Spectrum of in vivo and in vitro cell-mediated immune responses in coccidioidomycosis

Valley fever: danger lurking in a dust cloud

Coccidioides immitis and Coccidioides posadasii contribute to the development of Valley Fever. The ability of these fungal pathogens to evade the host immune system creates difficulty in recognition and treatment of this debilitating infection. In this review, we describe the current knowledge of Valley Fever and approaches to improve prevention, detection, and treatment.

Coccidioidomycosis: a review and update

Coccidioidomycosis occurs in arid and semi-arid regions of the New World from the western United States to Argentina. Highly endemic areas are present in the southwest United States. Coccidioides species live in the soil and produce pulmonary infection via airborne arthroconidia. The skin may be involved by dissemination of the infection, or by reactive eruptions, such as a generalized exanthem or erythema nodosum. Interstitial granulomatous dermatitis and Sweet's syndrome have recently been recognized as additional reactive signs of the infection. Coccidioidomycosis is a "great imitator" with protean manifestations. Cutaneous findings may be helpful clues in the diagnosis of this increasingly important disease.

Coccidioidomycosis: host response and vaccine development

Coccidioidomycosis is caused by the dimorphic fungi in the genus Coccidioides. These fungi live as mycelia in the soil of desert areas of the American Southwest, and when the infectious spores, the arthroconidia, are inhaled, they convert into the parasitic spherule/endospore phase. Most infections are mild, but these organisms are frank pathogens and can cause severe lethal disease in fully immunocompetent individuals. While there is increased risk of disseminated disease in certain racial groups and immunocompromised persons, the fact that there are hosts who contain the initial infection and exhibit long-term immunity to reinfection supports the hypothesis that a vaccine against these pathogens is feasible. Multiple studies have shown that protective immunity against primary disease is associated with T-helper 1 (Th-1)-associated immune responses. The single best vaccine in animal models, formalin-killed spherules (FKS), was tested in a human trial but was not found to be significantly protective. This result has prompted studies to better define immunodominant Coccidioides antigen with the thought that a subunit vaccine would be protective. These efforts have defined multiple candidates, but the single best individual immunogen is the protein termed antigen 2/proline-rich antigen (Ag2/PRA). Studies in multiple laboratories have shown that Ag2/PRA as both protein and genetic vaccines provides significant protection against mice challenged systemically with Coccidioides. Unfortunately, compared to the FKS vaccine, it is significantly less protective as measured by both assays of reduction in fungal CFU and assays of survival. The capacity of Ag2/PRA to induce only partial protection was emphasized when animals were challenged intranasally. Thus, there is a need to define new candidates to create a multivalent vaccine to increase the effectiveness of Ag2/PRA. Efforts of genomic screening using expression library immunization or bioinformatic approaches to identify new candidates have revealed at least two new protective proteins, expression library immunization antigen 1 (ELI-Ag1) and a beta-1,3-glucanosyltransferase (GEL-1). In addition, previously discovered antigens such as Coccidioides-specific antigen (CSA) should be evaluated in assays of protection. While studies have yet to be completed with combinations of the current candidates, the hypothesis is that with increased numbers of candidates in a multivalent vaccine, there will be increased protection. As the genome sequences of the two Coccidioides strains which are under way are completed and annotated, the effort to find new candidates can increase to provide a complete genomic scan for immunodominant proteins. Thus, much progress has been made in the discovery of subunit vaccine candidates against Coccidioides and there are several candidates showing modest levels of protection, but for complete protection against pulmonary challenge we need to continue the search for additional candidates.

In vitro whole-blood analysis of cellular immunity in patients with active coccidioidomycosis by using the antigen preparation T27K

Measurement of cellular immunity in human coccidioidomycosis has important diagnostic and prognostic implications. The coccidioidin skin test has been the standard for the measurement of this, but it is not available in the United States. We examined the utility of measuring surface expression of CD69 on T lymphocytes in whole blood incubated with the coccidioidal antigen preparation T27K as an alternative to the skin test. Seventy donors with active coccidioidomycosis were studied. The mean fluorescent intensity (MFI) of CD69 expression on CD3 lymphocytes in response to T27K was 28.61 +/- 1.77, significantly greater than the control response of 11.45 +/- 0.78 (P < 0.001). The MFI CD69 response to T27K above that for the control (MFI CD69 above control) was 6.35 +/- 2.18 for seven subjects with disseminated coccidioidomycosis who were studied within 5 months of diagnosis. This was significantly below the value of 20.17 +/- 3.17 for 18 subjects with pulmonary coccidioidomycosis studied within 5 months of diagnosis and the value of 19.58 +/- 2.91 for 27 subjects with disseminated coccidioidomycosis studied after 5 months of diagnosis (for both, P < 0.05). There was an inverse correlation between coccidioidal clinical score and MFI CD69 above control for all 34 subjects with disseminated coccidioidomycosis (r = 0.362; P = 0.036) but not for the 36 subjects with pulmonary disease (r < 0.001; P = 0.993). Among 30 subjects for whom data were available, there was a highly significant association between the MFI CD69 above control and the supernatant concentrations of gamma interferon, interleukin-2 (IL-2), and tumor necrosis factor alpha (for all, P < 0.001), but not for IL-4, IL-5, or IL-10. These data indicate that in vitro assessment of CD69 expression on T lymphocytes by using T27K may be a useful measure of cellular immune response among subjects with active coccidioidomycosis.

Role of signal sequence in vaccine-induced protection against experimental coccidioidomycosis

The vaccine efficacy of the gene sequence encoding the signal peptide of the antigen known as antigen 2 or proline-rich antigen (Ag2/PRA), an immunodominant antigen present in the cell wall of the fungal pathogen Coccidioides immitis, was investigated in a murine model of coccidioidomycosis. Expression plasmids for Ag2/PRA(1-18) DNA (signal sequence), Ag2/PRA(19-194) DNA (lacking the signal sequence), and Ag2/PRA(1-194) DNA (full length) were inserted in the pVR1012 vector, and the constructs were used to vaccinate the highly susceptible BALB/c mouse strain. Immunization with the signal gene sequence significantly reduced the fungal burden in the lungs and spleens of mice 12 days after intraperitoneal challenge with a lethal dose of 2,500 C. immitis arthroconidia, to a level comparable to the protection induced in mice immunized with the full-length Ag2/PRA(1-194) DNA. The Ag2/PRA(19-194) gene protected mice but to a significantly lower level than the signal sequence or the full-length Ag2 gene. The immunizing capacity of Ag2/PRA(1-18) was not attributable to a nonspecific immunostimulatory effect of DNA, as evidenced by the fact that mice immunized with a frameshift mutation of Ag2/PRA(1-18) were not protected against challenge. Furthermore, a synthetic peptide corresponding to the translated sequence of Ag2/PRA(1-18) DNA protected mice, albeit at a lower level than the Ag2/PRA(1-18) DNA vaccine. The protection induced with the signal gene vaccine correlated with the production of gamma interferon when splenocytes from Ag2/PRA(1-18)-immunized mice were stimulated with recombinant full-length Ag2 and was not associated with the production of anti-Coccidioides immunoglobulin G antibody. This is the first study to establish that a signal peptide sequence alone, administered as a gene vaccine or synthetic peptide, can induce protective immunity against a microbial pathogen.

Coadministration of interleukin 12 expression vector with antigen 2 cDNA enhances induction of protective immunity against Coccidioides immitis

Interleukin 12 (IL-12) plays an important role in the induction of protective immunity against cancer and infectious diseases. In this study we asked whether IL-12 cDNA could increase the protective capacity of the antigen 2 (Ag2) gene vaccine in experimental coccidioidomycosis. Coimmunization of BALB/c mice with a single-chain IL-12 cDNA (p40-L-p35) and Ag2 cDNA, both subcloned into the pVR1012 plasmid, significantly enhanced protection against systemic challenge with 2,500 arthroconidia, as evidenced by a greater-than-1.3-log-unit reduction in the fungal load in the lungs and spleens compared to mice receiving the pVR1012 vector alone, Ag2 cDNA alone, or IL-12 cDNA alone. The enhanced protection was associated with increased gamma interferon secretion; production of immunoglobulin G2a (IgG2a), IgG2b, and IgG3 antibodies to Coccidioides immitis antigen; and the influx of CD4(+) and CD8(+) T cells in lungs and spleens. When challenged by the pulmonary route, mice covaccinated with Ag2 cDNA and IL-12 cDNA were not protected at the lung level but did show a significant reduction in the fungal load in their livers and spleens compared to mice vaccinated with Ag2 cDNA or IL-12 cDNA alone. These results suggest that IL-12 acts as a therapeutic adjuvant to enhance Ag2 cDNA-induced protective immunity against experimental coccidioidomycosis through the induction of Th1-associated immune responses.

Construction of a single-chain interleukin-12-expressing retroviral vector and its application in cytokine gene therapy against experimental coccidioidomycosis

T-cell-mediated immunity is an important determinant in protection against primary infection with Coccidioides immitis, a dimorphic fungal pathogen that causes the disease coccidioidomycosis. To determine if interleukin-12 (IL-12) gene therapy could potentiate host response against C. immitis, we constructed a single-chain cDNA encoding the p40 and p35 subunits linked by a polylinker and, using a retroviral vector, transfected J774 macrophages with the construct. The transduced J774 cells expressed IL-12 in vitro, with a mean concentration of 28,440 pg from 10(6) cells in 48 h as measured by an IL-12 (p75)-specific enzyme-linked immunosorbent assay. The secreted IL-12 was biologically active, as judged by its ability to induce the production of gamma interferon (IFN-gamma) by spleen cells from BALB/c mice. Treatment of the highly susceptible BALB/c mouse strain with the IL-12-transduced J774 cells inhibited C. immitis growth in tissues from mice challenged by a pulmonary route, as evidenced by 1.37-, 2.59-, and 1.22-log reductions in the number of CFU in the lungs, spleens, and livers, respectively, compared to the fungal load in mice given vector-transduced J774 cells. The protective effect of IL-12 gene therapy was accompanied by increased levels of IFN-gamma in the lungs and sera of mice treated with IL-12-transduced J774 cells and the constitutive production of IFN-gamma by their spleen cells cultured in vitro. These results suggest that IL-12 gene therapy could be used as adjunct therapy for coccidioidomycosis.

Genetic vaccination against Coccidioides immitis: comparison of vaccine efficacy of recombinant antigen 2 and antigen 2 cDNA

Previous studies from our laboratory established that C-ASWS, an alkali-soluble, water-soluble extract from cell walls of Coccidioides immitis, protects mice against lethal challenge with this fungus. The C-ASWS extract contains a glycosylated protein, designated antigen 2 (Ag2), and a polysaccharide antigen. We recently cloned Ag2 cDNA and showed that the recombinant fusion protein elicited strong delayed-type hypersensitivity responses in immunized mice. This investigation was undertaken to determine if the recombinant Ag2 protein, expressed as an Ag2-glutathione S-transferase (GST) fusion protein, or Ag2 cDNA would protect mice against lethal challenge with C. immitis. The recombinant Ag2-GST protein protected BALB/c mice against intraperitoneal challenge with 250 arthroconidia, as assessed by a decrease in fungal CFU in tissues. The Ag2-GST-immunized mice did not show, however, an increased survival during a 30-day period postinfection. By contrast, immunization of mice with Ag2 cDNA ligated into the pVR1012 plasmid engendered protection against intraperitoneal challenge with 2,500 arthroconidia and against pulmonary challenge with 50 arthroconidia. Vaccine efficacy paralleled the development of delayed-type hypersensitivity responses to C. immitis antigen. Whereas mice vaccinated with the recombinant Ag2-GST protein did not mount footpad hypersensitivity to C-ASWS or the recombinant Ag2-GST protein, mice vaccinated with the pVR1012-Ag2 construct mounted a strong footpad hypersensitivity and their spleen cells secreted gamma interferon upon in vitro stimulation with the Ag2-containing C-ASWS extract. This is the first investigation to show that genetic immunization can protect against lethal challenge with C. immitis.

Protection against lethal murine coccidioidomycosis by a soluble vaccine from spherules

The formaldehyde-killed, whole-spherule vaccine, which is protective against lethal challenge of laboratory animals with Coccidioides immitis, was fractionated. It yielded a soluble, multicomponent, subcellular fraction termed the 27K vaccine. This vaccine, when it was accompanied by adjuvant, protected mice against lethal intranasal and intravenous challenge with C. immitis.

In vitro modulation of proliferation and cytokine production by human peripheral blood mononuclear cells from subjects with various forms of coccidioidomycosis

Using peripheral blood mononuclear cells (PBMC) from individuals with or without coccidioidal delayed-type hypersensitivity (DTH), we examined and attempted to modulate the in vitro responses of PBMC from various donors to the coccidioidal antigen toluene spherule lysate (TSL). Among healthy DTH-positive donors, 100 ng of human recombinant interleukin-10 (IL-10) per ml suppressed both PBMC proliferation (P = 0.01) and gamma interferon (IFN-gamma) and IL-12 production (for both, P < 0.05). In vitro proliferation and production of IFN-gamma and IL-12 by PBMC were significantly higher in DTH-positive donors with active coccidioidomycosis than in healthy, nonimmune controls (P < 0.05) but not in active DTH-negative donors with or without human immunodeficiency virus infection (for both, P > 0.05). Human recombinant IL-12 increased IFN-gamma production by PBMC from active, DTH-positive donors (P = 0.01) but not by PBMC from DTH-negative groups. For healthy DTH-positive donors, the median antigen-reactive cell frequency per 10(5) PBMC was 3.7, compared to 1.7 in DTH-negative donors with active coccidioidomycosis (P = 0.03). These data indicate that the in vitro TSL response is highly dependent on coccidioidal DTH. Not only do PBMC from individuals with DTH appear to respond to TSL, but their response can be modulated in vitro with either IL-10 or IL-12. On the other hand, PBMC from DTH-negative individuals do not respond in vitro to TSL and their response is not modulable, suggesting a lack of antigen response.

Molecular cloning and characterization of Coccidioides immitis antigen 2 cDNA

Previous experiments have provided evidence that Coccidioides immitis antigen 2 (Ag2) is a major T-cell-reactive component of mycelia and spherule cell walls. Here we report the identification and cloning of the cDNA that encodes Ag2 from a lambda ZAP cDNA expression library constructed from spherule-derived RNA. DNA sequence analysis established that the 1,255-bp clone contains a 174-bp 5' untranslated region, a 582-bp open reading frame which encodes for a protein consisting of 194 amino acids, and a 375-bp 3' untranslated region, including a poly(A) tail. The recombinant Ag2 protein has a predicted molecular mass of 19.5 kDa and contains an 18-amino-acid N terminus which has been tentatively identified as a signal peptide. The Ag2 cDNA was ligated into the pGEX-4T-3 vector and expressed in Escherichia coli TG-1 cells as a glutathione S-transferase fusion protein. The recombinant fusion protein showed reactivity with sera from patients with coccidioidomycosis and elicited delayed-type footpad hypersensitivity responses in Coccidioides-immune mice. These results suggest that the Ag2 cDNA can be used for the large-scale production of this immunologically important protein.

Roles of gamma interferon and interleukin-4 in genetically determined resistance to Coccidioides immitis

The profiles of gamma interferon (IFN-gamma) and interleukin-4 (IL-4) production were evaluated during the course of coccidioidomycosis in two inbred mouse strains which differ in their susceptibility to Coccidioides immitis. Cytokine responses, measured at the molecular and protein levels, showed increased levels of IFN-gamma in lung extracts from mice of the resistant DBA/2 strain after a pulmonary challenge, whereas the susceptible BALB/c strain manifested a predominant IL-4 response. The importance of these cytokines in host defense against C. immitis was established by treating the mice with recombinant cytokines or neutralizing anticytokine monoclonal antibodies. Treatment of the susceptible BALB/c mice with recombinant murine IFN-gamma significantly protected mice against systemic challenge, and in the reciprocal experiment, the administration of an anti-IFN-gamma monoclonal antibody to the resistant DBA/2 mice significantly decreased their capacity to control disease. Although the treatment of DBA/2 mice with recombinant IL-4 did not alter the disease, neutralization of endogenous IL-4 in infected BALB/c mice by administration of a neutralizing anti-IL-4 antibody led to a significant reduction in the fungal load in their tissues. These results, taken together, establish that IFN-gamma plays a pivotal role in resistance to C. immitis, whereas IL-4 down-regulates protective immunity against C. immitis.

Production of a murine monoclonal antibody that recognizes an epitope specific to Coccidioides immitis antigen 2

Antigen 2 (Ag2) has been implicated as a T-cell-reactive component of the pathogenic fungus Coccidioides immitis. We report the production of a murine monoclonal antibody (MAb) of the immunoglobulin G2a isotype that recognizes an epitope specific to C. immitis Ag2. This specificity was evidenced by the finding that the MAb did not recognize other antigens present in coccidioidin or spherulin and did not show reactivity with antigenic extracts from Histoplasma capsulatum or Blastomyces dermatitidis. The epitope was labile to enzymatic digestion with pronase but resistant to treatment with glycolytic enzymes and to periodate oxidation. This peptide epitope appears to require conformational structure on the basis that it was not recognized by the MAb in immunoblots of antigen that had been electrophoresed in polyacrylamide gels under denaturing, reducing conditions. Immunoaffinity chromatography of spherulin on columns containing the MAb established that the MAb was effective as a ligand for isolating Ag2 from heterogeneous extracts. The production of a MAb which recognizes an Ag2-specific epitope and its utility as a ligand for isolating Ag2 will provide a valuable reagent for studies of this immunologically important antigen.

Experimental coccidioidomycosis in the immunosuppressed rat

C. immitis inoculated rats are known to develop infection restricted to lung whereas cyclophosphamide (CY) treatment leads to widespread dissemination with considerable mortality. In this study, an attempt was made to elucidate the mechanisms involved in such behaviour. With this aim, spleen cells were transferred from infected CY-treated to infected untreated rats, achieving significant specific inhibition in footpad swelling to coccidioidin in recipients, attributable to a suppressor T cell subpopulation induced by greater fungal antigen concentration arising from widespread C. immitis dissemination in immunosuppressed animals. NK activity proved similar regardless of CY treatment. Lastly, chronically infected rats presented increased colony forming units count after several weekly doses of CY, as happens in immunosuppressed patients harbouring a previous infection.

An immunoreactive apoglycoprotein purified from Coccidioides immitis

Deglycosylation of glycoproteins in a lysate of spherules of Coccidioides immitis has permitted purification and partial characterization of a proline-rich pronase-sensitive antigen. Moreover, soluble antigen specifically stimulated lymphocytes from persons with dermal delayed-type hypersensitivity to coccidioidal antigens. When related to reference coccidioidin by tandem two-dimensional immunoelectrophoresis, the antigen fused in the anodal region with a specific reference antigen (antigen 2). It did not show identity with coccidioidal antigens used in conventional serologic assays. Although immunoblots of the purified protein with monospecific rabbit antiserum showed a single antigen at 33 kDa, the parent spherule lysate bound the same antibody in a broad band between 70 and greater than 200 kDa, which could be explained by microheterogeneity of glycosylation. Immunoelectron microscopy using affinity-purified human antibodies localized the antigen to the cell wall and internal septa of spherules. These findings suggest that the apoglycoprotein may be important in human immune responses to coccidioidal infection.

Coccidioidomycosis

Coccidioidomycosis is a largely self-limited fungal respiratory illness. However, the infrequent case of progressive or disseminated disease can be devastating. As international travel to and from endemic areas increases, physicians unfamiliar with the disease may be called upon to recognize and treat serious coccidioidal infections. The major risk factors for dissemination are race and immunosuppression. The most common sites of dissemination are the skin, lymph nodes, bone and meninges. Diagnosis is aided by investigation of the patient's clinical history, delayed-type hypersensitivity skin test reaction, serologic testing, and recovery of organisms from infected tissue or secretions for direct examination and culture. Fungicidal agents are not available, fortunately, fungistatic therapy allows many patients to recover. The availability of both intravenous/intrathecal and oral agents now allows more therapeutic flexibility in the treatment of this disease.

Suppression of T-lymphocyte response by Coccidioides immitis antigen

Intravenous injection of BALB/c mice with coccidioidin or an alkali-soluble cell wall extract of Coccidioides immitis mycelia resulted in the induction of a splenic cell population(s) that suppressed delayed-type hypersensitivity response to coccidioidal antigen. To determine whether the levels of C. immitis antigen produced during the course of active coccidioidal disease might also cause suppression of T-lymphocyte response, BALB/c mice were infected by intranasal instillation of arthroconidia, and 2 weeks later, their sera were evaluated for suppression of T-lymphocyte response in syngeneic recipients. Intravenous transfer of sera, which were shown to contain high levels of coccidioidal antigen by an enzyme-linked immunoadsorbent assay, suppressed the delayed-type hypersensitivity response of recipients to immunization with coccidioidin. Solid-phase immunoadsorption of the sera with goat antibodies to C. immitis antigens removed the suppressive component(s). To determine whether the suppressive effect of circulating coccidioidal antigen(s) was associated with the activation of a splenic suppressor cell(s), as was observed in mice injected intravenously with coccidioidal antigen, spleen cell lysates were prepared from infected donors, and after filtration to remove viable fungi, the lysates were transferred to syngeneic mice. Recipients of lysates from infected but not noninfected donors were suppressed in their response to immunization with coccidioidin. Collectively, these results provide evidence that depressed T-cell responses observed in coccidioidomycosis are associated with, and may be attributable to, the activation of a suppressor cell or factor by circulating C. immitis antigens.

Induction and expression of cell-mediated immune responses in inbred mice infected with Coccidioides immitis

Comparisons of the course of coccidioidomycosis in two strains of inbred mice established that BALB/c mice are significantly more susceptible to pulmonary infection with Coccidioides immitis than are DBA/2 mice. The susceptibility of BALB/c mice does not reside in their inability to mount a delayed-type hypersensitivity response to C. immitis antigen. That is, BALB/c mice manifested footpad hypersensitivity to coccidioidin early during the course of disease, to a level comparable to that of DBA/2 mice. In contrast to the more resistant DBA/2 mouse strain, however, BALB/c mice developed anergy by day 15 postinfection. Suppression of the delayed-type hypersensitivity response was not specific for C. immitis antigen, as evidenced by the finding that BALB/c mice immunized with mycobacterial purified protein derivative prior to infection with C. immitis were suppressed in their footpad response to mycobacterial antigen at day 15 postinfection. Taken together, these results establish that genetically determined susceptibility to this fungus is associated with an acquired suppression of cell-mediated immune reactivity.

Serum-mediated suppression of lymphocyte transformation responses in coccidioidomycosis

Lymphocyte transformation (LT) responses to coccidioidin (CDN) and spherulin were suppressed in 11 (73%) of 15 patients with active coccidioidomycosis when their mononuclear cells were assayed in autologous serum as compared to serum from healthy, CDN skin test-positive subjects. Suppressed LT responses were specific for Coccidioides immitis antigens in 7 (64%) of the 11 patients. Immunoaffinity chromatography of patient sera with Staphylococcus protein A adsorbed the suppressor component(s) and thereby established that suppression was attributed to immunoglobulin G, either alone or complexed with antigen. The possibility that suppression was mediated by immune complexes was examined by adding complexes formed in vivo or in vitro to mononuclear cell cultures of healthy CDN-reactive persons before LT assays. Although complexes prepared in this manner were reactive in an enzyme-linked immunosorbent assay designed to detect Coccidioides antigen-specific immune complexes, no suppression of LT responses was observed. We conclude that serum-mediated suppression of LT responses in coccidioidomycosis is attributed to monomeric and not immune-complexed immunoglobulin G antibody.

Experimental coccidioidomycosis: effects of cyclophosphamide in immunologic responses

Rats were infected with Coccidioides immitis and injected with cyclophosphamide three days pre or post infection. Administration of the drug before the infection caused enhancement of DTH response and decrease of the colony forming units (CFU). Conversely, injection of the drug three days post infection produced contrary effects, indicating that a normal T-cell function is essential as a defense mechanism in C. immitis infection.

Antigenic heterogeneity of an alkali-soluble, water-soluble cell wall extract of Coccidioides immitis

The antigenic composition of an alkali-soluble, water-soluble cell wall extract of Coccidioides immitis, designated C-ASWS, was assessed by two-dimensional immunoelectrophoresis against goat antisera to C-ASWS and coccidioidin. The results established that C-ASWS from mycelia or spherule cell walls is heterogeneous in composition, containing two distinct antigenic components. One is present as a polymer that is antigenically identical to a polymeric antigen in coccidioidin, designated antigen 2. The other component detected in C-ASWS presented an unusual precipitin pattern in that a cathodal leg was demonstrable in the absence of an anodal leg. This incomplete precipitinogen was also detected in coccidioidin. In addition to the finding that C-ASWS is antigenically heterogeneous, the results provide evidence that the conformational and/or configurational structure of the C-ASWS antigen 2 (or antigen 2-like polymer) is altered during physicochemical extraction. This conclusion is based upon the finding that the immunoelectrophoretic profile of the C-ASWS polymer differs from that of coccidioidin antigen 2. The C-ASWS polymer is characterized by having a small cathodal precipitin peak connected to a large anodal peak, whereas coccidioidin antigen 2 is characterized by a predominant cathodal peak.

Immunoadjuvant activity of amphotericin B as displayed in mice infected with Candida albicans

Mice receiving a single intraperitoneal injection of amphotericin B showed increased resistance to subsequent challenge with either Candida albicans or Staphylococcus aureus. This enhancement of resistance was obvious in terms of both survival criteria and clearance of the intravenously injected organism from different organs. The protective effect of amphotericin B was conditioned by dose, time of drug administration, and size of yeast or bacterial inoculum and was reversed by cyclophosphamide. Effector cells from mice treated with amphotericin B displayed enhanced fungicidal activity in vitro as measured in a short-term 51Cr release assay. Macrophages from intact animals exposed in vitro to amphotericin B also acquired strong candidacidal reactivity.

Systemic Coccidioides immitis infection in nude and beige mice

The course of experimental systemic Coccidioides immitis infection was assessed quantitatively and histologically in beige mice, congenitally athymic nude mice, and their respective normal counterparts. After intravenous inoculation with 50 arthroconidia, the number of viable C. immitis cultured from the spleens, livers, and lungs progressively increased throughout the assay in the organs of all mice. During the first 2 weeks of infection, significantly greater numbers of CFU were recovered from the spleens and livers, but not the lungs, of nude mice than from the respective organs of their phenotypically normal littermates. Significantly greater numbers of CFU were cultured from the lungs and spleens of beige mice compared with the number recovered from their functionally normal littermates. After intranasal inoculation, extrapulmonary dissemination of C. immitis occurred at an equal rate and resulted in similar organ burdens in nude mice and their normal littermates. Histological examination of infected tissues revealed a characteristic mixed inflammatory cell infiltrate in euthymic mice; the response in nude mice was less severe, consisting predominantly, if not solely, of granulocytes. In addition, in tissue sections from nude mice, but not in those from their euthymic counterparts, mature spherules were frequently observed to be devoid of an associated inflammatory response. The inflammatory lesion in beige mice contained a predominance of mononuclear cells, whereas their littermates responded with a typical mixed granulomatous infiltrate. Collectively, these results provide evidence supporting the hypothesis that resistance to C. immitis infection involves two primary cell populations, one under the direct influence of T-cells and the other independent of T-lymphocytes.

Reactivity of alkali-soluble, water-soluble cell wall antigen of Coccidioides immitis with anti-Coccidioides immunoglobulin M precipitin antibody

The alkali-soluble, water-soluble cell wall antigen of Coccidioides immitis (C-ASWS) mycelia and spherules was shown to react with anti-Coccidioides immunoglobulin M (IgM) precipitin antibody, both in the classical tube precipitin test and in the immunodiffusion assay for tube precipitin antibody (IDTP). The reactions obtained between C-ASWS and reference IgM precipitin antibody were identical to the reaction obtained when reference coccidioidin (CDN) was used. Definitive proof that C-ASWS extracts contain antigenic determinants that are reactive with IgM tube precipitin antibody was obtained by solid-phase immunoadsorption. Elution of reference IDTP antiserum over a column containing mycelium C-ASWS coupled to Sepharose 4B completely adsorbed precipitin antibody; i.e., reactivity in the IDTP was demonstrable in the column eluate but not in the column effluent fraction. The antigenic composition of C-ASWS extracts was evaluated and compared with that of CDN by two-dimensional immunoelectrophoresis against burro anti-CDN. The results established that both mycelium and spherule C-ASWS contain antigenic determinants in common with only one antigen present in CDN. The latter, designated antigen 2, is a large polymer which is predominant among the antigenic components in CDN. On a dry weight comparison, antigen 2 determinants were most concentrated in spherule C-ASWS, followed by mycelium C-ASWS and reference IDTP antigen. The finding that C-ASWS extracts are reactive with IgM tube precipitin antibody and are antigenically identical to antigen 2 in CDN suggests that antigen 2 is the biologically active component of CDN in tube precipitin assays.

Suppression of in vitro lymphocyte DNA synthesis by killed Pseudomonas aeruginosa

Whole antibiotic-killed classic Pseudomonas aeruginosa organisms elicited human lymphocyte [3H]thymidine (TdR) uptake in vitro after 5 days in culture. However, high concentrations of the same preparation did not elicit [3H]TdR incorporation. The investigation of this lymphocyte unresponsiveness revealed that a high dose of P. aeruginosa, when added to lymphocyte cultures together with optimal concentrations of lymphocyte activators (e.g., plant lectins or whole killed Staphylococcus aureus Cowan 1), caused a potent, nonspecifically expressed inhibition of lymphocyte [3H]TdR uptake in response to these mitogens. High doses of P. aeruginosa were not cytotoxic to lymphocytes, and the inhibition caused was reversed when lymphocytes were washed free of bacteria. The inhibition of [3H]TdR uptake by high-dose P. aeruginosa did not require the generation of adherent suppressor cells or prostaglandin-mediated, steroid-sensitive or radiation-sensitive suppressor mechanisms. At optimal lymphocyte stimulatory concentrations of P. aeruginosa, the addition of indomethacin or the depletion of adherent cells caused an increase in lymphocyte [3H]TdR incorporation. This is consistent with an adherent-cell population regulating [3H]TdR uptake in response to P. aeruginosa via a prostaglandin-dependent pathway. This population was not involved in the inhibition of lymphocyte [3H]TdR uptake by high concentrations of P. aeruginosa.

Specificity of immunoglobulin E in coccidioidomycosis and correlation with disease involvement

Serum immunoglobulin E (IgE) antibodies were quantitated in 26 patients with active pulmonary coccidioidomycosis, 59 patients with active disseminated disease, 12 patients in clinical remission, and 91 healthy subjects. Significant differences were obtained in IgE serum levels of patients with active disease versus healthy subjects (P less than 0.0001). Patients with pulmonary coccidioidomycosis did not differ in their IgE levels when compared with patients with disseminated disease. However, serum IgE levels were significantly increased in patients with disease involving two or more organ systems when compared with patients with pulmonary disease or extrapulmonary disease involving a single organ system (P less than 0.02). Total serum IgE correlated with anti-Coccidioides IgE (P less than 0.001), but with only six exceptions, patients with anti-Coccidioides IgE also exhibited IgE antibodies to 1 or more of 12 common allergens. The correlation between hyperproduction of IgE and disease severity coupled with the depressed cell-mediated immune status of patients with this disease suggests a defect(s) in the T-lymphocyte population which functions to regulate IgE synthesis.

Course of coccidioidomycosis in intratracheally infected guinea pigs

Two hundred Hartley-inbred guinea pigs were infected intratracheally with 50 viable arthrospores of Coccidioides immitis. At weeks 1 through 10 postinfection, groups of 20 guinea pigs were assayed for skin test, macrophage migration inhibitory factor (MIF), and lymphocyte transformation (LT) responses to coccidioidin. Forty-eight hours after skin testing and just before MIF and LT assays, blood was obtained for complement-fixing (CF) antibody titers and the animals were autopsied to assess the extent of fungal dissemination. Immunological assays established that skin tests and MIF responses converted within 3 weeks of infection. LT responses were not demonstrable until week 5. Dissemination of C. immitis to the liver or spleen was an early event, with 21% of guinea pigs positive by week 2 and 70% positive by week 5. CF antibody titers were demonstrable at week 5, increased logarithmically through week 7, then increased at a slower rate thereafter. Concomitant with the decreased rate of antibody production, guinea pigs began to clear C. immitis from their extrapulmonary tissues. Skin test responses peaked at 6 weeks postinfection when CF antibody titers were less than or equal to 1:16 and then plateaued with increased CF titers. Although this overall immunological profile is consistent with the disease in humans, there was not a direct correlation between CF antibody titer and dissemination to the liver or spleen, nor was there an inverse correlation between CF antibody titers and skin test or MIF responses. Rather, CF antibody titers and cell-mediated immune responses were equally demonstrable in guinea pigs with disseminated or nondisseminated disease.

Circulating immune complexes in coccidioidomycosis. Detection and characterization

Estrogen-receptor-positive breast tumors are treated with anti-estrogen (AE) therapies but frequently develop resistance. Cancer stem cells (CSCs) with high aldehyde dehydrogenase activity (ALDH⁺ cells) are enriched following AE treatment. Here, we show that the interleukin-1β (IL-1β) signaling pathway is activated in ALDH⁺ cells, and data from single cells reveals that AE treatment selects for IL-1 receptor (IL1R1)-expressing ALDH⁺ cells. Importantly, CSC activity is reduced by an IL1R1 inhibitor in AE-resistant models. Moreover, IL1R1 expression is increased in the tumors of patients treated with AE therapy and predicts treatment failure. Single-cell gene expression analysis revealed that at least two subpopulations exist within the ALDH⁺ population, one proliferative and one quiescent. Following AE therapy the quiescent population is expanded, which suggests CSC dormancy as an adaptive strategy that facilitates treatment resistance. Targeting of ALDH⁺IL1R1⁺ cells merits testing as a strategy to combat AE resistance in patients with residual disease.

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Anti-estrogen-resistant ALDH⁺ cells have increased CSC activity in ER⁺ tumors

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The IL1R1-expressing ALDH⁺ CSC population expands after anti-estrogen treatment

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IL1R1 expression predicts anti-estrogen treatment failure

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Targeting of ALDH⁺IL1R1⁺ cells reverses anti-estrogen resistance

Circulating immune complexes in coccidioidomycosis. Detection and characterization

Sera of 22 patients with active and 13 with inactive coccidioidomycosis, as well as 15 healthy subjects who were skin-test positive to coccidioidin and 39 healthy subjects who were coccidioidin skin-test negative, were assayed for immune complexes. Circulating immune complexes were measured by the Clq-binding assay, the Clq-solid phase assay, the monoclonal rheumatoid factor inhibition assay, and the monoclonal rheumatoid factor solid phase assay. An increased concentration of circulating immune complexes was detected in 73% of those with active disease by at least one assay compared with 13% of the healthy controls. Significantly increased levels of immune complexes were detected in sera of patients with active coccidioidomycosis by the Clq-binding assay (P < 0.001), the Clq-solid phase assay (P < 0.001), the monoclonal rheumatoid factor inhibition assay (P < 0.005), and the monoclonal rheumatoid solid phase assay (P < 0.05) compared with the results obtained in the 54 healthy subjects. In contrast, those with inactive disease did not show significantly increased concentrations of circulating immune complexes. Sucrose density gradient ultracentrifugation of patients' sera established that the immune complexes were of intermediate size, sedimenting between the 6.6S and 19S markers. Immune complexes were shown to contain both coccidioidin antigen and anticoccidioidin antibody. In addition, a radioimmunoassay was developed to quantitate coccidioidin antigen-containing immune complexes. The latter assay proved highly sensitive in detecting immune complexes in patients with active coccidioidomycosis.

Withdrawal of immunosuppresive agents in the treatment of disseminated coccidioidomycosis

Disseminated coccidioidomycosis is a systemic fungal infection that causes high mortality in the renal transplatn patient. Cell-mediated immunity, which appears to be the relevant host defense mechanism, is impaired by the immunosupressive agents used to prevent allograft rejection. In the case presented, immunosuppressive therapy was stopped as an adjunct to treatment of this infection. The patient has shown evidence of improvement, and his allograft has continued to function nine months after the withdrawal of immunosuppressive therapy and 18 months after the diagnosis. In vitro lymphocyte function studies indicate that the impairment in cell-mediated immunity detected prior to withdrawal of immunosuppressive therapy has persisted, probably accounting for allograft survival. Withdrawal of immunosuppressive therapy may prolong survival in renal transplant patients with disseminated coccidioidomycosis. Additionally, depression in cell-mediated immunity associated with the fungal infection itself may be sufficient to prevent allograft rejection in these patients.

Amphotericin B and 5-fluorocytosine: in vitro effects on lymphocyte function

The effects of amphotericin B, 5-fluorocytosine, and the combination of both drugs on lymphocyte function in vitro were investigated. Amphotericin B, alone or in combination with 5-fluorocytosine, significantly suppressed both spontaneous lymphocyte transformation and the response of lymphocytes to stimulation with streptokinase-streptodornase. 5-Fluorocytosine had no effect on spontaneous or antigen-induced transformation. Lymphocyte responses to the mitogens phytohemagglutinin and concanavalin A were not changed by exposure to amphotericin B, 5-fluorocytosine, or the combination of both drugs. T-lymphocyte receptors for sheep erythrocytes and B-lymphocyte surface immunoglobulin and receptors for complement were not changed by treatment with amphotericin B or 5-fluorocytosine.

Antigenic analysis of coccidioidin and spherulin determined by two-dimensional immunoelectrophoresis

Immunological tests are valuable aids for diagnosis of mycotic infections and, in some cases, as objective guides for clinical management and prognosis. The usefulness of these procedures is limited to the extents that crude antigen preparations are employed, that these are difficult to standardize uniformly, and that they contain antigens common to several species of pathogenic fungi. Analysis by two-dimensional immunoelectrophoresis methods of the two crude preparations used for coccidioidomycosis demonstrated that coccidioidin contained at least 26 antigens, with 10 of these found also in spherulin. In addition, spherulin contained two antigens not demonstrated in coccidioidin. No single test detected all antigens present, and multiple procedures were required to display the complete array of antigens. A reference system was established for coccidioidin and precipitated immunoglobulins from a burro hyperimmunized with coccidioidin. Evaluation of the reference system demonstrated that it was highly reproducible with respect to the reagents used, to repeated tests by the same person, and to comparative tests by two individuals using the same reagents. Applications of this reference system for standardization of reagents, for detecting common antigens, for monitoring successive steps during fractionation of crude preparations, and for fingerprinting strains for ecological and epidemiological studies are presented.

Use of an alkali-soluble water-soluble extract of Blastomyces dermatitidis yeast-phase cell walls and isoelectrically focused components in peripheral lymphocyte transformations

An alkali-soluble water-soluble extract of Blastomyces dermatitidis yeast-phase cell walls was tested for its ability to elicit a response in lymphocytes isolated from the peripheral blood of Blastomyces-infected guinea pigs. Sequential preparations of the antigen were reproducible and specific in the in vitro lymphocyte transformation assay. Cross-reactivity of the antigen was not evident in lymphocyte transformation assays on lymphocytes obtained from Histoplasma-infected guinea pigs or from animals sensitized with complete Freund adjuvant. Fractionation of the antigen was accomplished on an isoelectric-focusing column, using a sucrose density gradient support. Components were assayed for activity in skin testing and lymphocyte transformation. Comparison of column fractions to the whole antigen showed greater response to the whole antigen in in vivo and in vitro assays.