101
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Morrissey CO, Chen SCA, Sorrell TC, Bradstock KF, Szer J, Halliday CL, Gilroy NM, Schwarer AP, Slavin MA. Design issues in a randomized controlled trial of a pre-emptive versus empiric antifungal strategy for invasive aspergillosis in patients with high-risk hematologic malignancies. Leuk Lymphoma 2011; 52:179-93. [PMID: 21281234 DOI: 10.3109/10428194.2010.542600] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Invasive aspergillosis (IA) is a major cause of mortality in patients with hematological malignancies, due largely to the inability of traditional culture and biopsy methods to make an early or accurate diagnosis. Diagnostic accuracy studies suggest that Aspergillus galactomannan (GM) enzyme immunoassay (ELISA) and Aspergillus PCR-based methods may overcome these limitations, but their impact on patient outcomes should be evaluated in a diagnostic randomized controlled trial (D-RCT). This article describes the methodology of a D-RCT which compares a new pre-emptive strategy (GM-ELISA- and Aspergillus PCR-driven antifungal therapy) with the standard fever-driven empiric antifungal treatment strategy. Issues including primary end-point and patient selection, duration of screening, choice of tests for the pre-emptive strategy, antifungal prophylaxis and bias control, which were considered in the design of the trial, are discussed. We suggest that the template presented herein is considered by researchers when evaluating the utility of new diagnostic tests (ClinicalTrials.gov number, NCT00163722).
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Affiliation(s)
- C Orla Morrissey
- Infectious Diseases Unit, Department of Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia.
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102
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Vergoulidou M, Krause L, Foerster MH, Thiel E, Schwartz S. Endogenous filamentous fungal endophthalmitis--single-centre survey in patients with acute leukaemia or postallogeneic stem cell transplantation and review of the literature. Mycoses 2011; 54:e704-11. [PMID: 21605192 DOI: 10.1111/j.1439-0507.2010.02004.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Endogenous endophthalmitis caused by filamentous fungi has been infrequently described and its prognosis in immunocompromised patients is largely unknown. Patients were identified through a single-centre database containing patients with endophthalmitis. Cases published since 2002 were reviewed. Clinical and treatment features as well as outcomes were analysed. Six patients were identified from the database. Underlying conditions were haematological malignancies (HM) and/or allogeneic haematopoietic stem cell transplantation (HSCT). Three patients underwent vitrectomy. None of the patients survived and the median time from first evidence of endophthalmitis until death was 33 days. The median time from first evidence of an invasive fungal infection to endophthalmitis was only 5 days. Fifty-six patients were identified from the literature. The majority of these patients underwent vitrectomy (27) or enucleation (10) and received intraocular antifungal therapy (28). Only 13 (23%) of 56 patients experienced an improved vision. The survival rate was 52% in all 56 patients but was significantly less in patients with HM or post-HSCT when compared with all others (26% vs. 70%, respectively; P = 0.003). Endogenous endophthalmitis caused by filamentous fungi is frequently associated with a permanent decrease or loss of vision. This type of fungal infection carries a particular poor prognosis in patients with profound immunosuppression, requiring improved treatment strategies.
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Affiliation(s)
- Maria Vergoulidou
- Department of Hematology and Oncology, Charité-Campus Benjamin Franklin, Berlin, Germany
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103
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Mortensen KL, Johansen HK, Fuursted K, Knudsen JD, Gahrn-Hansen B, Jensen RH, Howard SJ, Arendrup MC. A prospective survey of Aspergillus spp. in respiratory tract samples: prevalence, clinical impact and antifungal susceptibility. Eur J Clin Microbiol Infect Dis 2011; 30:1355-63. [PMID: 21541671 DOI: 10.1007/s10096-011-1229-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 03/13/2011] [Indexed: 10/18/2022]
Abstract
A three-month laboratory-based prospective survey was conducted at four major university hospitals covering one-third of the Danish population in order to determine the prevalence, significance, and susceptibility pattern of aspergilli in airway samples. Samples received in January-March 2007 for routine microbiologic investigation were examined for Aspergillus following routine procedures and with extended incubation (5 days). Identification was done by morphologic criteria and susceptibility testing using EUCAST method for azoles and amphotericin B E-test. Invasive aspergillosis (IA) was evaluated using modified EORTC/MSG criteria. A total of 11,368 airway samples were received. Growth of Aspergillus spp. was found in 129 and 151 patients using routine and extended incubation, respectively. Three patients had proven IA (2%), 11 probable (7%), four had allergic bronchopulmonary aspergillosis (ABPA) (3%), but the majority was colonised (88%). Underlying conditions were cystic fibrosis in 82 patients (55%), chronic obstructive pulmonary disease in 19 (13%) and haematological disorder in 11 (7%). Twenty-six patients (18%) were at intensive care unit and 69 (47%) received steroid treatment. Azole MICs were elevated for five isolates as follows (itraconazole, posaconazole, voriconazole MICs [mg/L]): two A. fumigatus isolates (>4; >4; 2 and >4; 0.125; 1), one A. lentulus isolate (2; 2; 0.5) and two A. terreus isolates (2; 2; 2 and 2; 0.125; 1). For four isolates the amphotericin B MIC was >1 μg/ml (3/112 A. fumigatus, 1/2 A. terreus). In conclusion, Aspergillus appears to be an important pathogen in Denmark. Elevated itraconazole MICs were detected in 4% of the isolates including a multi-azole resistant isolate.
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Affiliation(s)
- K L Mortensen
- Mycology Unit, Department of Microbiological Surveillance and Research, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark.
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104
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Denning DW, Park S, Lass-Florl C, Fraczek MG, Kirwan M, Gore R, Smith J, Bueid A, Moore CB, Bowyer P, Perlin DS. High-frequency triazole resistance found In nonculturable Aspergillus fumigatus from lungs of patients with chronic fungal disease. Clin Infect Dis 2011; 52:1123-9. [PMID: 21467016 PMCID: PMC3106268 DOI: 10.1093/cid/cir179] [Citation(s) in RCA: 231] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 02/22/2011] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Oral triazole therapy is well established for the treatment of invasive (IPA), allergic (ABPA), and chronic pulmonary (CPA) aspergillosis, and is often long-term. Triazole resistance rates are rising internationally. Microbiological diagnosis of aspergillosis is limited by poor culture yield, leading to uncertainty about the frequency of triazole resistance. METHODS Using an ultrasensitive real-time polymerase chain reaction (PCR) assay for Aspergillus spp., we assessed respiratory fungal load in bronchoalveolar lavage (BAL) and sputum specimens. In a subset of PCR-positive, culture negative samples, we further amplified the CYP51A gene to detect key single-nucleotide polymorphisms (SNPs) associated with triazole resistance. RESULTS Aspergillus DNA was detected in BAL from normal volunteers (4/11, 36.4%) and patients with culture or microscopy confirmed IPA (21/22, 95%). Aspergillus DNA was detected in sputum in 15 of 19 (78.9%) and 30 of 42 (71.4%) patients with ABPA and CPA, compared with 0% and 16.7% by culture, respectively. In culture-negative, PCR-positive samples, we detected triazole-resistance mutations (L98H with tandem repeat [TR] and M220) within the drug target CYP51A in 55.1% of samples. Six of 8 (75%) of those with ABPA and 12 of 24 (50%) with CPA had resistance markers present, some without prior triazole treatment, and in most despite adequate plasma drug concentrations around the time of sampling. CONCLUSIONS The very low organism burdens of fungi causing infection have previously prevented direct culture and detection of antifungal resistance in clinical samples. These findings have major implications for the sustainability of triazoles for human antifungal therapy.
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Affiliation(s)
- David W Denning
- National Aspergillosis Centre, University of Manchester, Manchester, UK.
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105
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Chronic aspergillus infections of the respiratory tract: diagnosis, management and antifungal resistance. Curr Opin Infect Dis 2011; 23:584-9. [PMID: 20827190 DOI: 10.1097/qco.0b013e32833ed694] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chronic pulmonary aspergillosis (CPA) is a relatively rare, slowly progressive pulmonary syndrome due to Aspergillus spp. that requires specific knowledge in terms of disease entity, diagnosis, management and azole resistance. This review focuses on the recent understanding of CPA entity and the emergence of azole resistance in CPA. RECENT FINDINGS Due to complexities related to patients' background and limited pathological evidence, the disease entity of CPA was incomprehensive and numerous names were previously used. The disease entities and nomenclature of subtypes of CPA have recently been proposed, though previous literature had grouped several different forms of CPA together. Recent advances in the methodology of susceptibility testing have indicated increasing azole resistance in Aspergillus spp. CPA is potentially involved in producing azole resistance and associated with poor response to azoles. SUMMARY As there are few publications regarding CPA, there are still many unanswered questions. However, updating of disease entity will promote the clinical and basic research in this field. Moreover, the emergence of antifungal drug resistance of Aspergillus is becoming a major concern. Thus, more evidence and research regarding drug resistance are required to improve the outcome of CPA.
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106
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Roilides E, Simitsopoulou M. Local innate host response and filamentous fungi in patients with cystic fibrosis. Med Mycol 2011; 48 Suppl 1:S22-31. [PMID: 21067326 DOI: 10.3109/13693786.2010.511286] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Filamentous fungi especially Aspergillus spp. and Scedosporium spp. can colonize the lungs of cystic fibrosis (CF) patients. Persistent infection by these organisms may cause deterioration of lung function, mycetomas or local invasive disease. Although CF patients exert an excessive inflammatory response to inhaled bacteria, very little is known about the local innate immune response to filamentous fungi. In this paper, we review the innate immune response of respiratory tract of healthy individuals to filamentous fungi with some inference to CF patients and link the latter to existing data. We also report some preliminary findings on the in vitro antifungal responses of human phagocytes against Aspergillus spp. isolated from CF patients. Translation of these in vitro findings to appropriate in vivo systems and into clinical trials of immunomodulatory treatments may lead to improved strategies for appropriate innate host defenses in CF patients persistently infected with filamentous fungi.
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Affiliation(s)
- Emmanuel Roilides
- Department of Pediatrics, Aristotle University School of Medicine, Thessaloniki, Greece.
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107
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Kohno S, Izumikawa K, Kakeya H, Miyazaki Y, Ogawa K, Amitani R, Niki Y, Kurashima A. Clinical efficacy and safety of micafungin in Japanese patients with chronic pulmonary aspergillosis: a prospective observational study. Med Mycol 2011; 49:688-93. [PMID: 21355713 DOI: 10.3109/13693786.2011.561369] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Aspergillosis has been the prevailing deep-seated mycosis in Japan since the 1990s. Although micafungin (MCFG) has been approved in Japan for the management of patients with such infections caused by Candida and Aspergillus species, there are relatively few reports on its use in patients with chronic pulmonary aspergillosis (CPA). Therefore, we conducted a prospective observational study to evaluate the efficacy and safety of the use of MCFG in Japanese patients with CPA. The efficacy of the antifungal was assessed on the basis of improvements in clinical symptoms and radiological findings. In addition, adverse events, including abnormal laboratory findings were determined. The overall clinical efficacy rate was 68.4% (26/38 patients), which is comparable to the results obtained in clinical trials for marketing approval conducted in Japan. Although adverse drug reactions were observed in six patients (15.8%), they were not serious. The most common of these reactions was abnormal liver functions. No relationship between the incidence of adverse drug reactions and age of the patients, MCFG dose, or duration of treatment was observed. Consequently, MCFG has favorable efficacy and safety profiles in Japanese CPA patients with various backgrounds.
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Affiliation(s)
- Shigeru Kohno
- Department of Molecular Microbiology and Immunology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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108
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Tashiro T, Izumikawa K, Tashiro M, Takazono T, Morinaga Y, Yamamoto K, Imamura Y, Miyazaki T, Seki M, Kakeya H, Yamamoto Y, Yanagihara K, Yasuoka A, Kohno S. Diagnostic significance of Aspergillus species isolated from respiratory samples in an adult pneumology ward. Med Mycol 2011; 49:581-7. [PMID: 21208028 DOI: 10.3109/13693786.2010.548084] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Although the diagnostic significance of isolating Aspergillus spp. from respiratory cultures has been studied in immunocompromised hosts with invasive pulmonary aspergillosis (IPA), little is known of such infections in immunocompetent patients with other forms of aspergillosis. In this study of adult pneumology ward patients, we examined the association between Aspergillus spp. and disease prevalence. Laboratory records from April 1998 to March 2009 were reviewed to identify patients with Aspergillus spp. in respiratory samples. Correlations between the isolated species and clinical characteristics of patients were evaluated. During the study period, 165 Aspergillus spp. isolates were detected in the respiratory cultures of 139 patients. Of these patients, 62 (45%) were colonized with Aspergillus spp. and displayed no clinical symptoms of aspergillosis, while 77 (55%) had a form of pulmonary aspergillosis, characterized as either chronic necrotizing pulmonary aspergillosis (CNPA) (48%), aspergilloma (29%), IPA (13%), or allergic bronchopulmonary aspergillosis (ABPA) (10%). The dominant species were Aspergillus fumigatus (41%), A. niger (32%), and A. versicolor (12%). A. fumigatus was most commonly isolated in patients with IPA, aspergilloma, and CNPA, whereas A. niger was the dominant species in colonized patients and those with ABPA. Isolation of an Aspergillus spp. from respiratory samples does not confirm it as the etiologic pathogen because airway colonization by Aspergillus spp. is a common feature in several chronic lung diseases. Repeated isolation of the identical Aspergillus species and detection of anti-Aspergillus antibodies and/or Aspergillus antigens in sera are needed to determine the isolate represents the etiologic agent of disease.
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Affiliation(s)
- Takayoshi Tashiro
- Department of Health Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University Hospital, Nagasaki, Japan
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109
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Garbino J, Fluckiger U, Elzi L, Imhof A, Bille J, Zimmerli S. Survey of aspergillosis in non-neutropenic patients in Swiss teaching hospitals. Clin Microbiol Infect 2010; 17:1366-71. [PMID: 20950331 DOI: 10.1111/j.1469-0691.2010.03402.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Invasive aspergillosis (IA) is a live-threatening opportunistic infection that is best described in haematological patients with prolonged neutropenia or graft-versus-host disease. Data on IA in non-neutropenic patients are limited. The aim of this study was to establish the incidence, disease manifestations and outcome of IA in non-neutropenic patients diagnosed in five Swiss university hospitals during a 2-year period. Case identification was based on a comprehensive screening of hospital records. All cases of proven and probable IA were retrospectively analysed. Sixty-seven patients were analysed (median age 60 years; 76% male). Sixty-three per cent of cases were invasive pulmonary aspergillosis (IPA), and 17% of these were disseminated aspergillosis. The incidence of IPA was 1.2/10 000 admissions. Six of ten cases of extrapulmonary IA affected the brain. There were six cases of invasive rhinosinusitis, six cases of chronic pulmonary aspergillosis, and cases three of subacute pulmonary aspergillosis. The most frequent underlying condition of IA was corticosteroid treatment (57%), followed by chronic lung disease (48%), and intensive-care unit stays (43%). In 38% of patients with IPA, the diagnosis was established at autopsy. Old age was the only risk factor for post-mortem diagnosis, whereas previous solid organ transplantation and chronic lung disease were associated with lower odds of post-mortem diagnosis. The mortality rate was 57%.
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Affiliation(s)
- J Garbino
- Infectious Diseases, University Hospitals Geneva, Geneva, Switzerland.
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110
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Th1 and Th2 cytokines in a self-healing primary pulmonary Aspergillus flavus infection in BALB/c mice. Cytokine 2010; 52:258-64. [PMID: 20800507 DOI: 10.1016/j.cyto.2010.07.428] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 07/14/2010] [Accepted: 07/30/2010] [Indexed: 01/04/2023]
Abstract
Studies with non-immunocompromised mice have demonstrated that Aspergillus flavus is more virulent than almost all other Aspergillus species. However, the type of immune response this fungus induces in mammals has not been investigated thoroughly. The study was carried out to analyze the sequential pathogenesis of pulmonary A. flavus infection and the role of cytokines in host response in BALB/c mice. Two distinct phases were observed in mice: First, an intense rate of clearance of A. flavus occurred, most likely through recruited neutrophils and the resident alveolar macrophages with concurrent release of pro-inflammatory cytokines and second, fungal and cellular debris were cleaned by recruited monocytes, pro-inflammatory cytokine production rapidly decreased and infection self-healed. The pro-inflammatory cytokine IFN-γ demonstrated an upward trend up to 24h PI followed by a steady decline. The titers of TNF-α (a pro-inflammatory Th1 cytokine) were, however, inversely related to the titers of IL-10 an anti-inflammatory Th2 cytokine. The anti-inflammatory cytokine IL-4 showed slightly decreasing trend between 12 and 48 h PI, beyond that it again reached to the titers observed at 6h PI. The infected mice produced signs of Th1 type response with self healing capabilities.
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111
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Kohno S, Izumikawa K, Ogawa K, Kurashima A, Okimoto N, Amitani R, Kakeya H, Niki Y, Miyazaki Y. Intravenous micafungin versus voriconazole for chronic pulmonary aspergillosis: a multicenter trial in Japan. J Infect 2010; 61:410-8. [PMID: 20797407 DOI: 10.1016/j.jinf.2010.08.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 08/16/2010] [Accepted: 08/18/2010] [Indexed: 11/30/2022]
Abstract
Chronic pulmonary aspergillosis (CPA) is slowly progressive inflammatory pulmonary syndrome due to Aspergillus spp. The evidence regarding CPA treatment is limited. We conducted a randomized, multicenter, open-label trial comparing intravenous micafungin (MCFG) of 150-300 mg once daily with intravenous voriconazole (VRCZ) of 6 mg/kg twice on Day 1 followed by 4 mg/kg twice daily for the treatment of 107 in patients with CPA to compare the efficacy and safety of both drugs as initial treatment in Japan. Treatment effectiveness was defined by clinical, mycological, radiological and serological responses 2 weeks after the initial administration and at the end of therapy. The total of 50 and 47 patients were assigned to the MCFG and VRCZ groups, respectively. The difference in efficacy rates between MCFG and VRCZ was not significant, either after 2 weeks [68.0% vs. 58.7%; the absolute difference, 9.3% with a 95% confidence interval (CI), -9.97 to 28.58, P = 0.344] or at the end of therapy (60.0% vs. 53.2%; the absolute difference, 6.8% with a 95% CI, -12.92 to 26.54, P = 0.499). In the safety evaluation, fewer adverse events occurred in the MCFG than VRCZ group (26.4% vs. 61.1%, P = 0.0004). MCFG was as effective as VRCZ and significantly safer than as an initial treatment of CPA. (UMIN Clinical Trials Registry number, UMIN000001786.).
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Affiliation(s)
- Shigeru Kohno
- Department of Molecular Microbiology and Immunology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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112
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Abstract
Diseases caused by Aspergillus spp. are difficult to diagnose and thus require supplementary serological assays. This is the result of a selective review of the relevant literature with special regard to recent guidelines. In addition to conventional diagnostic tools (radiology, microscopy, culture) the measurement of the following serological markers is recommended, depending on the clinical type of aspergillosis: Invasive and chronic necrotising aspergillosis: Aspergillus-galactomannan antigen. Test format: EIA using the rat MAb EB-A2. Cut-off 0.5 (index). Monitoring of high risk patients: Twice weekly. Aspergillus-IgG (test format EIA) as confirmatory assay after recovery of the leukocyte function under therapy. Aspergilloma: Aspergillus IgG. Test format: EIA. Allergical aspergillosis: Aspergillus IgE. Test format: RAST. Galactomannan antigen detection rates high in the diagnosis of invasive aspergillosis. The evaluation of Aspergillus nucleic acid amplification assays is pending.
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Affiliation(s)
- R Kappe
- Institut für medizinische Laboratoriumsdiagnostik und Mikrobiologie, Südharz-Krankenhaus Nordhausen gGmbH, Nordhausen, Deutschland.
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113
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Gomez P, Hackett TL, Moore MM, Knight DA, Tebbutt SJ. Functional genomics of human bronchial epithelial cells directly interacting with conidia of Aspergillus fumigatus. BMC Genomics 2010; 11:358. [PMID: 20525375 PMCID: PMC2897809 DOI: 10.1186/1471-2164-11-358] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Accepted: 06/04/2010] [Indexed: 11/29/2022] Open
Abstract
Background Aspergillus fumigatus (A. fumigatus) is a ubiquitous fungus which reproduces asexually by releasing abundant airborne conidia (spores), which are easily respirable. In allergic and immunocompromised individuals A. fumigatus can cause a wide spectrum of diseases, including allergic bronchopulmonary aspergillosis, aspergilloma and invasive aspergillosis. Previous studies have demonstrated that A. fumigatus conidia are internalized by macrophages and lung epithelial cells; however the exact transcriptional responses of airway epithelial cells to conidia are currently unknown. Thus, the aim of this study was to determine the transcriptomic response of the human bronchial epithelial cell line (16HBE14o-) following interaction with A. fumigatus conidia. We used fluorescence-activated cell sorting (FACS) to separate 16HBE14o- cells having bound and/or internalized A. fumigatus conidia expressing green fluorescent protein from cells without spores. Total RNA was then isolated and the transcriptome of 16HBE14o- cells was evaluated using Agilent Whole Human Genome microarrays. Results Immunofluorescent staining and nystatin protection assays demonstrated that 16HBE14o- cells internalized 30-50% of bound conidia within six hrs of co-incubation. After FAC-sorting of the same cell culture to separate cells associated with conidia from those without conidia, genome-wide analysis revealed a set of 889 genes showing differential expression in cells with conidia. Specifically, these 16HBE14o- cells had increased levels of transcripts from genes associated with repair and inflammatory processes (e.g., matrix metalloproteinases, chemokines, and glutathione S-transferase). In addition, the differentially expressed genes were significantly enriched for Gene Ontology terms including: chromatin assembly, G-protein-coupled receptor binding, chemokine activity, and glutathione metabolic process (up-regulated); cell cycle phase, mitosis, and intracellular organelle (down-regulated). Conclusions We demonstrate a methodology using FACs for analyzing the transcriptome of infected and uninfected cells from the same cell population that will provide a framework for future characterization of the specific interactions between pathogens such as A. fumigatus with human cells derived from individuals with or without underlying disease susceptibility.
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Affiliation(s)
- Pol Gomez
- UBC James Hogg Research Centre, Providence Heart + Lung Institute, St, Paul's Hospital, Vancouver, BC, Canada
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114
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Arendrup MC, Mavridou E, Mortensen KL, Snelders E, Frimodt-Møller N, Khan H, Melchers WJG, Verweij PE. Development of azole resistance in Aspergillus fumigatus during azole therapy associated with change in virulence. PLoS One 2010; 5:e10080. [PMID: 20404915 PMCID: PMC2852403 DOI: 10.1371/journal.pone.0010080] [Citation(s) in RCA: 134] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 03/09/2010] [Indexed: 11/18/2022] Open
Abstract
Four sequential Aspergillus fumigatus isolates from a patient with chronic granulomatous disease (CGD) eventually failing azole-echinocandin combination therapy were investigated. The first two isolates (1 and 2) were susceptible to antifungal azoles, but increased itraconazole, voriconazole and posaconazole MICs were found for the last two isolates (3 and 4). Microsatellite typing showed that the 4 isolates were isogenic, suggesting that resistance had been acquired during azole treatment of the patient. An immunocompromised mouse model confirmed that the in vitro resistance corresponded with treatment failure. Mice challenged with the resistant isolate 4 failed to respond to posaconazole therapy, while those infected by susceptible isolate 2 responded. Posaconazole-anidulafungin combination therapy was effective in mice challenged with isolate 4. No mutations were found in the Cyp51A gene of the four isolates. However, expression experiments of the Cyp51A showed that the expression was increased in the resistant isolates, compared to the azole-susceptible isolates. The microscopic morphology of the four isolates was similar, but a clear alteration in radial growth and a significantly reduced growth rate of the resistant isolates on solid and in broth medium was observed compared to isolates 1 and 2 and to unrelated wild-type controls. In the mouse model the virulence of isolates 3 and 4 was reduced compared to the susceptible ones and to wild-type controls. For the first time, the acquisition of azole resistance despite azole-echinocandin combination therapy is described in a CGD patient and the resistance demonstrated to be directly associated with significant change of virulence.
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115
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Lass-Flörl C, Perkhofer S, Mayr A. In vitro susceptibility testing in fungi: a global perspective on a variety of methods. Mycoses 2010; 53:1-11. [PMID: 20078786 DOI: 10.1111/j.1439-0507.2009.01813.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Candida and Aspergillus species are the most common causes of invasive fungal infections in immunocompromised patients. The introduction of new antifungal agents and recent reports of resistance emerging during treatment have highlighted the need for in vitro susceptibility testing. For some drugs, there is a supporting in vitro-in vivo correlation available from studies of clinical efficacy. Both intrinsic and emergent antifungal drug resistance are encountered. Various testing procedures have been proposed, including macrodilution and microdilution, agar diffusion, disk diffusion and Etest. Early recognition of infections caused by pathogens that are resistant to one or more antifungals is highly warranted to optimise treatment and patient outcome.
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Affiliation(s)
- Cornelia Lass-Flörl
- Department of Hygiene, Microbiology and Social Medicine, Division of Hygiene and Medical Microbiology, Innsbruck Medical University, Innsbruck, Austria.
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116
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No JH, Yu JS, Kim EO, Choi HH, Kim SH, Kwon JC, Lee DG, Choi SM, Park SH, Choi JH, Yoo JH, Kim HJ, Min WS. A Case of Disseminated Aspergillosis Presenting Solely as Multiple Cutaneous Lesions in an Acute Leukemia Patient. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.4.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jin-Hee No
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Sok Yu
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun-Ho Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si-Hyun Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Cheol Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Mi Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Hong Yoo
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo-Sung Min
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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117
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Abstract
Aspergillus spp produce a wide range of saprophytic and invasive syndromes in the lungs, including allergic bronchopulmonary aspergillosis (ABPA), aspergilloma and invasive pulmonary aspergillosis (IPA). ABPA results from hypersensitivity to the fungus, and mainly affects patients with asthma or cystic fibrosis (CF). The treatment of choice consists of systemic corticosteroids and itraconazole. Aspergilloma is managed by observation or surgery. IPA is predominantly seen in patients with haematological malignancies, chronic granulomatous disease or immunosuppressive treatment. With the use of aggressive therapies for end-stage CF, such as heart-lung transplantation, the potential for a patient to convert from colonization or ABPA to IPA has increased. Suggestive clinical and radiological findings, supplemented with mycological data using serology and molecular biology, have enhanced the capacity to diagnose IPA in paediatric patients. While voriconazole is considered the first-line therapy in IPA, several other antifungal agents may be appropriate alternatives.
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Affiliation(s)
- Elpis Hatziagorou
- 3rd Department of Paediatrics, Aristotle University, Hippokration Hospital, Konstantinoupoleos 49, GR-54642 Thessaloniki, Greece
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118
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Isolated diffuse invasive renal aspergillosis in an immunocompromized patient due to longstanding steroid treatment: a case report. CASES JOURNAL 2009; 2:6825. [PMID: 19829869 PMCID: PMC2740170 DOI: 10.4076/1757-1626-2-6825] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 07/10/2009] [Indexed: 11/08/2022]
Abstract
A 53-year-old Indian lady suffered from type 2 diabetes and hypothyroidism and was on longstanding steroid therapy. She was urgently admitted to the hospital with a high white cell count and high creatinine. On imaging no space occupying lesions were shown. In spite of intensive therapy the patient died a week after admission. Post mortem examination revealed markedly enlarged kidneys with areas of necrosis, hemorrhagic infarction, inflammatory response and granulomas related to the widespread glomerular, tubulo-interstitial and vascular involvement by aspergillus. Renal disease may present as bilateral diffuse parenchymal involvement with blood vessel invasion causing organ failure.
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120
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Hope WW. Invasion of the alveolar-capillary barrier by Aspergillus spp.: therapeutic and diagnostic implications for immunocompromised patients with invasive pulmonary aspergillosis. Med Mycol 2009; 47 Suppl 1:S291-8. [PMID: 19306226 DOI: 10.1080/13693780802510232] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Aspergillus spp. are leading causes of morbidity and mortality in immunocompromised patients. This review provides an overview of host defenses, the mechanisms by which the alveolar-capillary barrier is breeched by Aspergillus, and the implications for diagnosis and treatment of patients with invasive pulmonary aspergillosis.
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121
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Losada L, Ajayi O, Frisvad JC, Yu J, Nierman WC. Effect of competition on the production and activity of secondary metabolites in Aspergillus species. Med Mycol 2009; 47 Suppl 1:S88-96. [PMID: 19255906 DOI: 10.1080/13693780802409542] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Secondary metabolites are of intense interest to humans due to their pharmaceutical and/or toxic properties. Also, these metabolites are clinically relevant because of their importance in fungal pathogenesis. Aspergillus species secrete secondary metabolites when grown individually and in the presence of other fungal species. However, it is not known whether secreted secondary metabolites provide a competitive advantage over other fungal species, or whether competition has any effect on the production of those metabolites. Here, we have performed co-cultivation competition assays among different species of Aspergillus to determine relative species fitness in culture, and to analyze the presence of possible antifungal activity of secondary metabolites in extracts. The results show that, for the most part, at 30 degrees C only one species is able to survive direct competition with a second species. In contrast, survival of both competitors was often observed at 37 degrees C. Consistent with these observations, antifungal activity of extracts from cultures grown at 30 degrees C was greater than that of extract from cultures at 37 degrees C. Interestingly, culture extracts from all species studied had some degree of antifungal activity, but in general, the extracts had greater antifungal activity when species were grown in the presence of a competitor. Using gas chromatography it was determined that the composition of extracts changed due to competition and a shift in temperature. These findings indicate that co-cultivation could be a very promising method for inducing and characterizing novel antifungal compounds produced by species of Aspergillus.
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Affiliation(s)
- Liliana Losada
- J. Craig Venter Institute, Rockville, Maryland 20850, USA
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122
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Rambach G, Maier H, Vago G, Mohsenipour I, Lass-Flörl C, Defant A, Würzner R, Dierich MP, Speth C. Complement induction and complement evasion in patients with cerebral aspergillosis. Microbes Infect 2008; 10:1567-76. [PMID: 18977454 DOI: 10.1016/j.micinf.2008.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 09/18/2008] [Accepted: 09/25/2008] [Indexed: 11/16/2022]
Abstract
Cerebral aspergillosis is a mostly lethal infection of the central nervous system. Former results identified low cerebral complement levels as one cause for insufficient immune reaction. Therefore we studied cerebral complement expression after fungal invasion and investigated putative mechanisms of Aspergillus spp to cope with the complement-induced selection pressure. Brain tissue derived from patients with cerebral aspergillosis or non-infected individuals was analyzed immunohistochemically for complement synthesis. Correlations between expression levels were determined statistically. Increased complement synthesis, a prerequisite for strengthened antifungal potency, was visible in resident astrocytes, neurons, oligodendrocytes as well as in infiltrating macrophages after fungal infection. Surprisingly, microglia, although regarded as major immune cells, only marginally participated in synthesis of most complement proteins. Several evasion mechanisms were found that help the fungus to establish a cerebral infection even in the presence of complement: Fungal hyphae limit the surface deposition of C3 and thus interfere with complement-dependent phagocytosis. Furthermore, the "sealing off" in brain abscesses not only inhibits fungal spreading but also forms protection shields against complement attack. Complement indeed seems to represent an important selection pressure and evokes the development of fungal evasion mechanisms. Counteractions for these evasion processes might represent interesting therapeutic approaches.
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Affiliation(s)
- Günter Rambach
- Department of Hygiene, Microbiology and Social Medicine, Innsbruck Medical University, Fritz-Pregl-Str. 3, 6020 Innsbruck, Austria
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123
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Mowat E, Williams C, Jones B, McChlery S, Ramage G. The characteristics of Aspergillus fumigatus mycetoma development: is this a biofilm? Med Mycol 2008; 47 Suppl 1:S120-6. [PMID: 18654926 DOI: 10.1080/13693780802238834] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Aspergillus fumigatus is an increasingly prevalent opportunistic fungal pathogen of various immuno-compromised individuals. It has the ability to filament within the lungs forming dense intertwined mycelial balls. These morphological characteristics resemble those of microbial biofilms, which are matrix enclosed microbial populations, adherent to each other and/or to surfaces or interfaces. The purpose of this paper is to review some recent experiments that indicate the potential biofilm forming capacity of A. fumigatus in vitro. Initially it was established that conidial seeding density is important for stable biofilm development. In the optimized model conidial germination and filamentous growth characteristics were not observed until 8 h, after which a multi-cellular population expanded exponentially forming a thick structure (approx. 250 microm). Calcofluor white staining of this revealed the presence of extracellular polymeric matrix material, which increased as the biofilm matured. Subsequent antifungal sensitivity testing of this structure showed that azoles, polyenes and echinocandins were ineffective in reducing the cellular viability at therapeutically attainable concentrations. Microarray and real-time PCR analysis demonstrated the up-regulation of AfuMDR4 during multicellular growth and development, which may account the recalcitrance observed. Overall, A. fumigatus appears to possess the classical elements of biofilm growth, namely multicellularity, matrix production and sessile resistance. This controversial approach to understanding the biology of A. fumigatus infection may provide crucial information on how to treat this pathogenic fungus more effectively.
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Affiliation(s)
- Eilidh Mowat
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
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124
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De Pauw B, Walsh TJ, Donnelly JP, Stevens DA, Edwards JE, Calandra T, Pappas PG, Maertens J, Lortholary O, Kauffman CA, Denning DW, Patterson TF, Maschmeyer G, Bille J, Dismukes WE, Herbrecht R, Hope WW, Kibbler CC, Kullberg BJ, Marr KA, Muñoz P, Odds FC, Perfect JR, Restrepo A, Ruhnke M, Segal BH, Sobel JD, Sorrell TC, Viscoli C, Wingard JR, Zaoutis T, Bennett JE. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis 2008; 46:1813-21. [PMID: 18462102 PMCID: PMC2671227 DOI: 10.1086/588660] [Citation(s) in RCA: 3826] [Impact Index Per Article: 239.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Invasive fungal diseases are important causes of morbidity and mortality. Clarity and uniformity in defining these infections are important factors in improving the quality of clinical studies. A standard set of definitions strengthens the consistency and reproducibility of such studies. METHODS After the introduction of the original European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group definitions, advances in diagnostic technology and the recognition of areas in need of improvement led to a revision of this document. The revision process started with a meeting of participants in 2003, to decide on the process and to draft the proposal. This was followed by several rounds of consultation until a final draft was approved in 2005. This was made available for 6 months to allow public comment, and then the manuscript was prepared and approved. RESULTS The revised definitions retain the original classifications of "proven," "probable," and "possible" invasive fungal disease, but the definition of "probable" has been expanded, whereas the scope of the category "possible" has been diminished. The category of proven invasive fungal disease can apply to any patient, regardless of whether the patient is immunocompromised, whereas the probable and possible categories are proposed for immunocompromised patients only. CONCLUSIONS These revised definitions of invasive fungal disease are intended to advance clinical and epidemiological research and may serve as a useful model for defining other infections in high-risk patients.
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Affiliation(s)
- Ben De Pauw
- Department of Blood Transfusion Service and Transplant Immunology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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125
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Locally Invasive Aspergillosis Within an Intralobar Sequestration in a Child. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2008. [DOI: 10.1097/ipc.0b013e318157d2c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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126
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Magill SS, Chiller TM, Warnock DW. Evolving strategies in the management of aspergillosis. Expert Opin Pharmacother 2008; 9:193-209. [PMID: 18201144 DOI: 10.1517/14656566.9.2.193] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aspergillus spp. remain the most common causes of invasive mould infections among patients with hematologic malignancies and recipients of solid-organ and hematopoietic stem-cell transplants. Despite advances in prevention and treatment, invasive aspergillosis continues to be a deadly disease. This paper reviews current approaches to treatment of aspergillosis in adults, including surgical and immune-based strategies, and developments in prophylaxis for aspergillosis in high-risk patient populations.
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Affiliation(s)
- Shelley S Magill
- Centers for Disease Control and Prevention, Mycotic Diseases Branch, Division of Foodborne, Bacterial and Mycotic Diseases, 1600 Clifton Road, Mailstop C-09, Atlanta, GA 30333, USA.
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127
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Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, Morrison VA, Segal BH, Steinbach WJ, Stevens DA, van Burik JA, Wingard JR, Patterson TF. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis 2008; 46:327-60. [PMID: 18177225 DOI: 10.1086/525258] [Citation(s) in RCA: 1839] [Impact Index Per Article: 114.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Thomas J Walsh
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland, USA
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128
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WONG CF, YAN SW, CHAN KW. ‘Fungal soup’: Report of two cases of tumour-like blocked pulmonary cavities with liquid content infected with aspergilli, a rare form of pulmonary aspergillosis. Respirology 2008; 13:306-8. [DOI: 10.1111/j.1440-1843.2007.01226.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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129
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Walsh T, Anaissie E, Denning D, Herbrecht R, Kontoyiannis D, Marr K, Morrison V, Segal B, Steinbach W, Stevens D, van Burik J, Wingard J, Patterson Y. Tratamiento de la Aspergilosis: Guías para la práctica clínica de la Sociedad de Enfermedades Infecciosas de los Estados Unidos de América (IDSA). Clin Infect Dis 2008. [DOI: 10.1086/590225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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130
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131
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Scott CJ, Lambert JS, Taylor CB, Poulton MB. Invasive Aspergillus fumigatus associated with liver and bone involvement in a patient with AIDS. Int J Infect Dis 2007; 11:550-3. [PMID: 17383211 DOI: 10.1016/j.ijid.2006.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Accepted: 12/12/2006] [Indexed: 11/30/2022] Open
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132
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Zimmerli S, Knecht U, Leib SL. A model of cerebral aspergillosis in non-immunosuppressed nursing rats. Acta Neuropathol 2007; 114:411-8. [PMID: 17602232 DOI: 10.1007/s00401-007-0255-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2007] [Revised: 06/04/2007] [Accepted: 06/08/2007] [Indexed: 10/23/2022]
Abstract
Central nervous system aspergillosis is an often fatal complication of invasive Aspergillus infection. Relevant disease models are needed to study the pathophysiology of cerebral aspergillosis and to develop novel therapeutic approaches. This study presents a model of central nervous system aspergillosis that mimics important aspects of human disease. Eleven-day-old non-immunosuppressed male Wistar rats were infected by an intracisternal injection of 10 mul of a conidial suspension of Aspergillus fumigatus. An inoculum of 7.18 log(10) colony-forming units (CFU) consistently produced cerebral infection and resulted in death of all animals (n = 25) within 3-10 days. Median survival time was 3 days. Histomorphologically, all animals developed intracerebral abscesses (2-26 per brain) containing abundant fungal hyphae and neutrophils. Fungal culture of cortical homogenates yielded maximal growth on day 3 after infection (5.4 log(10) CFU/g, n = 15) that declined over time. Galactomannan concentrations in cortical homogenates, assessed as an index for hyphal burden, peaked on days 3-5. Fungal infection spread to peripheral organs in 83% of animals. Fungal burden in lung, liver, spleen and kidney was two orders of magnitude lower than in the brain. The successful establishment of a model of cerebral aspergillosis in a non-immunosuppressed host provides the opportunity to investigate mechanisms of disease and to develop novel treatment regimens for this commonly fatal infection.
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Affiliation(s)
- Stefan Zimmerli
- Institute for Infectious Diseases, University of Bern, Friedbuehlstr, 51, PO Box 61, 3010, Bern, Switzerland.
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133
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Roehrl MHA, Croft WJ, Liao Q, Wang JY, Kradin RL. Hemorrhagic pulmonary oxalosis secondary to a noninvasive Aspergillus niger fungus ball. Virchows Arch 2007; 451:1067-73. [PMID: 17786471 DOI: 10.1007/s00428-007-0487-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 07/24/2007] [Accepted: 07/24/2007] [Indexed: 10/22/2022]
Abstract
We report a case of hemorrhagic pulmonary oxalosis secondary to a noninvasive Aspergillus niger fungus ball. A patient with cavitary lung disease and hemoptysis developed progressive lung infiltrates and intractable metabolic acidosis leading to death. At autopsy, aspergillomas were identified in both the right upper and middle lobes surrounded by a large rim of necrotic and hemorrhagic parenchyma. Microscopic examination showed extensive crystal deposition and vascular thrombosis. Fungal growth was limited to the intraluminal mycelia, and no tissue or blood vessel invasion was present. Remote crystal deposits were also localized in the absence of fungal organisms to the contralateral lung and to the tubules of both kidneys. The crystals were birefringent in polarized light and stained with colloidal iron. X-ray powder diffractometry and electron impact ionization mass spectrometry identified the crystals as calcium oxalate monohydrate. Furthermore, non-necrotizing granulomatous lesions were identified in the lungs, liver, and spleen, consistent with sarcoidosis, and may have predisposed this patient to developing pulmonary aspergillomas.
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Affiliation(s)
- Michael H A Roehrl
- Department of Pathology and Laboratory Medicine, James Homer Wright Pathology Laboratories, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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134
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del Palacio A, Alhambra A, Cuétara MS, Pontón J. Estado actual del diagnóstico precoz de las infecciones invasoras causadas por Aspergillus y otros hongos filamentosos emergentes. Rev Iberoam Micol 2007; 24:187-97. [PMID: 17874855 DOI: 10.1016/s1130-1406(07)70042-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The usefulness of surrogate markers in the diagnosis of invasive fungal infections caused by Aspergillus and other emerging mycelial fungi is based on the ability of surrogate markers to detect the infection caused by different species of mycelial fungi. Conventional microbiological methods for diagnosis of fungal disease are slow and insensitive. Antigen based assays or measurement of (1-3)-beta-D-glucan in blood have been developed and validated in clinical laboratories. We review these diagnostic contemporary tools, their clinical application and impact.
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Affiliation(s)
- Amalia del Palacio
- Unidad de Micología, Servicio de Microbiología, Hospital Doce de Octubre, Madrid, Spain.
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135
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Meersseman W, Lagrou K, Maertens J, Van Wijngaerden E. Invasive aspergillosis in the intensive care unit. Clin Infect Dis 2007; 45:205-16. [PMID: 17578780 DOI: 10.1086/518852] [Citation(s) in RCA: 233] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Accepted: 03/24/2007] [Indexed: 11/04/2022] Open
Abstract
Data regarding the incidence of invasive aspergillosis (IA) in the intensive care unit (ICU) are scarce, and the incidence varies. An incidence of 5.8% in a medical ICU has been reported. The majority of patients did not have a hematological malignancy, and conditions such as chronic obstructive pulmonary disease and liver failure became recognized as risk factors. Diagnosis of IA remains difficult. Mechanical ventilation makes it difficult to interpret clinical signs, and radiological diagnoses are clouded by underlying lung pathologies. The significance of a positive respiratory culture result is greatly uncertain, because cultures of respiratory specimens have low sensitivity (50%) and specificity (20%-70%, depending on whether the patient is immunocompromised). The use of serologic markers has never been validated in an ICU population. Limited experience with the detection of galactomannan in bronchoalveolar lavage fluid specimens has yielded promising results. Because of a delay in the diagnosis of IA, the mortality rate exceeds 50%. Recently, our therapeutic armamentarium against IA has improved. Data concerning the safety and efficacy of new antifungal agents in the ICU setting, however, are lacking.
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Affiliation(s)
- Wouter Meersseman
- Department of General Internal Medicine, Gasthuisberg University Hospital, Leuven, Belgium.
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136
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Maertens J, Theunissen K, Lodewyck T, Lagrou K, Van Eldere J. Advances in the serological diagnosis of invasive Aspergillus infections in patients with haematological disorders. Mycoses 2007; 50 Suppl 1:2-17. [PMID: 17394605 DOI: 10.1111/j.1439-0507.2007.01375.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A reliable diagnosis of invasive aspergillosis in patients with haematological malignancies is seldom achieved antemortem. Conventional laboratory diagnostic methods are insensitive and time-consuming, resulting in late diagnosis and treatment and contributing to unacceptably high mortality. As a result, routine antifungal prophylaxis and early empirical treatment have been recommended. However, overtreatment associated with these strategies results in increased toxicity and cost. The use of sensitive and rapid non-culture-based diagnostic assays, such as detection of Aspergillus antigens (galactomannan, beta-D-glucan) or detection of genomic DNA sequences may allow a shift in emphasis from empirical to pre-emptive therapy, especially when substantiated by suggestive radiological findings. These new tools may be used to confirm a presumed diagnosis of invasive aspergillosis, or, when used to screen high-risk patients, may identify an infection at the early stage of disease. The excellent negative predictive value of these assays should convince clinicians to withhold antifungal therapy in persistently febrile neutropenic patients with no other signs of fungal infection. On the other hand, consecutive positive results in a high-risk population should at least trigger a complete diagnostic work-up. This review will focus on the diagnostic utility as well as on the pitfalls of serial screening for the presence of circulating fungal antigens in haematology patients.
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Affiliation(s)
- Johan Maertens
- Department of Haematology, Universitaire Ziekenhuizen Leuven, Catholic University, Leuven, Belgium.
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137
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Gunaratne PS, Wijeyaratne CN, Seneviratne HR. Aspergillus meningitis in Sri Lanka--a post-tsunami effect? N Engl J Med 2007; 356:754-6. [PMID: 17301315 DOI: 10.1056/nejmc062547] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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138
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Verruculogen associated with Aspergillus fumigatus hyphae and conidia modifies the electrophysiological properties of human nasal epithelial cells. BMC Microbiol 2007; 7:5. [PMID: 17244350 PMCID: PMC1797047 DOI: 10.1186/1471-2180-7-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2006] [Accepted: 01/23/2007] [Indexed: 11/22/2022] Open
Abstract
Background The role of Aspergillus fumigatus mycotoxins in the colonization of the respiratory tract by conidia has not been studied extensively, even though patients at risk from invasive aspergillosis frequently exhibit respiratory epithelium damage. In a previous study, we found that filtrates of A. fumigatus cultures can specifically alter the electrophysiological properties of human nasal epithelial cells (HNEC) compared to those of non pathogenic moulds. Results We fractionated the organic phase of filtrate from 3-day old A. fumigatus cultures using high-performance liquid chromatography. The different fractions were tested for their ability to modify the electrophysiological properties of HNEC in an in vitro primary culture model. The fraction collected between 20 and 30 min mimicked the effects of the whole filtrate, i.e. decrease of transepithelial resistance and increase of potential differences, and contained secondary metabolites such as helvolic acid, fumagillin, and verruculogen. Only verruculogen (10-8 M) had effects similar to the whole filtrate. We verified that verruculogen was produced by a collection of 67 human, animal, plant and environmental A. fumigatus isolates. Using MS-MS analysis, we found that verruculogen was associated with both mycelium and conidia extracts. Conclusion Verruculogen is a secondary metabolite that modifies the electrophysiological properties of HNEC. The role of these modifications in the colonization and invasion of the respiratory epithelium by A. fumigatus on first contact with the epithelium remains to be determined.
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139
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Malicev E, Chowdhury HH, Macek P, Sepcic K. Effect of ostreolysin, an Asp-hemolysin isoform, on human chondrocytes and osteoblasts, and possible role of Asp-hemolysin in pathogenesis. Med Mycol 2007; 45:123-30. [PMID: 17365648 DOI: 10.1080/13693780601039615] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Aspergillus fumigatus, a pathogenic mould causing a wide range of diseases including aspergillosis, produces a series of toxic substances which appear to act in an additive and/or synergic way on cells. Aspergillosis generally occurs in immunocompromised hosts or is associated with organ transplantation. From the muscul skeleton system the vertebrae, ribs and orbit are the most commonly affected, while the joints are less frequent targets. The cytolytic protein Asp-hemolysin is one of the toxins produced by Aspergillus fumigatus during infection. It belongs to the aegerolysin protein family and shares 43% identity in amino acid sequence with ostreolysin, a cytolysin from the mushroom Pleurotus ostreatus. In this work, ostreolysin was used in an experimental model to study the in vitro effects of aegerolysin-like proteins on human chondrocytes and osteoblasts. Immunostaining analyses showed selective binding and clustering of the protein on chondrocyte membranes, pointing to its association with distinctive membrane microdomains. Consequently, ostreolysin can induce effective permeabilization of both chondrocytes and osteoblasts. Based on sequence similarities of ostreolysin and Asp-hemolysin, their comparable cytolytic effects towards different cells, and similar signs of intoxication in experimental animals, our results indicate that Asp-hemolysin might be considered as a possible virulence factor of Aspergillus fumigatus during the infection of bone and cartilage.
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140
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Izumikawa K, Ohtsu Y, Kawabata M, Takaya H, Miyamoto A, Sakamoto S, Kishi K, Tsuboi E, Homma S, Yoshimura K. Clinical efficacy of micafungin for chronic pulmonary aspergillosis. Med Mycol 2007; 45:273-8. [PMID: 17464848 DOI: 10.1080/13693780701278386] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The rising incidence of pulmonary aspergillosis is a major clinical concern. However, only a limited number of antifungal drugs are available in Japan that are effective for pulmonary Aspergillus infections. Micafungin (MCFG), a newly developed echinocandin family antifungal drug, has potent antifungal activity in vitro, but few reports detailing its clinical effectiveness have been published to date. A retrospective study was performed using data from nine patients (seven males and two females) with chronic invasive forms of pulmonary aspergillosis, who were treated with either MCFG alone or together with other antifungal drugs between April 2003 and March 2004. The overall efficacy of the treatments was evaluated in the terms of clinical, mycological, serological and radiological responses. The average age of the patients was 61.9 (20-83) years old. Four patients received only MCFG and the remaining five patients were treated with MCFG in combination with amphotericin B (AMB) only (1 patient), itraconazole (ITC) only (2 patients) or AMB backed up by ITC during AMB discontinuation periods (2 patients). The mean duration of MCFG administration was 59.2 (28-96) days. Overall, the treatment was judged to have been effective for seven of nine patients. No patient's condition deteriorated in response to treatment. Administration of MCFG alone was judged to have been effective in three of four patients. No notable adverse effects were documented during MCFG administration. These data suggest that MCFG may be an effective and safe antifungal drug for the treatment of chronic invasive forms of pulmonary aspergillosis.
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Affiliation(s)
- Koichi Izumikawa
- Department of Respiratory Medicine, Respiratory Center, Toranomon Hospital, Tokyo, Japan
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141
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Sambatakou H, Dupont B, Lode H, Denning DW. Voriconazole treatment for subacute invasive and chronic pulmonary aspergillosis. Am J Med 2006; 119:527.e17-24. [PMID: 16750972 DOI: 10.1016/j.amjmed.2005.11.028] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Revised: 11/23/2005] [Accepted: 11/23/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Voriconazole is a novel triazole antifungal with a broad spectrum including Aspergillus species. We conducted an open, noncomparative multicenter study to evaluate the efficacy and safety of voriconazole in subacute invasive and chronic pulmonary aspergillosis (CPA). METHODS Patients without profound neutropenia and a proven or probable diagnosis of subacute invasive aspergillosis (IA) or CPA received voriconazole 200 mg twice daily for a period of 4-24 weeks as primary or salvage therapy. Dose escalation was allowed if efficacy was suboptimal, and toleration and safety were satisfactory. Response was assessed by clinical, radiological and mycological changes. A complete or partial response in subacute IA and improved or stable in CPA were assessed as favorable responses. RESULTS Of 39 patients treated, 36 were assessable. The majority of patients had subacute IA (n = 21), proven in all 11 extra-pulmonary and in 23/25 (92%) of the pulmonary cases. Voriconazole was given as primary therapy in 22 (61%). All patients receiving salvage therapy (n = 14) had refractory IA, having failed itraconazole or amphotericin B (AmB) or both. Overall, a complete or partial response was seen in 9/21(43%) of subacute IA and improved or stable in 12/15 (80%) of those with CPA. Adverse events, mainly liver function test abnormalities, skin reactions, and visual disturbances were mild and transient, leading to early discontinuation of treatment in 5 cases. CONCLUSIONS In patients with subacute IA and CPA, voriconazole was efficacious as salvage or primary therapy.
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Affiliation(s)
- Helen Sambatakou
- Department of Medicine and Infectious Diseases, University of Athens, Greece
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Cuétara MS, Alhambra A, Moreno JM, Postigo C, Moragues MD, Pontón J, del Palacio A. Invasive aspergillosis due to subungual onychomycosis during treatment for non-Hodgkin lymphoma. Br J Dermatol 2006; 154:1200-2. [PMID: 16704657 DOI: 10.1111/j.1365-2133.2006.07240.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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143
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Peter Donnelly J. Consensus definitions for invasive fungal disease: Strengths, limitations, and revisions. Med Mycol 2006; 44:S285-S288. [PMID: 30408916 DOI: 10.1080/13693780600826707] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The European Organization for Research and Treatment of Cancer (EORTC)/ Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (MSG) consensus definitions for opportunistic invasive fungal infections have achieved their objective in fostering better communication between researchers but their limitations necessitated revision. In the last two years a group of experts drawn from both sides of the Atlantic have agreed a proposal for a new set of definitions that attempt to rectify omissions and problems arising from the original set whilst preserving their basic principles.
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Affiliation(s)
- J Peter Donnelly
- Department of Hematology and Nijmegen University Centre for Infectious Diseases, University Medical Centre St Radboud, Radboud University Nijmegen, Nijmegen, The Netherlands
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