Infections in the monogenic autoimmune syndrome APECED

Autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) is caused by mutations in the Autoimmune Regulator (AIRE) gene, which impair the thymic negative selection of self-reactive T-cells and underlie the development of autoimmunity that targets multiple endocrine and non-endocrine tissues. Beyond autoimmunity, APECED features heightened susceptibility to certain specific infections, which is mediated by anti-cytokine autoantibodies and/or T-cell driven autoimmune tissue injury. These include the 'signature' APECED infection chronic mucocutaneous candidiasis (CMC), but also life-threatening coronavirus disease 2019 (COVID-19) pneumonia, bronchiectasis-associated bacterial pneumonia, and sepsis by encapsulated bacteria. Here we discuss the expanding understanding of the immunological mechanisms that contribute to infection susceptibility in this prototypic syndrome of impaired central tolerance, which provide the foundation for devising improved diagnostic and therapeutic strategies for affected patients.

Folliculocentric cutaneous presentation of disseminated Candida krusei infection in a patient with acute myeloid leukemia

Candida krusei (C. krusei) is a multidrug-resistant opportunistic fungal pathogen that may cause disseminated infections in immunocompromised hosts. However, its clinical and histologic features are not well-characterized. We present a unique case to contribute to the growing knowledge base associated with this organism. During hospitalization for neutropenic fever, a 19-year-old man with acute myeloid leukemia, who underwent hematopoietic stem cell transplantation, developed a generalized folliculocentric eruption following initiation of antifungal therapy for newly diagnosed C. krusei fungemia. Despite adequate antifungal coverage and negative blood cultures, the follicular-based erythematous papules persisted. Biopsies demonstrated yeast within ruptured follicles, without angiotropism or involvement of the interfollicular dermis, subcutaneous tissue, or stratum corneum. Concurrent skin tissue cultures confirmed C. krusei. The patient remained febrile despite aggressive antifungal therapy, with relapse of leukemia and subsequent death. Our case is unusual given the development of cutaneous lesions following clearance of fungemia, with yeast limited to ruptured follicular lumina, possibly indicating a primary cutaneous source or early transfollicular/transepidermal elimination. Given the limited available descriptions of cutaneous histopathology for C. krusei, we seek to add to the understanding of its pathophysiology and aid in the diagnosis and treatment of this often fatal infection.

Signaling through IL-17C/IL-17RE is dispensable for immunity to systemic, oral and cutaneous candidiasis

Candida albicans is a commensal fungal microbe of the human orogastrointestinal tract and skin. C. albicans causes multiple forms of disease in immunocompromised patients, including oral, vaginal, dermal and disseminated candidiasis. The cytokine IL-17 (IL-17A) and its receptor subunits, IL-17RA and IL-17RC, are required for protection to most forms of candidiasis. The importance of the IL-17R pathway has been observed not only in knockout mouse models, but also in humans with rare genetic mutations that impact generation of Th17 cells or the IL-17 signaling pathway, including Hyper-IgE Syndrome (STAT3 or TYK2 mutations) or IL17RA or ACT1 gene deficiency. The IL-17 family of cytokines is a distinct subclass of cytokines with unique structural and signaling properties. IL-17A is the best-characterized member of the IL-17 family to date, but far less is known about other IL-17-related cytokines. In this study, we sought to determine the role of a related IL-17 cytokine, IL-17C, in protection against oral, dermal and disseminated forms of C. albicans infection. IL-17C signals through a heterodimeric receptor composed of the IL-17RA and IL-17RE subunits. We observed that IL-17C mRNA was induced following oral C. albicans infection. However, mice lacking IL-17C or IL-17RE cleared C. albicans infections in the oral mucosa, skin and bloodstream at rates similar to WT littermate controls. Moreover, these mice demonstrated similar gene transcription profiles and recovery kinetics as WT animals. These findings indicate that IL-17C and IL-17RE are dispensable for immunity to the forms of candidiasis evaluated, and illustrate a surprisingly limited specificity of the IL-17 family of cytokines with respect to systemic, oral and cutaneous Candida infections.

IL-22 and TNF-α represent a key cytokine combination for epidermal integrity during infection with Candida albicans

T cells exercise their full impact on target cells through a combination of secreted cytokines. The recently described T helper cell subset Th22 is characterized by a combinatorial secretion of IL-22 and TNF-α. Here, we demonstrate that IL-22 increases the TNF-α-dependent induction and secretion of several immune-modulatory molecules such as initial complement factors C1r and C1s, antimicrobial peptides S100A7 and HBD-2 (human β defensin 2), and antimicrobial chemokines CXCL-9/-10/-11 in primary human keratinocytes. The synergism of IL-22 and TNF-α is transmitted intracellularly by MAP kinases and downstream by transcription factors of the AP-1 family. The induction of innate immunity is relevant in an in vitro infection model, where keratinocytes stimulated with Th22 supernatants or recombinant IL-22 plus TNF-α effectively inhibit the growth of Candida albicans and maintain survival of epithelia. Accordingly, the combinatorial stimulation of keratinocytes with IL-22 and TNF-α most efficiently conserves the integrity of the epidermal barrier in a three-dimensional skin infection model as compared with IFN-γ, IL-17, IL-22 or TNF-α alone. In summary, we demonstrate that IL-22 and TNF-α represent a potent, synergistic cytokine combination for cutaneous immunity.

IL-23 and IL-17A, but not IL-12 and IL-22, are required for optimal skin host defense against Candida albicans

IL-23 and Th17 cells play important roles in host defense against systemic infections with extracellular bacteria and fungi, although their roles in immunity against localized skin infections are less well defined. Here, the contributions of IL-23 and Th17 cytokines in host defense against cutaneous Candida albicans infection were evaluated. Mice deficient in IL-23 or IL-17A demonstrated delayed healing and decreased IL-17A production after skin infection with C. albicans compared with wild-type mice or mice deficient in IL-12 or IL-22. Histologic examination revealed epidermal hyperplasia overlying infected dermis four days postinoculation in wild-type mice. In IL-23-deficient mice, fungal burden was greater in skin, neither IL-17A nor IL-22 mRNAs were expressed postinfection, and these mice demonstrated only minimal epidermal hyperplasia. Exogenous recombinant IL-17A injected at the site of skin infection promoted more rapid healing of candidiasis in both wild-type mice and mice deficient in IL-23 and IL-12. Taken together, these results demonstrate that IL-23 and IL-17A, but not IL-12 and IL-22, are required for optimal host defense against cutaneous candidiasis. In addition, recombinant IL-17A may serve as a potential therapy to enhance healing in individuals with chronic cutaneous candidiasis.

Candida krusei fungemia in an immunocompromised patient

Candida krusei is an emerging fungal pathogen found primarily in immunocompromised patients. Intrinsic resistance to fluconazole and decreasing susceptibility to other anti-fungal agents are problematic. When colonization occurs, dissemination may follow rapidly. We present a case of a patient with acute lymphoblastic leukemia who, despite being treated prophylactically with fluconazole, developed disseminated C. krusei.

Atopic dermatitis with mononuclear phagocytic activity deficiency

Five patients with atopic dermatitis, three males and two females, aged 2 to 17 years, had positive reactions to air allergens (Dermatophagoides pteronyssinus and/or farinae). All the patients suffered from severe recurrent dermatophytosis that responded poorly to antifungal treatment. The results of immunologic evaluation by laboratory tests were normal, except for a decrease in the ingestion phase by mononuclear phagocytes. After diagnosis of immunodeficiency, ketoconazole shampoo was used prophylactically and at the very first signs of recurrence of dermatophytosis, systemic antifungal treatment was started, without concurrent use of macrolides and with monitoring of hepatic function. The fungal infections responded well to this treatment and the patients' quality of life markedly improved.

Cytokine expression induced by Candida albicans in a model of cutaneous candidosis based on reconstituted human epidermis

Skin equivalents based on reconstituted human epidermis have been used recently to establish models for allergic/irritant contact dermatitis and cutaneous candidosis. In the present study the cytokine expression pattern and the morphological alterations in experimental cutaneous candidosis were investigated by RT-PCR and histological analysis. In experimental cutaneous C albicans infection the mRNA expression levels of interleukin (IL)-1a, IL-1beta, IL-8, GM-CSF, Exodus-2, tumour necrosis factor-alpha and PSL (P-selectin ligand) were upregulated. Cytokine profile and histological features of infected skin (separation of keratinocytes, oedema, vacuolisation) were comparable to that seen in experimental contact dermatitis. These immunomodulatory and morphological similarities might reflect a common pathogenesis factor in both diseases.

Nasal vaccination induces the ability to eliminate Candida colonization without influencing the pre-existing antigen-specific IgE Abs: a possibility for the control of Candida-related atopic dermatitis

In some cases of atopic dermatitis (AD), a possible pathological contribution to disease development by Candida albicans (C. albicans) has been suggested. AD patients with severe symptoms showing positive capsulated hydrolic carrier polymer radioallergosorbent test (CAP-RAST) against C. albicans demonstrated significantly higher levels of serum IgE Abs than did AD patients with mild symptoms. Based on the clinical facts, we have postulated that elimination of C. albicans by mucosal vaccination may lead to the restoration of severe symptoms in AD patients. For this purpose, we have developed an allergic murine model. Mice which were systemically challenged with C. albicans-associated antigen, manganese superoxide dismutase (MnSOD) or secreted aspartic proteases 2 (SAP2), together with alum, exhibited hyper IgE Abs. Systemically primed mice were then immunized with MnSOD or SAP2 plus cholera toxin (CT) as mucosal adjuvant through the nasal route. Interestingly, nasally immunized mice showed increased levels of Candida Ag-specific IgA Ab in fecal and nasal washes as well as in saliva samples but unchanged levels in Ag-specific IgE responses. Consistent with the Ab levels, high numbers of Candida Ag-specific IgA Ab-forming cells were induced in mononuclear cells isolated from intestinal lamina propria, nasal passages and salivary glands of nasally vaccinated mice with Ag plus CT. Furthermore, nasal immunization using MnSOD or SAP2 together with CT resulted in the elimination of colonized C. albicans from the intestinal tract. These results also suggest a potential role of mucosal vaccination in the control of C. albicans in patients with allergic diseases, including AD, although more research is needed to establish this therapeutic approach for mucosal vaccination.

Recombinant human antibody single chain variable fragments reactive with Candida albicans surface antigens

A combinatorial phage display library expressing human immunoglobulin heavy and light chain variable regions was used to identify phage clones capable of binding to the surface of Candida albicans blastoconidia. Single chain antibody variable fragments (scFv) derived from three clones detected C. albicans antigens by indirect immunofluorescence assay (IFA), enzyme-linked immunosorbent assay (ELISA), and Western blotting. The antigens detected were conserved among different strains of C. albicans and several other Candida species. Two scFv clones detected antigens specifically expressed by C. albicans blastoconidia; the third detected antigens in both blastoconidia and filamentous forms of C. albicans. The antigens containing the epitopes recognized by all three scFv could be extracted from blastoconidia by dithiothreitol, suggesting attachment to the cell wall via sulfhydryl bonds. Epitope detection by the scFv was sensitive to treatment of C. albicans blastoconidia with sodium periodate, but not proteinase K, indicating the cognate epitopes were composed of carbohydrate. Antigenic determinants for each of the three scFv were detected by immunohistochemical staining of skin sections from a model of cutaneous candidiasis, demonstrating expression in vivo. Through selection for the ability to bind intact organisms, the phage display system provides a means to rapidly identify monoclonal binding ligands to Candida surface antigens. Being entirely human, mature antibodies generated from the scFv have potential utility in the treatment of candidiasis.

Cutaneous candidosis in immunosuppressed patients

One-hundred patients with candidosis of the skin, mucous membranes and nail plates (confirmed by cultivation) were examined. Topical or systemic antimycotic treatment was successful in 58 patients. After a complete evaluation, 42 patients were found to suffer from factors supporting candidosis--diabetes mellitus (12), anemia (3) and various local factors (10 patients); 27 patients showed a deficiency in cell-mediated immunity. In addition to intensive antimycotic therapy, successful treatment is affected by the actual immunity level and can be ensured by efficient immunomodulation treatment of immunodeficiency.

Dermatophytes and host defence in cutaneous mycoses

Dermatophytosis is the infection of keratinized tissues such as hair, nails and the stratum corneum of the skin by dermatophyte fungi. These fungi are onygenalean anamorphs and anamorphic species belonging to the genera Trichophyton, Microsporum and Epidermophyton. An important characteristic of the dermatophytes as parasites is their restriction to the dead keratinized tissues, except in rare cases where the patient is immunosuppressed. In contrast to many fungi, including normally non-pathogenic species, which can invade systemically in severely immunocompromised (e.g. neutropenic) patients, dermatophytes appear to be unable to cause systemic infection in this population. Thus, these fungi appear to have an unique interaction with the immune system. A better understanding of this interaction will contribute significantly to our knowledge of mammalian host defences.

CD86 (B7-2), but not CD80 (B7-1), expression in the epidermis of transgenic mice enhances the immunogenicity of primary cutaneous Candida albicans infections

Transgenic (Tg) mice whose epidermal keratinocytes constitutively overexpress either B7-1 (CD80) or B7-2 (CD86) exhibited exaggerated cutaneous delayed type hypersensitivity (DTH) to haptens compared to non-Tg mice. To determine whether enhanced DTH in these Tg mice is seen in response to cutaneous fungal infections, a primary infection with Candida albicans was established by inoculating this organism on the occluded skin of Tg and non-Tg mice. These infections resolved 7 days after removal of occlusive dressing in all three groups of mice, without evidence of exaggerated inflammation in either the Tg or non-Tg mice. Only B7-2 Tg mice developed enhanced Th1-lymphocyte-mediated immune responses to C. albicans antigens after resolving this infection: enhanced footpad swelling in response to intradermal C. albicans antigens, enhanced production of mRNA encoding Th1 lymphokines in draining lymph nodes, and increased gamma interferon secreted into culture supernatants by lymph node T lymphocytes stimulated with Candida antigens in vitro. Lastly, Western blotting of sera from mice that had resolved this fungal infection indicated that only B7-2 Tg mice recognized a wide range of Candida-associated antigens. These data suggest that these two costimulatory molecules, when expressed by keratinocytes, do not deliver identical signals to C. albicans antigen-reactive Th1 lymphocytes. The enhanced immune response in B7-2 Tg mice to a cutaneous C. albicans infection demonstrates the importance of antigen presentation and costimulation in immune reactivity to fungi. Furthermore, B7-2 Tg mice may be useful in identification of protective Candida antigens.

Specific and non-specific parameters of the host defence system in patients with superficial fungal infections

Some measures of systemic host defences, i.e. white cell counts, lymphocyte subsets, delayed-type hypersensitivity and polymorphonuclear leucocyte functions, were evaluated in 42 patients suffering from cutaneous superficial mycoses and in 35 healthy volunteers. Patients were divided according to the extent of their lesions into two groups: group A (30 patients) with skin involvement > or = 30% and group B (12 patients) with skin involvement < or = 1%. No significant abnormalities in systemic defence mechanisms were observed in group B patients, whereas multiple alterations of polymorphonuclear phagocyte activities, i.e. chemotaxis, phagocytosis, mitogen-induced superoxide anion production, were observed in patients with extensive lesions. The values of these phagocytic functions remained significantly reduced (P < 0.01) in these patients after recovery and during a 6-month follow-up period.

Factor XIIIa-related antigen immunoreactivity of fungal cell wall: a biologically relevant feature?

BACKGROUND

A positive immunoreactivity of fungal walls for factor XIIIa has been recently described. Factor XIIIa is a transglutaminase involved in the formation of covalent peptide bounds between some specific proteins.

OBJECTIVE

The purpose of this study was to explore by experimental approaches the meaning of that immunoreactivity.

METHODS

The presence of a factor XIIIa-related antigen (FXIIIa RA) was searched on fungi by using immunohistochemistry. We studied fungi growing on agar plates, stratum corneum, artificial skin as well was in clinical conditions.

RESULTS

Our present studies show that the cell wall of some pathogenic fungi express FXIIIa RA immunoreactivity. This was found in clinical infections, as well as in selected in vitro situations including cultures on stratum corneum and on reconstructed skin.

CONCLUSION

The distinct intensity and pattern of FXIIIa RA immunoreactivity may suggest a relationship between this biological marker and the pathogenicity of fungi.

Pathogenesis of Candida infections

Candida infections of the skin and superficial mucosal sites are the result of an interplay between fungal virulence and host defenses. Epidermal proliferation and T-lymphocyte immune responses are expressed by the host to combat fungal invasion, but inflammatory responses and nonspecific inhibitors also probably play a role. Candida albicans can express at least three types of surface adhesion molecules to colonize epithelial surfaces, plus an aspartyl proteinase enzyme able to facilitate initial penetration of keratinized cells. Deeper penetration of keratinized epithelia is assisted by hypha formation, and C. albicans hyphae may use contact sensing (thigmotropism) as a guiding mechanism. Pathogenesis requires differential expression of virulence factors at each new stage of the process: a propensity for rapid alteration of the expressed phenotype in C. albicans may therefore be a significant factor in establishing the comparatively high pathogenic potential of this species.

Antifungal therapy of yeast infections

Candida infections of the skin and mucous membranes are common in both healthy and immunocompromised patients. Management with topical azole or polyene therapy is generally straightforward except in immunocompromised patients with oropharyngeal infections and in Candida onychomycosis. Oral candidosis in patients with AIDS generally requires oral therapy with fluconazole, itraconazole, or ketoconazole. Continuous suppressive therapy carries the risk of the development of clinical tolerance or secondary drug resistance. In nail disease, oral antifungal therapy is appropriate except in paronychia, for which topical azole antifungals appear to be equally effective. In any case it is important to determine whether Candida isolated from nail material is a true nail pathogen or merely colonizing the nail plate. Distal erosion of the nail plate, the presence of underlying host abnormalities such as Raynaud's disease, and hyphae in the nail plate are clues that organism is invading the nail plate.

Pachyonychia congenita: therapeutic and immunologic aspects

A 4-year-old girl with pachyonychia congenita was followed from birth. During childhood, slow progression of the nail hypertrophy was seen because she was not willing to have the nails ground or cut. After grinding of her nails under general anesthesia, the child has had acceptable nail thickness, and continued regular grinding without anesthesia. The child had recurrent oral and cutaneous candidiasis. Investigations showed a weakly positive response to Candida albicans in the lymphocyte transformation test, and absence of a delayed hypersensitivity skin test response to Candida. The secondary infection due to Candida seemed to prevail because of an immune defect.

Effect of immunosuppression on epidermal defenses in a murine model of cutaneous candidiasis

A number of pharmacologic treatment regimens were used to evaluate the early defenses against experimental cutaneous candidiasis in nonimmune mice. Severe immunosuppression of the animals was found to have little effect on the numbers of Candida pseudohyphae that initially infected the skin, but it did, however, modify the progression of the infection afterwards. Of the regimens tested, only the combination of intraperitoneal cyclophosphamide and intravenous phorbol myristate acetate both completely eliminated the epidermal neutrophilic infiltrates characteristic of these infections and promoted a significant degree of Candida invasion into the dermis. However, the epidermal proliferative response to the infections, generally considered to be an important mechanism of defense against superficial mycoses, was equivalent at the sites of both invasive and noninvasive foci, and it was generally comparable to that in normal animals. Dermal invasion in the treated animals was also found to occur at a time (between 12 and 24 hours after inoculation) when the epidermis was maximally proliferating. In contrast to these results, the intraperitoneal administration of colchicine significantly suppressed epidermal proliferation at the Candida foci but had only minimal effects in promoting dermal invasion. Therefore, whereas epidermal proliferation could be involved in the eventual clearance of these experimental cutaneous Candida infections, this mechanism apparently has little to do with either limiting the number of organisms initially infecting the skin or preventing their invasion into the dermis.

Neutrophil accumulation and cutaneous responses in experimental cutaneous candidiasis of genetically complement-deficient mice

Mice deficient in the fifth component of complement were studied for their ability to respond to and clear experimental cutaneous Candida albicans infections. The complement-deficient animals took longer to clear the infections and developed a significantly greater delayed hypersensitivity response to Candida than did normal animals. However, although the serum of the complement-deficient animals was incapable of generating in vitro chemotactic activity for neutrophils after appropriate stimulation, the epidermal neutrophilic infiltrate in the Candida-infected skin of these animals was equivalent to that in the normal animals. The progression of the infection, including the early relocation of the invading Candida pseudohyphae to a more superficial site in the stratum corneum and the thickening of the epidermis itself, was also similar in the complement-deficient and normal animals. Therefore, although mice lacking the fifth complement component cannot generate complement-derived serum chemotactic factors and are somewhat less efficient in clearing experimental cutaneous candidiasis, the accumulation of neutrophils in the Candida-infected skin of these animals and their initial cutaneous responses to the infections are normal.

Participation of neutrophils and delayed hypersensitivity in the clearance of experimental cutaneous candidiasis in mice

Involvement of neutrophils and delayed hypersensitivity in the clearance of Candida albicans infections was investigated with the use of a model of the disease in inbred mice. Experimental infections were produced by rubbing C albicans onto the shaved skin of the flank without the use of occlusive dressings. After a single infection, delayed hypersensitivity to Candida developed in C57BL/6 mice, and the infection cleared more rapidly than in C3H/He mice, in which delayed hypersensitivity did not develop. In both strains, the organisms were associated with neutrophilic microabscesses in the upper epidermis within 1 day of inoculation; by 3 days, the organisms and microabscesses had become relocated to a site just above the skin surface. At this time, the epidermis was intact under the microabscesses and significantly thickened, which indicated that epidermal proliferation had occurred. Delayed hypersensitivity reactions accelerated clearance of the infection, apparently by increasing the rate of removal of the microabscesses and associated organisms from the skin surface. However, delayed hypersensitivity was not an absolute requirement for clearance, because in animals of the C3H/He strain, in which delayed hypersensitivity did not develop during the first infection, the infection was eventually cleared. It is postulated that in these infections an important defense mechanism may be the enhancement, perhaps by the neutrophilic infiltrate, of epidermal proliferation early in the infection such that the infecting organisms are moved to a location above the skin surface from which they can be more easily removed by other processes, including delayed hypersensitivity reactions.

Inherited susceptibility to autoimmune Addison's disease is linked to human leukocyte antigens-DR3 and/or DR4, except when associated with type I autoimmune polyglandular syndrome

The inherited susceptibility to autoimmune Addison's disease was found to be strongly associated with human leukocyte antigens (HLA)-DR3 and DR4 alleles. In a study of 45 white patients from the United States with the disease, the relative risks (the number of times that an individual is at risk for Addison's disease if they had a marker, compared to those without such marker) were found to be 6.0, 4.6, and 26.5 for the DR3 allele, the DR4 allele, and for DR3/DR4 heterozygotes, respectively. Frequencies of DR2, DR5, and DR7 in the patients with Addison's disease were significantly decreased in comparison to 265 individuals in the control population. These HLA-DR frequencies in patients with Addison's disease were similar to those for 723 patients with insulin-dependent diabetes (IDD). However, the above HLA-DR associations persisted even when only data from the 37 patients with Addison's disease who did not have IDD were considered. Adrenocortical autoantibodies in 23 patients with IDD who did not have Addison's disease were equally frequent among those with DR4 and DR3 alleles. In contrast, HLA-DR frequencies in 17 patients with type I autoimmune polyglandular syndrome (chronic mucocutaneous moniliasis, hypoparathyroidism, Addison's disease, etc.) were not different from control. We conclude that genetic susceptibility to autoimmune Addison's disease may involve the same HLA-associated genetic determinants as IDD, except when Addison's disease occurs as part of type I autoimmune polyglandular syndrome.

Contact sensitivity to Candida albicans--comparative studies in man and animal (guinea-pig)

We studied the elicitation of contact sensitivity to Candida albicans antigen in guinea-pigs with experimental cutaneous candidiasis and in humans, using commercially available potent 1:100 C. albicans antigen (Torii) by patch testing on abraded skin. In guinea-pigs, non-immune animals became patch test-reactive 4-5 days after topical application of viable C. albicans, either under occlusion or without occlusive dressings, concurrently with the demonstrability of delayed responses to intradermally injected 1:10 000 Candida antigen. In humans, all healthy adults who showed delayed hypersensitivity reactions to intradermally injected 1:10 000 C. albicans antigen demonstrated positive patch-test reactions to 1:100 C. albicans antigen. There was a significant correlation between the magnitude of responses to these tests. In contrast, no positive patch test reactions were elicited to the 1:100 C. albicans antigen on neonatal skin, emphasizing the lack of irritability of this test agent. These results also indicate that in humans contact sensitivity to Candida antigen occurs during later life because C. albicans is a ubiquitous organism. The practical value of this Candida patch test for evaluation of patients' immune function was assessed by a prospective study in patients with various skin disorders. The results obtained suggested some potential value of the test for evaluation of cell-mediated immune function of patients with regard to ubiquitous recall antigens.

Pathological observations in experimental candida infection of sensitized guinea pigs

Guinea pigs immunized intramuscularly with heat-killed or viable Candida albicans were infected intracutaneously with C. albicans. Animals with negative delayed hypersensitivity against C. albicans antigen showed similar lesions with non-immunized controls. Delayed hypersensitivity-positive guinea pigs, which were detected in the animals immunized with heat-killed C. albicans in CFA and IFA, demonstrated a delay of the resolution of the inflammatory tissue reaction and, in the animals immunized with C. albicans in CFA, developed a granuloma. These results suggest that both humoral and cell-mediated immunities do not play a significant role for protection against candidiasis and at a late stage of infection, cell-mediated immunity may play a secondary role of the enhancement of resistance to candida infection associated with granuloma formation.

[Nature of the restructuring of the T- and B-immunity systems in patients with cutaneous and visceral candidiasis]

The examination of 90 patients with superficial and visceral candidiasis, as well as Candida carriers, has revealed that the heavy contamination of the body with fungi of the genus Candida is accompanied by the specific transformation of the immune system, manifested by differences in the character of sensitization to Candida antigens: in the patients with superficial and visceral candidiasis the B-system of immunity is sensitized to a greater degree, while in the Candida carriers the sensitization of the T-system is more pronounced. Despite the fact that the immune system of patients with the disseminated form of visceral candidiasis is capable of developing the delayed hypersensitivity (DH) reaction to bacterial allergens, such patients have been shown to develop DH to Candida antigens only in rare cases. This is probably due to disturbances in their immunocompetent systems, caused, seemingly, by the secondary immune insufficiency.

The fate of experimental cutaneous candidiasis in guinea pigs under the suppressed polymorphonuclear leukocyte chemotaxis by colchicine

Experimental cutaneous Candida albicans infections in guinea pigs are histologically characterized by intense epidermal polymorphonuclear leukocyte (PMN) accumulation. To study the role of PMNs in vivo, we injected 250 microgcolchicine/kg i.p., a strong inhibitor of PMN chemotaxis, and observed the influence of reduced PMN migration in experimental cutaneous candidiasis with special interest in the elimination course of the organisms. There was a significant delay in the clearance of the organisms in the colchicine-treated group with decreased epidermal PMN infiltration and prolonged visible scaling process. Our data suggest that the delay of epidermal PMN migration parallels the disappearance of the organisms from the infected skin and that PMNs play an important part in defense against candida infections especially in the elimination process.

Anti-ovarian and anti-lymphocyte antibodies in patients with chronic vaginal candidiasis

Seventeen of 30 patients with chronic vaginal candidiasis (CVC) of at least 5 years duration had varying degrees of menstrual problems and defective T lymphocyte function; 8 developed amenorrhea. In a group of 40 CVC patients, titers of autoantibodies to ovary, thymocytes, a T-cell line (CCRF-CEM), and a B-cell line (RN114) were significantly higher than those in 45 normal females (69 +/- 3 vs. 5 +/- 2, 70 +/- 27 vs. 4 +/- 2, l7 +/- 6, vs. 4 +/ 2, and 73 +/- 24 vs. 8 +/- 5, respectively, mean +/- S.E.). Antibody titers to sperm, T-cell line HSB-2, and B-cell lines RAJI and BALL-1 were within the normal range. Significant correlations were found between anti-Candida, anti-ovarian, and anti-thymocyte antibody titers. Similar results were found for 6 patients with chronic mucocutaneous candidiasis (CMCC) and in serial samples obtained over a one-year period from a representative patient with both CVC and CMCC. The anti-T-lymphocyte antibodies in these patients were directed primarily against non-suppressor (predominately helper) T cells. Absorption of the sera with either Candida cells, ovarian follicle cells, or thymocytes reduced all three antibody titers; absorption with sperm or B-cell lines did not alter the titers. These results suggest the presence of one or more cross-reactive antigens on ovarian follicle, T lymphocytes (especially the helper cell subpopulation), and Candida.

An evolution of therapy for mucocutaneous candidiasis

Chronic mucocutaneous candidiasis is a relatively uncommon form of candida infection, and can be found in patients with primary deficiencies of their immune systems. When such infection occurs in patients with non-lethal immune deficiences defects of chemotaxis or cellular immunity can be found. In addition, significant endocrinopathies may occur, particularly involving the parathyroid and adrenal glands. A number of therapies have been devised for the treatment of chronic candidiasis, and have included both local and systemic medications. The most useful of these in the past have included the polyene antibiotics -- most notably, nystatin and amphotericin B. Antifungal activity has also been demonstrated clinically with the use of 5-fluorocytosine (a fluorinated pyramidine) and clotrimazole (a synthetic imidazole derivative). However, long-term therapy with medication has been required, and re-emergence of symptomatic infection has occurred when medications have been stopped. More recently, immune reconstitution with transfer factor has been employed in the treatment of patients who have been found to be anergic to candida. Such treatment in conjunction with chemotherapy has indicated that effective patient remissions can be obtained in those patients who develop and maintain cell-mediated immunity to candida. Twelve patients with chronic mucocutaneous candidiasis are profiled. Sites of involvement in the head and neck included the skin and hair (9), ears (9), nose (4) and throat (12). One patient had candida laryngitis, while five patients had evidence for esophageal disease. Of this latter group, one (a 5-year old boy) developed esophageal stenosis which required gastrostomy and retrograde esophageal dilatations. Nine patients were found to be anergic to candida. In these patients, systemic chemotherapy (as amphotericin B or 5-fluorocytosine) was used to induce remissions of disease and transfer factor was given to induce reactivity to candida. By so doing, topical or oral medications (utilizing miconazole, clotrimazole and nystatin) were found to suffice in maintaining effective local control of infection.

Cell-directed inhibition of polymorphonuclear leukocyte chemotaxis in a patient with mucocutaneous candidiasis

A patient with mucocutaneous candidiasis and impaired polymorphonuclear leukocyte (PMN) chemotaxis is described. The patient's PMN chemotaxis was markedly decreased in the presence of autologous plasma but normal in control plasma. Cell-directed inhibitory activity was found in whole patient plasma as well as the 40% ammonium sulfate precipitate fraction of both the patient's and the control plasma. The inhibitor was heat stable, reversible, nondialyzable, eluted from DEAE cellulose with 0.005 M sodium phosphate buffer, and migrated with IgG on immunoelectrophoresis. The supernate from 40% ammonium sulfate-fractionated patient and control plasma contained a cell-directed enhancer of PMN chemotaxis that antagonized the cell-directed inhibitor activity. It is possible that the patient's chemotactic defect may be caused by imbalance between plasma factors that regulate chemotaxis.

Dermatophytosis in patients with chronic mucocutaneous candidiasis

We review the association of concurrent dermatophytic infections in patients with chronic mucocutaneous candidiasis and add twelve new patients to the seventeen previously reported ones. In sixty patients with chronic mucocutaneous candidiasis studied at the National Institutes of Health (NIH), twelve (20%) also had significant local or diffuse dermatophytosis. A comparison between candidiasis patients with and without dermatophytosis revealed no significant differences in their distribution within the various clinical syndromes of chronic mucocutaneous candidiasis nor in the immunologic responses that were tested. Failure to recognize coexistent dermatophytosis in candidiasis patients may lead to unsatisfactory responses to treatment.

A serum-dependent defect of neutrophil function in chronic mucocutaneous candidiasis

Investigations into the immunological functions of three patients with chronic mucocutaneous candidiasis were carried out. Phagocytosis of Candida albicans, nitroblue tetrazolium dye reduction, complement, and immunoglobulin levels were normal. Candidacidal assays using the neutrophils of the patients in autologous serum showed significant decreases below normal levels. This decrease in kill could be corrected by incubating the patients' cells in normal control or human AB serum. Cross-over serum studies also showed that the patients' sera had inhibitory effects on the candidacidal capacity of normal neutrophils. These changes in kill were related to candida antibody levels.

Cimetidine as an immunomodulator: chronic mucocutaneous candidiasis as a model

Four adult patients with chronic mucocutaneous candidiasis were studied to establish a possible role for cimetidine as an immunomodulator. These patients had negative baseline in-vivo and in-vitro cell-mediated immune response to candida antigen as measured by intradermal skin tests, lymphocyte transformation, and leukocyte migration inhibitory factor production to cimetidine, 300 mg by mouth, four times daily. Subsequently four of four patients developed strong (greater than 15 mm) intradermal skin test reactions, and two of four patients produced leukocyte migration inhibitory factor to candida antigen. Skin tests and leukocyte migration inhibitory factor production reverted to baseline negative values when repeated 4 weeks after discontinuation of therapy. After 4 additional weeks on cimetidine, four of four patients showed strong positive skin tests and leukocyte migration inhibitory factor production to candida antigen. Lymphocyte transformation was not affected by therapy.

The E-rosette augmenting factor (E-RAF): aspects of clinical application

It has recently been demonstrated that antigen- or mitogen-stimulated normal lymphocytes release a soluble E-rosette augmenting factor (E-RAF) which enhances E-rosette formation. Using this enhanced E-rosette formation as an immunologic marker, we studied lymphocytes from twelve normal volunteers, ten patients with chronic mucocutaneous candidiasis and one male patient with severe combined immune deficiency (SCID). These studies confirmed the observation that lymphocytes from normal donors respond to mitogen or specific antigen stimulation by release of E-RAF and increased E-rosette formation. Lymphocytes from the SCID patient were unable to release the soluble factor following mitogenic stimulation and increased E-rosette formation did not occur. Furthermore, our data indicated that short-term incubation (18 hr) of normal lymphocytes in mitogen (PHA or Con A)-derived supernatant fluids containing the soluble factor may offer a reliable and highly reproducible assay technique for total E-rosettes.

Comparison of antibody responses in chronic mucocutaneous candidiasis and tinea versicolor

Antibody titers against Candida albicans and Pityrosporum orbiculare, the presumed etiologic agent of tinea versicolor, were determined in normal subjects, and in patients with tinea versicolor or chronic mucocutaneous candidiasis. Whereas antibody against both organisms was found in low titer in normal subjects, a majority of patients with each infection had elevated antibody titers against the infecting organism. Patients infected with one organism did not have elevated titers against the other, and titers against one did not correlate with titers against the other. Therefore, these studies indicate that both of the superficial infections are capable of inducing a significant humoral immune response and that actual infection with the organism rather than mere colonization is required for production of the elevated antibody titers.

Widely disseminated cutaneous candidosis in adults

Of 9 adults, 5 males, 4 females, with wide dissemination of Candida albicans skin lesions, the eruption started in the groin, from which it spread to other areas in most cases. In 5 cases the disseminated lesions were papulo-pustular; the rest were erythematous-squamous. Hyphae and yeast cells of C. albicans were found on direct microscopy. Diabetes was present in 5 patients, lymphoma in 1, and bullous pemphigoid in another. Onychia and paronychia were found in 7 patients, intertriginous lesions of the fingers in 4 and oral thrush in 2. Intradermal skin tests were negative. The percentage and absolute numbers of T-lymphocytes were normal in 6 of 7 patients, whereas their functional activity was imparied in 4 of 6 patients, as evidenced by the negative Graft-versus host reaction. The role of concurrent disease in the pathogenesis of the candidosis is discussed.

Chronic mucocutaneous candidiasis. Immunologic studies of three generations of a single family

A family consisting of eight members in three generations (age 10 months to 53 years) affected with chronic mucocutaneous candidiasis was studied along with three unaffected relatives. Dermatophytosis, loss of teeth and recurrent viral infections were present in some members. Results of tests for endocrinologic, muscle or liver disease, thymoma, iron deficiency, antitissue antibodies and malabsorption were normal in all patients. Antibody function and levels, B cell counts, serum complement, leukocyte enzymes, chemotaxis, phagocytosis and adherence were normal in all members. Plasma inhibitors to lymphocyte transformation and leukocyte inhibitory factor were not found. No unique HLA haplotype or antigen segregated in this family. Evaluation of cell-mediated immunity revealed total cutaneous anergy in three of eight whereas four of the other five had negative lymphocyte transformation and skin tests to Candida but responded normally to other antigens. Leukocyte inhibitory factor was not produced to Candida antigen in all four patients tested. T cell counts were within normal limits in all. Extensive evaluation of all limbs of the immune system in this family revealed a defect in cell-mediated immunity to Candida that appeared to be inherited as a dominant characteristic.

Non-candidal infections in children with chronic mucocutaneous candidiasis

Chronic mucocutaneous candidiasis (CMCC) is a clinical syndrome characterized by persistent and recurrent Candida albicans infections of the mucous membranes and skin often associated with immunodeficiency. In order to gain insight into the frequency and severity of non-candidal infections in children with CMCC, four patients with CMCC are described in detail and 60 previously reported cases are reviewed. Fifty percent of children with CMCC had significant infections with other fungi, bacteria and viruses. Recurrent bacterial pneumonias and bronchiectasis were a major cause of morbidity and mortality. In addition, there were a large number of infections, in both the lung and other sites, due to opportunistic organisms. Thus the clincial syndrome of CMCC includes not only mucocutaneous candidiasis, endocrine failure and autoimmune phenomena, but patients with CMCC also show a remarkable susceptibility to non-candidal infections. These non-candidal infections represent a serious cause of morbidity for patients with CMCC.

Mucocutaneous candidiasis and thymoma

The clinical, pathologic and immunologic features of 27 patients with chronic mucocutaneous candidiasis and thymic tumors are reviewed. This form of chronic candidiasis is unique in that the infections do not occur until after the third decade and, in contrast to patients in whom candidiasis develops during infancy or childhood, it is not accompanied by failure of endocrine organs. Instead, the patients have the disorders that often accompany thymoma, such as myasthenia gravis, hypogammaglobulinemia, and abnormalities of the bone marrow and circulating blood elements. Evidence of impaired cell-mediated immunity was found in 16 of the 21 patients in whom studies were made. The pathogenesis of the immunodeficiency in these patients is unknown. Immunosuppressive activities in the plasma of four patients were found, but none of the five patients in whom the appropriate studies were made was found to have suppressor cells. The features of this disorder are unique enough that it should be considered a syndrome, and patients in whom candidiasis develops during their adult years should be studied for the presence of thymoma.