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Peçanha-Pietrobom PM, Tirado-Sánchez A, Gonçalves SS, Bonifaz A, Colombo AL. Diagnosis and Treatment of Pulmonary Coccidioidomycosis and Paracoccidioidomycosis. J Fungi (Basel) 2023; 9:218. [PMID: 36836333 PMCID: PMC9959547 DOI: 10.3390/jof9020218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Coccidioidomycosis (CM) and paracoccidioidomycosis (PCM) are systemic mycoses that are highly endemic in Latin America and have recently been included on the World Health Organization (WHO) Fungal Priority Pathogens List. Coccidioides immitis and Coccidioides posadasii are recognized as etiological agents of CM, with peculiarities in their geographic distribution. The genus Paracoccidioides now includes Paracoccidioides lutzii and the Paracoccidioides brasiliensis complex, which encompasses four phylogenetic species. In both diseases, pulmonary signs and symptoms are the main reasons for patients to seek medical assistance, and they are frequently misdiagnosed as tuberculosis. In this paper, we present a critical view of the strategies for diagnosis and clinical management of CM and PCM. Over the past few decades, there has been an increase in the number of reports of endemic fungal infections in areas previously thought to be "non-endemic" due to climate change and increased travel, among other factors. Learning to recognize their main epidemiological aspects and clinical manifestations is crucial so that clinicians can include them in the differential diagnosis of lung disease and avoid late diagnosis.
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Affiliation(s)
| | - Andrés Tirado-Sánchez
- Dermatology Service & Mycology Department, Hospital General de México, “Dr. Eduardo Liceaga”, Mexico City 06726, Mexico
- Internal Medicine Department, Hospital General de Zona 29, Instituto Mexicano del Seguro Social, Mexico City 07950, Mexico
| | - Sarah Santos Gonçalves
- Department of Pathology, Infectious Diseases Postgraduate Program, Federal University of Espírito Santo (UFES), Vitoria 29043900, Brazil
| | - Alexandro Bonifaz
- Internal Medicine Department, Hospital General de Zona 29, Instituto Mexicano del Seguro Social, Mexico City 07950, Mexico
| | - Arnaldo Lopes Colombo
- Department of Medicine, Division of Infectious Diseases, Federal University of São Paulo (UNIFESP), São Paulo 04039032, Brazil
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Paracoccidioidomycosis: What We Know and What Is New in Epidemiology, Diagnosis, and Treatment. J Fungi (Basel) 2022; 8:jof8101098. [PMID: 36294662 PMCID: PMC9605487 DOI: 10.3390/jof8101098] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Paracoccidioidomycosis (PCM) is a systemic mycosis endemic to Latin America caused by thermodimorphic fungi of the genus Paracoccidioides. In the last two decades, enhanced understanding of the phylogenetic species concept and molecular variations has led to changes in this genus’ taxonomic classification. Although the impact of the new species on clinical presentation and treatment remains unclear, they can influence diagnosis when serological methods are employed. Further, although the infection is usually acquired in rural areas, the symptoms may manifest years or decades later when the patient might be living in the city or even in another country outside the endemic region. Brazil accounts for 80% of PCM cases worldwide, and its incidence is rising in the northern part of the country (Amazon region), owing to new settlements and deforestation, whereas it is decreasing in the south, owing to agriculture mechanization and urbanization. Clusters of the acute/subacute form are also emerging in areas with major human intervention and climate change. Advances in diagnostic methods (molecular and immunological techniques and biomarkers) remain scarce, and even the reference center’s diagnostics are based mainly on direct microscopic examination. Classical imaging findings in the lungs include interstitial bilateral infiltrates, and eventually, enlargement or calcification of adrenals and intraparenchymal central nervous system lesions are also present. Besides itraconazole, cotrimoxazole, and amphotericin B, new azoles may be an alternative when the previous ones are not tolerated, although few studies have investigated their use in treating PCM.
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Resende VQ, Reis-Goes KH, Finato AC, de Fátima Almeida-Donanzam D, dos Santos AR, Perico J, Amorim BC, Venturini J. Combined Silymarin and Cotrimoxazole Therapy Attenuates Pulmonary Fibrosis in Experimental Paracoccidioidomycosis. J Fungi (Basel) 2022; 8:jof8101010. [PMID: 36294575 PMCID: PMC9605613 DOI: 10.3390/jof8101010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/18/2022] Open
Abstract
Paracoccidioidomycosis (PCM), which mainly affects rural workers, is a systemic mycosis caused by the Paracoccidioides genus that induces pulmonary sequelae in most adult patients, causing serious disability and impairing their quality of life. Silymarin is herbal medicine with an effective antifibrotic activity. Considering that in PCM, antifibrotic treatment is still not available in pulmonary fibrosis, we aimed to evaluate combined silymarin and cotrimoxazole (CMX) therapy via the intratracheal route in BALB/c mice infected with P. brasiliensis yeast. After 12 weeks of treatment, the lungs were collected for the determination of fungal burden, production of OH-proline, deposition of collagen fibers, pulmonary concentrations of cytokines, and expression of fibronectin, α-SMA, MMP-2, MMP-9, and TIMP-2. Spleen cell cultures were also performed. Our results showed that infected mice treated with combined silymarin/CMX showed lower deposition of collagen fibers in the lungs and lower pulmonary concentrations of hydroxyproline than the placebo groups. Decreased levels of TGF-β1 and fibronectin and high levels of MMP-2 and IFN-γ were also observed in this group of mice. Collectively, our findings indicate that the combination of antifungal treatment with silymarin has a potent antifibrotic effect associated with an immunomodulatory effect that potentializes the antifungal immune response.
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Affiliation(s)
| | - Karoline Hagata Reis-Goes
- Faculdade de Ciências, Universidade Estadual Paulista (UNESP), Bauru 17033-360, SP, Brazil
- Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Angela Carolina Finato
- Faculdade de Ciências, Universidade Estadual Paulista (UNESP), Bauru 17033-360, SP, Brazil
- Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | | | - Amanda Ribeiro dos Santos
- Faculdade de Medicina, Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande 79070-900, MS, Brazil
| | - Jonatas Perico
- Faculdade de Medicina, Universidade Estadual Paulista (UNESP), Botucatu 18618-970, SP, Brazil
| | - Barbara Casella Amorim
- Faculdade de Medicina, Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande 79070-900, MS, Brazil
| | - James Venturini
- Faculdade de Medicina, Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande 79070-900, MS, Brazil
- Correspondence: ; Tel.: +55-67-99101-1021
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Almeida Donanzam DDF, Donato TAG, Dos Reis KH, da Silva AP, Finato AC, Dos Santos AR, Cavalcante RS, Mendes RP, Venturini J. Exoantigens of Paracoccidioides spp. Promote Proliferation and Modulation of Human and Mouse Pulmonary Fibroblasts. Front Cell Infect Microbiol 2020; 10:590025. [PMID: 33194837 PMCID: PMC7662685 DOI: 10.3389/fcimb.2020.590025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/07/2020] [Indexed: 11/13/2022] Open
Abstract
Paracoccidioidomycosis (PCM) is a systemic granulomatous fungal infection caused by thermally dimorphic fungi of the genus Paracoccidioides. Endemic in Latin America, PCM presents with high incidence in Brazil, Colombia, and Venezuela, especially among rural workers. The main clinical types are acute/subacute (AF) form and chronic form (CF). Even after effective antifungal treatment, patients with CF usually present sequelae, such as pulmonary fibrosis. In general, pulmonary fibrosis is associated with dysregulation wound healing and abnormal fibroblast activation. Although fibrogenesis is recognized as an early process in PCM, its mechanisms remain unknown. In the current study, we addressed the role of Paracoccidioides spp. exoantigens in pulmonary fibroblast proliferation and responsiveness. Human pulmonary fibroblasts (MRC-5) and pulmonary fibroblasts isolated from BALB/c mice were cultivated with 2.5, 5, 10, 100, and 250 µg/ml of exoantigens produced from P. brasiliensis (Pb18 and Pb326) and P. lutzii (Pb01, Pb8334, and Pb66) isolates. Purified gp43, the immunodominant protein of P. brasiliensis exoantigens, was also evaluated at concentrations of 5 and 10 µg/ml. After 24 h, proliferation and production of cytokines and growth factors by pulmonary fibroblasts were evaluated. Each exoantigen concentration promoted a different level of interference of the pulmonary fibroblasts. In general, exoantigens induced significant proliferation of both murine and human pulmonary fibroblasts (p < 0.05). All concentrations of exoantigens promoted decreased levels of IL-6 (p < 0.05) and VEGF (p < 0.05) in murine fibroblasts. Interestingly, decreased levels of bFGF (p < 0.05) and increased levels of TGF-β1 (p < 0.05) and pro-collagen I (p < 0.05) were observed in human fibroblasts. The gp43 protein induced increased TGF-β1 production by human cells (p = 0.02). In conclusion, our findings showed for the first time that components of P. brasiliensis and P. lutzii interfered in fibrogenesis by directly acting on the biology of pulmonary fibroblasts.
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Affiliation(s)
- Débora de Fátima Almeida Donanzam
- Faculdade de Medicina, Universidade Federal do Mato Grosso do Sul, Campo Grande, Brazil.,Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | | | - Karoline Haghata Dos Reis
- Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - Adriely Primo da Silva
- Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - Angela Carolina Finato
- Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - Amanda Ribeiro Dos Santos
- Faculdade de Medicina, Universidade Federal do Mato Grosso do Sul, Campo Grande, Brazil.,Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - Ricardo Souza Cavalcante
- Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - Rinaldo Poncio Mendes
- Faculdade de Medicina, Universidade Federal do Mato Grosso do Sul, Campo Grande, Brazil.,Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
| | - James Venturini
- Faculdade de Medicina, Universidade Federal do Mato Grosso do Sul, Campo Grande, Brazil.,Faculdade de Medicina, Departamento de Doenças Tropicais e Diagnóstico por Imagem, UNESP, Botucatu, Brazil
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The Therapy of Pulmonary Fibrosis in Paracoccidioidomycosis: What Are the New Experimental Approaches? J Fungi (Basel) 2020; 6:jof6040217. [PMID: 33050568 PMCID: PMC7712212 DOI: 10.3390/jof6040217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
Pulmonary fibrosis (PF) is considered the most important sequela developed in patients suffering from the chronic form of paracoccidioidomycosis (PCM), which leads to the loss of respiratory function in 50% of cases; this residual pulmonary abnormality is present even after antifungal treatment. To date, there is no effective treatment for PF. However, the use of antifungal drugs in combination with other antibiotics or immunomodulatory compounds, as well as biological therapies that include a monoclonal antibody specific to neutrophils, or prophylactic vaccination employing a recombinant antigen of Paracoccidioides brasiliensis that successfully attenuated PF, has been reported. Additionally, mesenchymal stem cell transplantation in combination with antifungal therapy slightly reduced the inflammatory response and profibrotic molecules induced by P. brasiliensis infection. In this review, I report experimental findings from several studies aiming to identify promising therapeutic strategies for treating PF developed in PCM.
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