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van de Sande WWJ, Fahal AH. An updated list of eumycetoma causative agents and their differences in grain formation and treatment response. Clin Microbiol Rev 2024; 37:e0003423. [PMID: 38690871 PMCID: PMC11237709 DOI: 10.1128/cmr.00034-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024] Open
Abstract
SUMMARYIn 2023, the World Health Organization designated eumycetoma causative agents as high-priority pathogens on its list of fungal priority pathogens. Despite this recognition, a comprehensive understanding of these causative agents is lacking, and potential variations in clinical manifestations or therapeutic responses remain unclear. In this review, 12,379 eumycetoma cases were reviewed. In total, 69 different fungal species were identified as causative agents. However, some were only identified once, and there was no supporting evidence that they were indeed present in the grain. Madurella mycetomatis was by far the most commonly reported fungal causative agent. In most studies, identification of the fungus at the species level was based on culture or histology, which was prone to misidentifications. The newly used molecular identification tools identified new causative agents. Clinically, no differences were reported in the appearance of the lesion, but variations in mycetoma grain formation and antifungal susceptibility were observed. Although attempts were made to explore the differences in clinical outcomes based on antifungal susceptibility, the lack of large clinical trials and the inclusion of surgery as standard treatment posed challenges in drawing definitive conclusions. Limited case series suggested that eumycetoma cases caused by Fusarium species were less responsive to treatment than those caused by Madurella mycetomatis. However, further research is imperative for a comprehensive understanding.
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Affiliation(s)
- Wendy W. J. van de Sande
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ahmed H. Fahal
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
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Pintye A, Bacsó R, Kovács GM. Trans-kingdom fungal pathogens infecting both plants and humans, and the problem of azole fungicide resistance. Front Microbiol 2024; 15:1354757. [PMID: 38410389 PMCID: PMC10896089 DOI: 10.3389/fmicb.2024.1354757] [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: 12/12/2023] [Accepted: 01/23/2024] [Indexed: 02/28/2024] Open
Abstract
Azole antifungals are abundantly used in the environment and play an important role in managing fungal diseases in clinics. Due to the widespread use, azole resistance is an emerging global problem for all applications in several fungal species, including trans-kingdom pathogens, capable of infecting plants and humans. Azoles used in agriculture and clinics share the mode of action and facilitating cross-resistance development. The extensive use of azoles in the environment, e.g., for plant protection and wood preservation, contributes to the spread of resistant populations and challenges using these antifungals in medical treatments. The target of azoles is the cytochrome p450 lanosterol 14-α demethylase encoded by the CYP51 (called also as ERG11 in the case of yeasts) gene. Resistance mechanisms involve mainly the mutations in the coding region in the CYP51 gene, resulting in the inadequate binding of azoles to the encoded Cyp51 protein, or mutations in the promoter region causing overexpression of the protein. The World Health Organization (WHO) has issued the first fungal priority pathogens list (FPPL) to raise awareness of the risk of fungal infections and the increasingly rapid spread of antifungal resistance. Here, we review the main issues about the azole antifungal resistance of trans-kingdom pathogenic fungi with the ability to cause serious human infections and included in the WHO FPPL. Methods for the identification of these species and detection of resistance are summarized, highlighting the importance of these issues to apply the proper treatment.
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Affiliation(s)
- Alexandra Pintye
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
- Department of Plant Anatomy, Institute of Biology, Eötvös Loránd University, Budapest, Hungary
| | - Renáta Bacsó
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
| | - Gábor M. Kovács
- Centre for Agricultural Research, Plant Protection Institute, HUN-REN, Budapest, Hungary
- Department of Plant Anatomy, Institute of Biology, Eötvös Loránd University, Budapest, Hungary
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Hashizume H, Taga S, Sakata MK, Hussein M, Siddig EE, Minamoto T, Fahal AH, Kaneko S. Environmental detection of eumycetoma pathogens using multiplex real-time PCR for soil DNA in Sennar State, Sudan. Trop Med Health 2023; 51:71. [PMID: 38115141 PMCID: PMC10729560 DOI: 10.1186/s41182-023-00563-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Mycetoma is a chronic disease affecting the skin and subcutaneous tissue endemic in the tropical and subtropical regions. Several bacteria and fungi can cause mycetoma, but fungal mycetoma (eumycetoma) is challenging because the treatment requires a combination of a long-term antifungal agent and surgery. Although the transmission route has not yet been elucidated, infection from the soil is a leading hypothesis. However, there are few soil investigation studies, and the geographical distribution of mycetoma pathogens is not well documented. Here, we used multiplex real-time PCR technology to identify three fungal species from soil samples. METHODS In total, 64 DNA samples were extracted from soil collected in seven villages in an endemic area in Sennar State, Sudan, in 2019. Primers and fluorescent probes specifically targeting the ribosomal DNA of Madurella mycetomatis, Falciformispora senegalensis, and F. tompkinsii were designed. RESULTS Multiplex real-time PCR was performed and identified the major pathogen, M. mycetomatis that existed in most sites (95%). In addition, two other pathogens were identified from some sites. This is the first report on the use of this technique for identifying the eumycetoma causative microorganisms. CONCLUSIONS This study demonstrated that soil DNA investigation can elucidate the risk area of mycetoma-causative agents. The results will contribute to the design of prevention measures, and further large-scale studies may be effective in understanding the natural habitats of mycetoma pathogens.
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Affiliation(s)
- Hiroki Hashizume
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
- Department of Ecoepidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
| | - Suguru Taga
- Department of Ecoepidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan
| | - Masayuki K Sakata
- Graduate School of Human Development and Environment, Kobe University, 3-11 Tsurukabuto, Nada-Ku, Kobe, 657-8501, Japan
- Research Faculty of Agriculture, Hokkaido University, Kita-9, Nishi-9, Kita-Ku, Sapporo, Hokkaido, 060-8589, Japan
| | - Mahmoud Hussein
- Mycetoma Research Center, University of Khartoum, P.O. Box 102, Khartoum, Sudan
- Tumors Therapy and Cancer Research Center, Molecular Biology Unit, Shendi University, P.O .Box 142-143, Shendi, Sudan
| | - Emmanuel Edwar Siddig
- Mycetoma Research Center, University of Khartoum, P.O. Box 102, Khartoum, Sudan
- Faculty of Medical Laboratory Sciences, Unit of Basic Medical Sciences, University of Khartoum, Khartoum, Sudan
| | - Toshifumi Minamoto
- Graduate School of Human Development and Environment, Kobe University, 3-11 Tsurukabuto, Nada-Ku, Kobe, 657-8501, Japan
| | - Ahmed Hassan Fahal
- Mycetoma Research Center, University of Khartoum, P.O. Box 102, Khartoum, Sudan
| | - Satoshi Kaneko
- School of Tropical Medicine and Global Health, Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan.
- Department of Ecoepidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki, 852-8523, Japan.
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Litvintseva AP, Bakhiet S, Gade L, Wagner DD, Bagal UR, Batra D, Norris E, Rishishwar L, Beer KD, Siddig EE, Mhmoud NA, Chow NA, Fahal A. Genomics and metagenomics of Madurella mycetomatis, a causative agent of black grain mycetoma in Sudan. PLoS Negl Trop Dis 2022; 16:e0010787. [PMID: 36322569 PMCID: PMC9629555 DOI: 10.1371/journal.pntd.0010787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 09/03/2022] [Indexed: 11/20/2022] Open
Abstract
Madurella mycetomatis is one of the main causative agents of mycetoma, a debilitating neglected tropical disease. Improved understanding of the genomic diversity of the fungal and bacterial causes of mycetoma is essential to advances in diagnosis and treatment. Here, we describe a high-quality genome assembly of M. mycetomatis and results of the whole genome sequence analysis of 26 isolates from Sudan. We demonstrate evidence of at least seven genetically diverse lineages and extreme clonality among isolates within these lineages. We also performed shotgun metagenomic analysis of DNA extracted from mycetoma grains and showed that M. mycetomatis reads were detected in all sequenced samples with the average of 11,317 reads (s.d. +/- 21,269) per sample. In addition, 10 (12%) of the 81 tested grain samples contained bacterial reads including Streptococcus sp., Staphylococcus sp. and others.
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Affiliation(s)
- Anastasia P. Litvintseva
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| | - Sahar Bakhiet
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
| | - Lalitha Gade
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Dhwani Batra
- Office of Advanced Molecular Detection, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Emily Norris
- Applied Bioinformatics Laboratory, Atlanta, Georgia, United States of America
| | - Lavanya Rishishwar
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia, United States of America
| | - Karlyn D. Beer
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Najwa Adam Mhmoud
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
| | - Nancy A. Chow
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ahmed Fahal
- The Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
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Hassan R, Cano J, Fronterre C, Bakhiet S, Fahal A, Deribe K, Newport M. Estimating the burden of mycetoma in Sudan for the period 1991-2018 using a model-based geostatistical approach. PLoS Negl Trop Dis 2022; 16:e0010795. [PMID: 36240229 PMCID: PMC9604875 DOI: 10.1371/journal.pntd.0010795] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/26/2022] [Accepted: 09/06/2022] [Indexed: 11/26/2022] Open
Abstract
Mycetoma is widespread in tropical and subtropical regions favouring arid areas with low humidity and a short rainy season. Sudan is one of the highly endemic countries for mycetoma. Estimating the population at risk and the number of cases is critical for delivering targeted and equitable prevention and treatment services. In this study, we have combined a large dataset of mycetoma cases recorded by the Mycetoma Research Centre (MRC) in Sudan over 28 years (1991-2018) with a collection of environmental and water and hygiene-related datasets in a geostatistical framework to produce estimates of the disease burden across the country. We developed geostatistical models to predict the number of cases of actinomycetoma and eumycetoma in areas considered environmentally suitable for the two mycetoma forms. Then used the raster dataset (gridded map) with the population estimates for 2020 to compute the potentially affected population since 1991. The geostatistical models confirmed this heterogeneous and distinct distribution of the estimated cases of eumycetoma and actinomycetoma across Sudan. For eumycetoma, these higher-risk areas were smaller and scattered across Al Jazirah, Khartoum, White Nile and Sennar states, while for actinomycetoma a higher risk for infection is shown across the rural districts of North and West Kurdufan. Nationally, we estimated 63,825 people (95%CI: 13,693 to 197,369) to have been suffering from mycetoma since 1991 in Sudan,51,541 people (95%CI: 9,893-166,073) with eumycetoma and 12,284 people (95%CI: 3,800-31,296) with actinomycetoma. In conclusion, the risk of mycetoma in Sudan is particularly high in certain restricted areas, but cases are ubiquitous across all states. Both prevention and treatment services are required to address the burden. Such work provides a guide for future control and prevention programs for mycetoma, highly endemic areas are clearly targeted, and resources are directed to areas with high demand.
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Affiliation(s)
- Rowa Hassan
- Mycetoma Research Centre, Soba University Hospital, University of Khartoum, Khartoum, Sudan
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
- * E-mail: ,
| | - Jorge Cano
- Expanded Special Project for Elimination of Neglected Tropical Diseases, WHO Regional Office for Africa, Brazzaville, Democratic Republic of the Congo
| | - Claudio Fronterre
- Centre for health informatics, computing, and statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Sahar Bakhiet
- Mycetoma Research Centre, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Ahmed Fahal
- Mycetoma Research Centre, Soba University Hospital, University of Khartoum, Khartoum, Sudan
| | - Kebede Deribe
- Children’s Investment Fund Foundation, Addis Ababa, Ethiopia
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Melanie Newport
- Centre for health informatics, computing, and statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
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Santona A, Mhmoud NA, Siddig EE, Deligios M, Fiamma M, Paglietti B, Bakhiet SM, Rubino S, Fahal AH. Metagenomic detection of eumycetoma causative agents from households of patients residing in two Sudanese endemic villages in White Nile State. PLoS Negl Trop Dis 2022; 16:e0010385. [PMID: 36040926 PMCID: PMC9467367 DOI: 10.1371/journal.pntd.0010385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/12/2022] [Accepted: 07/14/2022] [Indexed: 12/04/2022] Open
Abstract
Eumycetoma is a chronic debilitating fungal disease endemic to tropical and subtropical regions, with Sudan featuring the highest eumycetoma incidence. Among the 50 species of fungi most commonly associated with eumycetoma Madurella mycetomatis (M. mycetomatis) is often referenced as the most common pathogen. However, there is an enormous knowledge gap related to this neglected disease and its pathogenesis, epidemiological features, and host-specific factors that could contribute to either the host susceptibility and resistance. In this study, we were able to utilize a metagenomic approach and samples collected from clinical black grains (BG) and familiar household environments aimed to assay both the habitat of eumycetoma-associated fungi and its possible connection with eumycetoma patients living in two different eumycetoma endemic villages within the White Nile State of Sudan. DNA sequencing targeting the fungal ITS2 domain was performed on soil, animal dung, housing walls and roofs, and Acacia-species thorn samples and compared with culture-dependent methods of fungal isolation. Additionally, we compared the soil samples obtained in the endemic zone with that from non-endemic zones, including Wagga village in Kassala State and Port Sudan suburb in Port Sudan State. Overall, a total of 392 Amplicon Sequence Variants (ASVs) were detected by ITS2 metagenomics Eumycetoma causative organisms accounted for 10% of total ASVs which included 11 genera: Exserohilum (2%), Aspergillus (1.7%), Curvularia (1%), Alternaria (0.9%), Madurella (0.5%), Fusarium (0.4%), Cladosporium (0.2%) Exophiala (0.15%), and, in a lesser extent, Microascus (0.05%) Bipolaris and Acremonium (0.01%) for each. Only five genera were identified by culture method, which included Fusarium (29%), Aspergillus (28%), Alternaria (2.5%), Bipolaris (1.6%), and Chaetomium (0.8%). M. mycetomatis was detected within all the studied patients’ houses, accounting for 0.7% of total sequences. It was the first common eumycetoma-associated agent detected in soil samples and the third common in the dung and wall samples. In contrast, it was not detected in the roof or thorn samples nor in the soils from non-endemic regions. Exserohilum rostratum, Aspergillus spp and Cladosporium spp were detected in all samples. M. mycetomatis and other eumycetoma-associated fungal identified in the patients’ black grains (BG) samples by metagenomics were identified in the environmental samples. Only Acremonium alternatum and Falciformispora senegalensis, responsible for eumycetoma in two patients were not detected, suggesting the infections in these patients happened outside these endemic areas. The soil, animal dung, and houses built from the same soil and dung are the main risk factors for M. mycetomatis infection in these endemic villages. Furthermore, the poor hygienic and environmental conditions, walking barefooted, and the presence of animals within the houses increase the risk of M. mycetomatis and other fungi causing eumycetoma. In this pilot study, using a metagenomic approach, we revealed in two Sudanese eumycetoma endemic villages within the While Nile State in Sudan, the habitat of M. mycetomatis and other fungal species responsible for eumycetoma. Although never isolated in culture, M. mycetomatis represented the most abundant eumycetoma-associated species found within soil samples and the third most common species within dung and housing wall samples. All the eumycetoma-associated fungal species detected by metagenomic in black grains samples were identified in patient’s houses, except Falciformispora senegalensis and Acremonium alternatum. The findings obtained in this study provided insight into the habitat of eumycetoma-associated causative species and improved knowledge on eumycetoma origin and risk factors in endemic villages. Furthermore, despite the limited number of samples, these results suggest the main prevention measurements to contain eumycetoma in these endemic areas. These measurements include using gloves and alternative materials to endemic soil and animal dung in building the wall of the houses walls, constructing animal fences and appropriate use of footwear.
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Affiliation(s)
- Antonella Santona
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Najwa A. Mhmoud
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- Faculty of Medical Laboratory Sciences, University of Khartoum, Khartoum, Sudan
| | - Emmanuel Edwar Siddig
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- Faculty of Medical Laboratory Sciences, University of Khartoum, Khartoum, Sudan
| | - Massimo Deligios
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Maura Fiamma
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Bianca Paglietti
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Sahar Mubarak Bakhiet
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- Institute for Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Salvatore Rubino
- Department of Biomedical Sciences, University of Sassari, Sassari, Italy
| | - Ahmed Hassan Fahal
- Mycetoma Research Centre, University of Khartoum, Khartoum, Sudan
- * E-mail: ,
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