Aspergillosis: diagnosis and treatment

Role of the osaA Gene in Aspergillus fumigatus Development, Secondary Metabolism and Virulence

Aspergillus fumigatus is the leading cause of aspergillosis, associated with high mortality rates, particularly in immunocompromised individuals. In search of novel genetic targets against aspergillosis, we studied the WOPR transcription factor OsaA. The deletion of the osaA gene resulted in colony growth reduction. Conidiation is also influenced by osaA; both osaA deletion and overexpression resulted in a decrease in spore production. Wild-type expression levels of osaA are necessary for the expression of the conidiation regulatory genes brlA, abaA, and wetA. In addition, osaA is necessary for normal cell wall integrity. Furthermore, the deletion of osaA resulted in a reduction in the ability of A. fumigatus to adhere to surfaces, decreased thermotolerance, as well as increased sensitivity to oxidative stress. Metabolomics analysis indicated that osaA deletion or overexpression led to alterations in the production of multiple secondary metabolites, including gliotoxin. This was accompanied by changes in the expression of genes in the corresponding secondary metabolite gene clusters. These effects could be, at least in part, due to the observed reduction in the expression levels of the veA and laeA global regulators when the osaA locus was altered. Importantly, our study shows that osaA is indispensable for virulence in both neutropenic and corticosteroid-immunosuppressed mouse models.

An Unexpected Endobronchial Mass Appearing During Bronchoscopy

A 60-year-old man was admitted to the hospital with productive cough and yellowish sputum, severe fatigue, and weight loss of 4 kg over the past month; furthermore, he reported a slowly progressive shortness of breath on exertion over the past 6 months. Before admission, he received ampicillin/sulbactam (750 mg) orally twice daily for 7 days without significant clinical improvement.

Assessment Techniques to Detect Aspergillus fumigatus in Different Samples of Immunosuppressed Male Western Albino Rats

Background:

There are several conventional, immunological and molecular techniques to diagnose the fungi that cause aspergillosis in biological samples; these methods have some advantages and disadvantages.

Objectives:

The current study aimed to evaluate different methods used in identification and diagnosis of fungi causing aspergillosis.

Materials and Methods:

Male Western Albino rats were provided by Animal Care Unit at Faculty of Pharmacy, King Saud University. After adaptation for a reasonable period, rat's immunity was debilitated by injection of cyclophosphamide (i.p.); the infection was induced by injecting (i.v.) the prepared suspension of Aspergillus fumigatus spores. Blood samples, lung tissue, lung fluid smears and nasal fluid smears were obtained during the periods before and after injection. Isolation of fungus was carried out by synthetic media; and macro- and micro-characteristics were studied to identify the fungus. Enzyme-linked immunesorbent (ELISA) and LightCycler-based PCR was employed to check the existence of the fungus in blood samples.

Results:

The results indicated that all methods were unable to diagnose the A. fumigatus on the following day of infection except ELISA method; however, culturing methods varied according to the type of vital samples where lung tissue and lung fluid smears were the best. Moreover, more than half of the samples used in the culturing techniques had negative results. The highest rate of the cases diagnosed by ELISA and polymerase chain reaction (PCR) was recorded during the second week following the infection, and then it declined gradually till the end of the experiment. The molecular methods showed high efficiency followed by ELISA.

Conclusions:

It could be concluded that the best methods to identify A. fumigatus were molecular methods; however, the early diagnosis requires the enzymatic-immunological methods (ELISA). The current study recommends the integration among all possible techniques whenever the facilities are available. But when only microbiological methods are used, samples should be collected from different organs of the infected hosts.

Antifungal and Antioxidant Activities of the Essential Oil from Angelica koreana Nakai

Purpose. The purpose of this study is to determine the antifungal and antioxidant activities of the essential oil from Angelica koreana. Methods. Essential oil was obtained from the dried roots of A. koreana by steam distillation, and its composition was identified by gas chromatography and mass spectrometry (GC-MS). The minimal inhibitory concentrations (MICs) of the oil fraction and its main components were determined by broth dilution assay using common pathogenic Aspergillus and Trichophyton species. The combined effects of the oils with itraconazole were evaluated using a checkerboard titer test. In addition, 1,1-diphenyl-2-picryl-hydrazil (DPPH) free radical scavenging, nitrite inhibition, and reducing power were determined to assess the antioxidant activity of this oil. Results. The essential oil fraction and its main components showed inhibitory activity against all of the tested fungi, with minimal inhibitory concentrations (MICs) of 250–1000 μg/mL. Furthermore, this oil exhibited synergism when combined with itraconazole. Conclusion. In the treatment of infections caused by Aspergillus and Trichophyton species, combining itraconazole with either A. koreana essential oil or its main components may reduce the minimum effective dose of itraconazole required and, thus, minimize its side effects. In addition, this oil is a promising source of natural antioxidant agents.

Exposure of Aspergillus fumigatus to caspofungin results in the release, and de novo biosynthesis, of gliotoxin

Caspofungin is a member of the echinocandin class of antifungal agents that inhibit the synthesis of β 1,3 glucan thus disrupting fungal cell wall structure and function. Exposure of the Aspergillus fumigatus cultures to caspofungin (0.01, 0.1 or 1.0 μg/ml) resulted in a reduction in cell growth, but the production of the epipolythiodioxopiperazine toxin, gliotoxin, was comparable, or greater, in cultures exposed to caspofungin than untreated controls. Exposure of A. fumigatus hyphae to 1.0 μg/ml caspofungin for 4 h resulted in the release of amino acids (P = 0.01), protein (P = 0.002) and gliotoxin (P = 0.02). Cultures of A. fumigatus incubated in the presence of caspofungin for 4 or 24 h demonstrated enhanced gliotoxin release (P = 0.04 and 0.03, respectively) and biosynthesis (P = 0.04 and 0.03, respectively) compared to that by control cultures. The results presented here indicate that exposure of A. fumigatus to caspofungin results in increased cell permeability and an increase in the synthesis and release of gliotoxin. Since gliotoxin has well established immunosuppressive properties it is possible that exposure of A. fumigatus to caspofungin may potentiate the production of this toxin at the site of infection. Elevated gliotoxin biosynthesis may be an attempt by the fungus to restore the redox balance of the cell following exposure to the antifungal agent but the overall effect appears to be enhanced synthesis and release.

Health effects of Aspergillus in food and air

This review summarizes the health aspects of the medically important fungal genus Aspergillus. The morphology and systematics of the genus are explained as well as its biogeography. Major mycotoxins, the aspergilli that produce them, affected crops, and symptoms of the toxicoses are summarized, as are the major mycoses caused by aspergilli. The current status of the relationship between Aspergillus in the indoor environment and health issues are discussed.

Pathogenesis of Aspergillus fumigatus in Invasive Aspergillosis

Aspergillus species are globally ubiquitous saprophytes found in a variety of ecological niches. Almost 200 species of aspergilli have been identified, less than 20 of which are known to cause human disease. Among them, Aspergillus fumigatus is the most prevalent and is largely responsible for the increased incidence of invasive aspergillosis (IA) in the immunocompromised patient population. IA is a devastating illness, with mortality rates in some patient groups reaching as high as 90%. Studies identifying and assessing the roles of specific factors of A. fumigatus that contribute to the pathogenesis of IA have traditionally focused on single-gene deletion and mutant characterization. In combination with recent large-scale approaches analyzing global fungal responses to distinct environmental or host conditions, these studies have identified many factors that contribute to the overall pathogenic potential of A. fumigatus. Here, we provide an overview of the significant findings regarding A. fumigatus pathogenesis as it pertains to invasive disease.

Rapid detection and quantification of Aspergillus fumigatus in environmental air samples using solid-phase cytometry

Aspergillus fumigatus is an ubiquitous fungus capable of causing severe infections such as aspergilloma, allergic bronchopulmonary aspergillosis, and invasive aspergillosis, especially in immunocompromised patients. Monitoring the number of Aspergillus fumigatus spores in the air is crucial for infection control. In the present study, a novel approach for the quantification of Aspergillus fumigatus, based on solid-phase cytometry (SPC) and immunofluorescent labeling, was developed. The sensitivity and specificity of the assay were confirmed by testing pure cultures. Paecilomyces variotii and Rhizopus stolonifer were codetected but could be excluded on the basis of morphology of the microcolonies. The SPC method has considerable advantages compared to the culture-based method, including its low detection limit (4 cells/m3), its speed (results are obtained within 24 h), and the straightforward microscopic identification of Aspergillus fumigatus. Additionally, comparison of results obtained with both methods demonstrated that they are equally accurate for the quantification of Aspergillus fumigatus in environmental air samples.

Aspergillosis of a dog genital tract-Case report

The information about aspergillosis locations in the reproductive organ is scarce. This short paper deals with aspergillosis in the dog genital tract with hyphae present in semen. There are two therapy schemes used in visceral mycoses, non-invasive treatment and surgical intervention. Considering the future reproductive career of the dog, we decided on antifungal drugs administration. Based on the microbiological results, we administered amoxycillin with clavulonate (Synulox 500mg, twice daily) orally. Itraconazole was used as an antimycological agent (Orungal, 100mg, twice daily) every other week. In 8th week of therapy no Aspergillus spp. growth was noted, yet slight Penicillium growth was observed. After 12 weeks of treatment, no fungus growth was present. Neither spores or hyphae were seen in the microscopic examination. Three months after the termination of the therapy, the dog mated with two females. In one case, unifetal pregnancy was diagnosed by ultrasound examination on day 42 after mating. Due to purulent discharge on day 45 after mating, the owner decided to terminate the pregnancy. In the other case, severe pyometra appeared 12 days after the second mating and the owner decided to put the female to sleep. The pathogen eradication from the ejaculates may be treated as a serious success, yet the lack of litters after mating calls for an explanation and consequences of Aspergillus spp. infection need to be considered.

Amphotericin B enhances the synthesis and release of the immunosuppressive agent gliotoxin from the pulmonary pathogen Aspergillus fumigatus

Exposure of the pulmonary pathogen Aspergillus fumigatus to amphotericin B alters membrane permeability as indicated by the escape of amino acids and protein from the mycelium. Amphotericin B exposure for periods of 2-4 h also leads to increased release of the immunosuppressive agent gliotoxin into the surrounding culture medium. Examination of the intracellular gliotoxin concentration following exposure to amphotericin B indicated elevated levels within the hyphae as well as in the culture medium--an effect which was also evident upon exposure of A. fumigatus to DMSO. These results indicate that in parallel with the ability of amphotericin B to act as a fungistatic agent it can also induce the synthesis of gliotoxin and facilitate its release by increasing the permeability of the fungal cell membrane. Increased synthesis of gliotoxin may result from the commencement of secondary metabolism in the presence of amphotericin B. The ability of amphotericin B to enhance the synthesis and release of gliotoxin may exacerbate the effects of the toxin and facilitate fungal invasion of pulmonary tissue.

Detection of Aspergillus fumigatus mycotoxins: immunogen synthesis and immunoassay development

Immunological detection of secreted low molecular weight toxins represents a potentially novel means of diagnosing infection by the fungus Aspergillus fumigatus. Two such metabolites, gliotoxin and helvolic acid, were selected and conjugated to thyroglobulin for antisera generation in rabbits. Gliotoxin was initially activated using N-[p-maleimidophenyl] isocyanate (PMPI) and subsequently conjugated to S-acetyl thioglycolic acid N-hydroxysuccinimide-activated thyroglobulin, whereas helvolic acid was activated with N-(3-Dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) in the presence of thyroglobulin prior to immunisation. To facilitate subsequent antisera evaluation, both toxins were similarly conjugated to bovine serum albumin (BSA). Matrix-Assisted Laser Desorption Ionisation-Time Of Flight (MALDI-TOF) mass spectrometry and SDS-PAGE analysis confirmed covalent attachment of toxins to BSA in the ratios of 15 and 2.4 mol per mol BSA for gliotoxin and helvolic acid, respectively. Resultant high titer antisera were capable of detecting both BSA-conjugated toxins (inhibitory concentration (IC)(50): 4-5 microg/ml). Free toxins were also detectable by competitive immunoassay, whereby 10 microg/ml free gliotoxin (30 microM) and helvolic acid (17 microM), respectively, inhibited antibody binding to cognate toxin-BSA previously immobilised on microwells. This work confirms that sensitive and specific antisera can be raised against fungal toxins and may have an application in diagnosing fungal infection.

Immobilization of Aspergillus fumigatus colonies in a soft agar matrix allows visualization of A549 cell detachment and death

A model to examine the effects of proliferating Aspergillus fumigatus ATCC 26933 colonies embedded in a thin layer of soft agar on a monolayer of A549 cells was developed and enabled an investigation of the response of cultured cells to fungal growth. This model simulates the conditions on the respiratory surface in patients with invasive aspergillosis and also in the mucus secretions of cystic fibrosis patients with allergic bronchopulmonary aspergillosis. Conidia of A. fumigatus adhering to A549 cells were immobilized in a thin layer of soft agar (0.6% (w/v)) and allowed to germinate at 37 degrees C. Fungal colonies greater than 5 mm in diameter caused rounding-up and detachment of A549 cells underneath the colony and towards the hyphal tips. As the fungal colony diameter increased, cell detachment occurred ahead of the hyphal tips. Cells detached for short periods (less than 6 h) showed no annexin-V (AV) or propidium iodide (PI) staining, suggesting no externalization of phosphatidylserine and an intact plasma membrane. Cells that had detached for periods greater than 6 h were positive for AV and PI indicating the rupture of the plasma membrane and cell death by necrosis. Chemical extraction and separation by thin layer chromatography of agar from zones of cell detachment around fungal colonies revealed the presence of three compounds that may play a role in inducing cell death.

Effect of itraconazole on the pharmacokinetics of prednisolone and methylprednisolone and cortisol secretion in healthy subjects

AIMS

Itraconazole is a potent inhibitor of CYP3A4 activity and is often used in combination with corticosteroids. Since the latter are partly metabolized by CYP3A4, we studied the interaction between itraconazole, prednisone and methylprednisolone in healthy male subjects.

METHODS

The effects of 4 days administration of oral itraconazole (400 mg on the first day then 200 mg day-1 for 3 days) on the pharmacokinetics of prednisolone after a single oral dose of prednisone (60 mg) and the pharmacokinetics of methylprednisolone after single oral dose of methylprednisolone (48 mg) were studied in 14 healthy male subjects in a two-period cross-over trial. Plasma cortisol concentrations were determined as a pharmacodynamic index.

RESULTS

Itraconazole increased the mean area under the methylprednisolone concentration-time curve from 2773 ng ml-1 h to 7011 ng ml-1 h (P < 0.001) and the elimination half-life from 3.2 h to 5.5 h (P < 0.001). The pharmacokinetics of prednisolone were unchanged. Cortisol concentrations at 24 h were lower after administration of methylprednisolone with itraconazole than after methylprednisolone alone (24 ng ml-1 vs 109 ng ml-1, P < 0.001).

CONCLUSIONS

Itraconazole increased methylprednisolone concentrations markedly with enhanced suppression of endogenous cortisol secretion, but had no effect on prednisolone pharmacokinetics. The pharmacokinetic interaction between methylprednisolone and itraconazole is probably related to inhibition of hepatic CYP3A4 activity by itraconazole.

Low incidence of candidaemia among neutropenic patients treated for haematological diseases

Candida colonization and haematogenous infection were studied retrospectively in 277 patients with haematological diseases by reviewing the microbiological reports of fungal surveillance and blood cultures over a 4-year period. Most patients (83%) were colonized by Candida and in the majority (68%) the same Candida species was isolated from at least 2 body sites. However, candidaemia was diagnosed in only 3 patients. During the same period invasive aspergillosis was diagnosed in 7 patients. Possible causes for the low incidence of candidaemia were fluconazole prophylaxis, empirical amphotericin B and strict indication for antibacterial therapy.