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Barker BM, Thompson GR, Ampel NM. Challenges to Implementing a Vaccine for Coccidioidomycosis. Open Forum Infect Dis 2024; 11:ofae095. [PMID: 38887487 PMCID: PMC11181188 DOI: 10.1093/ofid/ofae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/20/2024] [Indexed: 06/20/2024] Open
Abstract
A vaccine for coccidioidomycosis is likely to undergo trials in the near future. In this paper, we raise 4 questions that should be answered before its use and offer our solutions to these questions. These include defining the goals of vaccination, determining who should be vaccinated, how to measure vaccine immunity and protection, and how to address vaccine hesitancy and denial.
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Affiliation(s)
- Bridget M Barker
- Department of Biological Sciences, Northern Arizona University, Flagstaff, Arizona, USA
| | - George R Thompson
- Department of Medical Microbiology and Immunology, University of California at Davis, Davis, California, USA
| | - Neil M Ampel
- Departments of Medicine and Immunobiology, University of Arizona, Tucson, Arizona, USA
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2
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Hayes JF, Nix DE. Challenges Facing Antimicrobial Stewardship Programs in the Endemic Region for Coccidioidomycosis. Open Forum Infect Dis 2024; 11:ofae041. [PMID: 38887479 PMCID: PMC11181196 DOI: 10.1093/ofid/ofae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 06/20/2024] Open
Abstract
Coccidioidomycosis poses a significant cost and morbidity burden in the United States. Additionally, coccidioidomycosis requires constant decision-making related to prevention, diagnosis, and management. Delays in diagnosis lead to significant consequences, including unnecessary diagnostic workup and antibacterial therapy. Antifungal stewardship considerations regarding empiric, prophylactic, and targeted management of coccidioidomycosis are also complex. In this review, the problems facing antimicrobial stewardship programs (ASPs) in the endemic region for coccidioidomycosis, consequences due to delayed or missed diagnoses of coccidioidomycosis on antibacterial prescribing, and excess antifungal prescribing for prevention and treatment of coccidioidomycosis are elucidated. Finally, our recommendations and research priorities for ASPs in the endemic region for coccidioidomycosis are outlined.
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Affiliation(s)
- Justin F Hayes
- Division of Infectious Diseases, University of Arizona, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona, Tucson, Arizona, USA
| | - David E Nix
- Valley Fever Center for Excellence, University of Arizona, Tucson, Arizona, USA
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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3
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Ferguson AJ, Thompson GR, Bruyette D, Sykes JE. The dog as a sentinel and animal model for coccidioidomycosis. Med Mycol 2024; 62:myad139. [PMID: 38148116 DOI: 10.1093/mmy/myad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 12/28/2023] Open
Abstract
Coccidioidomycosis is a potentially fatal fungal disease of humans and animals that follows inhalation of Coccidioides spp. arthroconidia in the environment. The disease in dogs resembles that in people, and because dogs may be at increased risk of exposure due to their proximity to the ground and digging behavior, they are valuable models for the disease in humans. Dogs have been sentinels for identification of new regions of endemicity in Washington and Texas. Canine serosurveillance has also been used to predict variables associated with environmental presence of Coccidioides spp. Expansion of the endemic region of coccidioidomycosis with climate change-along with predicted population increases and increased development in the southwest United States-may result in 45.4 million additional people at risk of infection by 2090. Here we provide an overview of the value of dogs as sentinels for the disease and encourage the routine reporting of coccidioidomycosis cases in dogs to public health agencies. We also highlight the value of dogs as naturally occurring models for studying novel treatment options and preventatives, such as a novel live avirulent coccidioidomycosis vaccine.
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Affiliation(s)
- Adam J Ferguson
- Department of Biological Sciences, University of California-San Diego, La Jolla, USA
| | - George R Thompson
- Department of Internal Medicine - Division of Infectious Diseases, University of California-Davis, Davis, USA
| | | | - Jane E Sykes
- Department of Medicine & Epidemiology, University of California-Davis, Davis, USA
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4
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Zangeneh TT, Al-Obaidi MM. Diagnostic Approach to Coccidioidomycosis in Solid Organ Transplant Recipients. J Fungi (Basel) 2023; 9:jof9050513. [PMID: 37233224 DOI: 10.3390/jof9050513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Coccidioidomycosis is a fungal infection endemic in the southwestern United States, Mexico, and parts of Central and South America. While coccidioidomycosis is associated with mostly mild infections in the general population, it can lead to devastating infections in immunocompromised patients, including solid organ transplant (SOT) recipients. Early and accurate diagnosis is important in achieving better clinical outcomes in immunocompromised patients. However, the diagnosis of coccidioidomycosis in SOT recipients can be challenging due to the limitations of diagnostic methods including cultures, serology, and other tests in providing a timely and accurate diagnosis. In this review, we will discuss the available diagnostic modalities and approaches when evaluating SOT recipients with coccidioidomycosis, from the use of conventional culture methods to serologic and molecular testing. Additionally, we will discuss the role of early diagnosis in assisting with the administration of effective antifungal therapy to reduce infectious complications. Finally, we will discuss ways to improve the performance of coccidioidomycosis diagnostic methods in SOT recipients with an option for a combined testing approach.
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Affiliation(s)
- Tirdad T Zangeneh
- Division of Infectious Diseases, College of Medicine, University of Arizona, 1501 N Campbell Avenue, P.O. Box 245022, Tucson, AZ 85724, USA
| | - Mohanad M Al-Obaidi
- Division of Infectious Diseases, College of Medicine, University of Arizona, 1501 N Campbell Avenue, P.O. Box 245022, Tucson, AZ 85724, USA
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5
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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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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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Kelly BT, Pennington KM, Limper AH. Advances in the diagnosis of fungal pneumonias. Expert Rev Respir Med 2020; 14:703-714. [PMID: 32290725 PMCID: PMC7500531 DOI: 10.1080/17476348.2020.1753506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/06/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Fungal infections are increasingly encountered in clinical practice due to more favorable environmental conditions and increasing prevalence of immunocompromised individuals. The diagnostic approach for many fungal pathogens continues to evolve. Herein, we outline available diagnostic tests for the most common fungal infections with a focus on recent advances and future directions. AREAS COVERED We discuss the diagnostic testing methods for angioinvasive molds (Aspergillus spp. and Mucor spp.), invasive yeast (Candida spp. and Cryptococcus ssp.), Pneumocystis, and endemic fungi (Blastomyces sp., Coccidioides ssp., and Histoplasma sp.). The PubMed-NCBI database was searched within the past 5 years to identify the most recent available literature with dates extended in cases where literature was sparse. Diagnostic guidelines were utilized when available with references reviewed. EXPERT OPINION Historically, culture and/or direct visualization of fungal organisms were required for diagnosis of infection. Significant limitations included ability to collect specimens and delayed diagnosis associated with waiting for culture results. Antigen and antibody testing have made great strides in allowing quicker diagnosis of fungal infections but can be limited by low sensitivity/specificity, cross-reactivity with other fungi, and test availability. Molecular methods have a rich history in some fungal diseases, while others continue to be developed.
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Affiliation(s)
- Bryan T Kelly
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
| | - Kelly M Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
- Department of Internal Medicine, Robert D. And Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, MN, USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, MN, USA
- Department of Internal Medicine, Robert D. And Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic , Rochester, MN, USA
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Campuzano A, Zhang H, Ostroff GR, Dos Santos Dias L, Wüthrich M, Klein BS, Yu JJ, Lara HH, Lopez-Ribot JL, Hung CY. CARD9-Associated Dectin-1 and Dectin-2 Are Required for Protective Immunity of a Multivalent Vaccine against Coccidioides posadasii Infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2020; 204:3296-3306. [PMID: 32358020 PMCID: PMC7323849 DOI: 10.4049/jimmunol.1900793] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
Coccidioides species are fungal pathogens that can cause a widely varied clinical manifestation from mild pulmonary symptom to disseminated, life-threatening disease. We have previously created a subunit vaccine by encapsulating a recombinant coccidioidal Ag (rCpa1) in glucan-chitin particles (GCPs) as an adjuvant-delivery system. The GCP-rCpa1 vaccine has shown to elicit a mixed Th1 and Th17 response and confers protection against pulmonary coccidioidomycosis in mice. In this study, we further delineated the vaccine-induced protective mechanisms. Depletion of IL-17A in vaccinated C57BL/6 mice prior to challenge abrogated the protective efficacy of GCP-rCpa1 vaccine. Global transcriptome and Ingenuity Pathway Analysis of murine bone marrow-derived macrophages after exposure to this vaccine revealed the upregulation of proinflammatory cytokines (TNF-α, IL-6, and IL-1β) that are associated with activation of C-type lectin receptors (CLR) Dectin-1- and Dectin-2-mediated CARD9 signaling pathway. The GCP formulation of rCpa1 bound soluble Dectin-1 and Dectin-2 and triggered ITAM signaling of corresponding CLR reporter cells. Furthermore, macrophages that were isolated from Dectin-1 -/-, Dectin-2 -/-, and CARD9 -/- mice significantly reduced production of inflammatory cytokines in response to the GCP-rCpa1 vaccine compared with those of wild-type mice. The GCP-rCpa1 vaccine had significantly reduced protective efficacy in Dectin-1 -/-, Dectin-2 -/-, and CARD9 -/- mice that showed decreased acquisition of Th cells in Coccidioides-infected lungs compared with vaccinated wild-type mice, especially Th17 cells. Collectively, we conclude that the GCP-rCpa1 vaccine stimulates a robust Th17 immunity against Coccidioides infection through activation of the CARD9-associated Dectin-1 and Dectin-2 signal pathways.
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Affiliation(s)
- Althea Campuzano
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Hao Zhang
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Gary R Ostroff
- Program in Molecular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605; and
| | - Lucas Dos Santos Dias
- Department of Pediatrics, University of Wisconsin Medical School, University of Wisconsin Hospital and Clinics, Madison, WI 53792
| | - Marcel Wüthrich
- Department of Pediatrics, University of Wisconsin Medical School, University of Wisconsin Hospital and Clinics, Madison, WI 53792
| | - Bruce S Klein
- Department of Pediatrics, University of Wisconsin Medical School, University of Wisconsin Hospital and Clinics, Madison, WI 53792
| | - Jieh-Juen Yu
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Humberto H Lara
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Jose L Lopez-Ribot
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Chiung-Yu Hung
- South Texas Center for Emerging Infectious Diseases, Department of Biology, The University of Texas at San Antonio, San Antonio, TX 78249;
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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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10
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Krogstad P, Johnson R, Garcia-Lloret MI, Heidari A, Butte MJ. Host-Pathogen Interactions in Coccidioidomycosis: Prognostic Clues and Opportunities for Novel Therapies. Clin Ther 2019; 41:1939-1954.e1. [PMID: 31648806 PMCID: PMC10482146 DOI: 10.1016/j.clinthera.2019.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 01/09/2023]
Abstract
PURPOSE Coccidioidomycosis (CM) is a systemic fungal disease caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. In its endemic areas of the United States, CM is growing as a public health challenge with a marked increase in incidence in the last 15 years. Although Coccidioides infection is asymptomatic in most cases, symptomatic pulmonary disease occurs in ~40% and disseminated coccidioidomycosis (DCM) occurs in ~1% of previously healthy children and adults. DCM is markedly more common in immunocompromised people, who often experience life-threatening disease despite use of antifungal medications. Although options for antifungal therapy have improved, lifelong therapy is needed for those who develop coccidioidal meningitis. The purpose of this article was to review the state of antifungal therapy and recent studies of host-pathogen interactions in CM in light of advances in immunomodulatory therapy. METHODS The study included a review of PubMed and abstracts of the Coccidioidomycosis Study Group (years 2000-2019). FINDINGS Current therapy for CM relies upon azole and polyene antifungal agents. Murine models and studies of DCM in patients with monogenic primary immunodeficiency states and acquired immunodeficiency have revealed the importance of both innate and adaptive immune responses in the control of infections with Coccidioides species. In particular, defects in sensing of fungi and induction of cellular immune responses have been frequently reported. More recently, polymorphisms in key signaling pathways and in the generation of Th17 and Th1 immune responses have been linked with DCM. IMPLICATIONS Antifungal therapy is sufficient to control disease in most cases of CM, but treatment failure occurs in cases of severe pulmonary disease and nonmeningeal disseminated disease. Lifelong therapy is recommended for meningitis in view of the very high risk of recurrence. Corticosteroid therapy is advised by some experts for severe pulmonary disease and for some neurologic complications of DCM. DCM is only rarely the result of a severe monogenic immunodeficiency. Case studies suggest that reorienting cellular immune responses or augmenting effector immune responses may help resolve DCM. Systematic investigation of immunotherapy for coccidioidomycosis is advisable and may help to address the recent marked increase in reports of the disease in endemic areas.
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Affiliation(s)
- Paul Krogstad
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Molecular and Medical Pharmacology, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA.
| | - Royce Johnson
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Maria I Garcia-Lloret
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Arash Heidari
- Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
| | - Manish J Butte
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA; Department of Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA, USA
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11
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Hage CA, Carmona EM, Epelbaum O, Evans SE, Gabe LM, Haydour Q, Knox KS, Kolls JK, Murad MH, Wengenack NL, Limper AH. Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2019; 200:535-550. [PMID: 31469325 PMCID: PMC6727169 DOI: 10.1164/rccm.201906-1185st] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Fungal infections are of increasing incidence and importance in immunocompromised and immunocompetent patients. Timely diagnosis relies on appropriate use of laboratory testing in susceptible patients.Methods: The relevant literature related to diagnosis of invasive pulmonary aspergillosis, invasive candidiasis, and the common endemic mycoses was systematically reviewed. Meta-analysis was performed when appropriate. Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: This guideline includes specific recommendations on the use of galactomannan testing in serum and BAL and for the diagnosis of invasive pulmonary aspergillosis, the role of PCR in the diagnosis of invasive pulmonary aspergillosis, the role of β-d-glucan assays in the diagnosis of invasive candidiasis, and the application of serology and antigen testing in the diagnosis of the endemic mycoses.Conclusions: Rapid, accurate diagnosis of fungal infections relies on appropriate application of laboratory testing, including antigen testing, serological testing, and PCR-based assays.
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