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Girmenia C, Busca A, Candoni A, Cesaro S, Luppi M, Nosari AM, Pagano L, Rossi G, Venditti A, Aversa F. Breakthrough invasive fungal diseases in acute myeloid leukemia patients receiving mould active triazole primary prophylaxis after intensive chemotherapy: An Italian consensus agreement on definitions and management. Med Mycol 2019; 57:S127-S137. [PMID: 30816979 DOI: 10.1093/mmy/myy091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/17/2022] Open
Abstract
In the attempt to establish definitions and provide shared approaches to breakthrough invasive fungal diseases (br-IFD) in acute myeloid leukemia (AML) patients submitted to intensive chemotherapy and receiving triazoles as mould active primary antifungal prophylaxis (MA-PAP), literature on br-IFD in AML patients receiving triazoles MA-PAP was reviewed and a Consensus Development Conference Project was convened. The following four candidate key-questions were generated and formed the set of questions of the present document: "definition of br-IFD," "diagnostic strategy during MA-PAP to detect br-IFD," "possible causes of MA-PAP failure," "management of br-IFD."
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Affiliation(s)
- Corrado Girmenia
- Dipartimento di Ematologia, Oncologia, e Dermatologia, Azienda Policlinico Umberto I, Rome
| | - Alessandro Busca
- A.O.U. Città della Salute e della Scienza, Dipartimento di Oncologia, SSD Trapianto allogenico di cellule staminali, Turin, Italy
| | - Anna Candoni
- Clinica Ematologica-Centro trapianti e Terapie Cellulari, Azienda Ospedaliero-Universitaria di Udine
| | - Simone Cesaro
- Oncoematologia Pediatrica, Azienda Ospedaliera Universitaria Integrata, Verona
| | - Mario Luppi
- Cattedra ed UO Ematologia. Dipartimento di Scienze Mediche e Chirurgiche Materno Infantile e dell' Adulto. AOU Modena. UNIMORE. Modena
| | - Anna Maria Nosari
- Divisione di Ematologia e Centro Trapianti Midollo ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Livio Pagano
- Istituto di Ematologia, Fondazione Policlinico A. Gemelli- IRCCS - Università Cattolica del Sacro Cuore, Rome
| | - Giuseppe Rossi
- S.C. Ematologia e Dipartimento Oncologia Medica Spedali Civili, Brescia
| | | | - Franco Aversa
- Haematology and BMT Unit, University of Parma, Parma, Italy
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2
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Screening and Characterization of a Non-cyp51A Mutation in an Aspergillus fumigatus cox10 Strain Conferring Azole Resistance. Antimicrob Agents Chemother 2016; 61:AAC.02101-16. [PMID: 27799210 DOI: 10.1128/aac.02101-16] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/18/2016] [Indexed: 12/14/2022] Open
Abstract
The rapid and global emergence of azole resistance in the human pathogen Aspergillus fumigatus has drawn attention. Thus, a thorough understanding of its mechanisms of drug resistance requires extensive exploration. In this study, we found that the loss of the putative calcium-dependent protein-encoding gene algA causes an increased frequency of azole-resistant A. fumigatus isolates. In contrast to previously identified azole-resistant isolates related to cyp51A mutations, only one isolate carries a point mutation in cyp51A (F219L mutation) among 105 independent stable azole-resistant isolates. Through next-generation sequencing (NGS), we successfully identified a new mutation (R243Q substitution) conferring azole resistance in the putative A. fumigatus farnesyltransferase Cox10 (AfCox10) (AFUB_065450). High-performance liquid chromatography (HPLC) analysis verified that the decreased absorption of itraconazole in related Afcox10 mutants is the primary reason for itraconazole resistance. Moreover, a complementation experiment by reengineering the mutation in a parental wild-type background strain demonstrated that both the F219L and R243Q mutations contribute to itraconazole resistance in an algA-independent manner. These data collectively suggest that the loss of algA results in an increased frequency of azole-resistant isolates with a non-cyp51A mutation. Our findings indicate that there are many unexplored non-cyp51A mutations conferring azole resistance in A. fumigatus and that algA defects make it possible to isolate drug-resistant alleles. In addition, our study suggests that genome-wide sequencing combined with alignment comparison analysis is an efficient approach to identify the contribution of single nucleotide polymorphism (SNP) diversity to drug resistance.
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Cho SY, Lee DG, Choi SM, Choi JK, Lee HJ, Kim SH, Park SH, Choi JH, Yoo JH, Kim YJ, Kim HJ, Min WS. Posaconazole for primary antifungal prophylaxis in patients with acute myeloid leukaemia or myelodysplastic syndrome during remission induction chemotherapy: a single-centre retrospective study in Korea and clinical considerations. Mycoses 2015. [PMID: 26214656 DOI: 10.1111/myc.12357] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Posaconazole was introduced as the primary antifungal prophylaxis (PAP) in acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS) patients during remission induction chemotherapy. Data on breakthrough invasive fungal infections (IFIs) from various centres are essential, as there are several considerations in treating IFIs in the posaconazole era. The aim of this study was to evaluate the effectiveness of posaconazole PAP and identify characteristics of IFIs at a single centre in Korea. We retrospectively reviewed consecutive patients with AML/MDS undergoing remission induction chemotherapy between December 2010 and November 2013. Of the 424 patients, 140 received posaconazole and 284 received fluconazole prophylaxis. The incidence of breakthrough proven/probable IFIs (15.5% vs. 2.9%, P < 0.001) and empirical antifungal treatment (EAFT) (45.8% vs. 12.9%, P < 0.001) decreased in the posaconazole group compared to the fluconazole group. In the posaconazole PAP group, two cases of breakthrough mucormycosis were noted among 13 proven/probable/possible IFI cases (15.4%). Overall and IFI-related mortality was 12.1% and 1.9% respectively. Fungus-free survival was significantly higher in the posaconazole group (74.7% vs. 87.1%, P = 0.028). Breakthrough IFIs and EAFT decreased significantly after posaconazole PAP. The benefit in fungus-free survival was noted with posaconazole PAP. Clinicians should be vigilant to identify non-Aspergillus IFIs with active diagnostic effort.
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Affiliation(s)
- Sung-Yeon Cho
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Mi Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ki Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo-Jin Lee
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Si-Hyun Kim
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sun Hee Park
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jin-Hong Yoo
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo-Sung Min
- The Catholic Blood and Marrow Transplantation Centre, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Abstract
Invasive fungal infections remain a major source of global morbidity and mortality, especially among patients with underlying immune suppression. Successful patient management requires antifungal therapy. Yet, treatment choices are restricted due to limited classes of antifungal agents and the emergence of antifungal drug resistance. In some settings, the evolution of multidrug-resistant strains insensitive to several classes of antifungal agents is a major concern. The resistance mechanisms responsible for acquired resistance are well characterized and include changes in drug target affinity and abundance, and reduction in the intracellular level of drug by biofilms and efflux pumps. The development of high-level and multidrug resistance occurs through a stepwise evolution of diverse mechanisms. The genetic factors that influence these mechanisms are emerging and they form a complex symphony of cellular interactions that enable the cell to adapt and/or overcome drug-induced stress. Drivers of resistance involve a complex blend of host and microbial factors. Understanding these mechanisms will facilitate development of better diagnostics and therapeutic strategies to overcome and prevent antifungal resistance.
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Affiliation(s)
- David S Perlin
- Public Health Research Institute, Rutgers Biomedical and Health Sciences, New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
| | - Erika Shor
- Public Health Research Institute, Rutgers Biomedical and Health Sciences, New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
| | - Yanan Zhao
- Public Health Research Institute, Rutgers Biomedical and Health Sciences, New Jersey Medical School, 185 S Orange Ave, Newark, NJ 07103, USA
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Maschmeyer G, Patterson TF. Our 2014 approach to breakthrough invasive fungal infections. Mycoses 2014; 57:645-51. [DOI: 10.1111/myc.12213] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 12/25/2022]
Affiliation(s)
- Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care; Klinikum Ernst von Bergmann; Academic Teaching Hospital of the Charité University Medicine of Berlin; Potsdam Germany
| | - Thomas F. Patterson
- Division of Infectious Diseases; San Antonio Center for Medical Mycology; The University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; San Antonio TX USA
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Faria-Ramos I, Farinha S, Neves-Maia J, Tavares PR, Miranda IM, Estevinho LM, Pina-Vaz C, Rodrigues AG. Development of cross-resistance by Aspergillus fumigatus to clinical azoles following exposure to prochloraz, an agricultural azole. BMC Microbiol 2014; 14:155. [PMID: 24920078 PMCID: PMC4061453 DOI: 10.1186/1471-2180-14-155] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 06/04/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to unveil whether azole antifungals used in agriculture, similar to the clinical azoles used in humans, can evoke resistance among relevant human pathogens like Aspergillus fumigatus, an ubiquitous agent in nature. Additionally, cross-resistance with clinical azoles was investigated. Antifungal susceptibility testing of environmental and clinical isolates of A. fumigatus was performed according to the CLSI M38-A2 protocol. In vitro induction assays were conducted involving daily incubation of susceptible A. fumigatus isolates, at 35°C and 180 rpm, in fresh GYEP broth medium supplemented with Prochloraz (PCZ), a potent agricultural antifungal, for a period of 30 days. Minimal inhibitory concentrations (MIC) of PCZ and clinical azoles were monitored every ten days. In order to assess the stability of the developed MIC, the strains were afterwards sub-cultured for an additional 30 days in the absence of antifungal. Along the in vitro induction process, microscopic and macroscopic cultural observations were registered. RESULTS MIC of PCZ increased 256 times after the initial exposure; cross-resistance to all tested clinical azoles was observed. The new MIC value of agricultural and of clinical azoles maintained stable in the absence of the selective PCZ pressure. PCZ exposure was also associated to morphological colony changes: macroscopically the colonies became mostly white, losing the typical pigmentation; microscopic examination revealed the absence of conidiation. CONCLUSIONS PCZ exposure induced Aspergillus fumigatus morphological changes and an evident increase of MIC value to PCZ as well as the development of cross-resistance with posaconazole, itraconazole and voriconazole.
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Affiliation(s)
| | | | | | | | | | | | | | - Acácio G Rodrigues
- Microbiology Department, Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal.
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Arendrup MC, Cuenca-Estrella M, Lass-Flörl C, Hope WW. Breakpoints for antifungal agents: an update from EUCAST focussing on echinocandins against Candida spp. and triazoles against Aspergillus spp. Drug Resist Updat 2014; 16:81-95. [PMID: 24618110 DOI: 10.1016/j.drup.2014.01.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Candida and Aspergillus infections have emerged as significant pathogens in recent decades. During this same time, broad spectrum triazole and echinocandin antifungal agents have been developed and increasingly used. One consequence of widespread use is leading to the emergence of mutants with acquired resistance mutations. Therefore, accurate susceptibility testing and appropriate clinical breakpoints for the interpretation of susceptibility results have become increasingly important. Here we review the underlying methodology by which breakpoints have been selected by EUCAST (European Committee on Antimicrobial Susceptibility Testing). Five parameters are evaluated: dosing regimens used; EUCAST MIC distributions from multiple laboratories, species and compound specific epidemiological cut off values (upper MIC limits of wild type isolates or ECOFFs), pharmacokinetic/pharmacodynamic relationships and targets associated with outcome and finally clinical data by species and MIC when available. The general principles are reviewed followed by a detailed review of the individual aspects for Candida species and the three echinocandins and for Aspergillus and the three mould-active azoles. This review provides an update of the subcommittee on antifungal susceptibility testing (AFST) of the EUCAST methodology and summarises the current EUCAST breakpoints for Candida and Aspergillus. Recommendations about applicability of antifungal susceptibility testing in the routine setting are also included.
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Affiliation(s)
- Maiken C Arendrup
- Unit of Mycology, Dept. Microbiology & Infection Control, Statens Serum Institut, Copenhagen, Denmark.
| | | | - Cornelia Lass-Flörl
- Division of Hygiene and Medical Microbiology, Innsbruck Medical University, Austria
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
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Balhara M, Ruhil S, kumar M, Dhankhar S, Chhillar AK. An anti-Aspergillusprotein fromEscherichia coliDH5α: Putative inhibitor of siderophore biosynthesis inAspergillus fumigatus. Mycoses 2013; 57:153-62. [DOI: 10.1111/myc.12119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/18/2013] [Accepted: 07/18/2013] [Indexed: 12/01/2022]
Affiliation(s)
- Meenakshi Balhara
- Centre for Biotechnology; Maharshi Dayanand University; Rohtak Haryana India
| | - Sonam Ruhil
- Centre for Biotechnology; Maharshi Dayanand University; Rohtak Haryana India
| | - Manish kumar
- Centre for Biotechnology; Maharshi Dayanand University; Rohtak Haryana India
| | - Sandeep Dhankhar
- Centre for Biotechnology; Maharshi Dayanand University; Rohtak Haryana India
| | - A. K. Chhillar
- Centre for Biotechnology; Maharshi Dayanand University; Rohtak Haryana India
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Dollive S, Chen YY, Grunberg S, Bittinger K, Hoffmann C, Vandivier L, Cuff C, Lewis JD, Wu GD, Bushman FD. Fungi of the murine gut: episodic variation and proliferation during antibiotic treatment. PLoS One 2013; 8:e71806. [PMID: 23977147 PMCID: PMC3747063 DOI: 10.1371/journal.pone.0071806] [Citation(s) in RCA: 166] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 07/03/2013] [Indexed: 01/01/2023] Open
Abstract
Antibiotic use in humans has been associated with outgrowth of fungi. Here we used a murine model to investigate the gut microbiome over 76 days of treatment with vancomycin, ampicillin, neomycin, and metronidazole and subsequent recovery. Mouse stool was studied as a surrogate for the microbiota of the lower gastrointestinal tract. The abundance of fungi and bacteria was measured using quantitative PCR, and the proportional composition of the communities quantified using 454/Roche pyrosequencing of rRNA gene tags. Prior to treatment, bacteria outnumbered fungi by >3 orders of magnitude. Upon antibiotic treatment, bacteria dropped in abundance >3 orders of magnitude, so that the predominant 16S sequences detected became transients derived from food. Upon cessation of treatment, bacterial communities mostly returned to their previous numbers and types after 8 weeks, though communities remained detectably different from untreated controls. Fungal communities varied substantially over time, even in the untreated controls. Separate cages within the same treatment group showed radical differences, but mice within a cage generally behaved similarly. Fungi increased ∼40-fold in abundance upon antibiotic treatment but declined back to their original abundance after cessation of treatment. At the last time point, Candida remained more abundant than prior to treatment. These data show that 1) gut fungal populations change radically during normal mouse husbandry, 2) fungi grow out in the gut upon suppression of bacterial communities with antibiotics, and 3) perturbations due to antibiotics persist long term in both the fungal and bacterial microbiota.
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Affiliation(s)
- Serena Dollive
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Ying-Yu Chen
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Stephanie Grunberg
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Kyle Bittinger
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Christian Hoffmann
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Lee Vandivier
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Christopher Cuff
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - James D. Lewis
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
| | - Gary D. Wu
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
- * E-mail: (FDB); (GDW)
| | - Frederic D. Bushman
- University of Pennsylvania School of Medicine, Department of Microbiology, Philadelphia, Pennsylvania, United States of America
- * E-mail: (FDB); (GDW)
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Microcalorimetry assay for rapid detection of voriconazole resistance in Aspergillus fumigatus. Antimicrob Agents Chemother 2013; 57:5704-6. [PMID: 23939893 DOI: 10.1128/aac.01379-13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We describe a calorimetric assay for detection of voriconazole-resistant Aspergillus fumigatus within 8 h. Among 27 genetically distinct strains, all 21 resistant and all 6 susceptible strains were correctly identified by measurement of fungal heat production in the presence of voriconazole. This proof-of-concept study demonstrates the potential of microcalorimetry for rapid detection of azole resistance in A. fumigatus.
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Badali H, Vaezi A, Haghani I, Yazdanparast SA, Hedayati MT, Mousavi B, Ansari S, Hagen F, Meis JF, Chowdhary A. Environmental study of azole-resistantAspergillus fumigatuswith TR34/L98H mutations in thecyp51A gene in Iran. Mycoses 2013; 56:659-63. [DOI: 10.1111/myc.12089] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 04/22/2013] [Indexed: 01/15/2023]
Affiliation(s)
- Hamid Badali
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
- Molecular and Cell Biology Research Centre (MCBRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Afsane Vaezi
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Iman Haghani
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Seyed A. Yazdanparast
- Department of Medical Parasitology and Mycology; School of Allied Medicine; Iran University of Medical Sciences; Tehran Iran
| | - Mohammad T. Hedayati
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
- Molecular and Cell Biology Research Centre (MCBRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Bita Mousavi
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Saham Ansari
- Department of Medical Mycology and Parasitology/Invasive Fungi Research Center (IFRC); School of Medicine; Mazandaran University of Medical Sciences; Sari Iran
| | - Ferry Hagen
- Department of Medical Microbiology and Infectious Diseases; Canisius Wilhelmina Hospital; Nijmegen The Netherlands
| | - Jacques F. Meis
- Department of Medical Microbiology and Infectious Diseases; Canisius Wilhelmina Hospital; Nijmegen The Netherlands
- Department of Medical Microbiology; Radboud University Nijmegen Medical Centre; Nijmegen The Netherlands
| | - Anuradha Chowdhary
- Department of Medical Mycology; Vallabhbhai Patel Chest Institute; University of Delhi; Delhi India
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