto
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Rua. Gal. Gustavo Cordeiro de Faria S/N, Petrópolis, CEP: 59012-570. Natal, Rio Grande do Norte, Brazil.
| | - Mariana Araújo Paulo de Medeiros
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Rua. Gal. Gustavo Cordeiro de Faria S/N, Petrópolis, CEP: 59012-570. Natal, Rio Grande do Norte, Brazil.
| | - Diana Luzia Zuza Alves
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Rua. Gal. Gustavo Cordeiro de Faria S/N, Petrópolis, CEP: 59012-570. Natal, Rio Grande do Norte, Brazil.
| | - Guilherme Maranhão Chaves
- Laboratory of Medical and Molecular Mycology, Department of Clinical and Toxicological Analyses, Federal University of Rio Grande do Norte, Rua. Gal. Gustavo Cordeiro de Faria S/N, Petrópolis, CEP: 59012-570. Natal, Rio Grande do Norte, Brazil.
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12
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Deng H, Zhang J, Li J, Wang D, Pan L, Xue X. Clinical features and radiological characteristics of pulmonary cryptococcosis. J Int Med Res 2018; 46:2687-2695. [PMID: 29848126 PMCID: PMC6124262 DOI: 10.1177/0300060518769541] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Diagnosis of pulmonary cryptococcosis is difficult. In this study, we examined the clinical and radiological features that increase the diagnostic accuracy for pulmonary cryptococcosis. Methods This retrospective study included clinical data from 68 patients with pulmonary cryptococcosis from 2012 to 2016 in 3 tertiary hospitals. Results Among the 68 patients, 39 (57.35%) had no complications, 39 (57.35%) had clinical symptoms, 6 (8.82%) had a history of occupational exposure, 27 (39.71%) had a single nodule/mass (the most common type of pulmonary cryptococcosis) on chest computed tomography images, 21 (30.88%) had multiple nodules/masses, 16 (23.53%) had ground glass opacity with or without nodules, 2 (2.94%) had miliary nodules, and 2 (2.94%) had enlarged mediastinal lymph nodes. Fifty-three (77.94%) patients had lesions with irregular margins, 33 (48.53%) had spiculated lesions, 32 (47.06%) had air bronchograms, 9 (13.24%) had cavities, and 4 (5.88%) had calcifications. Twenty-four patients underwent surgery, 35 received antifungal treatment, and 9 received both treatments. Conclusion The clinical features and computed tomography signs found in this study are not specific for a diagnosis of pulmonary cryptococcosis. Therefore, an increased awareness of pulmonary cryptococcosis is needed among clinicians.
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Affiliation(s)
- Hui Deng
- 1 Department of Respiratory & Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jie Zhang
- 1 Department of Respiratory & Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jia Li
- 1 Department of Respiratory & Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Dongxu Wang
- 2 Department of Radiology, the Second Affiliated Hospital of Qiqihar Medical College, Qiqihar, Heilongjiang, China
| | - Lei Pan
- 1 Department of Respiratory & Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xinying Xue
- 1 Department of Respiratory & Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Firacative C, Lizarazo J, Illnait-Zaragozí MT, Castañeda E. The status of cryptococcosis in Latin America. Mem Inst Oswaldo Cruz 2018; 113:e170554. [PMID: 29641639 PMCID: PMC5888000 DOI: 10.1590/0074-02760170554] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/06/2018] [Indexed: 12/23/2022] Open
Abstract
Cryptococcosis is a life-threatening fungal infection caused by the encapsulated
yeasts Cryptococcus neoformans and C. gattii,
acquired from the environment. In Latin America, as occurring
worldwide, C. neoformans causes more than 90% of the cases of
cryptococcosis, affecting predominantly patients with HIV, while C.
gattii generally affects otherwise healthy individuals. In this
region, cryptococcal meningitis is the most common presentation, with
amphotericin B and fluconazole being the antifungal drugs of choice. Avian
droppings are the predominant environmental reservoir of C.
neoformans, while C. gattii is associated with
several arboreal species. Importantly, C. gattii has a high
prevalence in Latin America and has been proposed to be the likely origin of
some C. gattii populations in North America. Thus, in the
recent years, significant progress has been made with the study of the basic
biology and laboratory identification of cryptococcal strains, in understanding
their ecology, population genetics, host-pathogen interactions, and the clinical
epidemiology of this important mycosis in Latin America.
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Affiliation(s)
- Carolina Firacative
- Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Jairo Lizarazo
- Internal Medicine Department, Hospital Universitario Erasmo Meoz, Universidad de Pamplona, Cúcuta, Colombia
| | - María Teresa Illnait-Zaragozí
- Diagnosis and Reference Centre, Bacteriology-Mycology Department Research, Tropical Medicine Institute Pedro Kourí, Havana, Cuba
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Yang R, Yan Y, Wang Y, Liu X, Su X. Plain and contrast-enhanced chest computed tomography scan findings of pulmonary cryptococcosis in immunocompetent patients. Exp Ther Med 2017; 14:4417-4424. [PMID: 29104652 DOI: 10.3892/etm.2017.5096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/23/2017] [Indexed: 11/05/2022] Open
Abstract
Pulmonary cryptococcosis is most commonly reported in immunocompromised patients, whereas immunocompetent hosts are rarely affected and may be asymptomatic, resulting in reduced diagnostic performance of computed tomography (CT) imaging. Thus, the aim of the present study was to review the plain and contrast-enhanced chest CT scan findings of primary pulmonary cryptococcosis in immunocompetent patients, with the aim of improving the diagnosis of this type of pulmonary disease. In the present study, a total of 27 immunocompetent patients of clinically confirmed pulmonary cryptococcosis were analyzed retrospectively. Of the 27 patients, 14 patients underwent plain and contrast-enhanced chest CT scans, while 13 patients only underwent plain chest CT scanning. The clinical and imaging characteristics, including the location, shape, size, number, edge and attenuation or intensity of each lesion, in unenhanced and contrast-enhanced CT scans were reviewed. The results indicated that the most common CT finding was pulmonary nodules (40.74%), with multiple nodules (25.93%) being more common compared with solitary nodules (14.81%). The majority of the nodules were poorly defined and inhomogeneous with observed air-bubble sign. Other findings included consolidation (25.93%), ground-glass opacities (GGO; 22.22%) and a mass (11.11%). The halo, air bronchogram and cavity signs were observed more frequently (22.22, 18.52 and 14.81%, respectively). The pulmonary lesions presented a predominant distribution in the lower lung lobes and peripheral area in 55.55 and 74.07% of the cases, respectively. On the contrast-enhanced CT images, the majority of nodules presented ring enhancement with the mean maximal enhancement value of 20.92±5.67 Hu, and masses demonstrated inhomogeneous enhancement with a mean maximal enhancement value of 35.61±8.32 Hu. In conclusion, familiarity with the CT findings and occupational environment exposure history will assist in earlier and easier diagnosis of pulmonary cryptococcosis in immunocompetent patients.
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Affiliation(s)
- Rongshui Yang
- Department of Radiology, Xinglin Branch Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, P.R. China
| | - Yan Yan
- Department of Radiology, Xinglin Branch Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, P.R. China
| | - Yuhuan Wang
- Department of Pathology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, P.R. China
| | - Xiaohuan Liu
- Department of Radiology, Xinglin Branch Hospital, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, P.R. China
| | - Xinhui Su
- Department of Nuclear Medicine, Zhongshan Hospital, Xiamen University, Xiamen, Fujian 361004, P.R. China
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15
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Sacht GL, Lima AMD, Perdomo YC, Boigues RS, Takita LC, Hans G. Disseminated cryptococcosis with cutaneous involvement in an immunocompetent patient. An Bras Dermatol 2017; 91:832-834. [PMID: 28099613 PMCID: PMC5193202 DOI: 10.1590/abd1806-4841.20165478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 06/09/2016] [Indexed: 11/22/2022] Open
Abstract
Cryptococcosis is a fungal infection of opportunistic behavior that is unusual in immunocompetent patients. We report a rare case of disseminated cryptococcosis with cutaneous involvement in an immunocompetent individual. During hospitalization, Cryptococcus gattii was isolated from skin lesions, lung and spinal fluid. The diagnosis of disseminated cryptococcosis was confirmed and treatment was established. The patient showed improvement. Due to the probable clinical severity of the disease and the possibility that skin lesions may be the first manifestation of this illness, prompt diagnosis must be established and treatment provided.
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Affiliation(s)
| | | | | | | | - Luiz Carlos Takita
- Universidade Federal de Mato Grosso do Sul (UFMS) - Campo Grande (MS), Brasil
| | - Günter Hans
- Universidade Federal de Mato Grosso do Sul (UFMS) - Campo Grande (MS), Brasil
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16
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Thomson P, Mayayo E, López-Fernández L, Guarro J, Capilla J. Combined antifungal therapy against systemic murine infections by rare Cryptococcus species. Mycoses 2016; 60:112-117. [PMID: 27696562 DOI: 10.1111/myc.12569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 11/28/2022]
Abstract
Cryptococcus albidus and Cryptococcus laurentii are uncommon species of this genus that in recent decades have increasingly caused opportunistic infections in humans, mainly in immunocompromised patients; the best therapy for such infection being unknown. Using a murine model of systemic infection by these fungi, we have evaluated the efficacy of amphotericin B (AMB) at 0.8 mg/kg, administered intravenously, fluconazole (FLC) or voriconazole (VRC), both administered orally, at 25 mg/kg and the combination of AMB plus VRC against three C. albidus and two C. laurentii strains. All the treatments significantly reduced the fungal burden in all the organs studied. The combination showed a synergistic effect in the reduction in fungal load, working better than both monotherapies. The histopathological study confirmed the efficacy of the treatments.
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Affiliation(s)
- Pamela Thomson
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV; Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Emilio Mayayo
- Unitat d'Anatomia Patològica, Facultat de Medicina i Ciències de la Salut, IISPV; Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Loida López-Fernández
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV; Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Josep Guarro
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV; Universitat Rovira i Virgili, Reus, Tarragona, Spain
| | - Javier Capilla
- Unitat de Microbiologia, Facultat de Medicina i Ciències de la Salut, IISPV; Universitat Rovira i Virgili, Reus, Tarragona, Spain
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Alves GSB, Freire AKL, Bentes ADS, Pinheiro JFDS, de Souza JVB, Wanke B, Matsuura T, Jackisch-Matsuura AB. Molecular typing of environmental Cryptococcus neoformans/C. gattii species complex isolates from Manaus, Amazonas, Brazil. Mycoses 2016; 59:509-15. [PMID: 27005969 DOI: 10.1111/myc.12499] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Abstract
Cryptococcus neoformans and Cryptococcus gattii are the main causative agents of cryptococcosis, a systemic fungal disease that affects internal organs and skin, and which is acquired by inhalation of spores or encapsulated yeasts. It is currently known that the C. neoformans/C. gattii species complex has a worldwide distribution, however, some molecular types seem to prevail in certain regions. Few environmental studies of Cryptococcus have been conducted in the Brazilian Amazon. This is the first ecological study of the pathogenic fungi C. neoformans/C. gattii species complex in the urban area of Manaus, Amazonas, Brazil. A total of 506 samples from pigeon droppings (n = 191), captive bird droppings (n = 60) and tree hollows (n = 255) were collected from June 2012 to January 2014 at schools and public buildings, squares, pet shops, households, the zoo and the bus station. Samples were plated on niger seed agar (NSA) medium supplemented with chloramphenicol and incubated at 25°C for 5 days. Dark-brown colonies were isolated and tested for thermotolerance at 37°C, cycloheximide resistance and growth on canavanine-glycine-bromothymol blue agar. Molecular typing was done by PCR-RFLP. Susceptibility to the antifungal drugs amphotericin B, fluconazole, itraconazole and ketoconazole was tested using Etest(®) strips. In total, 13 positive samples were obtained: one tree hollow (C. gattiiVGII), nine pigeon droppings (C. neoformansVNI) and three captive bird droppings (C. neoformansVNI). The environmental cryptococcal isolates found in this study were of the same molecular types as those responsible for infections in Manaus.
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Affiliation(s)
- Gleica Soyan Barbosa Alves
- Programa de Pós-Graduação em Saúde Sociedade e Endemias na Amazônia - UFAM and CPqLMD/FIOCRUZ, Manaus, Amazonas, Brazil
| | - Ana Karla Lima Freire
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas (UEA) and Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil
| | - Amaury Dos Santos Bentes
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas (UEA) and Fundação de Medicina Tropical Dr. Heitor Vieira Dourado (FMT-HVD), Manaus, Amazonas, Brazil
| | | | | | - Bodo Wanke
- Laboratório de Micologia do Instituto Nacional de Infectologia Evandro Chagas (INI)/FIOCRUZ, Rio de Janeiro, Brazil
| | - Takeshi Matsuura
- Laboratório de Microbiologia, Universidade Federal do Amazonas (UFAM), Manaus, Amazonas, Brazil
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Abulreesh HH, Organji SR, Elbanna K, Osman GEH, Almalki MHK, Abdel-Mallek AY. First report of environmental isolation of Cryptococcus neoformans and other fungi from pigeon droppings in Makkah, Saudi Arabia and in vitro susceptibility testing. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2015. [DOI: 10.1016/s2222-1808(15)60901-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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