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Blohm JE, Panthula M, Aggarwal A, Swazo R, Ashoka A, Ainapurapu B. Fatal Disseminated Coccidioidomycosis in Cirrhosis: A case series. Am J Med 2023:S0002-9343(23)00245-0. [PMID: 37068575 DOI: 10.1016/j.amjmed.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE Coccidioidomycosis is endemic to the Southwest United States and Mexico. In this case series, we describe three cases occurring in the Southwest US of patients with disseminated coccidioidomycosis infection in cirrhosis, all with a miliary pattern present on chest imaging. METHODS This case series was performed conducting a review of patients' electronic health records and thorough review of the literature for coccidioidomycosis infection in patients with liver disease. RESULTS Three patients with different etiology of liver disease with MELD-Na scores greater than 20 had chest imaging findings indicative of a miliary pattern on presentation. Each patient subsequently had extensive infectious disease workup that showed evidence of disseminated coccidioidomycosis. All three patients clinically worsened and eventually died. CONCLUSIONS This case series highlights the severity of disseminated coccidioidomycosis in patients with cirrhosis in an endemic area, as well as potential early clues such as miliary patterns on chest imaging. A review of the literature found a significant connection between potential mechanisms describing why patients with cirrhosis have such adverse outcomes in the setting of disseminated coccidioidomycosis including cirrhosis-associated immune dysfunction and genetic defects in immune functioning.
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Affiliation(s)
| | | | - Avin Aggarwal
- University of Arizona College of Medicine-Tucson; Department of Medicine, Banner-University Medical Center, Tucson, Arizona
| | - Roberto Swazo
- Orlando Health Medical Group - Lung & Sleep Medicine; Orlando, FL
| | - Ankita Ashoka
- University of Arizona College of Medicine-Tucson; Department of Medicine, Banner-University Medical Center, Tucson, Arizona
| | - Bujji Ainapurapu
- University of Arizona College of Medicine-Tucson; Department of Medicine, Banner-University Medical Center, Tucson, Arizona.
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2
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Jaffey JA, Shubitz LF, Johnson MDL, Bolch CA, da Cunha A, Murthy AK, Lopez BS, Monasky R, Carswell I, Spiker J, Neubert MJ, Menghani SV. Evaluation of Host Constitutive and Ex Vivo Coccidioidal Antigen-Stimulated Immune Response in Dogs with Naturally Acquired Coccidioidomycosis. J Fungi (Basel) 2023; 9:jof9020213. [PMID: 36836327 PMCID: PMC9959558 DOI: 10.3390/jof9020213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
The early innate immune response to coccidioidomycosis has proven to be pivotal in directing the adaptive immune response and disease outcome in mice and humans but is unexplored in dogs. The objectives of this study were to evaluate the innate immune profile of dogs with coccidioidomycosis and determine if differences exist based on the extent of infection (i.e., pulmonary or disseminated). A total of 28 dogs with coccidioidomycosis (pulmonary, n = 16; disseminated, n = 12) and 10 seronegative healthy controls were enrolled. Immunologic testing was performed immediately, without ex vivo incubation (i.e., constitutive), and after coccidioidal antigen stimulation of whole blood cultures. Whole blood cultures were incubated with a phosphate-buffered solution (PBS) (negative control) or a coccidioidal antigen (rCTS1 (105-310); 10 µg/mL) for 24 h. A validated canine-specific multiplex bead-based assay was used to measure 12 cytokines in plasma and cell culture supernatant. Serum C-reactive protein (CRP) was measured with an ELISA assay. Leukocyte expression of toll-like receptors (TLRs)2 and TLR4 was measured using flow cytometry. Dogs with coccidioidomycosis had higher constitutive plasma keratinocyte chemotactic (KC)-like concentrations (p = 0.02) and serum CRP concentrations compared to controls (p < 0.001). Moreover, dogs with pulmonary coccidioidomycosis had higher serum CRP concentrations than those with dissemination (p = 0.001). Peripheral blood leukocytes from dogs with coccidioidomycosis produced higher concentrations of tumor necrosis factor (TNF)-α (p = 0.0003), interleukin (IL)-6 (p = 0.04), interferon (IFN)-γ (p = 0.03), monocyte chemoattractant protein (MCP)-1 (p = 0.02), IL-10 (p = 0.02), and lower IL-8 (p = 0.003) in supernatants following coccidioidal antigen stimulation when compared to those from control dogs. There was no detectable difference between dogs with pulmonary and disseminated disease. No differences in constitutive or stimulated leukocyte TLR2 and TLR4 expression were found. These results provide information about the constitutive and coccidioidal antigen-specific stimulated immune profile in dogs with naturally acquired coccidioidomycosis.
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Affiliation(s)
- Jared A. Jaffey
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
- Correspondence:
| | - Lisa F. Shubitz
- Valley Fever Center for Excellence, College of Medicine-Tucson, University of Arizona, Tucson, AZ 85724, USA
| | - Michael D. L. Johnson
- Department of Immunobiology, Valley Fever Center for Excellence, BIO5 Institute, Asthma and Airway Disease Research Center, University of Arizona, College of Medicine-Tucson, Tucson, AZ 85724, USA
| | - Charlotte A. Bolch
- Office of Research and Sponsored Programs, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
| | - Anderson da Cunha
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Ashlesh K. Murthy
- Department of Pathology, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Brina S. Lopez
- Department of Pathology, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Ross Monasky
- Department of Pathology, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Imani Carswell
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Justine Spiker
- Department of Specialty Medicine, College of Veterinary Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Miranda J. Neubert
- Department of Immunobiology, College of Medicine-Tucson, Tucson, AZ 85724, USA
| | - Sanjay V. Menghani
- Department of Immunobiology, Medical Scientist Training Program, College of Medicine-Tucson, Tucson, AZ 85724, USA
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Ferreira SDC, Nóbrega FJF, de Araújo RC, de Almeida PH, Villanova MG, Santana RDC, Zambelli Ramalho LN, Martinelli ADLC, Troncon LEDA. Histoplasmosis Related to Immunosuppression in a Patient with Crohn's Disease: A Diagnostic Challenge. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e925345. [PMID: 34495947 PMCID: PMC8438646 DOI: 10.12659/ajcr.925345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Infliximab, a monoclonal antibody against tumor necrosis factor (TNF) alpha with proven efficacy and known safety profile, is currently widely used in the treatment of inflammatory bowel diseases. Increased risk for serious infections and malignant neoplasms secondary to immunosuppression is a major concern during therapy with this medication. Histoplasmosis is a granulomatous disease caused by the fungus Histoplasma capsulatum. Disseminated forms of the disease have immunodepression as a major risk factor. CASE REPORT A 39-years-old man had been followed with refractory fistulizing ileocolonic Crohn's disease using combination therapy (infliximab plus azathioprine) and also receiving short courses of steroids. After 2 years of this immunosuppressive therapy, the patient presented with high fever (39.5ºC) for 5 days, associated with profuse sweating, and moderate pain in the left hypochondrium. The patient was hospitalized. Diagnoses of tuberculosis, malignancy, autoimmune diseases, and bacterial and viral infections were rapidly discarded after investigation. Clinical, laboratory, and image signs of liver involvement prompted a guided percutaneous biopsy, which revealed granulomatous hepatitis, with the presence of fungal structures suggestive of Histoplasma capsulatum. Upon treatment with liposomal amphotericin followed by itraconazole, the patient showed an impressively positive clinical response. CONCLUSIONS TNF blockers, particularly when associated with other immunosuppressors, are a serious risk factor for opportunistic infections. This unusual case of disseminated histoplasmosis in a patient with Crohn's disease using infliximab in combination with azathioprine and steroids emphasizes the need for surveillance of this uncommon but potentially lethal complication before starting TNF blockers therapy.
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Affiliation(s)
- Sandro da Costa Ferreira
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Fernando Jorge Firmino Nóbrega
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Roberta Chaves de Araújo
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Patrícia Holanda de Almeida
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Márcia Guimarães Villanova
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Rodrigo de Carvalho Santana
- Division of Infectious Diseases, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | | | - Ana de Lourdes Candolo Martinelli
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Luiz Ernesto de Almeida Troncon
- Division of Gastroenterology, Department of Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
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4
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Ward RA, Thompson GR, Villani AC, Li B, Mansour MK, Wuethrich M, Tam JM, Klein BS, Vyas JM. The Known Unknowns of the Immune Response to Coccidioides. J Fungi (Basel) 2021; 7:jof7050377. [PMID: 34065016 PMCID: PMC8151481 DOI: 10.3390/jof7050377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/11/2022] Open
Abstract
Coccidioidomycosis, otherwise known as Valley Fever, is caused by the dimorphic fungi Coccidioides immitis and C. posadasii. While most clinical cases present with self-limiting pulmonary infection, dissemination of Coccidioides spp. results in prolonged treatment and portends higher mortality rates. While the structure, genome, and niches for Coccidioides have provided some insight into the pathogenesis of disease, the underlying immunological mechanisms of clearance or inability to contain the infection in the lung are poorly understood. This review focuses on the known innate and adaptive immune responses to Coccidioides and highlights three important areas of uncertainty and potential approaches to address them. Closing these gaps in knowledge may enable new preventative and therapeutic strategies to be pursued.
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Affiliation(s)
- Rebecca A. Ward
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA; (R.A.W.); (M.K.M.)
| | - George R. Thompson
- Department of Internal Medicine, University of California Davis Medical Center, Sacramento, CA 96817, USA;
| | - Alexandra-Chloé Villani
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; (A.-C.V.); (B.L.)
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Harvard Medical School, Boston, MA 02115, USA;
| | - Bo Li
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA; (A.-C.V.); (B.L.)
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Harvard Medical School, Boston, MA 02115, USA;
| | - Michael K. Mansour
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA; (R.A.W.); (M.K.M.)
- Harvard Medical School, Boston, MA 02115, USA;
| | - Marcel Wuethrich
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA; (M.W.); (B.S.K.)
| | - Jenny M. Tam
- Harvard Medical School, Boston, MA 02115, USA;
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
| | - Bruce S. Klein
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA; (M.W.); (B.S.K.)
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
- Department of Medical Microbiology and Immunology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53706, USA
| | - Jatin M. Vyas
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA; (R.A.W.); (M.K.M.)
- Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: ; Tel.: +1-617-643-6444
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5
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Heung LJ. Monocytes and the Host Response to Fungal Pathogens. Front Cell Infect Microbiol 2020; 10:34. [PMID: 32117808 PMCID: PMC7031161 DOI: 10.3389/fcimb.2020.00034] [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: 10/30/2019] [Accepted: 01/17/2020] [Indexed: 12/11/2022] Open
Abstract
Monocytes and their derivatives, including macrophages and dendritic cells, play diverse roles in the response to fungal pathogens. Sensing of fungi by monocytes triggers signaling pathways that mediate direct effects like phagocytosis and cytokine production. Monocytes can also present fungal antigens to elicit adaptive immune responses. These monocyte-mediated pathways may be either beneficial or harmful to the host. In some instances, fungi have developed mechanisms to evade the consequences of monocyte activation and subvert these cells to promote disease. Thus, monocytes are critically involved in mediating the outcomes of these often highly fatal infections. This review will highlight the roles of monocytes in the immune response to some of the major fungi that cause invasive human disease, including Aspergillus, Cryptococcus, Candida, Histoplasma, Blastomyces, and Coccidioides, and discuss potential strategies to manipulate monocyte responses in order to enhance anti-fungal immunity in susceptible hosts.
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Affiliation(s)
- Lena J Heung
- Division of Infectious Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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6
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Blair JE, Ampel NM, Hoover SE. Coccidioidomycosis in selected immunosuppressed hosts. Med Mycol 2019; 57:S56-S63. [PMID: 29669037 DOI: 10.1093/mmy/myy019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/08/2018] [Indexed: 12/23/2022] Open
Abstract
After contracting coccidioidomycosis, persons with impaired cellular immunity are more likely than healthy persons to have severe infection, disseminated infection, and higher mortality rates. In this brief review, we summarize the clinical manifestations, diagnosis, treatment, and prevention of coccidioidomycosis in persons infected with human immunodeficiency virus (HIV), recipients of solid organ or hematopoietic stem cell transplants, and recipients of biologic response modifiers. Among individuals infected with HIV, a diagnosis of acquired immunodeficiency syndrome (AIDS) and a CD4 T-lymphocyte count <250 cells/μl were associated with more severe coccidioidomycosis, whereas less severe disease occurred among those with undetectable HIV-RNA and higher CD4 T-lymphocyte counts, indicating that controlled HIV viremia and improved cellular immune status are important in limiting disease. For transplant recipients whose immunosuppression typically peaks in the first 3 to 6 months and tapers thereafter, the greatest risk of acute coccidioidomycosis occurs 6 to 12 months after transplantation. Relapses of recent coccidioidomycosis may occur during ongoing immunosuppression when patients are not taking suppressive antifungal medication. Recipients of biologic agents, especially those that impair tumor necrosis factor α (TNF-α), may be at increased risk for poorly controlled coccidioidomycosis; however, the best way to prevent and treat such infections has yet to be defined.
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Affiliation(s)
- Janis E Blair
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Neil M Ampel
- Division of Infectious Diseases, Mayo Clinic Hospital, Phoenix, Arizona, USA.,Southern Arizona Veterans Affairs Medical Center, Tucson, Arizona, USA
| | - Susan E Hoover
- Division of Infectious Diseases, Sanford Health, Sioux Falls, South Dakota, USA
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7
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Şeyhoğlu E, Erden A, Kılıç L, Karadağ Ö, Akdağlı SA, Akdoğan A, Kalyoncu U. Pulmonary aspergillosis after treatment with infliximab in Still's disease and a literature review of Still's disease and pulmonary aspergillosis. Eur J Rheumatol 2018; 5:75-78. [PMID: 29657880 DOI: 10.5152/eurjrheum.2016.15081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The use of anti-tumor necrosis factor alpha (anti-TNF-α) agents has increased during the past decade in rheumatology practice. Opportunistic infections have been reported with anti-TNF-α agents in clinical trials and post-marketing usage. Aspergillus infection is a rare opportunistic infection that is associated with immunosuppression, and there are reported cases of pulmonary aspergillosis in various rheumatic diseases treated with anti-TNF-α agents. Here, we present the first case of pulmonary aspergillosis associated with infliximab treatment in a patient with Still's disease.
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Affiliation(s)
- Emrah Şeyhoğlu
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Abdülsamet Erden
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Levent Kılıç
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ömer Karadağ
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Sevtap Arıkan Akdağlı
- Department of Medical Microbiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ali Akdoğan
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Umut Kalyoncu
- Division of Rheumatology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
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8
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Immune Response to Coccidioidomycosis and the Development of a Vaccine. Microorganisms 2017; 5:microorganisms5010013. [PMID: 28300772 PMCID: PMC5374390 DOI: 10.3390/microorganisms5010013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 03/03/2017] [Accepted: 03/14/2017] [Indexed: 02/07/2023] Open
Abstract
Coccidioidomycosis is a fungal infection caused by Coccidioides posadasii and Coccidioides immitis. It is estimated that 150,000 new infections occur in the United States each year. The incidence of this infection continues to rise in endemic regions. There is an urgent need for the development of better therapeutic drugs and a vaccine against coccidioidomycosis. This review discusses the features of host innate and adaptive immune responses to Coccidioides infection. The focus is on the recent advances in the immune response and host-pathogen interactions, including the recognition of spherules by the host and defining the signal pathways that guide the development of the adaptive T-cell response to Coccidioides infection. Also discussed is an update on progress in developing a vaccine against these fungal pathogens.
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9
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Gundacker ND, Baddley JW. Fungal Infections in the Era of Biologic Therapies. CURRENT CLINICAL MICROBIOLOGY REPORTS 2015. [DOI: 10.1007/s40588-015-0018-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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10
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Johnson L, Gaab EM, Sanchez J, Bui PQ, Nobile CJ, Hoyer KK, Peterson MW, Ojcius DM. Valley fever: danger lurking in a dust cloud. Microbes Infect 2014; 16:591-600. [PMID: 25038397 DOI: 10.1016/j.micinf.2014.06.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/23/2014] [Accepted: 06/24/2014] [Indexed: 12/01/2022]
Abstract
Coccidioides immitis and Coccidioides posadasii contribute to the development of Valley Fever. The ability of these fungal pathogens to evade the host immune system creates difficulty in recognition and treatment of this debilitating infection. In this review, we describe the current knowledge of Valley Fever and approaches to improve prevention, detection, and treatment.
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Affiliation(s)
- Larry Johnson
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Erin M Gaab
- Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Javier Sanchez
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Phuong Q Bui
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Clarissa J Nobile
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Katrina K Hoyer
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA
| | - Michael W Peterson
- Department of Internal Medicine, University of California San Francisco - Fresno, Fresno, CA 93703, USA
| | - David M Ojcius
- Department of Molecular Cell Biology, University of California, Merced, CA 95343, USA; Health Sciences Research Institute, University of California, Merced, CA 95343, USA.
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11
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Abstract
Patients with inflammatory bowel disease are susceptible to complications from pharmacologic treatment of their disease. Tumor necrosis factor (TNF)-α inhibitors are being used increasingly in the treatment of inflammatory bowel disease and can be associated with adverse events, including common infections, and rarely the development of serious life-threatening opportunistic infections. TNF-α inhibitors have the ability to prevent an effective patient granulomatous response, and this may be associated with an increased risk of developing mycobacterial and certain fungal infections, including histoplasmosis, blastomycosis, and coccidioidomycosis, endemic in several parts of the United States. The concern for invasive fungal infection was realized during clinical trials and further demonstrated after the marketing of TNF-α inhibitors. Because of this awareness, the Food and Drug Administration developed an adverse event-reporting system to capture cases of infections associated with the use of TNF-α inhibitors. These opportunistic fungi have a great degree of regional variability, and it has been very difficult to quantify the incidence of infection in patients treated with TNF-α inhibitors. Currently, there are no formal guidelines regarding the use of TNF-α inhibitors and these fungal infections. Considering that gastroenterologists have embraced the use TNF-α inhibitors as a valuable armamentarium in the treatment of inflammatory bowel disease, they must be aware of therapy-related infectious complications, including appropriate diagnostic, therapeutic, and preventive strategies. In this article, we explore the association of these fungal entities in relation to the TNF-α inhibitor therapy by considering information provided in the gastroenterology, infectious diseases, rheumatology, and transplant literature. Finally, we provide some recommendations on diagnosis and treatment.
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Vinh DC, Schwartz B, Hsu AP, Miranda DJ, Valdez PA, Fink D, Lau KP, Long-Priel D, Kuhns DB, Uzel G, Pittaluga S, Hoover S, Galgiani JN, Holland SM. Interleukin-12 receptor β1 deficiency predisposing to disseminated Coccidioidomycosis. Clin Infect Dis 2011; 52:e99-e102. [PMID: 21258095 DOI: 10.1093/cid/ciq215] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Donald C Vinh
- Immunopathogenesis Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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13
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Borchers AT, Gershwin ME. The immune response in Coccidioidomycosis. Autoimmun Rev 2010; 10:94-102. [DOI: 10.1016/j.autrev.2010.08.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 08/13/2010] [Indexed: 12/20/2022]
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14
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Nedel WL, Kontoyiannis DP, Pasqualotto AC. Aspergillosis in patients treated with monoclonal antibodies. Rev Iberoam Micol 2009; 26:175-83. [DOI: 10.1016/j.riam.2009.04.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Accepted: 04/01/2009] [Indexed: 12/16/2022] Open
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15
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Siqueira KZ, Campos Soares ÂMVD, Dias-Melicio LA, Calvi SA, Peraçoli MTS. Interleukin-6 treatment enhances human monocyte permissiveness forParacoccidioides brasiliensisgrowth by modulating cytokine production. Med Mycol 2009; 47:259-67. [DOI: 10.1080/13693780802244204] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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16
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do Nascimento MPP, de Campos Soares AMV, Dias-Melicio LA, Parise-Fortes MR, Martins RAR, Nakaira ET, Peraçoli MTS. Fungicidal activity of human monocyte-derived multinucleated giant cells induced in vitro by Paracoccidioides brasiliensis antigen. Mycopathologia 2008; 166:25-33. [DOI: 10.1007/s11046-007-9051-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 08/14/2007] [Indexed: 10/22/2022]
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17
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Wong M, Ziring D, Korin Y, Desai S, Kim S, Lin J, Gjertson D, Braun J, Reed E, Singh RR. TNFalpha blockade in human diseases: mechanisms and future directions. Clin Immunol 2008; 126:121-36. [PMID: 17916444 PMCID: PMC2291518 DOI: 10.1016/j.clim.2007.08.013] [Citation(s) in RCA: 211] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 08/16/2007] [Indexed: 02/07/2023]
Abstract
Tumor necrosis factor-alpha (TNFalpha) antagonists have shown remarkable efficacy in a variety of immune-mediated inflammatory diseases (IMIDs). Therapeutic scope and limitations of these agents are reviewed in a recently published article in the Journal. In spite of their therapeutic popularity, little is known about their modes of action in vivo and factors that limit their scope of therapeutic use. Intriguingly, while all TNFalpha antagonists including blocking antibodies and soluble receptors are effective in certain IMIDs, only anti-TNFalpha antibodies are effective in other IMIDs. Early efforts at understanding how TNFalpha antagonists act in IMIDs centered on their ability to neutralize soluble TNFalpha or to block TNF receptors from binding to their ligands. Subsequent studies suggested a role of complement-mediated lysis or antibody-dependent cell cytotoxicity in their therapeutic effects. More recent models postulate that TNFalpha blockers may act by affecting intracellular signaling, with the end result being a hastened cell cycle arrest, apoptosis, suppression of cytokine production, or improved Treg cell function. TNFalpha antagonists can also modulate the functions of myofibroblasts and osteoclasts, which might explain how TNFalpha antagonists reduce tissue damage in chronic IMIDs. Focusing on the human therapeutic experience, this analytical review will review the biology of mechanisms of action, the limiting factors contributing to disease restriction in therapeutic efficacy, and the mechanism and frequency of treatment-limiting adverse responses of TNFalpha antagonists. It is hoped that the overview will address the needs of clinicians to decide on optimal use, spur clinical innovation, and incite translational researchers to set priorities for in vivo human investigations.
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MESH Headings
- Adalimumab
- Animals
- Anti-Inflammatory Agents, Non-Steroidal/adverse effects
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antirheumatic Agents/adverse effects
- Antirheumatic Agents/therapeutic use
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/immunology
- Cytokines/immunology
- Cytokines/metabolism
- Etanercept
- Humans
- Immunoglobulin G/adverse effects
- Immunoglobulin G/therapeutic use
- Inflammation/drug therapy
- Inflammation/immunology
- Inflammatory Bowel Diseases/drug therapy
- Inflammatory Bowel Diseases/immunology
- Infliximab
- Receptors, Tumor Necrosis Factor/immunology
- Receptors, Tumor Necrosis Factor/metabolism
- Receptors, Tumor Necrosis Factor/therapeutic use
- Tumor Necrosis Factor-alpha/antagonists & inhibitors
- Tumor Necrosis Factor-alpha/immunology
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
| | | | | | - Sheetal Desai
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Sungjin Kim
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Jan Lin
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - David Gjertson
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Jonathan Braun
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Elaine Reed
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - Ram Raj Singh
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
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18
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Desai SB, Furst DE. Problems encountered during anti-tumour necrosis factor therapy. Best Pract Res Clin Rheumatol 2007; 20:757-90. [PMID: 16979537 DOI: 10.1016/j.berh.2006.06.002] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Worldwide, over 400,000 patients have been treated with tumour necrosis factor (TNF)-alpha antagonists for indications that include rheumatoid arthritis, juvenile rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis and ankylosing spondylitis. Since their approval, concerns regarding safety have been raised. There is a risk of re-activation of granulomatous diseases, especially tuberculosis, and measures should be taken for detection and treatment of latent tuberculosis infections. Preliminary data suggest that anti-TNF therapy may be safe in chronic hepatitis C. However, TNF-alpha antagonists have resulted in re-activation of chronic hepatitis B if not given concurrently with antiviral therapy. Solid tumours do not appear to be increased with anti-TNF therapy. Variable rates of increased lymphoma risk have been described with anti-TNF therapy compared with the general population, although no increased risk was found compared with a rheumatoid arthritis population. Large phase II and III trials with TNF-alpha antagonists in advanced heart failure have shown trends towards a worse prognosis, and should therefore be avoided in this population. Both etanercept and infliximab are associated with the formation of autoantibodies, and these autoantibodies are rarely associated with any specific clinical syndrome. Rare cases of aplastic anaemia, pancytopenia, vasculitis and demyelination have been described with anti-TNF therapy. This chapter will discuss the safety profile and adverse events of the three commercially available TNF-alpha antagonists: etanercept, infliximab and adalimumab. The data presented in this review have been collected from published data, individual case reports or series, package inserts, the Food and Drug Administration postmarketing adverse events surveillance system, and abstracts from the American College of Rheumatology and European Congress of Rheumatology meetings for 2005.
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Affiliation(s)
- Sheetal B Desai
- Department of Rheumatology, University of California, Los Angeles, CA 90095-1670, USA.
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19
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Zucker KE, Kamberi P, Sobel RA, Cloud G, Meli DN, Clemons KV, Stevens DA, Williams PL, Leib SL. Temporal expression of inflammatory mediators in brain basilar artery vasculitis and cerebrospinal fluid of rabbits with coccidioidal meningitis. Clin Exp Immunol 2006; 143:458-66. [PMID: 16487245 PMCID: PMC1809608 DOI: 10.1111/j.1365-2249.2006.03011.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2005] [Indexed: 11/29/2022] Open
Abstract
Strokes due to transmural vasculitis associated with coccidioidal meningitis result in significant morbidity and mortality. The immunological and inflammatory processes responsible are poorly understood. To determine the inflammatory mediators, i.e. cytokines, chemokines, iNOS, matrix metalloproteinase-9 (MMP-9), that possibly contribute to vasculitis, temporal mRNA expression in brain basilar artery samples and MMP-9 protein in the CSF of male NZW rabbits infected intracisternally with 6.5 x 10(4) arthroconidia of Coccidioides immitis were assessed. Five infected and 3 sham-injected rabbits at each time point were euthanized 4, 9, 14 and 20 days post infection. All infected rabbits had neurological abnormalities and severe vasculitis in the basilar arteries on days 9-20. In basilar arteries of infected animals versus controls, mRNAs encoding for IL-6, iNOS, IFN-gamma, IL-2, MCP-1, IL-1beta, IL-10, TNF-alpha, CCR-1, MMP-9, TGF-beta, as well as MMP-9 protein in CSF, were found to be significantly up-regulated. Thus, this study identified inflammatory mediators associated with CNS vasculitis and meningitis due to C. immitis infection. Assessment of the individual contribution of each mediator to vasculitis may offer novel approaches to the treatment of coccidioidal CNS infection. This study also provides unique methodology for immunology studies in a rabbit model.
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Affiliation(s)
- K E Zucker
- Dept. of Laboratory Medicine (SC-12), Children's Hospital Central California, 9300 Valley Children's Place, Madera, CA 93638-8762, USA.
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20
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Abstract
Tumor necrosis factor (TNF)-alpha antagonists are promising therapeutic agents for patients with severe autoimmune and rheumatologic conditions. Unfortunately, their use has been associated with an increased rate of tuberculosis, endemic mycoses, and intracellular bacterial infections. Infliximab, 1 of 3 available drugs in this novel class, appears to be associated with the greatest risk of infection, likely because of its long half-life and induction of monocyte apoptosis. Prospective trials are necessary to determine the exact risk associated with these agents, particularly the newer TNF-alpha antagonists. More specific TNF-alpha blockers, which reduce inflammation while maintaining adequate immunity, are needed. In the meantime, a thorough work-up is mandatory for all febrile illness occurring in TNF-alpha blocker recipients. We present 4 patients who developed severe infections during TNF-alpha antagonist therapy, review the literature, and discuss current guidelines for surveillance and prophylaxis.
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Affiliation(s)
- Nancy F Crum
- From Infectious Diseases Division (NFC, MRW), Naval Medical Center San Diego, San Diego, California and United States Naval Medical Research Unit 2 (ERL), Jakarta, Indonesia
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21
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Cox RA, Magee DM. Coccidioidomycosis: host response and vaccine development. Clin Microbiol Rev 2004; 17:804-39, table of contents. [PMID: 15489350 PMCID: PMC523560 DOI: 10.1128/cmr.17.4.804-839.2004] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Coccidioidomycosis is caused by the dimorphic fungi in the genus Coccidioides. These fungi live as mycelia in the soil of desert areas of the American Southwest, and when the infectious spores, the arthroconidia, are inhaled, they convert into the parasitic spherule/endospore phase. Most infections are mild, but these organisms are frank pathogens and can cause severe lethal disease in fully immunocompetent individuals. While there is increased risk of disseminated disease in certain racial groups and immunocompromised persons, the fact that there are hosts who contain the initial infection and exhibit long-term immunity to reinfection supports the hypothesis that a vaccine against these pathogens is feasible. Multiple studies have shown that protective immunity against primary disease is associated with T-helper 1 (Th-1)-associated immune responses. The single best vaccine in animal models, formalin-killed spherules (FKS), was tested in a human trial but was not found to be significantly protective. This result has prompted studies to better define immunodominant Coccidioides antigen with the thought that a subunit vaccine would be protective. These efforts have defined multiple candidates, but the single best individual immunogen is the protein termed antigen 2/proline-rich antigen (Ag2/PRA). Studies in multiple laboratories have shown that Ag2/PRA as both protein and genetic vaccines provides significant protection against mice challenged systemically with Coccidioides. Unfortunately, compared to the FKS vaccine, it is significantly less protective as measured by both assays of reduction in fungal CFU and assays of survival. The capacity of Ag2/PRA to induce only partial protection was emphasized when animals were challenged intranasally. Thus, there is a need to define new candidates to create a multivalent vaccine to increase the effectiveness of Ag2/PRA. Efforts of genomic screening using expression library immunization or bioinformatic approaches to identify new candidates have revealed at least two new protective proteins, expression library immunization antigen 1 (ELI-Ag1) and a beta-1,3-glucanosyltransferase (GEL-1). In addition, previously discovered antigens such as Coccidioides-specific antigen (CSA) should be evaluated in assays of protection. While studies have yet to be completed with combinations of the current candidates, the hypothesis is that with increased numbers of candidates in a multivalent vaccine, there will be increased protection. As the genome sequences of the two Coccidioides strains which are under way are completed and annotated, the effort to find new candidates can increase to provide a complete genomic scan for immunodominant proteins. Thus, much progress has been made in the discovery of subunit vaccine candidates against Coccidioides and there are several candidates showing modest levels of protection, but for complete protection against pulmonary challenge we need to continue the search for additional candidates.
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Affiliation(s)
- Rebecca A Cox
- Department of Microbiology and Immunology, The University of Texas Health Science Center at San Antonio, Texas Research Park, 15355 Lambda Dr., San Antonio, TX 78245-3027, USA.
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22
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Kuberski TT, Servi RJ, Rubin PJ. Successful treatment of a critically ill patient with disseminated coccidioidomycosis, using adjunctive interferon-gamma. Clin Infect Dis 2004; 38:910-2. [PMID: 14999639 DOI: 10.1086/382075] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2003] [Accepted: 11/18/2003] [Indexed: 11/04/2022] Open
Abstract
Conventional antifungal therapy was not successful for a critically ill patient who had been hospitalized for 137 days in the intensive care unit with disseminated Coccidioides immitis infection and respiratory failure. The addition of interferon- gamma to the therapeutic regimen resulted in improvement and discharge from the hospital. Adjunctive interferon- gamma used in the successful treatment of severe coccidioidomycosis has not been reported previously.
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23
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Bergstrom L, Yocum DE, Ampel NM, Villanueva I, Lisse J, Gluck O, Tesser J, Posever J, Miller M, Araujo J, Kageyama DM, Berry M, Karl L, Yung CM. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor ? antagonists. ACTA ACUST UNITED AC 2004; 50:1959-66. [PMID: 15188373 DOI: 10.1002/art.20454] [Citation(s) in RCA: 211] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe a group of patients who were treated with tumor necrosis factor alpha (TNF alpha) antagonists and who developed coccidioidomycosis, and to test the hypothesis that patients with inflammatory arthritis receiving TNF alpha antagonist therapy are at higher risk for developing symptomatic coccidioidomycosis. METHODS Cases of coccidioidomycosis were identified and reviewed from among patients receiving TNF alpha antagonist therapy from May 1998 through February 2003 in 5 practices within the areas endemic for coccidioidomycosis (Arizona, California, and Nevada). In addition, the relative risk of developing symptomatic coccidioidomycosis was calculated in patients with inflammatory arthritis who were receiving treatment with infliximab, in comparison with patients with inflammatory arthritis who were not receiving infliximab, from January 2000 to February 2003 in a single medical center. RESULTS Thirteen cases of documented coccidioidomycosis were associated with TNF alpha antagonist therapy. Twelve cases were associated with the use of infliximab and 1 case with etanercept. Among the cohort of patients from a single medical center, 7 of the 247 patients receiving infliximab and 4 of the 738 patients receiving other therapies developed symptomatic coccidioidomycosis (relative risk 5.23, 95% confidence interval 1.54-17.71; P < 0.01). CONCLUSION Patients with inflammatory arthritis who are undergoing treatment with infliximab appear to be at higher risk for developing symptomatic coccidioidomycosis as compared with those not receiving infliximab.
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24
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Calvi SA, Soares AMVC, Peraçoli MTS, Franco M, Ruiz RL, Marcondes-Machado J, Fecchio D, Mattos MCI, Mendes RP. Study of bronchoalveolar lavage fluid in paracoccidioidomycosis: cytopathology and alveolar macrophage function in response to gamma interferon; comparison with blood monocytes. Microbes Infect 2003; 5:1373-9. [PMID: 14670450 DOI: 10.1016/j.micinf.2003.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Patients with paracoccidioidomycosis (PCM) present marked involvement of the lungs during the course of the mycosis. The purpose of this work was to obtain bronchoalveolar lavage (BAL) fluid from these patients to study the cytopathology, TNF levels and the oxidative and fungicidal response of alveolar macrophages (AMs) to in vitro incubation with recombinant IFN-gamma. To compare the lung and blood compartments, these determinations were also made in plasma and blood monocytes (BMs) obtained from the same patients. The cytopathology of BAL fluid revealed a predominance of macrophages, but with the presence of neutrophil exudation, and rare lymphocytes and epithelioid and giant cells. Comparison of the oxidative status and fungicidal activity of AMs and circulating BMs demonstrated that both cell types are highly activated for these two functions when compared to control cells. However, TNF levels were higher in BAL fluid than in plasma. The possible mechanisms involved in the hyperresponsiveness of cells from PCM patients are discussed.
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Affiliation(s)
- Sueli A Calvi
- Department of Tropical Diseases and Imaging Diagnosis, São Paulo State University, Botucatu, São Paulo, Brazil
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25
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Calvi SA, Peraçoli MTS, Mendes RP, Marcondes-Machado J, Fecchio D, Marques SA, Soares AMVC. Effect of cytokines on the in vitro fungicidal activity of monocytes from paracoccidioidomycosis patients. Microbes Infect 2003; 5:107-13. [PMID: 12650768 DOI: 10.1016/s1286-4579(02)00078-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Peripheral blood monocytes obtained from paracoccidioidomycosis patients and healthy individuals were preactivated with recombinant gamma interferon (IFN-gamma) in different concentrations (250, 500 and 1000 U/ml) and evaluated for fungicidal activity against Paracoccidiodes brasiliensis strain 18 (Pb 18, high-virulence strain) and strain 265 (Pb 265, low-virulence strain) by plating of cocultures and counting of colony-forming units, after 10 d. Monocytes from healthy individuals failed to present fungicidal activity against P. brasiliensis even after IFN-gamma activation at the three concentrations. However, patient monocytes activated with IFN-gamma (1000 U/ml) showed a significant fungicidal activity when compared to that obtained with non-activated or activated cells with other IFN-gamma concentrations (250 and 500 U/ml). Moreover, patient monocytes presented higher fungicidal activity than the control, even before the activation process. These results may be explained by the activation state of patients' cells as a function of the in vivo contact with the fungus, which was confirmed by their higher capacity to release H(2)O(2) in vitro. Unlike the results obtained with Pb 18, patient and control cells presented a significant fungicidal activity against Pb 265, after priming with IFN- gamma. These results are explained by the higher levels of TNF-alpha in supernatants of cultures challenged with Pb 265. Moreover, higher levels of the cytokine were obtained in patient cell supernatants. Taken together, our results suggest that for effective killing of P. brasiliensis by monocytes, an initial activation signal induced by IFN-gamma is necessary to stimulate the cells to produce TNF-alpha. This cytokine may be involved, through an autocrine pathway, in the final phase activation process. The effectiveness of this process seems to depend on the virulence of the fungal strain and the activation state of the challenged cells.
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Affiliation(s)
- Sueli A Calvi
- Department of Tropical Diseases and Diagnosis by Image, São Paulo State University, Botucatu, SP, Brazil
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26
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Anjos AR, Calvi SA, Ferracini R, Peraçoli MTS, Silva CL, Soares AMVC. Role of Paracoccidioides brasiliensis cell wall fraction containing beta-glucan in tumor necrosis factor-alpha production by human monocytes: correlation with fungicidal activity. Med Mycol 2002; 40:377-82. [PMID: 12230216 DOI: 10.1080/mmy.40.4.377.382] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The polysaccharide fraction of Paracoccidioides brasiliensis mycelial cell wall (F1 fraction), the active component of which is composed of beta-glucan, was investigated in regard to the activation of human monocytes for fungal killing. The cells were primed with interferon-gamma (IFN-gamma) or F1 (100 and 200 microg ml(-1)) or F1 (100 and 200 microg ml(-1)) plus IFN-gamma for 24 h and then evaluated for H2O2 release. In other experiments, the cells were pretreated with the same stimuli, challenged with a virulent strain of P. brasiliensis and evaluated for fungicidal activity and levels of tumor necrosis factor (TNF-alpha) in the supernatants. F1 increased the levels of H2O2 in a similar manner to IFN-gamma. However, a synergistic effect between these two activators was not detected. On the contrary, a significant fungicidal activity was only obtained after priming with IFN-gamma plus F1. This higher activity was associated with high levels of TNF-alpha in the supernatants of the cocultures. Overall, P. brasiliensis F1 fraction induced human monocytes to release relatively high levels of TNF-alpha, which, in combination with IFN-gamma, is responsible for the activation of human monocytes for effective killing of P. brasiliensis.
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27
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Abuodeh RO, Shubitz LF, Siegel E, Snyder S, Peng T, Orsborn KI, Brummer E, Stevens DA, Galgiani JN. Resistance to Coccidioides immitis in mice after immunization with recombinant protein or a DNA vaccine of a proline-rich antigen. Infect Immun 1999; 67:2935-40. [PMID: 10338502 PMCID: PMC96603 DOI: 10.1128/iai.67.6.2935-2940.1999] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Two inbred strains of mice (BALB/c and C57BL/6) were vaccinated with either recombinant expression protein of a Coccidioides immitis spherule-derived proline-rich antigen (rPRA) in monophosphoryl lipid A-oil emulsion adjuvant or a DNA vaccine based on the same antigen. Four weeks after vaccination, mice were infected intraperitoneally with arthroconidia. By 2 weeks, groups of mice receiving saline or plasmids with no PRA insert exhibited significant weight loss, and quantitative CFUs in the lungs ranged from 5.9 to 6.4 log10. In contrast, groups of mice immunized with either rPRA or DNA vaccine had significantly smaller pulmonary fungal burdens, ranging from 3.0 to 4.5 log10 fewer CFUs. In vitro immunologic markers of lymphocyte proliferation and gamma interferon (IFN-gamma) release after splenocytes were stimulated with rPRA correlated with protection. Also, plasma concentrations of rPRA-specific total immunoglobulin G (IgG), IgG1, and IgG2a showed increases in vaccinated mice. These studies expand earlier work by demonstrating protection in mice which differ in H-2 background, by using an adjuvant that is potentially applicable to human use, and by achieving comparable protections with a DNA-based vaccine. Our in vitro results substantiate a Th1 response as evidenced by IFN-gamma release and increased IgG2a. However, IgG1 was also stimulated, suggesting some Th2 response as well. PRA is a promising vaccine candidate for prevention of coccidioidomycosis and warrants further investigation.
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Affiliation(s)
- R O Abuodeh
- Valley Fever Center for Excellence, Veterans Affairs Medical Center, and University of Arizona, Tucson, Arizona, USA
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28
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Kullberg BJ, Anaissie EJ. Cytokines as therapy for opportunistic fungal infections. RESEARCH IN IMMUNOLOGY 1998; 149:478-88; discussion 515. [PMID: 9720965 DOI: 10.1016/s0923-2494(98)80771-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Cox RA, Magee DM. Protective immunity in coccidioidomycosis. RESEARCH IN IMMUNOLOGY 1998; 149:417-28; discussion 506-7. [PMID: 9720959 DOI: 10.1016/s0923-2494(98)80765-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- R A Cox
- Department of Clinical Investigation, Texas Center for Infectious Disease, San Antonio 78223, USA
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30
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Zimmermann CR, Johnson SM, Martens GW, White AG, Zimmer BL, Pappagianis D. Protection against lethal murine coccidioidomycosis by a soluble vaccine from spherules. Infect Immun 1998; 66:2342-5. [PMID: 9573127 PMCID: PMC108201 DOI: 10.1128/iai.66.5.2342-2345.1998] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/1997] [Accepted: 01/02/1998] [Indexed: 02/07/2023] Open
Abstract
The formaldehyde-killed, whole-spherule vaccine, which is protective against lethal challenge of laboratory animals with Coccidioides immitis, was fractionated. It yielded a soluble, multicomponent, subcellular fraction termed the 27K vaccine. This vaccine, when it was accompanied by adjuvant, protected mice against lethal intranasal and intravenous challenge with C. immitis.
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Affiliation(s)
- C R Zimmermann
- Department of Medical Microbiology and Immunology, School of Medicine, University of California, Davis 95616, USA.
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31
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Lucey DR, Clerici M, Shearer GM. Type 1 and type 2 cytokine dysregulation in human infectious, neoplastic, and inflammatory diseases. Clin Microbiol Rev 1996; 9:532-62. [PMID: 8894351 PMCID: PMC172909 DOI: 10.1128/cmr.9.4.532] [Citation(s) in RCA: 441] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
In the mid-1980s, Mosmann, Coffman, and their colleagues discovered that murine CD4+ helper T-cell clones could be distinguished by the cytokines they synthesized. The isolation of human Th1 and Th2 clones by Romagnani and coworkers in the early 1990s has led to a large number of reports on the effects of Th1 and Th2 on the human immune system. More recently, cells other than CD4+ T cells, including CD8+ T cells, monocytes, NK cells, B cells, eosinophils, mast cells, basophils, and other cells, have been shown to be capable of producing "Th1" and "Th2" cytokines. In this review, we examine the literature on human diseases, using the nomenclature of type 1 (Th1-like) and type 2 (Th2-like) cytokines, which includes all cell types producing these cytokines rather than only CD4+ T cells. Type 1 cytokines include interleukin-2 (IL-2), gamma interferon, IL-12 and tumor necrosis factor beta, while type 2 cytokines include IL-4, IL-5, IL-6, IL-10, and IL-13. In general, type 1 cytokines favor the development of a strong cellular immune response whereas type 2 cytokines favor a strong humoral immune response. Some of these type 1 and type 2 cytokines are cross-regulatory. For example, gamma interferon and IL-12 decrease the levels of type 2 cytokines whereas IL-4 and IL-10 decrease the levels of type 1 cytokines. We use this cytokine perspective to examine human diseases including infections due to viruses, bacteria, parasites, and fungi, as well as selected neoplastic, atopic, rheumatologic, autoimmune, and idiopathic-inflammatory conditions. Clinically, type 1 cytokine-predominant responses should be suspected in any delayed-type hypersensitivity-like granulomatous reactions and in infections with intracellular pathogens, whereas conditions involving hypergammaglobulinemia, increased immunoglobulin E levels, and/or eosinophilia are suggestive of type 2 cytokine-predominant conditions. If this immunologic concept is relevant to human diseases, the potential exists for novel cytokine-based therapies and novel cytokine-directed preventive vaccines for such diseases.
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Affiliation(s)
- D R Lucey
- Experimental Immunology Branch, National Cancer Institute, Bethesda, Maryland 20892, USA
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32
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Cox RA, Magee DM. Production of tumor necrosis factor alpha, interleukin-1 alpha, and interleukin-6 during murine coccidioidomycosis. Infect Immun 1995; 63:4178-80. [PMID: 7558338 PMCID: PMC173589 DOI: 10.1128/iai.63.10.4178-4180.1995] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The proinflammatory cytokines tumor necrosis factor alpha (TNF-alpha), interleukin-1 alpha (IL-1 alpha), and interleukin-6 (IL-6) were induced in mice infected with Coccidioides immitis. Analyses of the cytokine profiles of two inbred mouse strains which differ in their susceptibility to pulmonary challenge with C. immitis revealed higher levels of IL-6 in lungs from DBA/2 mice (resistant strain) than in those from BALB/c mice (susceptible strain) beginning at day 6 and continuing through day 15 postinfection. Spleen cells from both mouse strains secreted TNF-alpha, IL-1 alpha, and IL-6 in vitro in response to stimulation with killed spherules but differed in that spleen cells from the resistant strain produced increased levels of these cytokines earlier after pulmonary challenge and at increased levels throughout the course of the disease.
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Affiliation(s)
- R A Cox
- Department of Research Immunology, Texas Center for Infectious Disease, San Antonio 78223-3597, USA
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33
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Magee DM, Cox RA. Roles of gamma interferon and interleukin-4 in genetically determined resistance to Coccidioides immitis. Infect Immun 1995; 63:3514-9. [PMID: 7642285 PMCID: PMC173486 DOI: 10.1128/iai.63.9.3514-3519.1995] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The profiles of gamma interferon (IFN-gamma) and interleukin-4 (IL-4) production were evaluated during the course of coccidioidomycosis in two inbred mouse strains which differ in their susceptibility to Coccidioides immitis. Cytokine responses, measured at the molecular and protein levels, showed increased levels of IFN-gamma in lung extracts from mice of the resistant DBA/2 strain after a pulmonary challenge, whereas the susceptible BALB/c strain manifested a predominant IL-4 response. The importance of these cytokines in host defense against C. immitis was established by treating the mice with recombinant cytokines or neutralizing anticytokine monoclonal antibodies. Treatment of the susceptible BALB/c mice with recombinant murine IFN-gamma significantly protected mice against systemic challenge, and in the reciprocal experiment, the administration of an anti-IFN-gamma monoclonal antibody to the resistant DBA/2 mice significantly decreased their capacity to control disease. Although the treatment of DBA/2 mice with recombinant IL-4 did not alter the disease, neutralization of endogenous IL-4 in infected BALB/c mice by administration of a neutralizing anti-IL-4 antibody led to a significant reduction in the fungal load in their tissues. These results, taken together, establish that IFN-gamma plays a pivotal role in resistance to C. immitis, whereas IL-4 down-regulates protective immunity against C. immitis.
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Affiliation(s)
- D M Magee
- Department of Research Immunology, Texas Center for Infectious Diseases, San Antonio 78223, USA
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Dooley DP, Cox RA, Hestilow KL, Dolan MJ, Magee DM. Cytokine induction in human coccidioidomycosis. Infect Immun 1994; 62:3980-3. [PMID: 8063416 PMCID: PMC303056 DOI: 10.1128/iai.62.9.3980-3983.1994] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
To investigate the immune response to human infection with the fungus Coccidioides immitis, we measured cytokine production from peripheral blood mononuclear cells (PBMC) and plastic-adherent monocytes/macrophages (Mphi) isolated from healthy subjects who were skin test positive to spherulin, healthy subjects who were skin test negative, and patients with active coccidioidomycosis. PBMC and Mphi from all these donor groups secreted increased levels of tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6 in response to stimulation with formalin-killed spherules (FKS), as measured by enzyme-linked immunosorbent assays. Viable C. immitis spherules also stimulated PBMC and Mphi from healthy subjects and patients to secrete tumor necrosis factor alpha, interleukin-1 beta, and interleukin-6, although at levels lower than those induced by FKS. The production of these acute inflammatory cytokines may contribute to the immunopathogenesis of active coccidioidomycosis and could account for the toxicity of the FKS vaccine in humans.
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Affiliation(s)
- D P Dooley
- Department of Research Immunology, Texas Center for Infectious Disease, San Antonio 78223-3597
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Kullberg BJ, van 't Wout JW. Cytokines in the treatment of fungal infections. BIOTHERAPY (DORDRECHT, NETHERLANDS) 1994; 7:195-210. [PMID: 7865351 DOI: 10.1007/bf01878486] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The incidence of invasive fungal infections in the immunocompromized host has increased during the past decade. Even the recently developed antifungal drugs are unable to cure these infections in patients with severely impaired host defense mechanisms. Cytokines have great potential to augment host resistance and as adjunctive therapy of invasive mycoses. We discuss the mechanisms of host defense against invasive candidiasis, aspergillosis, and cryptococcosis, and review the use of cytokines and growth factors in this setting. Interleukin-1 has been shown effective in an animal model of disseminated candidiasis, even during severe granulocytopenia. Interferon-gamma has been very effective as a modulator of resistance against a variety of fungal infections in vitro. The effect of interferon-gamma against disseminated candidiasis has been demonstrated in a mouse model. Activation of neutrophils is the main mechanism by which interferon-gamma enhances the elimination of Candida, and consequently the agent is not effective in severely granulocytopenic animals. Data on the role of colony-stimulating factors against fungal pathogens are accumulating, and trials with these agents for hematologic patients with invasive fungal infections are now being performed.
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Affiliation(s)
- B J Kullberg
- Department of Medicine, University Hospital Nijmegen, The Netherlands
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Galgiani JN. Coccidioidomycosis. West J Med 1993; 159:153-71. [PMID: 8212681 PMCID: PMC1022222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Coccidioidomycosis is a systemic fungal infection endemic to the southwestern United States and other parts of the western hemisphere. Although producing a wide range of disorders in healthy persons, immunosuppression predisposes to especially severe disease. Thus, a knowledge of the pathogenesis of coccidioidal infections and its relation to the normal immune responses is useful to understand the diversity of problems that Coccidioides immitis may cause. Diagnosis usually requires laboratory studies such as fungal culture or specific serologic testing. Fortunately, many patients do not need to be treated for the infection to resolve. Therapy for the more severe forms of coccidioidal infection was once limited to amphotericin B but now includes azole antifungal agents. These expanded alternatives now require physicians to weigh many factors in determining the best management for specific patients.
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Affiliation(s)
- J N Galgiani
- Medical Service, Department of Veterans Affairs Medical Center, Tucson, AZ 85723
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Ampel NM, Bejarano GC, Galgiani JN. Killing of Coccidioides immitis by human peripheral blood mononuclear cells. Infect Immun 1992; 60:4200-4. [PMID: 1398931 PMCID: PMC257453 DOI: 10.1128/iai.60.10.4200-4204.1992] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The ability of human peripheral blood mononuclear cells (MNL) obtained from healthy donors to kill the fungus Coccidioides immitis was examined in vitro with an assay that uses a single fungal particle per well. MNL killed 25.0% +/- 3.5% of a coccidioidal arthroconidial target, compared with the 4.7% +/- 2.9% killed by polymorphonuclear leukocytes obtained from the same donors (P = 0.012). Arthroconidial killing by MNL was not dependent on donor delayed dermal hypersensitivity to spherulin. Killing of another fungal target, Candida glabrata, was not significantly different between MNL and polymorphonuclear leukocytes (P = 0.783). Depletion of monocytes from MNL with Sephadex G-10 resulted in a significant reduction in arthroconidial killing (21.4% +/- 13.6% versus 2.4% +/- 3.4%; P = 0.025), while enrichment of monocytes by Percoll density gradient centrifugation or plastic adherence resulted in significantly increased arthroconidial killing compared with that by MNL (P = 0.005 and 0.001, respectively). Killing of 96-h spherules by MNL was 7.3% +/- 3.1%, significantly less than the 21.4% +/- 2.8% killing of arthroconidia in the same experiments (P = 0.016). Incubation of MNL with human recombinant gamma interferon or tumor necrosis factor alpha did not result in increased MNL killing of coccidioidal arthroconidia under various conditions. These results suggest that MNL have an inherent ability to kill coccidioidal arthroconidia in vitro which is not dependent on prior host exposure to C. immitis. This activity appears to reside in peripheral blood monocytes.
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Affiliation(s)
- N M Ampel
- Medical Service, Tucson Veterans Affairs Medical Center, Arizona
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Wu-Hsieh BA, Lee GS, Franco M, Hofman FM. Early activation of splenic macrophages by tumor necrosis factor alpha is important in determining the outcome of experimental histoplasmosis in mice. Infect Immun 1992; 60:4230-8. [PMID: 1398934 PMCID: PMC257457 DOI: 10.1128/iai.60.10.4230-4238.1992] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Experimental infection of animals with Histoplasma capsulatum caused a massive macrophage infiltration into the spleen and induced the production of tumor necrosis factor alpha (TNF-alpha) locally. The cytokine was also produced in vitro by peritoneal exudate macrophages exposed to a large inoculum of yeast cells. Depletion of the cytokine by injection of polyclonal sheep anti-TNF-alpha antibody was detrimental to sublethally infected mice. Fungous burdens in the spleens of TNF-alpha-depleted mice were higher than they were in the infected control mice at days 2, 7, and 9 after infection, and the antibody-treated animals succumbed to the infection. Histopathological study of spleen sections revealed that splenic macrophages were not able to control proliferation of intracellular yeasts as a result of TNF-alpha depletion. It seems that TNF-alpha plays a role in early activation of splenic macrophages which is important in controlling the outcome of an infection.
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Affiliation(s)
- B A Wu-Hsieh
- Department of Microbiology and Immunology, UCLA School of Medicine 90024
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