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Armstrong‐James D. Antifungal chemotherapies and immunotherapies for the future. Parasite Immunol 2023; 45:e12960. [PMID: 36403106 PMCID: PMC10078527 DOI: 10.1111/pim.12960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/21/2022]
Abstract
Human fungal pathogens cause a broad plethora of infections, spanning cutaneous dermatophytoses to invasive infections in immunocompromised hosts. As eukaryotic pathogens are capable of morphotype switching, they present unique challenges both for drug development and the immunological response. Whilst current antifungal therapies are limited to the orally available triazoles, intravenous echonocandins and polyenes, and flucytosine and terbinafine, there has been recent significant progress in the antifungal armamentorium with ibrexafungerp, a novel orally available terpanoid that inhibits 1,3-beta-D-glucan-approved by Food and Drug Administration in 2021, and fosmanogepix, an orally available pro-drug of manogepix, which targets glycosylphosphatidylinositol-anchored protein maturation entering Phase 3 studies for candidaemia. A number of further candidates are in development. There has been significant use of existing immunotherapies such as recombinant interferon-γ and G-CSF for fungal disease in immunocompromised patients, and there are emerging opportunities for monoclonal antibodies targeting TH2 inflammation. Omalizumab, an anti-IgE monoclonal antibody in asthma, is now used routinely for the treatment of allergic bronchopulmonary aspergillosis, and further agents targeting IL-4 and IL-5 are being evaluated. In addition, T-cell CAR therapy is showing early promise for fungal disease. Thus, we are likely to see rapid advances to our approach to the management of fungal disease in the near future.
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Affiliation(s)
- Darius Armstrong‐James
- Department of Infectious DiseasesMedical Research Council Centre for Molecular Bacteriology and Infection, Imperial College LondonLondonUK
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2
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Serum Cytokine Profile in Patients with Candidemia versus Bacteremia. Pathogens 2021; 10:pathogens10101349. [PMID: 34684298 PMCID: PMC8537900 DOI: 10.3390/pathogens10101349] [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: 07/22/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Bloodstream Candida infections constitute a major threat for hospitalized patients in intensive care units and immunocompromised hosts. Certain serum cytokines play a decisive role in anti-microbial host defense. Cytokines may act as discriminatory biomarkers that can significantly increase in candidemia compared to bacteremia patients. The concentration of secreted cytokine/chemokines was determined using a multiplexed cytometric bead array run on a cell analyzer. The cytokines tested during the study were interleukin (IL)-1β, IL-6, IL-17A, IL-10, IFN-γ, IL-4, IL-2, IL-8, IL-12p70 and the tumor necrosis factor (TNF)-α. The cytokines of 51 candidemia patients were characterized and compared to the cytokine levels of 20 bacteremia patients. Levels were significantly elevated in patients with bloodstream infections compared to healthy controls. Cytokines comprising IL-2, IL-17A, IL-6 and IL-10 were significantly elevated in the patients with bloodstream Candida infection as compared to the patients having bloodstream bacterial infections. The levels were found to be promising as a potential diagnostic marker for bloodstream Candida infections.
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Wang Q, Wang C, Yang M, Li X, Cui J, Wang C. Diagnostic efficacy of serum cytokines and chemokines in patients with candidemia and bacteremia. Cytokine 2020; 130:155081. [PMID: 32247169 DOI: 10.1016/j.cyto.2020.155081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The role of serum cytokines/chemokines in differential diagnosis between fungal infections and bacterial infections have not been fully understood. This study aims to measure the serum levels of cytokines/chemokines in cases of candidemia and to compare them with those observed in cases of bacteremia. MATERIAL AND METHODS Patients with febrile episodes and were identified as bloodstream infections through blood culture were enrolled, while healthy people were included as control group. Fourteen serum cytokine and chemokine levels were detected with multiplex platform. ROC analysis was performed and an area under the curve (AUC), sensitivity and specificity values were calculated to determine the efficacy of various cytokines and chemokines for candidemia and bacteremia. Binary logistic regression was performed to further explore the combination mode of cytokines and chemokines, which could increase the diagnostic efficiency. RESULTS We included 40 patients with an episode of microbiologically proven fungal infection, 175 patients with bacteremia (85 with Gram-positive bacteremia and 90 with Gram-negative bacteremia) and another 30 healthy controls. Routine laboratory parameters including CRP and PCT were not statistically significant between candidemia group and bacteremia group (both gram-positive and gram-negative). There were significantly higher levels of IFN-γ, TNF-α, IL-10 and lower levels of IL-3, IL-4 in candidemia group, compared with gram-positive and gram-negative bacteremia groups. G-CSF was significantly lower and MIP-1β was higher in candidemia group, when compared with gram-negative bacteremia group. While IL-6, IL-8 and IL-17 were all significantly higher in candidemia group, when compared with gram-positive bacteremia group. Combination of IFN-γ and IL-17 could improve the diagnostic efficiency between candidemia and gram-positive bacteremia, with the AUROC of 0.873 (95% CI: 0.767-0.929). While combination of G-CSF and MIP-1β improved the diagnostic efficiency between candidemia and gram-negative bacteremia, with the AUROC of 0.896 (95% CI: 0.792-0.939). CONCLUSION Our study demonstrates that serum cytokines and chemokines including IFN-γ, MIP-1β, IL-17 and G-CSF could be considered as diagnostic markers to distinguish between candidemia and bacteremia. Combination of these biomarkers might improve the diagnostic efficiency of candidemia when compared with bacteremia.
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Affiliation(s)
- Qi Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China; Department of Orthopedics, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China
| | - Chi Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China
| | - Ming Yang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China; Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Xinjun Li
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China
| | - Jiayue Cui
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China; School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou 325035, China
| | - Chengbin Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing 100853, China.
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Prophylaxis and Treatment of Invasive Aspergillosis: Who and How of Prophylaxis, Treatment, and New Therapies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00213-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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5
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Danion F, Aimanianda V, Bayry J, Duréault A, Wong SSW, Bougnoux ME, Tcherakian C, Alyanakian MA, Guegan H, Puel A, Picard C, Lortholary O, Lanternier F, Latgé JP. Aspergillus fumigatus Infection in Humans With STAT3-Deficiency Is Associated With Defective Interferon-Gamma and Th17 Responses. Front Immunol 2020; 11:38. [PMID: 32047500 PMCID: PMC6997434 DOI: 10.3389/fimmu.2020.00038] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/08/2020] [Indexed: 12/23/2022] Open
Abstract
In humans, loss-of-function mutation in the Signal Transducer and Activator of Transcription 3 (STAT3) gene is frequently associated with susceptibility to bacterial as well as fungal infections including aspergillosis, although its pathogenesis remains largely unknown. In the present study, we investigated the immune responses obtained after stimulation with Aspergillus fumigatus in STAT3-deficient patients. A. fumigatus conidial killing efficiencies of both monocytes and neutrophils isolated from whole blood samples of STAT3-deficient patients were not different compared to those of healthy controls. After stimulation with A. fumigatus conidia, lower concentrations of adaptive cytokines (IFN-γ, IL-17 and IL-22) were secreted by peripheral blood mononuclear cells from STAT3-deficient patients compared to those from healthy controls. Moreover, the frequency of IFN-γ and IL-17 producing CD4+ T cells was lower in STAT3-deficient patients vs. healthy controls. Among the STAT3-deficient patients, those with aspergillosis showed further lower secretion of IFN-γ upon stimulation of their PBMCs with A. fumigatus conidia compared to the patients without aspergillosis. Together, our study indicated that STAT3-deficiency leads to a defective adaptive immune response against A. fumigatus infection, particularly with a lower IFN-γ and IL-17 responses in those with aspergillosis, suggesting potential therapeutic benefit of recombinant IFN-γ in STAT3-deficient patients with aspergillosis.
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Affiliation(s)
- François Danion
- Université de Paris, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris, France.,Unité des Aspergillus, Institut Pasteur, Paris, France
| | | | - Jagadeesh Bayry
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Equipe-Immunopathologie et Immunointervention Thérapeutique, Sorbonne Université, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Amélie Duréault
- Université de Paris, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Marie-Elisabeth Bougnoux
- Unité de Parasitologie-Mycologie service de Microbiologie, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France.,INRA USC 2019, Unite Biologie et Pathogenicite Fongiques, Institut Pasteur, INRA, Paris, France
| | | | - Marie-Alexandra Alyanakian
- Service d'Immunologie Biologique, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - Hélène Guegan
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Rennes, Rennes, France.,Univ Rennes, INSERM, IRSET (Institut de Recherche en santé, Environnement et travail) - UMR_S 1085, Rennes, France
| | - Anne Puel
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, United States.,Génétique Humaine des Maladies Infectieuses, Hôpital Necker-Enfants Malades, INSERM U1163, Paris and Université de Paris, Imagine Institut, Paris, France
| | - Capucine Picard
- Centre d'étude des Déficits Immunitaires (CEDI), Centre de Référence des Déficits Immunitaires Héréditaires (CEREDIH), Unité d'Immuno-Hématologie, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris, Paris and Institut Imagine, INSERM UMR1163, Paris, France
| | - Olivier Lortholary
- Université de Paris, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris, France.,Institut Pasteur, CNRS, Centre National de Référence Mycoses Invasives et Antifongiques, Unité de Mycologie Moléculaire, UMR 2000, Paris, France
| | - Fanny Lanternier
- Université de Paris, Centre d'Infectiologie Necker Pasteur, IHU Imagine, Hôpital Necker-Enfants Malades, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris, France.,St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY, United States
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6
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Wang Q, Yang M, Wang C, Cui J, Li X, Wang C. Diagnostic efficacy of serum cytokines and chemokines in fungal bloodstream infection in febrile patients. J Clin Lab Anal 2020; 34:e23149. [PMID: 31971308 PMCID: PMC7171303 DOI: 10.1002/jcla.23149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The role of serum cytokines/chemokines in early diagnosis of fungal infections has not been clearly clarified yet. This study aims to measure the serum levels of cytokines/chemokines in cases of fungemia and to compare them with culture-negative controls. METHODS In total, fourteen types of serum cytokines and chemokines from 41 patients with fungemia were compared with 57 patients with negative blood culture results. The cytokine and chemokine levels were detected with multiplex platform. We then performed statistical analysis as a two-tailed P < .05. ROC analysis was performed, and an area under the curve (AUC), and sensitivity and specificity values were calculated to determine the efficacy of various cytokines and chemokines for fungemia. Binary logistic regression was performed to further explore the combination mode of cytokines and chemokines, which could increase the diagnostic efficiency. RESULTS C-reactive protein and procalcitonin were significantly higher compared with those in negative control group, while white blood cell, percentage of neutrophil, percentage of lymphocyte, and ratio of neutrophil and lymphocyte did not differentiate between two groups. Serum levels of IFN-γ, TNF-α, MIP-1β, IL-6, IL-8, IL-10, IL-12p70, and IL-17 were significantly higher in patients with fungemia compared with the control group. Combination of MIP-1β and IL-17 could improve the AUC, sensitivity, and specificity for the diagnosis of fungemia. CONCLUSION Our study demonstrates that serum cytokines and chemokines including IFN-γ, TNF-α, MIP-1β, IL-6, IL-8, IL-10, IL-12p70, and IL-17 could be considered as diagnostic markers for fungemia. Combination of these biomarkers might improve the diagnostic efficiency of fungemia.
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Affiliation(s)
- Qi Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China.,Department of Orthopedics, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China
| | - Ming Yang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China.,Department of Clinical Laboratory, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Chi Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China
| | - Jiayue Cui
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China.,School of Laboratory Medicine and Life Sciences, Wenzhou Medical University, Wenzhou, China
| | - Xinjun Li
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China
| | - Chengbin Wang
- Department of Clinical Laboratory Medicine, Chinese PLA General Hospital & Medical School of Chinese PLA, Beijing, China
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7
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Armstrong-James D, Brown GD, Netea MG, Zelante T, Gresnigt MS, van de Veerdonk FL, Levitz SM. Immunotherapeutic approaches to treatment of fungal diseases. THE LANCET. INFECTIOUS DISEASES 2017; 17:e393-e402. [PMID: 28774700 DOI: 10.1016/s1473-3099(17)30442-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 11/20/2016] [Accepted: 02/09/2017] [Indexed: 12/15/2022]
Abstract
Fungal infections cause morbidity worldwide and are associated with an unacceptably high mortality despite the availability of antifungal drugs. The incidence of mycoses is rising because of the HIV pandemic and because immunomodulatory drugs are increasingly used to treat autoimmune diseases and cancer. New classes of antifungal drugs have only been partly successful in improving the prognosis for patients with fungal infection. Adjunctive host-directed therapy is therefore believed to be the only option to further improve patient outcomes. Recent advances in the understanding of complex interactions between fungi and host have led to the design and exploration of novel therapeutic strategies in cytokine therapy, vaccines, and cellular immunotherapy, each of which might become viable adjuncts to existing antifungal regimens. In this report, we discuss immunotherapeutic approaches-the rationale behind their design, the challenges in their use, and the progress that is so urgently needed to overcome the devastating effect of fungal diseases.
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Affiliation(s)
- Darius Armstrong-James
- Fungal Pathogens Laboratory, National Heart and Lung Institute, Imperial College London, UK.
| | - Gordon D Brown
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, University of Aberdeen, Aberdeen, UK
| | - Mihai G Netea
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Teresa Zelante
- Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Mark S Gresnigt
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank L van de Veerdonk
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Stuart M Levitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Shah A, Kannambath S, Herbst S, Rogers A, Soresi S, Carby M, Reed A, Mostowy S, Fisher MC, Shaunak S, Armstrong-James DP. Calcineurin Orchestrates Lateral Transfer of Aspergillus fumigatus during Macrophage Cell Death. Am J Respir Crit Care Med 2017; 194:1127-1139. [PMID: 27163634 PMCID: PMC5114448 DOI: 10.1164/rccm.201601-0070oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE Pulmonary aspergillosis is a lethal mold infection in the immunocompromised host. Understanding initial control of infection and how this is altered in the immunocompromised host are key goals for comprehension of the pathogenesis of pulmonary aspergillosis. OBJECTIVES To characterize the outcome of human macrophage infection with Aspergillus fumigatus and how this is altered in transplant recipients on calcineurin inhibitor immunosuppressants. METHODS We defined the outcome of human macrophage infection with A. fumigatus, as well as the impact of calcineurin inhibitors, through a combination of single-cell fluorescence imaging, transcriptomics, proteomics, and in vivo studies. MEASUREMENTS AND MAIN RESULTS Macrophage phagocytosis of A. fumigatus enabled control of 90% of fungal germination. However, fungal germination in the late phagosome led to macrophage necrosis. During programmed necroptosis, we observed frequent cell-cell transfer of A. fumigatus between macrophages, which assists subsequent control of germination in recipient macrophages. Lateral transfer occurred through actin-dependent exocytosis of the late endosome in a vasodilator-stimulated phosphoprotein envelope. Its relevance to the control of fungal germination was also shown by direct visualization in our zebrafish aspergillosis model in vivo. The calcineurin inhibitor FK506 (tacrolimus) reduced cell death and lateral transfer in vitro by 50%. This resulted in uncontrolled fungal germination in macrophages and also resulted in hyphal escape. CONCLUSIONS These observations identify programmed, necrosis-dependent lateral transfer of A. fumigatus between macrophages as an important host strategy for controlling fungal germination. This process is critically dependent on calcineurin. Our studies provide fundamental insights into the pathogenesis of pulmonary aspergillosis in the immunocompromised host.
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Affiliation(s)
| | | | | | | | - Simona Soresi
- 3 Lung Transplant Unit, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - Martin Carby
- 3 Lung Transplant Unit, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - Anna Reed
- 3 Lung Transplant Unit, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - Serge Mostowy
- 4 Medical Research Council Centre for Molecular Bacteriology and Infection
| | | | - Sunil Shaunak
- 6 Department of Infectious Diseases and Immunity, Imperial College London, London, United Kingdom; and
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Herbst S, Shah A, Mazon Moya M, Marzola V, Jensen B, Reed A, Birrell MA, Saijo S, Mostowy S, Shaunak S, Armstrong-James D. Phagocytosis-dependent activation of a TLR9-BTK-calcineurin-NFAT pathway co-ordinates innate immunity to Aspergillus fumigatus. EMBO Mol Med 2015; 7:240-58. [PMID: 25637383 PMCID: PMC4364943 DOI: 10.15252/emmm.201404556] [Citation(s) in RCA: 136] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Transplant recipients on calcineurin inhibitors are at high risk of invasive fungal infection. Understanding how calcineurin inhibitors impair fungal immunity is a key priority for defining risk of infection. Here, we show that the calcineurin inhibitor tacrolimus impairs clearance of the major mould pathogen Aspergillus fumigatus from the airway, by inhibiting macrophage inflammatory responses. This leads to defective early neutrophil recruitment and fungal clearance. We confirm these findings in zebrafish, showing an evolutionarily conserved role for calcineurin signalling in neutrophil recruitment during inflammation. We find that calcineurin–NFAT activation is phagocytosis dependent and collaborates with NF-κB for TNF-α production. For yeast zymosan particles, activation of macrophage calcineurin–NFAT occurs via the phagocytic Dectin-1–spleen tyrosine kinase pathway, but for A. fumigatus, activation occurs via a phagosomal TLR9-dependent and Bruton's tyrosine kinase-dependent signalling pathway that is independent of MyD88. We confirm the collaboration between NFAT and NF-κB for TNF-α production in primary alveolar macrophages. These observations identify inhibition of a newly discovered macrophage TLR9–BTK–calcineurin–NFAT signalling pathway as a key immune defect that leads to organ transplant-related invasive aspergillosis.
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Affiliation(s)
- Susanne Herbst
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Anand Shah
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Maria Mazon Moya
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | - Vanessa Marzola
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Barbara Jensen
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Anna Reed
- Lung Transplant Unit, Royal Brompton and Harefield Hospital, London, UK
| | - Mark A Birrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Shinobu Saijo
- Medical Mycology Research Centre, Chiba University, Chiba, Japan
| | - Serge Mostowy
- MRC Centre for Molecular Bacteriology and Infection, Imperial College London, London, UK
| | - Sunil Shaunak
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Darius Armstrong-James
- Department of Infectious Diseases and Immunity, Imperial College London, London, UK National Heart and Lung Institute, Imperial College London, London, UK
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Radowsky JS, Brown TS, Lisboa FA, Rodriguez CJ, Forsberg JA, Elster EA. Serum Inflammatory Cytokine Markers of Invasive Fungal Infection in Previously Immunocompetent Battle Casualties. Surg Infect (Larchmt) 2015; 16:526-32. [PMID: 26110227 DOI: 10.1089/sur.2013.124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive fungal infection (IFI) is described increasingly in individuals experiencing high-energy military trauma. Hallmarks of successful treatment involve aggressive surgical debridement and early initiation of systemic antimicrobial therapy. Currently, intravenous anti-fungal therapy commences based on appearance of wounds and patient's clinical course. Whereas some clinical protocols exist to predict which critically injured patients should receive anti-fungal therapies, there are no established serum markers associated with IFI. Our hypothesis is that serum inflammatory cytokines exist that can assist in identifying individuals at risk for IFI. METHODS This is a retrospective case control study at a single institution. Nine patients with IFI (Saksenaea vasiformis, Fusarium sp., Graphium sp., Scedosporium sp., Aspergillus sp., Mucor sp., and Alternaria sp.) after battlefield trauma were matched to nine individuals with similar injury patterns whose laboratory results were negative for IFI. The combination of serum inflammatory cytokines from the first and second debridements was examined with multiplex platform proteomic analysis. We defined statistical significance as a two-tailed α<0.05 after adjusting for multiple comparisons using the false discovery rate method. This model was refined further with correlation-based filter selection and the area under the curve of the receiver operating characteristics (AUROC) was tested. RESULTS Both groups had similar Injury Severity Scores (ISS) (mean±standard deviation [SD]) (26.8±15.5 vs. 29.2±16.8, p=0.766). Elevated RANTES (regulated on activation, normal T cell expressed and secreted) alone (10,492.8±4,450.1 vs. 5,333.3±4,162.2, p=0.006) correlated with IFI. Also, the combination of persistent elevations in RANTES, interleukin (IL)-2R, and IL-15 was a robust model for predicting IFI with the AUROC being 0.9. CONCLUSIONS Elevation in serum cytokines, particularly RANTES, correlated with IFI in this small group of patients. This demonstrates the potential of future rapid serum testing for early initiation and guidance of anti-fungal therapies.
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Affiliation(s)
- Jason S Radowsky
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Trevor S Brown
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Felipe A Lisboa
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Carlos J Rodriguez
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Jonathan A Forsberg
- 2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,3 Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
| | - Eric A Elster
- 1 Department of General Surgery, Walter Reed National Military Medical Center, Bethesda , Maryland.,2 Naval Medical Research Center , Regenerative Medicine Department, Silver Spring, Maryland.,4 Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,5 Surgical Critical Care Initiative (SC2i), Uniformed Services University of the Health Sciences , Department of Surgery, Bethesda, Maryland
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Khan A, El-Charabaty E, El-Sayegh S. Fungal infections in renal transplant patients. J Clin Med Res 2015; 7:371-8. [PMID: 25883698 PMCID: PMC4394908 DOI: 10.14740/jocmr2104w] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/12/2022] Open
Abstract
Organ transplantation has always been considered to be the standard therapeutic interventions in patients with end-stage organ failure. In 2008, more than 29,000 organ transplants were performed in US. Survival rates among transplant recipients have greatly improved due to better understanding of transplant biology and more effective immunosuppressive agents. After transplant, the extent of the immune response is influenced by the amount of interleukin 2 (IL-2) being produced by the T-helper cells. Transplant immunosuppressive therapy primarily targets T cell-mediated graft rejection. Calcineurin inhibitor, which includes cyclosporine, pimecrolimus and tacrolimus, impairs calcineurin-induced up-regulation of IL-2 expression, resulting in increased susceptibility to invasive fungal diseases. This immunosuppressive state allows infectious complication, leading to a high mortality rate. Currently, overall mortality due to invasive fungal infections (IFIs) in solid organ transplant recipients ranges between 25% and 80%. The risk of IFI following renal transplant is associated with the dosage of immunosuppressive agents given, environmental factors and post-transplant duration. Most fungal infections occur in the first 6 months after transplant because of the use of numerous immunosuppressors. Candida spp. and Cryptococcus spp. are the yeasts most frequently isolated, while most frequent filamentous fungi (molds) isolated are Aspergillus spp. The symptoms of systemic fungal infections are non-specific and early detection of fungal infections and proper therapy are important in improving survival and reducing mortality. This article will provide an insight on the risk factors and clinical presentation, compare variation in treatment of IFIs in renal transplant patients, and evaluate the role of prophylactic therapy in this group of patients. We also report the course and management of two renal transplant recipients admitted to Staten Island University Hospital, both of whom developed pulmonary complications secondary to Aspergillus infection.
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Affiliation(s)
- Asif Khan
- Department of Medicine, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Elie El-Charabaty
- Department of Nephrology, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA
| | - Suzanne El-Sayegh
- Department of Nephrology, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA
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Shirkhani K, Teo I, Armstrong-James D, Shaunak S. Nebulised amphotericin B-polymethacrylic acid nanoparticle prophylaxis prevents invasive aspergillosis. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2015; 11:1217-26. [PMID: 25791815 PMCID: PMC4503863 DOI: 10.1016/j.nano.2015.02.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/12/2015] [Accepted: 02/14/2015] [Indexed: 11/25/2022]
Abstract
Aspergillus species are the major life threatening fungal pathogens in transplant patients. Germination of inhaled fungal spores initiates infection, causes severe pneumonia, and has a mortality of > 50%. This is leading to the consideration of pre-exposure prophylaxis to prevent infection. We made a very low MWt amphotericin B-polymethacrylic acid nanoparticle. It was not toxic to lung epithelial cells or monocyte-derived-macrophages in-vitro, or in an in-vivo transplant immuno-suppression mouse model of life threatening invasive aspergillosis. Three days of nebuliser based prophylaxis delivered the nanoparticle effectively to lung and prevented both fungal growth and lung inflammation. Protection from disease was associated with > 99% killing of the Aspergillus and a 90% reduction in lung TNF-α; the primary driver of tissue destructive immuno-pathology. This study provides in-vivo proof-of-principle that very small and cost-effective nanoparticles can be made simply, and delivered safely and effectively to lung by the aerosol route to prevent fungal infections. From the Clinical Editor Aspergillus is an opportunistic pathogen, which affects immunocompromised patients. One novel way to help fight against this infection is pre-exposure prophylaxis. The authors here made PMA based anionic hydrogels carrying amphotericin B, with mucoadhesive behavior. They showed that aerosol route of the drug was very effective in protecting against the disease in an in-vivo model and should provide a stepping-stone towards clinical trials in the future.
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Affiliation(s)
- Khojasteh Shirkhani
- Departments of Medicine, Infectious Diseases, Immunity and Chemistry, Imperial College London, Hammersmith campus, London, UK
| | - Ian Teo
- Departments of Medicine, Infectious Diseases, Immunity and Chemistry, Imperial College London, Hammersmith campus, London, UK
| | - Darius Armstrong-James
- Departments of Medicine, Infectious Diseases, Immunity and Chemistry, Imperial College London, Hammersmith campus, London, UK
| | - Sunil Shaunak
- Departments of Medicine, Infectious Diseases, Immunity and Chemistry, Imperial College London, Hammersmith campus, London, UK.
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Smith NLD, Denning DW. Clinical implications of interferon-γ genetic and epigenetic variants. Immunology 2015; 143:499-511. [PMID: 25052001 DOI: 10.1111/imm.12362] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/15/2014] [Accepted: 07/18/2014] [Indexed: 12/25/2022] Open
Abstract
Interferon-γ (IFN-γ) is an integral and critical molecule of the immune system, with multiple functions, mostly related to the T helper type 1 (Th1) response to infection. It is critical for defence against mycobacterial infection and is of increasing interest in defence against fungi. In this article, we review the genetic and epigenetic variants affecting IFN-γ expression and investigate its role in disease, with an emphasis on fungal diseases such as invasive and chronic pulmonary aspergillosis. Over 347 IFN-γ gene variants have been described, in multiple ethnic populations. Many appear to confer a susceptibility to disease, especially tuberculosis (TB) and hepatitis, but also some non-infectious conditions such as aplastic anaemia, cervical cancer and psoriasis. Several epigenetic modifications are also described, increasing IFN-γ expression in Th1 lymphocytes and reducing IFN-γ expression in Th2 lymphocytes. Recombinant IFN-γ administration is licensed for the prophylaxis of infection (bacterial and fungal) in patients with the phagocyte functional deficiency syndrome chronic granulomatous disease, although the benefits appear limited. Interferon-γ therapy is given to patients with profound defects in IFN-γ and interleukin-12 production and appears to be beneficial for patients with invasive aspergillosis and cryptococcal meningitis, but the studies are not definitive. A high proportion of patients with chronic pulmonary aspergillosis are poor producers of IFN-γ in response to multiple stimuli and could also benefit from IFN-γ administration. The investigation and management of patients with possible or demonstrated IFN-γ deficiency in adulthood is poorly studied and could be greatly enhanced with the integration of genetic data.
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Affiliation(s)
- Nicola L D Smith
- Manchester Fungal Infection Group, Faculty of Medical and Human Science, The University of Manchester, Manchester, UK; Manchester Academic Health Science Centre, University Hospital South Manchester NHS Foundation Trust, Manchester, UK; NIHR South Manchester Respiratory and Allergy Clinical Research Facility, Manchester, UK
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Interferon-gamma as adjunctive immunotherapy for invasive fungal infections: a case series. BMC Infect Dis 2014; 14:166. [PMID: 24669841 PMCID: PMC3987054 DOI: 10.1186/1471-2334-14-166] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/14/2014] [Indexed: 12/28/2022] Open
Abstract
Background Invasive fungal infections are very severe infections associated with high mortality rates, despite the availability of new classes of antifungal agents. Based on pathophysiological mechanisms and limited pre-clinical and clinical data, adjunctive immune-stimulatory therapy with interferon-gamma (IFN-γ) may represent a promising candidate to improve outcome of invasive fungal infections by enhancing host defence mechanisms. Methods In this open-label, prospective case series, we describe eight patients with invasive Candida and/or Aspergillus infections who were treated with recombinant IFN-γ (rIFN-γ, 100 μg s.c., thrice a week) for 2 weeks in addition to standard antifungal therapy. Results Recombinant IFN-γ treatment in patients with invasive Candida and/or Aspergillus infections partially restored immune function, as characterized by an increased HLA-DR expression in those patients with a baseline expression below 50%, and an enhanced capacity of leukocytes from treated patients to produce proinflammatory cytokines involved in antifungal defence. Conclusions The present study provides evidence that adjunctive immunotherapy with IFN-γ can restore immune function in fungal sepsis patients, warranting future clinical studies to assess its potential clinical benefit. Trial registration ClinicalTrials.gov - NCT01270490
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