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Höft MA, Duvenage L, Salie S, Keeton R, Botha A, Schwartz IS, Govender NP, Brown GD, Hoving JC. The pathogenesis of experimental Emergomycosis in mice. PLoS Negl Trop Dis 2024; 18:e0011850. [PMID: 38198478 PMCID: PMC10805315 DOI: 10.1371/journal.pntd.0011850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 01/23/2024] [Accepted: 12/07/2023] [Indexed: 01/12/2024] Open
Abstract
Emergomyces africanus is a recently identified thermally-dimorphic fungal pathogen that causes disseminated infection in people living with advanced HIV disease. Known as emergomycosis, this disseminated disease is associated with very high case fatality rates. Over the last decade, improved diagnostics and fungal identification in South Africa resulted in a dramatic increase in the number of reported cases. Although the true burden of disease is still unknown, emergomycosis is among the most frequently diagnosed dimorphic fungal infections in Southern Africa; and additional species in the genus have been identified on four continents. Little is known about the pathogenesis and the host's immune response to this emerging pathogen. Therefore, we established a murine model of pulmonary infection using a clinical isolate, E. africanus (CBS 136260). Both conidia and yeast forms caused pulmonary and disseminated infection in mice with organisms isolated in culture from lung, spleen, liver, and kidney. Wild-type C57BL/6 mice demonstrated a drop in body weight at two weeks post-infection, corresponding to a peak in fungal burden in the lung, spleen, liver, and kidney. An increase in pro-inflammatory cytokine production was detected in homogenized lung supernatants including IFN-γ, IL-1β, IL-6, IL12-p40 and IL-17 at three- and four-weeks post-infection. No significant differences in TNF, IL-12p70 and IL-10 were observed in wild-type mice between one and four-weeks post-infection. Rag-1-deficient mice, lacking mature T-and B-cells, had an increased fungal burden associated with reduced IFN-γ production. Together our data support a protective T-helper type-1 immune response to E. africanus infection. This may provide a possible explanation for the susceptibility of only a subset of people living with advanced HIV disease despite hypothesized widespread environmental exposure. In summary, we have established a novel murine model of E. africanus disease providing critical insights into the host immune components required for eliminating the infection.
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Affiliation(s)
- Maxine A. Höft
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Lucian Duvenage
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sumayah Salie
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Roanne Keeton
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Alfred Botha
- Department of Microbiology, Stellenbosch University, Stellenbosch, South Africa
| | - Ilan S. Schwartz
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Nelesh P. Govender
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Medical Research Council Centre for Medical Mycology at the University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, United Kingdom
| | - Gordon D. Brown
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Medical Research Council Centre for Medical Mycology at the University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, United Kingdom
| | - Jennifer Claire Hoving
- CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Medical Research Council Centre for Medical Mycology at the University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, United Kingdom
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Ibe C, Mnyambwa NP, Mfinanga SG. Emergomycosis in Africa: Time to Pay Attention to This Emerging Deadly Fungal Infection. Int J Gen Med 2023; 16:2313-2322. [PMID: 37309324 PMCID: PMC10257923 DOI: 10.2147/ijgm.s403797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/13/2023] [Indexed: 06/14/2023] Open
Abstract
Emergomycosis is an emerging deadly infectious disease caused primarily by a little-known airborne pathogen Emergomyces africanus, which can cause clinical management challenge especially in patients with advanced HIV disease. This minireview describes Es. africanus as the main cause of emergomycosis in Africa as well as considers contributing factors to the difficulties encountered in managing this infection. Emergomycosis is common in HIV-positive persons with low CD4 lymphocyte count and has an estimated fatality of 50%. The infection exhibits airborne transmission with pulmonary and extrapulmonary manifestations leading to skin lesions. However, the pathogenesis of Es. africanus is still poorly understood. The management of the infection is complicated due to lack of defined diagnostic and therapeutic guidelines. Limited expertise, poor research funding, and lack of awareness and national surveillance are thought to impact the recognition and prioritisation of the infection. These factors may ultimately assign emergomycosis a 'neglected infection status' even as it is suspected to be prevalent in more African countries than previously recognised. Increased awareness and integrated and targeted strategies such as mobilising manpower in clinical mycology are of paramount importance in managing emergomycosis in Africa and beyond.
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Affiliation(s)
- Chibuike Ibe
- Department of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria
| | - Nicholaus P Mnyambwa
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania
- Alliance for Africa Health and Research (A4A), Dar es Salaam, Tanzania
| | - Sayoki G Mfinanga
- National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania
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Reddy DL, Nel J, Govender NP. Review: Emergomycosis. J Mycol Med 2023; 33:101313. [PMID: 36272380 DOI: 10.1016/j.mycmed.2022.101313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022]
Abstract
Purpose of Review In this review, we provide an overview of emergomycosis from a clinical perspective and discuss the taxonomy and classification of the pathogens, epidemiology, pathophysiology of infection and mechanisms of pathogenesis, immunology, clinical manifestations, laboratory culture and diagnosis, molecular characterisation, therapy and prognosis. Recent Findings While Emergomyces pasteurianus is the most geographically-widespread species, Emergomyces africanus is endemic to Southern Africa and causes disseminated disease with cutaneous involvement primarily among patients with advanced human immunodeficiency virus (HIV) disease. Summary Emergomycosis, a disseminated clinical disease resulting from infection with dimorphic fungi in the genus Emergomyces, occurs primarily among immunocompromised patients. Further knowledge is needed on the pathophysiology, diagnosis and management of emergomycosis.
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Affiliation(s)
- Denasha L Reddy
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - Jeremy Nel
- Division of Infectious Diseases, Department of Internal Medicine, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa.
| | - Nelesh P Govender
- National Institute for Communicable Diseases, a Division of the National Health Laboratory Service; School of Pathology, University of the Witwatersrand, Johannesburg, South Africa; Division of Medical Microbiology, University of Cape Town, South Africa; Institute of Infection and Immunity, St George's University of London, United Kingdom; MRC Centre for Medical Mycology, University of Exeter, United Kingdom.
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4
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Dangarembizi R, Wasserman S, Hoving JC. Emerging and re-emerging fungal threats in Africa. Parasite Immunol 2023; 45:e12953. [PMID: 36175380 PMCID: PMC9892204 DOI: 10.1111/pim.12953] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/04/2023]
Abstract
The emergence of deadly fungal infections in Africa is primarily driven by a disproportionately high burden of human immunodeficiency virus (HIV) infections, lack of access to quality health care, and the unavailability of effective antifungal drugs. Immunocompromised people in Africa are therefore at high risk of infection from opportunistic fungal pathogens such as Cryptococcus neoformans and Pneumocystis jirovecii, which are associated with high morbidity, mortality, and related socioeconomic impacts. Other emerging fungal threats include Emergomyces spp., Histoplasma spp., Blastomyces spp., and healthcare-associated multi-drug resistant Candida auris. Socioeconomic development and the Covid-19 pandemic may influence shifts in epidemiology of invasive fungal diseases on the continent. This review discusses the epidemiology, clinical manifestations, and current management strategies available for these emerging fungal diseases in Africa. We also discuss gaps in knowledge, policy, and research to inform future efforts at managing these fungal threats.
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Affiliation(s)
- Rachael Dangarembizi
- Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa,CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Contact information of corresponding author Dr Rachael Dangarembizi, Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, Neuroscience Institute, Faculty of Health Sciences, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa, CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Jennifer Claire Hoving
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa,CMM AFRICA Medical Mycology Research Unit, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Ibe C, Otu AA, Mnyambwa NP. Advancing disease genomics beyond COVID-19 and reducing health disparities: what does the future hold for Africa? Brief Funct Genomics 2022; 22:241-249. [DOI: 10.1093/bfgp/elac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/03/2022] [Accepted: 10/14/2022] [Indexed: 11/27/2022] Open
Abstract
Abstract
The COVID-19 pandemic has ushered in high-throughput sequencing technology as an essential public health tool. Scaling up and operationalizing genomics in Africa is crucial as enhanced capacity for genome sequencing could address key health problems relevant to African populations. High-quality genomics research can be leveraged to improve diagnosis, understand the aetiology of unexplained illnesses, improve surveillance of infectious diseases and inform efficient control and therapeutic methods of known, rare and emerging infectious diseases. Achieving these within Africa requires strong commitment from stakeholders. A roadmap is needed to guide training of scientists, infrastructural development, research funding, international collaboration as well as promote public–private partnerships. Although the COVID-19 pandemic has significantly boosted genomics capacity in Africa, the continent still lags other regions. Here, we highlighted key initiatives in genomics research and efforts to address health challenges facing the diverse and fast-growing populations on the continent. We explore the scalability of genomic tools and techniques to tackle a broader range of infectious diseases in Africa, a continent that desperately requires a boost from genomic science.
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Affiliation(s)
- Chibuike Ibe
- Abia State University Department of Microbiology, Faculty of Biological Sciences, , Uturu, Nigeria
| | | | - Nicholaus P Mnyambwa
- National Institute for Medical Research , Muhimbili Research Centre, Dar es Salaam , Tanzania
- Alliance for Africa Health and Research (A4A), Dar es Salaam , Tanzania
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New Histoplasma Diagnostic Assays Designed via Whole Genome Comparisons. J Fungi (Basel) 2021; 7:jof7070544. [PMID: 34356923 PMCID: PMC8305531 DOI: 10.3390/jof7070544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/16/2022] Open
Abstract
Histoplasmosis is a systemic fungal disease caused by the pathogen Histoplasma spp. that results in significant morbidity and mortality in persons with HIV/AIDS and can also affect immunocompetent individuals. Although some PCR and antigen-detection assays have been developed, conventional diagnosis has largely relied on culture, which can take weeks. Our aim was to provide a proof of principle for rationally designing and standardizing PCR assays based on Histoplasma-specific genomic sequences. Via automated comparisons of aligned genome contigs/scaffolds and gene (sub)sequences, we identified protein-coding genes that are present in existing sequences of Histoplasma strains but not in other genera. Two of the genes, PPK and CFP4, were used for designing primer sets for conventional and real-time PCR assays. Both resulted in a 100% analytical specificity in vitro and detected 62/62 H. capsulatum isolates using purified DNA. We also obtained positive detections of 2/2 confirmed H. capsulatum clinical FFPE (formalin-fixed paraffin-embedded) samples using both primer sets. Positive control plasmid 10-fold serial dilutions confirmed the analytical sensitivity of the assays. The findings suggest that these novel primer sets should allow for detection sensitivity and reduce false positive results/cross-reactions. New assays for detecting pathogenic fungi, constructed along these lines, could be simple and affordable to implement.
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Vitale RG, Giudicessi SL, Romero SM, Al-Hatmi AMS, Li Q, de Hoog GS. Recent developments in less known and multi-resistant fungal opportunists. Crit Rev Microbiol 2021; 47:762-780. [PMID: 34096817 DOI: 10.1080/1040841x.2021.1927978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Fungal infections have increased in recent years due to host factors, such as oncohaematological and transplant-related disorders, immunosuppressive therapy, and AIDS. Additionally, molecular and proteomic facilities have become available to identify previously unrecognizable opportunists. For these reasons, reports on less-known and recalcitrant mycoses, such as those caused by black fungi, hyaline filamentous fungi, coelomycetes, Mucorales, and non-Candida yeasts have emerged. In this review, novel taxonomy in these groups, which often are multi-resistant to one or several classes of antifungals, is discussed. Clinical presentations, diagnosis and current treatment of some major groups are summarised.
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Affiliation(s)
- Roxana G Vitale
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina.,Unidad de Parasitología, Sector Micología, Hospital J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Silvana L Giudicessi
- Facultad de Farmacia y Bioquímica, Cátedra de Biotecnología, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Nanobiotecnología (NANOBIOTEC), UBA-CONICET, Buenos Aires, Argentina
| | - Stella M Romero
- Consejo Nacional de Investigaciones Científicas y Tecnológicas (CONICET), Buenos Aires, Argentina.,Instituto Multidisciplinario de Biología Vegetal (IMBIV), CONICET, FCEFyN, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Abdullah M S Al-Hatmi
- Center of Expertise in Mycology of Radboud, University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Natural & Medical Science Research Center, University of Nizwa, Nizwa, Omán
| | - Qirui Li
- Department of Pharmacy, Guiyang Medical University, Guiyang, PR China
| | - G Sybren de Hoog
- Center of Expertise in Mycology of Radboud, University Medical Center/Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.,Key Laboratory of Environmental Pollution Monitoring and Disease Control, School of Basic Medical Sciences, Guizhou Medical University, Guiyang, PR China.,Department of Medical Microbiology, People's Hospital of Suzhou, National New & Hi-Tech Industrial Development Zone, Suzhou, PR China
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Abstract
Various uncommon fungal pathogens have been increasingly identified as causes of disseminated and invasive fungal disease (IFD) worldwide. Growing recognition and clinical knowledge of these emerging fungal pathogens has occurred through improved molecular diagnostics, nucleic sequence databases, and taxonomic reclassification of medically significant fungi. However, emerging fungal diseases carry significant morbidity and mortality and, due to a paucity of published literature, the collective clinical experience with these fungi is often limited. In this review, we focus on unusual emerging fungal pathogens not extensively covered elsewhere in this issue of Infectious Diseases Clinics of North America.
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Samaddar A, Sharma A. Emergomycosis, an Emerging Systemic Mycosis in Immunocompromised Patients: Current Trends and Future Prospects. Front Med (Lausanne) 2021; 8:670731. [PMID: 33968970 PMCID: PMC8104006 DOI: 10.3389/fmed.2021.670731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
Recently, the global emergence of emergomycosis, a systemic fungal infection caused by a novel dimorphic fungus Emergomyces species has been observed among immunocompromised individuals. Though initially classified under the genus Emmonsia, a taxonomic revision in 2017 based on DNA sequence analyses placed five Emmonsia-like fungi under a separate genus Emergomyces. These include Emergomyces pasteurianus, Emergomyces africanus, Emergomyces canadensis, Emergomyces orientalis, and Emergomyces europaeus. Emmonsia parva was renamed as Blastomyces parvus, while Emmonsia crescens and Emmonsia sola remained within the genus Emmonsia until a taxonomic revision in 2020 placed both the species under the genus Emergomyces. However, unlike other members of the genus, Emergomyces crescens and Emergomyces sola do not cause disseminated disease. The former causes adiaspiromycosis, a granulomatous pulmonary disease, while the latter has not been associated with human disease. So far, emergomycosis has been mapped across four continents: Asia, Europe, Africa and North America. However, considering the increasing prevalence of HIV/AIDS, it is presumed that the disease must have a worldwide distribution with many cases going undetected. Diagnosis of emergomycosis remains challenging. It should be considered in the differential diagnosis of histoplasmosis as there is considerable clinical and histopathological overlap between the two entities. Sequencing the internal transcribed spacer region of ribosomal DNA is considered as the gold standard for identification, but its application is compromised in resource limited settings. Serological tests are non-specific and demonstrate cross-reactivity with Histoplasma galactomannan antigen. Therefore, an affordable, accessible, and reliable diagnostic test is the need of the hour to enable its diagnosis in endemic regions and also for epidemiological surveillance. Currently, there are no consensus guidelines for the treatment of emergomycosis. The recommended regimen consists of amphotericin B (deoxycholate or liposomal formulation) for 1–2 weeks, followed by oral itraconazole for at least 12 months. This review elaborates the taxonomic, clinical, diagnostic, and therapeutic aspects of emergomycosis. It also enumerates several novel antifungal drugs which might hold promise in the treatment of this condition and therefore, can be potential areas of future studies.
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Affiliation(s)
- Arghadip Samaddar
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, India
| | - Anuradha Sharma
- Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, India
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Maphanga TG, Naicker SD, Gómez BL, Mhlanga M, Mpembe RS, Schwartz IS, Bamford C, Nel J, Govender NP. Cross-reactivity of a Histoplasma capsulatum antigen enzyme immunoassay in urine specimens from persons with emergomycosis in South Africa. Med Mycol 2020; 59:672-682. [PMID: 33330930 DOI: 10.1093/mmy/myaa100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/26/2020] [Indexed: 01/20/2023] Open
Abstract
Histoplasma antigen detection in urine is a rapid diagnostic method for disseminated histoplasmosis, although cross-reactivity has been reported in specimens from patients with other thermally dimorphic fungal infections. We tested urine specimens, from persons with suspected invasive fungal infections, using a commercial monoclonal antibody Histoplasma enzyme immunoassay (EIA) at a South African national mycology reference laboratory from August 2014 through December 2018. Corresponding fungal culture and histopathology results were obtained from an electronic laboratory information system. In some cases, cultured fungal isolates were sent with the urine specimen for species-level identification by phenotypic and molecular methods. Cross-reactivity was confirmed using culture filtrates of several fungal pathogens. Of 212 referred cases, 41 (19%) were excluded since they had no recorded clinical history (n = 1), alternative diagnoses were confirmed (n = 2), or no fungal culture or histopathology results (n = 38). Eighty-seven of 212 (41%) had laboratory evidence of an invasive fungal disease, while 84 (40%) did not. Of the 87 cases, 37 (43%) were culture-confirmed mycoses: emergomycosis (n = 18), histoplasmosis (n = 8), sporotrichosis (n = 6), cryptococcosis (n = 2), talaromycosis (n = 1), and other fungi isolated (n = 2). The sensitivity and specificity of the EIA were calculated for two groups: culture-confirmed (n = 37) and histology-confirmed invasive fungal disease (n = 50). The sensitivity and specificity of the EIA for diagnosis of histoplasmosis compared to culture were 88% (7/8, 95%CI 47-100%) and 72% (21/29, 95%CI 53-87%), respectively, and for diagnosis of emergomycosis/histoplasmosis compared to histology was 83% (29/35, 95%CI 66-93%) and 93% (14/15, 95%CI 68-100%), respectively. Cross-reactions occurred in urine specimens of patients with Emergomyces africanus infection and in culture filtrates of E. africanus, T. marneffei and Blastomyces species. A commercial Histoplasma EIA had satisfactory accuracy for diagnosis of culture-confirmed histoplasmosis, but cross-reacted in urine specimens from patients with invasive disease caused by the closely-related pathogen, E. africanus and in culture filtrates of E. africanus and other related fungi. LAY SUMMARY Emergomyces africanus and Histoplasma capsulatum are fungi that cause a multi-system disease among HIV-seropositive persons with a low CD4 cell count. Handling live cultures of these fungi to confirm a diagnosis requires specialized laboratory equipment and infrastructure which is infrequently accessible in low-resource settings. The features of the two diseases (i.e., disseminated histoplasmosis and emergomycosis) may be indistinguishable when infected tissue is prepared, stained, and examined under a microscope. Enzyme immunoassays (EIA) have been developed as rapid diagnostic tools for the detection of a cell wall component of H. capsulatum in urine specimens, although cross-reactions have been reported in specimens from patients with other fungal infections. We evaluated the accuracy of a commercial Histoplasma EIA to diagnose histoplasmosis and to assess cross-reactions in urine specimens from persons with emergomycosis and in cultures of E. africanus and related fungi. We report a sensitivity and specificity of 88% (95%CI 47-100%) and 72% (95%CI 53-87%) for diagnosis of histoplasmosis compared to culture and 83% (95%CI 66-93%) and 93% (95%CI 68-100%) for diagnosis of either histoplasmosis/emergomycosis compared to a diagnosis made by microscopic examination of infected tissue. The assay cross-reacted in urine specimens from patients with emergomycosis and in culture filtrates of related fungi. Although the EIA cross-reacted with other related fungi, this test can decrease the time to diagnosis and facilitate early treatment of emergomycosis and histoplasmosis in South Africa.
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Affiliation(s)
- Tsidiso G Maphanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Department of Medical Microbiology, University of the Free State, Bloemfontein, South Africa
| | - Serisha D Naicker
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Beatriz L Gómez
- School of Medicine and Health Sciences, Universidad del Rosario, Bogota, Colombia
| | - Mabatho Mhlanga
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ruth S Mpembe
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ilan S Schwartz
- Department of Medicine, University of Alberta, Alberta, Canada
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Jeremy Nel
- School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, University of the Witwatersrand, Johannesburg, South Africa.,Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
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11
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van Schalkwyk E, Mhlanga M, Maphanga TG, Mpembe RS, Shillubane A, Iyaloo S, Tsotetsi E, Pieton K, Karstaedt AS, Sahid F, Menezes CN, Tsitsi M, Motau A, Wadula J, Seetharam S, van den Berg E, Sriruttan C, Govender NP. Screening for invasive fungal disease using non-culture-based assays among inpatients with advanced HIV disease at a large academic hospital in South Africa. Mycoses 2020; 63:478-487. [PMID: 32125004 DOI: 10.1111/myc.13071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Despite widespread access to antiretroviral therapy (ART), the burden of advanced HIV disease in South Africa is high. This translates into an increased risk of AIDS-related opportunistic infections, including invasive mycoses. METHODS Using a limited number of non-culture-based diagnostic assays, we aimed to determine the prevalence of invasive mycoses and tuberculosis among hospitalised adults with very advanced HIV (CD4 counts < 100 cells/µL) at a large academic hospital. We conducted interviews and prospective medical chart reviews. We performed point-of-care finger stick and serum cryptococcal antigen lateral flow assays; serum (1 → 3) ß-D-glucan assays; urine Histoplasma galactomannan antigen enzyme immunoassays and TB lipoarabinomannan assays. RESULTS We enrolled 189 participants from 5280 screened inpatients. Fifty-eight per cent were female, with median age 37 years (IQR: 30-43) and median CD4 count 32 cells/µL (IQR: 13-63). At enrolment, 60% (109/181) were receiving ART. Twenty-one participants (11%) had a diagnosis of an invasive mycosis, of whom 53% (11/21) had cryptococcal disease. Thirteen participants (7%) had tuberculosis and a concurrent invasive mycosis. ART-experienced participants were 60% less likely to have an invasive mycosis than those ART-naïve (adjusted OR: 0.4; 95% CI 0.15-1.0; P = .03). Overall in-hospital mortality was 13% (invasive mycosis: 10% [95% CI 1.2-30.7] versus other diagnoses: 13% (95% CI 8.4-19.3)). CONCLUSIONS One in ten participants had evidence of an invasive mycosis. Diagnosis of proven invasive fungal disease and differentiation from other opportunistic infections was challenging. More fungal-specific screening and diagnostic tests should be applied to inpatients with advanced HIV disease.
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Affiliation(s)
- Erika van Schalkwyk
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Mabatho Mhlanga
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Tsidiso G Maphanga
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Ruth S Mpembe
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Amanda Shillubane
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Samantha Iyaloo
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ernest Tsotetsi
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kim Pieton
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Alan S Karstaedt
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faieza Sahid
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Colin N Menezes
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Merika Tsitsi
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ayanda Motau
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Dermatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Jeannette Wadula
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Sharona Seetharam
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Eunice van den Berg
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Charlotte Sriruttan
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Ashraf N, Kubat RC, Poplin V, Adenis AA, Denning DW, Wright L, McCotter O, Schwartz IS, Jackson BR, Chiller T, Bahr NC. Re-drawing the Maps for Endemic Mycoses. Mycopathologia 2020; 185:843-865. [PMID: 32040709 PMCID: PMC7416457 DOI: 10.1007/s11046-020-00431-2] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 01/24/2020] [Indexed: 01/19/2023]
Abstract
Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within specific geographic areas of known endemicity. However, over the past few decades, there have been increasingly frequent reports of infections due to endemic fungi in areas previously thought to be “non-endemic.” There are numerous potential reasons for this shift such as increased use of immune suppressive medications, improved diagnostic tests, increased disease recognition, and global factors such as migration, increased travel, and climate change. Regardless of the causes, it has become evident that our previous understanding of endemic regions for these fungal diseases needs to evolve. The epidemiology of the newly described Emergomyces is incomplete; our understanding of it continues to evolve. This review will focus on the evidence underlying the established areas of endemicity for these mycoses as well as new data and reports from medical literature that support the re-thinking these geographic boundaries. Updating the endemic fungi maps would inform clinical practice and global surveillance of these diseases.
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Affiliation(s)
- Nida Ashraf
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Ryan C Kubat
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Victoria Poplin
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Antoine A Adenis
- Centre d'Investigation Clinique Antilles-Guyane, Inserm 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - David W Denning
- Faculty of Biology, Medicine, and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Laura Wright
- Geographic Research Analysis and Services Program, Division of Toxicology and Human Health Services, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Orion McCotter
- Mycotic Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Brendan R Jackson
- Mycotic Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Tom Chiller
- Mycotic Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Nathan C Bahr
- Division of Infectious Diseases, Department of Internal Medicine, University of Kansas, Kansas City, KS, USA.
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13
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Rooms I, Mugisha P, Gambichler T, Hadaschik E, Esser S, Rath PM, Haase G, Wilmes D, McCormick-Smith I, Rickerts V. Disseminated Emergomycosis in a Person with HIV Infection, Uganda. Emerg Infect Dis 2020; 25:1750-1751. [PMID: 31441766 PMCID: PMC6711225 DOI: 10.3201/eid2509.181234] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We describe emergomycosis in a patient in Uganda with HIV infection. We tested a formalin-fixed, paraffin-embedded skin biopsy to identify Emergomyces pasteurianus or a closely related pathogen by sequencing broad-range fungal PCR amplicons. Results suggest that emergomycosis is more widespread and genetically diverse than previously documented. PCR on tissue blocks may help clarify emergomycosis epidemiology.
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14
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Disseminated Emergomyces pasteurianus Infection in India: A Case Report and a Review. Mycopathologia 2019; 185:193-200. [PMID: 31659677 DOI: 10.1007/s11046-019-00387-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 09/21/2019] [Indexed: 12/28/2022]
Abstract
We report here a case of disseminated Emergomyces pasteurianus infection from India in a patient with AIDS. The patient presented with weight loss, dyspnoea and multiple non-tender skin lesions over face, neck and chest over 3 months. The case was diagnosed by microscopy, histopathology of sample and isolation of fungus from skin lesion, breast nodule, bone marrow and sputum. The identification of the isolates was confirmed by sequencing internal transcribed spacer region of rDNA, beta-tubulin, actin and intein PRP8. The patient responded well to intravenous amphotericin B deoxycholate followed by itraconazole therapy.
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15
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Emerging Fungal Infections: New Patients, New Patterns, and New Pathogens. J Fungi (Basel) 2019; 5:jof5030067. [PMID: 31330862 PMCID: PMC6787706 DOI: 10.3390/jof5030067] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/13/2023] Open
Abstract
The landscape of clinical mycology is constantly changing. New therapies for malignant and autoimmune diseases have led to new risk factors for unusual mycoses. Invasive candidiasis is increasingly caused by non-albicans Candida spp., including C. auris, a multidrug-resistant yeast with the potential for nosocomial transmission that has rapidly spread globally. The use of mould-active antifungal prophylaxis in patients with cancer or transplantation has decreased the incidence of invasive fungal disease, but shifted the balance of mould disease in these patients to those from non-fumigatus Aspergillus species, Mucorales, and Scedosporium/Lomentospora spp. The agricultural application of triazole pesticides has driven an emergence of azole-resistant A. fumigatus in environmental and clinical isolates. The widespread use of topical antifungals with corticosteroids in India has resulted in Trichophyton mentagrophytes causing recalcitrant dermatophytosis. New dimorphic fungal pathogens have emerged, including Emergomyces, which cause disseminated mycoses globally, primarily in HIV infected patients, and Blastomyceshelicus and B. percursus, causes of atypical blastomycosis in western parts of North America and in Africa, respectively. In North America, regions of geographic risk for coccidioidomycosis, histoplasmosis, and blastomycosis have expanded, possibly related to climate change. In Brazil, zoonotic sporotrichosis caused by Sporothrix brasiliensis has emerged as an important disease of felines and people.
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16
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Schwartz IS, Sanche S, Wiederhold NP, Patterson TF, Sigler L. Emergomyces canadensis, a Dimorphic Fungus Causing Fatal Systemic Human Disease in North America. Emerg Infect Dis 2019; 24:758-761. [PMID: 29553321 PMCID: PMC5875289 DOI: 10.3201/eid2404.171765] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
We report 4 patients in North America with disease caused by Emergomyces canadensis, a newly proposed species of pathogenic dimorphic fungus. Affected persons were immunocompromised; lived in Saskatchewan, Colorado, and New Mexico; and had systemic disease involving blood, skin, cervix, lung, and lymph node. Two cases were fatal.
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17
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Warnock DW. Name Changes for Fungi of Medical Importance, 2016-2017. J Clin Microbiol 2019; 57:e01183-18. [PMID: 30257904 PMCID: PMC6355541 DOI: 10.1128/jcm.01183-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/18/2018] [Indexed: 11/20/2022] Open
Abstract
This article lists proposed new or revised species names and classification changes associated with fungi of medical importance that were published in the years 2016 and 2017. While many of the revised names listed have been widely adopted without further discussion, some may take longer to achieve more general usage.
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18
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Abstract
Purpose of Review This review highlights some of the recent concerning emerging infectious diseases, a number of them specifically that the World Health Organization has categorized as priorities for research. Recent Findings Emerging and reemerging infectious diseases account for significant losses in not only human life, but also financially. There are a number of contributing factors, most commonly surrounding human behavior, that lead to disease emergence. Zoonoses are the most common type of infection, specifically from viral pathogens. The most recent emerging diseases in the USA are Emergomyces canadensis, the Heartland virus, and the Bourbon virus. Summary In addition to the aforementioned pathogens, the Severe Acute Respiratory Syndrome, Middle East Respiratory Syndrome, Nipah virus, New Delhi metallo-ß-lactamase-1 Enterobacteriaceae, Rift Valley Fever virus, and Crimean-Congo Hemorrhagic Fever virus are reviewed. These pathogens are very concerning with a high risk for potential epidemic, ultimately causing both significant mortality and financial costs. Research should be focused on monitoring, prevention, and treatment of these diseases.
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Affiliation(s)
- Kevin Watkins
- Cleveland Clinic Foundation, Akron General Medical Center, 1 Akron General Avenue, Akron, OH 44307 USA
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