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Moreira IDMB, de Sousa NSO, de Almeida JDR, Rosas RLL, Cruz KS, Matsuura ABJ, Melhem MDSC, de Souza ÉS, Frickmann H, Lacerda MVG, de Souza JVB. Fluconazole Resistance and Heteroresistance in Cryptococcus spp.: Mechanisms and Implications. Rev Soc Bras Med Trop 2025; 58:e002002025. [PMID: 40136153 PMCID: PMC11941007 DOI: 10.1590/0037-8682-0328-2024] [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: 09/19/2024] [Accepted: 01/24/2025] [Indexed: 03/27/2025] Open
Abstract
The reference methodology for evaluating antifungal susceptibility is based on determining the minimum inhibitory concentration (MIC), which is the lowest drug concentration capable of inhibiting fungal growth. However, such MIC data are insufficient to measure antifungal susceptibility if a strain is heteroresistant to the tested drug. In such cases, a minority subpopulation of fungal cells, originating from an initially susceptible lineage, can grow at antifungal drug concentrations above the MIC. In studies on fluconazole heteroresistance in Cryptococcus spp., chromosomal disomy has been shown to result in the overexpression of two genes located on chromosome 1 (Chr1) linked to antifungal resistance: ERG11 and AFR1. This review addresses the underlying mechanisms of antifungal resistance, the evolution of methods for determining antifungal susceptibility, and the clinical implications of Cryptococcus heteroresistance to fluconazole. The analysis of the findings indicated a correlation between heteroresistance and adverse clinical outcomes, although this observation still lacks definite confirmation in the literature. This highlights the need to implement more efficient therapeutic strategies and improve antifungal susceptibility and heteroresistance testing.
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Affiliation(s)
| | | | | | | | - Katia Santana Cruz
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brasil
| | | | - Márcia de Souza Carvalho Melhem
- Faculdade de Medicina, PPG Doenças Infecciosas e Parasitárias, UFMS, Campo Grande, MS, Brasil
- Faculdade de Medicina, PPG Doenças Tropicais, Unesp, Botucatu, SP, Brasil
- Instituto de Medicina Tropical de São Paulo, LIM 53, São Paulo, SP, Brasil
| | - Érica Simplício de Souza
- Programa de Pós-Graduação em Biodiversidade e Biotecnologia da Rede BIONORTE, Manaus, AM, Brasil
| | - Hagen Frickmann
- Bundeswehr Hospital Hamburg, Department of Microbiology and Hospital Hygiene, Germany
- University Medicine Rostock, Institute for Medical Microbiology, Virology and Hygiene, Germany
| | - Marcus Vinícius Guimarães Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brasil
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, AM, Brasil
- University of Texas Medical Branch, Galveston, USA
| | - João Vicente Braga de Souza
- Programa de Pós-Graduação em Biodiversidade e Biotecnologia da Rede BIONORTE, Manaus, AM, Brasil
- Instituto Nacional de Pesquisas da Amazônia, Manaus, AM, Brasil
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Fernández Plaza J, Gregorio Malagón S, Poyato Borrego M, Luque Márquez R. Use of isavuconazole in cryptococcal meningitis in a cirrhotic patient. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2024; 42:460-462. [PMID: 38902157 DOI: 10.1016/j.eimce.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Jesús Fernández Plaza
- Unidad de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
| | | | - Manuel Poyato Borrego
- Unidad de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain; CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Luque Márquez
- Unidad de Enfermedades Infecciosas, Microbiología y Parasitología, Hospital Universitario Virgen del Rocío, Sevilla, Spain; Infectious Diseases Research Group, Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocío, Sevilla, Spain
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Cognialli RCR, Fratucci GF, Carneiro BH, Antonio KL, Voidaleski MF, Favarello LM, Vicente VA, Queiroz-Telles F. Case report: First case of fungemia caused by Papiliotrema laurentii in a patient with SARS-CoV-2 infection. Rev Soc Bras Med Trop 2024; 57:e008002023. [PMID: 38324809 PMCID: PMC10852462 DOI: 10.1590/0037-8682-0480-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/14/2023] [Indexed: 02/09/2024] Open
Abstract
Previously considered saprobe and non-pathogenic, the fungus Papiliotrema laurentii (formerly known as Cryptococcus laurentii), is rarely associated with human infection. Nevertheless, there has been an increase in reported infections by non-neoformans cryptococci. After a literature search on the Cochrane Library, LILACS, SciELO, MEDLINE, PubMed, and PMC (PubMed Central) databases, we conclude that this is the first case report of fungemia and probable meningitis caused by Papiliotrema laurentii in a previously immunocompetent host with associated COVID-19.
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Affiliation(s)
| | | | | | | | - Morgana Ferreira Voidaleski
- Universidade Federal do Paraná, Programa de Pós-Graduação em Microbiologia, Parasitologia e Patologia, Curitiba, PR, Brasil
| | | | | | - Flávio Queiroz-Telles
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Saúde Coletiva, Curitiba, PR, Brasil
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Melhem MSC, Leite Júnior DP, Takahashi JPF, Macioni MB, de Oliveira L, 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] [MESH Headings] [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; (D.P.L.J.); (M.B.M.)
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
- Graduate Program in Tropical Diseases, State University of São Paulo, Botucatu 18618-687, SP, Brazil
| | - Diniz Pereira Leite Júnior
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil; (D.P.L.J.); (M.B.M.)
| | - Juliana P. F. Takahashi
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
- Pathology Division, Adolfo Lutz Institute, São Paulo 01246-002, SP, Brazil
| | - Milena Bronze Macioni
- Graduate Program in Sciences, Secretary of Health, São Paulo 01246-002, SP, Brazil; (D.P.L.J.); (M.B.M.)
| | | | - Lisandra Siufi de Araújo
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
- 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; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
| | - 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; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
| | - James Venturini
- Graduate Program in Infectious and Parasitic Diseases, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, MS, Brazil; (J.P.F.T.); (W.S.F.); (A.M.M.P.)
| | - 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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