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Maertens J, Slavin M, Hoenigl M, Thompson GR, Richardson M, Lass-Flörl C. Breaking the mould: challenging the status quo of clinical trial response definitions for invasive fungal diseases-a debate. J Antimicrob Chemother 2024; 79:1786-1793. [PMID: 39084680 PMCID: PMC11334067 DOI: 10.1093/jac/dkae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 05/01/2024] [Indexed: 08/02/2024] Open
Affiliation(s)
- Johan Maertens
- University Hospitals Leuven, Department of Haematology and ECMM Excellence Center of Medical Mycology, Campus Gasthuisberg Leuven, Belgium
| | - Monica Slavin
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Martin Hoenigl
- Division of Infectious Diseases, ECMM Excellence Center of Medical Mycology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - George R Thompson
- Division of Infectious Diseases, and Departments of Internal Medicine and Medical Microbiology and Immunology, University of California-Davis, Sacramento, CA, USA
| | - Malcolm Richardson
- Mycology Reference Centre Manchester, ECMM Excellence Center of Medical Mycology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Cornelia Lass-Flörl
- Christian-Doppler Laboratory for Invasive Fungal Infections, Institute of Hygiene and Medical Microbiology, ECMM Excellence Center of Medical Mycology, Medical University of Innsbruck, Innsbruck, Austria
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Martins Oliveira-Brito PK, de Campos GY, Guimarães JG, Machado MP, Serafim LC, Lazo Chica JE, Roque-Barreira MC, da Silva TA. Adjuvant ArtinM favored the host immunity against Cryptococcus gattii infection in C57BL/6 mice. Immunotherapy 2024; 16:733-748. [PMID: 38940276 PMCID: PMC11421300 DOI: 10.1080/1750743x.2024.2360384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/22/2024] [Indexed: 06/29/2024] Open
Abstract
Aim: Cryptococcus gattii causes a severe fungal infection with high mortality rate among immunosuppressed and immunocompetent individuals. Due to limitation of current antifungal treatment, new immunotherapeutic approaches are explored.Methods: This study investigated an immunization strategy utilizing heat-inactivated C. gattii with ArtinM as an adjuvant. C57BL/6 mice were intranasally immunized with heat-killed C. gattii and ArtinM was administrated either before immunization or along with HK-C. gattii. Mice were infected with C. gattii and the efficacy of the immunization protocol was evaluated.Results: Mice that received ArtinM exhibited increased levels of IL-10 and relative expression of IL-23 in the lungs, reduced fungal burden and preserved tissue integrity post-infection.Conclusion: Adjuvant ArtinM improved immunization against C. gattii infection in C57BL/6 mice.
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Affiliation(s)
- Patrícia Kellen Martins Oliveira-Brito
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gabriela Yamazaki de Campos
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Júlia Garcia Guimarães
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Michele Procópio Machado
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Letícia Costa Serafim
- Microbiology Postgraduate Program of the Microbiology Department of the Biomedical Sciences Institute (ICB) of University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Javier Emílio Lazo Chica
- Institute of Natural & Biological Sciences, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Maria Cristina Roque-Barreira
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Thiago Aparecido da Silva
- Department of Cell & Molecular Biology & Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Clinical Hematology Lab, Department of Clinical Analysis, School of Pharmaceutical Sciences in Araraquara (FCFAR), Sao Paulo State University (UNESP), Araraquara, São Paulo, Brazil
- National Institute of Science & Technology in Human Pathogenic Fungi, School of Pharmaceutical Sciences of Ribeirao Preto, University of São Paulo, Ribeirão Preto, São Paulo,Brazil
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Thambugala KM, Daranagama DA, Tennakoon DS, Jayatunga DPW, Hongsanan S, Xie N. Humans vs. Fungi: An Overview of Fungal Pathogens against Humans. Pathogens 2024; 13:426. [PMID: 38787278 PMCID: PMC11124197 DOI: 10.3390/pathogens13050426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
Human fungal diseases are infections caused by any fungus that invades human tissues, causing superficial, subcutaneous, or systemic diseases. Fungal infections that enter various human tissues and organs pose a significant threat to millions of individuals with weakened immune systems globally. Over recent decades, the reported cases of invasive fungal infections have increased substantially and research progress in this field has also been rapidly boosted. This review provides a comprehensive list of human fungal pathogens extracted from over 850 recent case reports, and a summary of the relevant disease conditions and their origins. Details of 281 human fungal pathogens belonging to 12 classes and 104 genera in the divisions ascomycota, basidiomycota, entomophthoromycota, and mucoromycota are listed. Among these, Aspergillus stands out as the genus with the greatest potential of infecting humans, comprising 16 species known to infect humans. Additionally, three other genera, Curvularia, Exophiala, and Trichophyton, are recognized as significant genera, each comprising 10 or more known human pathogenic species. A phylogenetic analysis based on partial sequences of the 28S nrRNA gene (LSU) of human fungal pathogens was performed to show their phylogenetic relationships and clarify their taxonomies. In addition, this review summarizes the recent advancements in fungal disease diagnosis and therapeutics.
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Affiliation(s)
- Kasun M. Thambugala
- Genetics and Molecular Biology Unit, Faculty of Applied Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda 10250, Sri Lanka; (K.M.T.); (D.P.W.J.)
- Center for Biotechnology, Department of Zoology, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
- Center for Plant Materials and Herbal Products Research, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
| | - Dinushani A. Daranagama
- Department of Plant and Molecular Biology, Faculty of Science, University of Kelaniya, Kelaniya 11300, Sri Lanka;
| | - Danushka S. Tennakoon
- Bioengineering and Technological Research Centre for Edible and Medicinal Fungi, Jiangxi Agricultural University, Nanchang 330045, China;
| | - Dona Pamoda W. Jayatunga
- Genetics and Molecular Biology Unit, Faculty of Applied Sciences, University of Sri Jayewardenepura, Gangodawila, Nugegoda 10250, Sri Lanka; (K.M.T.); (D.P.W.J.)
- Center for Biotechnology, Department of Zoology, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
- Center for Plant Materials and Herbal Products Research, University of Sri Jayewardenepura, Nugegoda 10250, Sri Lanka
| | - Sinang Hongsanan
- Shenzhen Key Laboratory of Microbial Genetic Engineering, College of Life Science and Oceanography, Shenzhen University, Shenzhen 518060, China
| | - Ning Xie
- Shenzhen Key Laboratory of Microbial Genetic Engineering, College of Life Science and Oceanography, Shenzhen University, Shenzhen 518060, China
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4
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Roland LT, Humphreys IM, Le CH, Babik JM, Bailey CE, Ediriwickrema LS, Fung M, Lieberman JA, Magliocca KR, Nam HH, Teo NW, Thomas PC, Winegar BA, Birkenbeuel JL, David AP, Goshtasbi K, Johnson PG, Martin EC, Nguyen TV, Patel NN, Qureshi HA, Tay K, Vasudev M, Abuzeid WM, Hwang PH, Jafari A, Russell MS, Turner JH, Wise SK, Kuan EC. Diagnosis, Prognosticators, and Management of Acute Invasive Fungal Rhinosinusitis: Multidisciplinary Consensus Statement and Evidence-Based Review with Recommendations. Int Forum Allergy Rhinol 2023; 13:1615-1714. [PMID: 36680469 DOI: 10.1002/alr.23132] [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: 08/23/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute invasive fungal sinusitis (AIFS) is an aggressive disease that requires prompt diagnosis and multidisciplinary treatment given its rapid progression. However, there is currently no consensus on diagnosis, prognosis, and management strategies for AIFS, with multiple modalities routinely employed. The purpose of this multi-institutional and multidisciplinary evidence-based review with recommendations (EBRR) is to thoroughly review the literature on AIFS, summarize the existing evidence, and provide recommendations on the management of AIFS. METHODS The PubMed, EMBASE, and Cochrane databases were systematically reviewed from inception through January 2022. Studies evaluating management for orbital, non-sinonasal head and neck, and intracranial manifestations of AIFS were included. An iterative review process was utilized in accordance with EBRR guidelines. Levels of evidence and recommendations on management principles for AIFS were generated. RESULTS A review and evaluation of published literature was performed on 12 topics surrounding AIFS (signs and symptoms, laboratory and microbiology diagnostics, endoscopy, imaging, pathology, surgery, medical therapy, management of extrasinus extension, reversing immunosuppression, and outcomes and survival). The aggregate quality of evidence was varied across reviewed domains. CONCLUSION Based on the currently available evidence, judicious utilization of a combination of history and physical examination, laboratory and histopathologic techniques, and endoscopy provide the cornerstone for accurate diagnosis of AIFS. In addition, AIFS is optimally managed by a multidisciplinary team via a combination of surgery (including resection whenever possible), antifungal therapy, and correcting sources of immunosuppression. Higher quality (i.e., prospective) studies are needed to better define the roles of each modality and determine diagnosis and treatment algorithms.
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Affiliation(s)
- Lauren T Roland
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ian M Humphreys
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Christopher H Le
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Jennifer M Babik
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher E Bailey
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Lilangi S Ediriwickrema
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California, Irvine, Irvine, California, USA
| | - Monica Fung
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Joshua A Lieberman
- Department of Pathology and Laboratory Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University Medical Center, Atlanta, Georgia, USA
| | - Hannah H Nam
- Division of Infectious Diseases, Department of Medicine, University of California, Irvine, Orange, California, USA
| | - Neville W Teo
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Penelope C Thomas
- Department of Radiology, University of Washington Medical Center, Seattle, Washington, USA
| | - Blair A Winegar
- Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Patricia G Johnson
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Elaine C Martin
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Theodore V Nguyen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Neil N Patel
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hannan A Qureshi
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kaijun Tay
- Department of Otorhinolaryngology, Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Milind Vasudev
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
| | - Waleed M Abuzeid
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Peter H Hwang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Aria Jafari
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin H Turner
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University Medical Center, Atlanta, Georgia, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, USA
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Tejeda-Garibay S, Hoyer KK. Coccidioidomycosis and Host Microbiome Interactions: What We Know and What We Can Infer from Other Respiratory Infections. J Fungi (Basel) 2023; 9:586. [PMID: 37233297 PMCID: PMC10219296 DOI: 10.3390/jof9050586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/25/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
Between 70 and 80% of Valley fever patients receive one or more rounds of antibiotic treatment prior to accurate diagnosis with coccidioidomycosis. Antibiotic treatment and infection (bacterial, viral, fungal, parasitic) often have negative implications on host microbial dysbiosis, immunological responses, and disease outcome. These perturbations have focused on the impact of gut dysbiosis on pulmonary disease instead of the implications of direct lung dysbiosis. However, recent work highlights a need to establish the direct effects of the lung microbiota on infection outcome. Cystic fibrosis, chronic obstructive pulmonary disease, COVID-19, and M. tuberculosis studies suggest that surveying the lung microbiota composition can serve as a predictive factor of disease severity and could inform treatment options. In addition to traditional treatment options, probiotics can reverse perturbation-induced repercussions on disease outcomes. The purpose of this review is to speculate on the effects perturbations of the host microbiome can have on coccidioidomycosis progression. To do this, parallels are drawn to aa compilation of other host microbiome infection studies.
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Affiliation(s)
- Susana Tejeda-Garibay
- Quantitative and Systems Biology, Graduate Program, University of California Merced, Merced, CA 95343, USA
| | - Katrina K. Hoyer
- Department of Molecular and Cell Biology, University California Merced, Merced, CA 95343, USA
- Health Sciences Research Institute, University of California Merced, Merced, CA 95343, USA
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Bogdanov IV, Fateeva SI, Voropaev AD, Ovchinnikova TV, Finkina EI. Immunomodulatory Effects of the Pea Defensin Psd1 in the Caco-2/Immune Cells Co-Culture upon Candida albicans Infection. Int J Mol Sci 2023; 24:7712. [PMID: 37175419 PMCID: PMC10178127 DOI: 10.3390/ijms24097712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/15/2023] Open
Abstract
Candidiasis is one of the most common fungal diseases that can pose a threat to life in immunodeficient individuals, particularly in its disseminated form. Not only fungal invasion but also fatal infection-related inflammation are common causes of systemic candidiasis. In this study, we investigated in vitro immunomodulatory properties of the antifungal pea defensin Psd1 upon Candida albicans infection. Using the real-time PCR, we showed that Psd1 inhibited the antimicrobial peptide HBD-2 and pro-inflammatory cytokines IL-1 and IL-8 downregulation at mRNA level in epithelium cells caused by C. albicans infection. By using the Caco-2/immune cells co-culture upon C. albicans infection and the multiplex xMAP assay, we demonstrated that this pathogenic fungus induced a pronounced host defense response; however, the cytokine responses were different in the presence of dendritic cells or monocytes. We revealed that Psd1 at a low concentration (2 µM) had a pronounced immunomodulatory effect on the Caco-2/immune cells co-culture upon fungal infection. Thus, we hypothesized that the pea defensin Psd1 might be an effective agent in the treatment of candidiasis not only due to its antifungal activity, but also owing to its ability to modulate a protective immune response upon infection.
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Affiliation(s)
- Ivan V. Bogdanov
- M.M. Shemyakin & Yu.A. Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, 117997 Moscow, Russia
| | - Serafima I. Fateeva
- M.M. Shemyakin & Yu.A. Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, 117997 Moscow, Russia
| | - Alexander D. Voropaev
- G.N. Gabrichevsky Research Institute for Epidemiology and Microbiology, Admiral Makarov St. 10, 125212 Moscow, Russia
| | - Tatiana V. Ovchinnikova
- M.M. Shemyakin & Yu.A. Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, 117997 Moscow, Russia
| | - Ekaterina I. Finkina
- M.M. Shemyakin & Yu.A. Ovchinnikov Institute of Bioorganic Chemistry, Russian Academy of Sciences, 117997 Moscow, Russia
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7
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Infection and Immunity. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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8
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Petrucelli MF, Cantelli BAM, Marins M, Fachin AL. The Transcriptional Regulation of Genes Involved in the Immune Innate Response of Keratinocytes Co-Cultured with Trichophyton rubrum Reveals Important Roles of Cytokine GM-CSF. J Fungi (Basel) 2022; 8:1151. [PMID: 36354918 PMCID: PMC9693189 DOI: 10.3390/jof8111151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/27/2022] [Accepted: 10/29/2022] [Indexed: 04/05/2024] Open
Abstract
Trichophyton rubrum is the most causative agent of dermatophytosis worldwide. The keratinocytes are the first line of defense during infection, triggering immunomodulatory responses. Previous dual RNA-seq data showed the upregulation of several human genes involved in immune response and epithelial barrier integrity during the co-culture of HaCat cells with T. rubrum. This work evaluates the transcriptional response of this set of genes during the co-culture of HaCat with different stages of T. rubrum conidia development and viability. Our results show that the developmental stage of fungal conidia and their viability interfere with the transcriptional regulation of innate immunity genes. The CSF2 gene encoding the cytokine GM-CSF is the most overexpressed, and we report for the first time that CSF2 expression is contact and conidial-viability-dependent during infection. In contrast, CSF2 transcripts and GM-CSF secretion levels were observed when HaCat cells were challenged with bacterial LPS. Furthermore, the secretion of proinflammatory cytokines was dependent on the conidia developmental stage. Thus, we suggest that the viability and developmental stage of fungal conidia interfere with the transcriptional patterns of genes encoding immunomodulatory proteins in human keratinocytes with regard to important roles of GM-CSF during infection.
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Affiliation(s)
- Monise Fazolin Petrucelli
- Biotechnology Unity, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
- Laboratory of Genetics and Molecular Biology of Fungi, Department of Genetics, Ribeirão Preto Medical School, University of São Paulo, Ribeirao Preto 14049-900, Brazil
| | - Bruna Aline M. Cantelli
- Biotechnology Unity, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
| | - Mozart Marins
- Biotechnology Unity, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
- Medicine Course, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
| | - Ana Lúcia Fachin
- Biotechnology Unity, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
- Medicine Course, University of Ribeirão Preto (UNAERP), Ribeirao Preto 14096-900, Brazil
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Dos Santos MH, Machado MP, Kumaresan PR, da Silva TA. Modification of Hinge/Transmembrane and Signal Transduction Domains Improves the Expression and Signaling Threshold of GXMR-CAR Specific to Cryptococcus spp. Cells 2022; 11:3386. [PMID: 36359781 PMCID: PMC9653562 DOI: 10.3390/cells11213386] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/12/2022] [Accepted: 10/15/2022] [Indexed: 11/19/2023] Open
Abstract
Chimeric antigen receptors (CARs) redirect T cells to recognize a specific target. CAR components play a pivotal role in antigen specificity, structure stability, expression on cell surface, and induction of cellular activation, which together determine the success of CAR T-cell therapy. CAR products targeting B-cell lymphoma encouraged the development of new CAR applications beyond cancer. For example, our group developed a CAR to specifically target glucuronoxylomannan (GXM) in the capsule of Cryptococcus species, called GXMR-CAR or GXMR-IgG4-28ζ. Cryptococcus are fungi that cause the life-threatening disease cryptococcosis, and GXMR-IgG4-28ζ redirected T cells to target yeast and titan cell forms of Cryptococcus spp. Here, we replaced the IgG4-hinge and CD28-transmembrane domains from GXMR-CAR with a CD8α molecule as the hinge/transmembrane and used CD28 or 4-1BB molecules as co-stimulatory domains, creating GXMR-8-28ζ and GXMR-8-BBζ, respectively. Jurkat cells expressing GXMR-CAR containing CD8α as the hinge/transmembrane improved the CAR expression and induced a tonic signaling. GXMR-8-28ζ and GXMR-8-BBζ induced high levels of IL-2 and up-regulation of CD69 expression in the presence of reference strains of C. neoformans and C. gattii. Moreover, GXMR-8-28ζ and GXMR-8-BBζ showed increased strength in response to incubation with clinical isolates of Cryptococcuss spp., and 4-1BB co-stimulatory domain triggered a more pronounced cellular activation. Dasatinib, a tyrosine kinase inhibitor, attenuated the GXMR-CAR signaling cascade's engagement in the presence or absence of its ligand. This study optimized novel second-generation GXMR-CARs containing the CD8-hinge/transmembrane domain that improved CAR expression, antigen recognition, and signal strength in T-cell activation.
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Affiliation(s)
- Matheus Henrique Dos Santos
- Department of Cell and Molecular Biology and Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 140490-900, SP, Brazil
| | - Michele Procópio Machado
- Department of Cell and Molecular Biology and Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 140490-900, SP, Brazil
| | - Pappanaicken R Kumaresan
- Department of Hematopoietic Biology and Malignancy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Thiago Aparecido da Silva
- Department of Cell and Molecular Biology and Pathogenic Bioagents, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 140490-900, SP, Brazil
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10
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Wurster S, Watowich SS, Kontoyiannis DP. Checkpoint inhibitors as immunotherapy for fungal infections: Promises, challenges, and unanswered questions. Front Immunol 2022; 13:1018202. [PMID: 36389687 PMCID: PMC9640966 DOI: 10.3389/fimmu.2022.1018202] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/11/2022] [Indexed: 09/22/2023] Open
Abstract
Opportunistic fungal infections have high mortality in patients with severe immune dysfunction. Growing evidence suggests that the immune environment of invasive fungal infections and cancers share common features of immune cell exhaustion through activation of immune checkpoint pathways. This observation gave rise to several preclinical studies and clinical case reports describing blockade of the Programmed Cell Death Protein 1 and Cytotoxic T-Lymphocyte Antigen 4 immune checkpoint pathways as an adjunct immune enhancement strategy to treat opportunistic fungal infections. The first part of this review summarizes the emerging evidence for contributions of checkpoint pathways to the immunopathology of fungal sepsis, opportunistic mold infections, and dimorphic fungal infections. We then review the potential merits of immune checkpoint inhibitors (ICIs) as an antifungal immunotherapy, including the incomplete knowledge of the mechanisms involved in both immuno-protective effects and toxicities. In the second part of this review, we discuss the limitations of the current evidence and the many unknowns about ICIs as an antifungal immune enhancement strategy. Based on these gaps of knowledge and lessons learned from cancer immunology studies, we outline a research agenda to determine a "sweet spot" for ICIs in medical mycology. We specifically discuss the importance of more nuanced animal models, the need to study ICI-based combination therapy, potential ICI resistance, the role of the immune microenvironment, and the impact of ICIs given as part of oncological therapies on the natural immunity to various pathogenic fungi.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephanie S. Watowich
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dimitrios P. Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Loeffen YGT, Scharloo F, Goemans BF, Heitink-Polle KMJ, Lindemans CA, van der Bruggen T, Hagen F, Wolfs TFW. Mucormycosis in Children With Hematologic Malignancies: A Case Series and Review of the Literature. Pediatr Infect Dis J 2022; 41:e369-e376. [PMID: 35703287 DOI: 10.1097/inf.0000000000003608] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mucormycosis is classified as the third leading cause of invasive fungal disease in immunocompromised patients and is characterized by high morbidity and mortality (33%-56%). The aim of this study is to describe presentation, treatment and outcome of Dutch pediatric hemato-oncology patients recently diagnosed with mucormycosis and to review the literature to gain more insight specifically into contemporary outcome data. METHODS Ten cases were diagnosed in the Princess Máxima Center for Pediatric Oncology from 2018 to 2021 and were retrospectively reviewed. In addition, 9 case series (n = 148) were included from literature. RESULTS In our case series, 5 patients of 10 children (age 2-17 years) had disseminated invasive fungal disease. Four patients had localized pulmonary disease and 1 had a localized renal infection. One diagnosis was made postmortem. The underlying diseases were acute lymphoblastic leukemia (n = 6), acute myeloid leukemia (n = 2) and lymphoma (n=2). Seven patients received combination therapy comprising of a lipid amphotericin B formulation and a triazole, surgery was performed in 67%. All neutropenic patients received granulocyte transfusions and/or granulocyte colony-stimulating factor. Mucormycosis-related mortality was 20%. In the literature review, mucormycosis-related mortality was 36% for all patients and 66% for patients with disseminated disease. Survival rates were similar over the past 2 decades. The most common underlying disorder was acute lymphoblastic leukemia. Liposomal amphotericin B was the mainstay of treatment. Seventy percent of patients underwent surgery. CONCLUSIONS Although survival of mucormycosis improved significantly overtime, it plateaued in the past decades. This series shows that with screening, early diagnostics and early antifungal and if possible surgical treatment, mortality is low and even disseminated disease is salvageable if approached aggressively with a combination of surgery and antifungal treatment. Further research focused on diagnostics, combination antifungal and adjunctive therapy is necessary to enhance the survival of mucormycosis in children.
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Affiliation(s)
- Yvette G T Loeffen
- From the Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht
| | | | - Bianca F Goemans
- Department of Hemato-Oncology, Princess Máxima Center for Pediatric Oncology
| | | | - Caroline A Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Pediatric Blood and Bone Marrow Transplantation, Prinses Máxima Center for Pediatric Oncology
| | | | - Ferry Hagen
- Department of Medical Microbiology, University Medical Center Utrecht
| | - Tom F W Wolfs
- From the Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht
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12
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A Fun-Guide to Innate Immune Responses to Fungal Infections. J Fungi (Basel) 2022; 8:jof8080805. [PMID: 36012793 PMCID: PMC9409918 DOI: 10.3390/jof8080805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 11/22/2022] Open
Abstract
Immunocompromised individuals are at high risk of developing severe fungal infections with high mortality rates, while fungal pathogens pose little risk to most healthy people. Poor therapeutic outcomes and growing antifungal resistance pose further challenges for treatments. Identifying specific immunomodulatory mechanisms exploited by fungal pathogens is critical for our understanding of fungal diseases and development of new therapies. A gap currently exists between the large body of literature concerning the innate immune response to fungal infections and the potential manipulation of host immune responses to aid clearance of infection. This review considers the innate immune mechanisms the host deploys to prevent fungal infection and how these mechanisms fail in immunocompromised hosts. Three clinically relevant fungal pathogens (Candida albicans, Cryptococcus spp. and Aspergillus spp.) will be explored. This review will also examine potential mechanisms of targeting the host therapeutically to improve outcomes of fungal infection.
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13
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Current Treatment Options for COVID-19 Associated Mucormycosis: Present Status and Future Perspectives. J Clin Med 2022; 11:jcm11133620. [PMID: 35806905 PMCID: PMC9267579 DOI: 10.3390/jcm11133620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 12/04/2022] Open
Abstract
Mucormycosis has become increasingly associated with COVID-19, leading to the use of the term “COVID-19 associated mucormycosis (CAM)”. Treatment of CAM is challenging due to factors such as resistance to many antifungals and underlying co-morbidities. India is particularly at risk for this disease due to the large number of patients with COVID-19 carrying comorbidities that predispose them to the development of mucormycosis. Additionally, mucormycosis treatment is complicated due to the atypical symptoms and delayed presentation after the resolution of COVID-19. Since this disease is associated with increased morbidity and mortality, early identification and diagnosis are desirable to initiate a suitable combination of therapies and control the disease. At present, the first-line treatment involves Amphotericin B and surgical debridement. To overcome limitations associated with surgery (invasive, multiple procedures required) and amphotericin B (toxicity, extended duration and limited clinical success), additional therapies can be utilized as adjuncts or alternatives to reduce treatment duration and improve prognosis. This review discusses the challenges associated with treating CAM and the critical aspects for controlling this invasive fungal infection—early diagnosis and initiation of therapy, reversal of risk factors, and adoption of a multipronged treatment strategy. It also details the various therapeutic options (in vitro, in vivo and human case reports) that have been used for the treatment of CAM.
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14
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Prathapan P. A determination of pan-pathogen antimicrobials? MEDICINE IN DRUG DISCOVERY 2022; 14:100120. [PMID: 35098103 PMCID: PMC8785259 DOI: 10.1016/j.medidd.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/01/2022] [Accepted: 01/17/2022] [Indexed: 11/29/2022] Open
Abstract
While antimicrobial drug development has historically mitigated infectious diseases that are known, COVID-19 revealed a dearth of 'in-advance' therapeutics suitable for infections by pathogens that have not yet emerged. Such drugs must exhibit a property that is antithetical to the classical paradigm of antimicrobial development: the ability to treat infections by any pathogen. Characterisation of such 'pan-pathogen' antimicrobials requires consolidation of drug repositioning studies, a new and growing field of drug discovery. In this review, a previously-established system for evaluating repositioning studies is used to highlight 4 therapeutics which exhibit pan-pathogen properties, namely azithromycin, ivermectin, niclosamide, and nitazoxanide. Recognition of the pan-pathogen nature of these antimicrobials is the cornerstone of a novel paradigm of antimicrobial development that is not only anticipatory of pandemics and bioterrorist attacks, but cognisant of conserved anti-infective mechanisms within the host-pathogen interactome which are only now beginning to emerge. Ultimately, the discovery of pan-pathogen antimicrobials is concomitantly the discovery of a new class of antivirals, and begets significant implications for pandemic preparedness research in a world after COVID-19.
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Affiliation(s)
- Praveen Prathapan
- New Biochemistry, University of Oxford, South Parks Road, Oxford OX1 3QU, United Kingdom
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15
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Dong N, Jordan AE, Shen X, Wu X, Guo X, Zhao H, Wang Y, Wang D, Fang Q. Rhino-Orbital Cerebral Mucormycosis in a Patient With Diabetic Ketoacidosis: A Case Report and Literature Review. Front Neurol 2022; 13:815902. [PMID: 35599740 PMCID: PMC9114505 DOI: 10.3389/fneur.2022.815902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/21/2022] [Indexed: 12/14/2022] Open
Abstract
Background Rhino-orbital cerebral mucormycosis (ROCM) is a rare, invasive, and fatal fungal disease. Due to the lack of specific clinical manifestations and adequate auxiliary examinations, patients are easily misdiagnosed in the early stage. Early diagnosis and timely therapy are essential for successful treatment. Case Report We report a 68-year-old man with diabetic ketoacidosis, presented with orbital apex syndrome (OAS), fever, and pansinusitis, which progressively worsened to death only 4 days after admission. It was finally confirmed as a fungal Rhizopus arrhizus infection by metagenomics cell-free DNA next-generation sequencing (mNGS) testing. Conclusion Orbital apex syndrome could be the initial presentation for mucormycosis. Thus, it is necessary to evaluate the presence of mucormycosis in patients with OAS, especially in diabetic or immunosuppressed hosts, and mNGS testing and timely antifungal therapy should be strongly recommended in highly suspected cases.
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Affiliation(s)
- Nan Dong
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Neurology, Suzhou Industrial Park Xinghai Hospital, Suzhou, China
| | - Ashly E. Jordan
- Independent Research Epidemiologist, New York, NY, United States
| | - Xiaozhu Shen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuan Wu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xianghong Guo
- Department of Neurology, Suzhou Industrial Park Xinghai Hospital, Suzhou, China
| | - Hongru Zhao
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yajuan Wang
- Genoxor Medical Science and Technology Inc., Shanghai, China
| | - Dapeng Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
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16
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Reddy GKK, Padmavathi AR, Nancharaiah Y. Fungal infections: Pathogenesis, antifungals and alternate treatment approaches. CURRENT RESEARCH IN MICROBIAL SCIENCES 2022; 3:100137. [PMID: 35909631 PMCID: PMC9325902 DOI: 10.1016/j.crmicr.2022.100137] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Increasing incidence of fungal infections of recent times requires immediate intervention. Fungal infections are seldom construed at initial stages that intensify the severity of infections and complicate the treatment procedures. Fungal pathogens employ various mechanisms to evade the host immune system and to progress the severity of infections. For the treatment of diverse superficial and systemic infections, antifungal drugs from the available repertoire are administered. However, well documented evidence of fungal resistance to most of the antifungal drugs hampers disease control and poses challenges in antifungal therapy. Several physiological adaptations and genetic mutations followed by their selection in presence of antifungal agents drive the resistance development in fungi. The availability of limited antifungal arsenal, emergence of resistance and biofilm-conferred resistance drives the need for development of novel drugs and alternate approaches for the better treatment outcome against mycoses. This graphical review explicitly shed light on various fungal infections and causative organisms, pathogenesis, different antifungal drugs and resistance mechanisms including host immune response and evasion strategies. Here, we have highlighted recent developments on novel antifungal agents and other alternate approaches for fighting against fungal infections.
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17
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Wurster S, Albert ND, Bharadwaj U, Kasembeli MM, Tarrand JJ, Daver N, Kontoyiannis DP. Blockade of the PD-1/PD-L1 Immune Checkpoint Pathway Improves Infection Outcomes and Enhances Fungicidal Host Defense in a Murine Model of Invasive Pulmonary Mucormycosis. Front Immunol 2022; 13:838344. [PMID: 35251033 PMCID: PMC8896628 DOI: 10.3389/fimmu.2022.838344] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 12/21/2022] Open
Abstract
Anecdotal clinical reports suggested a benefit of adjunct immune checkpoint inhibitors (ICIs) to treat invasive mucormycosis. However, proof-of-concept data in animal models and mechanistic insights into the effects of ICIs on host defense against Mucorales are lacking. Therefore, we studied the effects of PD-1 and PD-L1 inhibitors (4 doses of 250 µg/kg) on outcomes and immunopathology of invasive pulmonary mucormycosis (IPM) in cyclophosphamide- and cortisone acetate-immunosuppressed mice. Rhizopus arrhizus-infected mice receiving either of the ICI treatments had significantly improved survival, less morbidity, and lower fungal burden compared to isotype-treated infected mice. While early improvement of morbidity/mortality was comparable between the ICI treatments, anti-PD-L1 provided more consistent sustained protection through day 7 post-infection than anti-PD-1. Both ICIs enhanced the fungicidal activity of ex-vivo splenocytes and effectively counteracted T-cell exhaustion; however, macrophages of ICI-treated mice showed compensatory upregulation of other checkpoint markers. Anti-PD-1 elicited stronger pulmonary release of proinflammatory cytokines and chemokines than anti-PD-L1, but also induced cytokines associated with potentially unfavorable type 2 T-helper-cell and regulatory T-cell responses. Although no signs of hyperinflammatory toxicity were observed, mice with IPM receiving ICIs, particularly anti-PD-1, had elevated serum levels of IL-6, a cytokine linked to ICI toxicities. Altogether, inhibition of the PD-1/PD-L1 pathway improved clinical outcomes of IPM in immunosuppressed mice, even without concomitant antifungals. PD-L1 inhibition yielded more favorable immune responses and more consistent protection from IPM-associated morbidity and mortality than PD-1 blockade. Future dose-effect studies are needed to define the “sweet spot” between ICI-induced augmentation of antifungal immunity and potential immunotoxicities.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nathaniel D Albert
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Uddalak Bharadwaj
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Moses M Kasembeli
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jeffrey J Tarrand
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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18
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Jang AY, Monmai C, Rod-In W, Kim JE, You S, Lee TH, Park WJ. Immune-modulation effect of Halocynthia aurantium tunic lipid on RAW264.7 cells. Food Sci Biotechnol 2021; 31:101-110. [PMID: 35059234 PMCID: PMC8733137 DOI: 10.1007/s10068-021-01017-4] [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: 07/25/2021] [Revised: 11/04/2021] [Accepted: 11/30/2021] [Indexed: 01/02/2023] Open
Abstract
The current study evaluated the immune-regulatory potential of lipid extract from Halocynthia aurantium tunic on macrophage cells. The results showed that H. aurantium lipid is composed of primarily SFA (68.32%), followed by MUFA and PUFA (17.61% and 14.07%, respectively). Halocynthia aurantium lipid dose-dependently modulated the NO and PGE2 production in RAW264.7 cells without any LPS stimulation. The lipid effectively up-regulated the cytokine expression, including IL-1β, IL-6, and TNF-α in RAW264.7 cells. The COX-2 expression as a key biomarker for inflammation was also significantly increased. Conversely, H. aurantium lipid down-regulated the expression of inflammatory cytokines in LPS-stimulated RAW264.7 cells. Halocynthia aurantium lipid modulated the phosphorylation of NF-κB p-65, p38, ERK, and JNK, indicating that this lipid activated through NF-κB and MAPK pathways. These results provide insight into the immune-regulatory activities of H. aurantium tunic lipid and suggest that H. aurantium tunic may a potential lipid source for immune-regulatory molecules.
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Affiliation(s)
- A-yeong Jang
- grid.411733.30000 0004 0532 811XDepartment of Wellness-Bio Industry, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
| | - Chaiwat Monmai
- grid.411733.30000 0004 0532 811XDepartment of Marine Food Science and Technology, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
| | - Weerawan Rod-In
- grid.411733.30000 0004 0532 811XDepartment of Marine Food Science and Technology, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
| | - Ji-Eun Kim
- grid.411733.30000 0004 0532 811XDepartment of Wellness-Bio Industry, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
| | - SangGuan You
- grid.411733.30000 0004 0532 811XDepartment of Marine Food Science and Technology, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
| | - Tae Ho Lee
- Department of Power Plant, Korea Polytechnic College (Mokpo Campus), Muan-gun, Jeollanam-do 58542 Korea
| | - Woo Jung Park
- grid.411733.30000 0004 0532 811XDepartment of Wellness-Bio Industry, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea ,grid.411733.30000 0004 0532 811XDepartment of Marine Food Science and Technology, Gangneung-Wonju National University, Gangneung, Gangwon 25457 Korea
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19
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Luberto L, Neroni B, Gandini O, Fiscarelli EV, Salvatori G, Roscilli G, Marra E. Genetic Vaccination as a Flexible Tool to Overcome the Immunological Complexity of Invasive Fungal Infections. Front Microbiol 2021; 12:789774. [PMID: 34975811 PMCID: PMC8715041 DOI: 10.3389/fmicb.2021.789774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
The COVID-19 pandemic has highlighted genetic vaccination as a powerful and cost-effective tool to counteract infectious diseases. Invasive fungal infections (IFI) remain a major challenge among immune compromised patients, particularly those undergoing allogeneic hematopoietic bone marrow transplantation (HSCT) or solid organ transplant (SOT) both presenting high morbidity and mortality rates. Candidiasis and Aspergillosis are the major fungal infections among these patients and the failure of current antifungal therapies call for new therapeutic aids. Vaccination represents a valid alternative, and proof of concept of the efficacy of this approach has been provided at clinical level. This review will analyze current understanding of antifungal immunology, with a particular focus on genetic vaccination as a suitable strategy to counteract these diseases.
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Affiliation(s)
- Laura Luberto
- Takis s.r.l., Rome, Italy
- *Correspondence: Laura Luberto,
| | - Bruna Neroni
- Cystic Fibrosis Diagnostic Section, U.O. Microbiology and Immunology Diagnostic, Department of Immunology and Laboratory Medicine, Children’s Hospital Bambino Gesù Organization IRCCS, Rome, Italy
| | - Orietta Gandini
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Ersilia Vita Fiscarelli
- Cystic Fibrosis Diagnostic Section, U.O. Microbiology and Immunology Diagnostic, Department of Immunology and Laboratory Medicine, Children’s Hospital Bambino Gesù Organization IRCCS, Rome, Italy
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20
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Immunomodulation: An immune regulatory mechanism in carcinoma therapeutics. Int Immunopharmacol 2021; 99:107984. [PMID: 34303999 DOI: 10.1016/j.intimp.2021.107984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/29/2021] [Accepted: 07/11/2021] [Indexed: 01/01/2023]
Abstract
Cancer has been generally related to the possession of numerous mutations which interrupt important signaling pathways. Nevertheless, deregulated immunological signaling is considered as one of the key factors associated with the development and progression of cancer. The signaling pathways operate as modular network with different components interacting in a switch-like fashion with two proteins interplaying between each other leading to direct or indirect inhibition or stimulation of down-stream factors. Genetic, epigenetic, and transcriptomic alterations maintain the pathological conduit of different signaling pathways via affecting diverse mechanisms including cell destiny. At present, immunotherapy is one of the best therapies opted for cancer treatment. The cancer immunotherapy strategy includes harnessing the specificity and killing mechanisms of the immunological system to target and eradicate malignant cells. Targeted therapies utilizing several little molecules including Galunisertib, Astragaloside-IV, Melatonin, and Jervine capable of regulating key signaling pathways can effectively help in the management of different carcinomas.
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21
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Deng W, Su Z, Liang P, Ma Y, Liu Y, Zhang K, Zhang Y, Liang T, Shao J, Liu X, Han W, Li R. Single-cell immune checkpoint landscape of PBMCs stimulated with Candida albicans. Emerg Microbes Infect 2021; 10:1272-1283. [PMID: 34120578 PMCID: PMC8238073 DOI: 10.1080/22221751.2021.1942228] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Immune checkpoints play various important roles in tumour immunity, which usually contribute to T cells’ exhaustion, leading to immunosuppression in the tumour microenvironment. However, the roles of immune checkpoints in infectious diseases, especially fungal infection, remain elusive. Here, we reanalyzed a recent published single-cell RNA-sequencing (scRNA-seq) data of peripheral blood mononuclear cells (PBMCs) stimulated with Candida albicans (C. albicans), to explore the expression patterns of immune checkpoints after C. albicans bloodstream infection. We characterized the heterogeneous pathway activities among different immune cell subpopulations after C. albicans infection. The CTLA-4 pathway was up-regulated in stimulated CD4+ and CD8+ T cells, while the PD-1 pathway showed high activity in stimulated plasmacytoid dendritic cell (pDC) and monocytes. Importantly, we found that immunosuppressive checkpoints HAVCR2 and LAG3 were only expressed in stimulated NK and CD8+ T cells, respectively. Their viabilities were validated by flow cytometry. We also identified three overexpressed genes (ISG20, LY6E, ISG15) across all stimulated cells. Also, two monocyte-specific overexpressed genes (SNX10, IDO1) were screened out in this study. Together, these results supplemented the landscape of immune checkpoints in fungal infection, which may serve as potential therapeutic targets for C. albicans infection. Moreover, the genes with the most relevant for C. albicans infection were identified in this study.
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Affiliation(s)
- Weiwei Deng
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Zhen Su
- Department of Dermatology and Venerology, The Third Affiliated Hospital of Sun Yat-Sen university, Guangzhou, People's Republic of China
| | - Panpan Liang
- Clinical laboratory, The Third Affiliated Hospital of Sun Yat-Sen university, Guangzhou, People's Republic of China
| | - Yubo Ma
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Yufang Liu
- Department of Dermatology and Venerology, The Third Affiliated Hospital of Sun Yat-Sen university, Guangzhou, People's Republic of China
| | - Kai Zhang
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Yi Zhang
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Tianyu Liang
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Jin Shao
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Xiao Liu
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
| | - Wenling Han
- Department of Immunology, School of Basic Medical Sciences, Peking University Health Science Center, Peking University Center for Human Disease Genomics, Key Laboratory of Medical Immunology, Ministry of Health, Beijing, People's Republic of China
| | - Ruoyu Li
- Department of Dermatology and Venerology, Peking University First Hospital, Peking University; National Clinical Research Center for Skin and Immune Diseases; Beijing Key Laboratory of Molecular Diagnosis of Dermatoses, Beijing, People's Republic of China
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22
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Ghramh HA, Ibrahim EH, Ahmad Z. Antimicrobial, immunomodulatory and cytotoxic activities of green synthesized nanoparticles from Acacia honey and Calotropis procera. Saudi J Biol Sci 2021; 28:3367-3373. [PMID: 34121874 PMCID: PMC8175998 DOI: 10.1016/j.sjbs.2021.02.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/10/2021] [Accepted: 02/28/2021] [Indexed: 12/11/2022] Open
Abstract
Calotropis procera and Somra (Acacia) honey are used in traditional medicine. The benefits of mixing 20% Somra honey and C. procera leaf water extract (CPLWExt) were aimed to be studied. Honey/CPLWExt were utilized to produce silver nanoparticles (AgNPs) separately. AgNPs were characterized via UV/Vis and electron microscope scanning. Bio-molecules in CPLWExt/honey were investigated utilizing FT-IR spectroscopy. Biological activities of CPLWExt and honey were tested. The outcomes showed that CPLWExt and honey have numerous functional groups and could produce AgNPs. CPLWExt, CPLWExt + AgNPs, honey and honey + AgNPs hindered the growth of rat splenocytes, while CPLWExt + honey invigorated it. Antimicrobial power was found in CPLWExt and honey, which increased in the presence of AgNPs. Honey/honey + AgNPs suppressed the proliferation of HeLa and HepG2 cells. In conclusion, honey/CPLWExt could produce AgNPs and showed immunomodulatory and antibacterial power. Somra honey/honey + AgNPs have anticancer power. Somra honey + CPLWExt reflected a good immunostimulatory powers that can be nominated as an immunostimulant.
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Affiliation(s)
- Hamed A. Ghramh
- Research Center for Advanced Materials Science (RCAMS), King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
- Unit of Bee Research and Honey Production, Faculty of Science, King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
- Biology Department, Faculty of Science, King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
| | - Essam H. Ibrahim
- Research Center for Advanced Materials Science (RCAMS), King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
- Biology Department, Faculty of Science, King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
- Blood Products Quality Control and Research Department, National Organization for Research and Control of Biologicals, Cairo 12611, Egypt
| | - Zubair Ahmad
- Research Center for Advanced Materials Science (RCAMS), King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
- Unit of Bee Research and Honey Production, Faculty of Science, King Khalid University, P.O. Box 9004, Abha 61413, Saudi Arabia
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23
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Fernández-Cruz A, Lewis RE, Kontoyiannis DP. How Long Do We Need to Treat an Invasive Mold Disease in Hematology Patients? Factors Influencing Duration of Therapy and Future Questions. Clin Infect Dis 2021; 71:685-692. [PMID: 32170948 DOI: 10.1093/cid/ciz1195] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 03/11/2019] [Indexed: 12/18/2022] Open
Abstract
Treatment duration for invasive mold disease (IMD) in patients with hematological malignancy is not standardized and is a challenging subject in antifungal stewardship. Concerns for IMD relapse during subsequent reinduction or consolidation chemotherapy or graft versus host disease treatment in hematopoietic stem cell transplant recipients often results in prolonged or indefinite antifungal treatment. There are no validated criteria that predict when it is safe to stop antifungals. Decisions are individualized and depend on the offending fungus, site and extent of IMD, comorbidities, hematologic disease prognosis, and future plans for chemotherapy or transplantation. Recent studies suggest that FDG-PET/CT could help discriminate between active and residual fungal lesions to support decisions for safely stopping antifungals. Validation of noninvasive biomarkers for monitoring treatment response, tests for quantifying the "net state of immunosuppression," and genetic polymorphisms associated with poor fungal immunity could lead to a personalized assessment for the continued need for antifungal therapy.
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Affiliation(s)
- Ana Fernández-Cruz
- Infectious Diseases Unit, Internal Medicine Department, Hospital Universitario Puerta de Hierro-Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
| | - Russell E Lewis
- Clinic of Infectious Diseases, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Wurster S, Robinson P, Albert ND, Tarrand JJ, Goff M, Swamydas M, Lim JK, Lionakis MS, Kontoyiannis DP. Protective Activity of Programmed Cell Death Protein 1 Blockade and Synergy With Caspofungin in a Murine Invasive Pulmonary Aspergillosis Model. J Infect Dis 2021; 222:989-994. [PMID: 32432714 DOI: 10.1093/infdis/jiaa264] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/15/2020] [Indexed: 12/19/2022] Open
Abstract
Pharmacological immune checkpoint blockade has revolutionized oncological therapies, and its remarkable success has sparked interest in expanding checkpoint inhibitor therapy in infectious diseases. Herein, we evaluated the efficacy of programmed cell death protein 1 (PD-1) blockade in a murine invasive pulmonary aspergillosis model. We found that, compared with isotype-treated infected control mice, anti-PD-1-treated mice had improved survival, reduced fungal burden, increased lung concentrations of proinflammatory cytokines and neutrophil-attracting chemokines, and enhanced pulmonary leukocyte accumulation. Furthermore, combined treatment with anti-PD-1 and caspofungin resulted in a significant survival benefit compared with caspofungin or anti-PD-1 therapy alone, indicating a synergistic effect between PD-1 inhibitors and immunomodulatory antifungal agents.
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Affiliation(s)
- Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prema Robinson
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nathaniel D Albert
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey J Tarrand
- Department of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marisa Goff
- Department of Microbiology, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muthulekha Swamydas
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jean K Lim
- Department of Microbiology, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Michail S Lionakis
- Fungal Pathogenesis Section, Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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25
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Thompson A, da Fonseca DM, Walker L, Griffiths JS, Taylor PR, Gow NAR, Orr SJ. Dependence on Mincle and Dectin-2 Varies With Multiple Candida Species During Systemic Infection. Front Microbiol 2021; 12:633229. [PMID: 33717025 PMCID: PMC7951061 DOI: 10.3389/fmicb.2021.633229] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
More than 95% of invasive Candida infections are caused by four Candida spp. (C. albicans, C. glabrata, C. tropicalis, C. parapsilosis). C-type lectin-like receptors (CLRs), such as Dectin-1, Dectin-2, and Mincle mediate immune responses to C. albicans. Dectin-1 promotes clearance of C. albicans, C. glabrata, C. tropicalis, and C. parapsilosis, however, dependence on Dectin-1 for specific immune responses varies with the different Candida spp. Dectin-2 is important for host immunity to C. albicans and C. glabrata, and Mincle is important for the immune response to C. albicans. However, whether Dectin-2 drives host immunity to C. tropicalis or C. parapsilosis, and whether Mincle mediates host immunity to C. glabrata, C. tropicalis or C. parapsilosis is unknown. Therefore, we compared the roles of Dectin-2 and Mincle in response to these four Candida spp. We demonstrate that these four Candida spp. cell walls have differential mannan contents. Mincle and Dectin-2 play a key role in regulating cytokine production in response to these four Candida spp. and Dectin-2 is also important for clearance of all four Candida spp. during systemic infection. However, Mincle was only important for clearance of C. tropicalis during systemic infection. Our data indicate that multiple Candida spp. have different mannan contents, and dependence on the mannan-detecting CLRs, Mincle, and Dectin-2 varies between different Candida spp. during systemic infection.
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Affiliation(s)
- Aiysha Thompson
- Division of Infection and Immunity, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
- UK Dementia Research Institute, Cardiff, United Kingdom
| | - Diogo M. da Fonseca
- Division of Infection and Immunity, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
- School of Medicine, Dentistry and Biomedical Science, Wellcome Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
| | - Louise Walker
- Aberdeen Fungal Group, University of Aberdeen, Aberdeen, United Kingdom
| | - James S. Griffiths
- Division of Infection and Immunity, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
- Faculty of Dentistry, Oral & Craniofacial Sciences, Centre for Host-Microbiome Interactions, King’s College London, London, United Kingdom
| | - Philip R. Taylor
- Division of Infection and Immunity, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
- UK Dementia Research Institute, Cardiff, United Kingdom
| | - Neil A. R. Gow
- Aberdeen Fungal Group, University of Aberdeen, Aberdeen, United Kingdom
- Medical Research Council Centre for Medical Mycology, University of Exeter, Exeter, United Kingdom
| | - Selinda J. Orr
- Division of Infection and Immunity, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, United Kingdom
- School of Medicine, Dentistry and Biomedical Science, Wellcome Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
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Fuloria S, Fuloria N, Subramaniyan V, Darnal H, Meenakshi D, Sekar M, Nordin R, Chakravarthi S, Sathasivam K, Khan S, Wu Y, Kumari U, Sudhakar K, Malviya R, Sharma V. COVID-19-associated mucormycosis and treatments. ASIAN PAC J TROP MED 2021. [DOI: 10.4103/1995-7645.326253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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Hryniewicka A, Niemirowicz-Laskowska K, Wielgat P, Car H, Hauschild T, Morzycki JW. Dehydroepiandrosterone derived imidazolium salts and their antimicrobial efficacy. Bioorg Chem 2020; 108:104550. [PMID: 33353805 DOI: 10.1016/j.bioorg.2020.104550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/22/2020] [Accepted: 12/07/2020] [Indexed: 12/13/2022]
Abstract
Hybrid molecules consisting of steroid-imidazolium salts reveal interesting biological properties, especially regarding antimicrobial activities. Novel dehydroepiandrosterone derived imidazolium salts (11 salts) with side chains of different lengths were obtained in an efficient and straightforward synthetic route. Antimicrobial properties of new salts were examined by determining their minimum inhibitory concentrations (MICs). They were studied against several strains of bacteria, including clinical isolates of MRSA, and fungi. New compounds showed high activity against Gram-positive bacteria and Candida albicans as well as good compatibility with the representatives of the host cells when applied at concentrations corresponding to MIC value. The studies indicated high antimicrobial efficacy of imidazolium salts against the above-mentioned microorganisms with low hemolytic activity at a concentration that restricts the growth of the microorganisms. The interference of salts with the immune defense system, the influence on the biological activity of monocytes/macrophages measured by their viability and metabolic activity was also studied. The new compounds have shown immunoprotective properties.
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Affiliation(s)
- Agnieszka Hryniewicka
- Faculty of Chemistry, University of Bialystok, Ciołkowskiego 1K, 15-245 Białystok, Poland.
| | | | - Przemysław Wielgat
- Department of Clinical Pharmacology, Medical University of Bialystok, Waszyngtona 15A, 15-274 Białystok, Poland
| | - Halina Car
- Department of Experimental Pharmacology, Medical University of Bialystok, Szpitalna 37, 15-295 Białystok, Poland; Department of Clinical Pharmacology, Medical University of Bialystok, Waszyngtona 15A, 15-274 Białystok, Poland
| | - Tomasz Hauschild
- Faculty of Biology, University of Bialystok, Ciołkowskiego 1J, 15-245 Białystok, Poland
| | - Jacek W Morzycki
- Faculty of Chemistry, University of Bialystok, Ciołkowskiego 1K, 15-245 Białystok, Poland
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28
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Stanford FA, Voigt K. Iron Assimilation during Emerging Infections Caused by Opportunistic Fungi with emphasis on Mucorales and the Development of Antifungal Resistance. Genes (Basel) 2020; 11:genes11111296. [PMID: 33143139 PMCID: PMC7693903 DOI: 10.3390/genes11111296] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023] Open
Abstract
Iron is a key transition metal required by most microorganisms and is prominently utilised in the transfer of electrons during metabolic reactions. The acquisition of iron is essential and becomes a crucial pathogenic event for opportunistic fungi. Iron is not readily available in the natural environment as it exists in its insoluble ferric form, i.e., in oxides and hydroxides. During infection, the host iron is bound to proteins such as transferrin, ferritin, and haemoglobin. As such, access to iron is one of the major hurdles that fungal pathogens must overcome in an immunocompromised host. Thus, these opportunistic fungi utilise three major iron acquisition systems to overcome this limiting factor for growth and proliferation. To date, numerous iron acquisition pathways have been fully characterised, with key components of these systems having major roles in virulence. Most recently, proteins involved in these pathways have been linked to the development of antifungal resistance. Here, we provide a detailed review of our current knowledge of iron acquisition in opportunistic fungi, and the role iron may have on the development of resistance to antifungals with emphasis on species of the fungal basal lineage order Mucorales, the causative agents of mucormycosis.
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Affiliation(s)
- Felicia Adelina Stanford
- Jena Microbial Resource Collection, Leibniz Institute for Natural Product Research, and Infection Biology–Hans Knöll Institute, Jena, Adolf-Reichwein-Straße 23, 07745 Jena, Germany;
- Institute of Microbiology, Faculty of Biological Sciences, Friedrich-Schiller University Jena, Neugasse 25, 07743 Jena, Germany
| | - Kerstin Voigt
- Jena Microbial Resource Collection, Leibniz Institute for Natural Product Research, and Infection Biology–Hans Knöll Institute, Jena, Adolf-Reichwein-Straße 23, 07745 Jena, Germany;
- Institute of Microbiology, Faculty of Biological Sciences, Friedrich-Schiller University Jena, Neugasse 25, 07743 Jena, Germany
- Leibniz Institute for Natural Product Research and Infection Biology–Hans Knöll Institute, Jena Microbial Resource Collection Adolf-Reichwein-Straße 23, 07745 Jena, Germany
- Correspondence: ; Tel.: +49-3641-532-1395; Fax: +49-3641-532-2395
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29
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Born TA. A Pragmatic Approach to Immunity & Respiratory Viral Infections. Integr Med (Encinitas) 2020; 19:8-15. [PMID: 33488301 PMCID: PMC7815253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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30
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Mercer DK, O'Neil DA. Innate Inspiration: Antifungal Peptides and Other Immunotherapeutics From the Host Immune Response. Front Immunol 2020; 11:2177. [PMID: 33072081 PMCID: PMC7533533 DOI: 10.3389/fimmu.2020.02177] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022] Open
Abstract
The purpose of this review is to describe antifungal therapeutic candidates in preclinical and clinical development derived from, or directly influenced by, the immune system, with a specific focus on antimicrobial peptides (AMP). Although the focus of this review is AMP with direct antimicrobial effects on fungi, we will also discuss compounds with direct antifungal activity, including monoclonal antibodies (mAb), as well as immunomodulatory molecules that can enhance the immune response to fungal infection, including immunomodulatory AMP, vaccines, checkpoint inhibitors, interferon and colony stimulating factors as well as immune cell therapies. The focus of this manuscript will be a non-exhaustive review of antifungal compounds in preclinical and clinical development that are based on the principles of immunology and the authors acknowledge the incredible amount of in vitro and in vivo work that has been conducted to develop such therapeutic candidates.
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31
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Ademe M. Immunomodulation for the Treatment of Fungal Infections: Opportunities and Challenges. Front Cell Infect Microbiol 2020; 10:469. [PMID: 33042859 PMCID: PMC7522196 DOI: 10.3389/fcimb.2020.00469] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/30/2020] [Indexed: 01/03/2023] Open
Abstract
Opportunistic fungal infections are major causes of morbidity and mortality in patients with single or multiple defects in their immunity. Antifungal agents targeting the pathogen remain the treatment of choice for fungal infections. However, antifungal agents are toxic to the host mainly due to the close evolutionary similarity of fungi and humans. Moreover, antifungal therapy is ineffective in patients with immunosuppression. For this reason, there is an increased demand to develop novel strategies to enhance immune function and augment the existing antifungal drugs. In recent times, targeting the immune system to improve impaired host immune responses becomes a reasonable approach to improve the effectiveness of antifungal drugs. In this regard, immunomodulating therapeutic agents that turn up the immune response in the fight against fungal infections hold promise for enhancing the efficacy and safety of conventional antifungal therapy. In general, immunomodulating therapies are safe with decreased risk of resistance and broad spectrum of activity. In this review, therefore, clinical evidences supporting the opportunities and challenges of immunomodulation therapies in the treatment of invasive fungal infections are included.
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Affiliation(s)
- Muluneh Ademe
- Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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32
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Dutta O, Espinosa V, Wang K, Avina S, Rivera A. Dectin-1 Promotes Type I and III Interferon Expression to Support Optimal Antifungal Immunity in the Lung. Front Cell Infect Microbiol 2020; 10:321. [PMID: 32733815 PMCID: PMC7360811 DOI: 10.3389/fcimb.2020.00321] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/26/2020] [Indexed: 12/18/2022] Open
Abstract
Pulmonary infections with Aspergillus fumigatus (Af) are a significant cause of invasive fungal disease and lead to high morbidity and mortality in diverse populations throughout the world. Currently available antifungal drugs are often ineffective, thus contributing to unacceptably high mortality rates in patients suffering from invasive fungal infections. The use of cytokines as adjunctive immune therapies holds the promise of significantly improving patient outcomes in the future. In recent studies, we identified an essential role for type I and III interferons as regulators of optimal antifungal responses by pulmonary neutrophils during infection with Af. Although various membrane and cytosolic nucleic acid sensors are known to regulate interferon production in response to viruses, the pathways that regulate the production of these cytokines during fungal infection remain uncovered. In the current study, we demonstrate that dectin-1-mediated recognition of β-glucan on the cell wall of the clinically relevant fungal pathogen Aspergillus fumigatus promotes the activation of a protective cascade of type I and III interferon expression. We further demonstrate that exogenous administration of type I and III interferons can rescue inadequate antifungal responses in dectin-1−/− mice, suggesting the potential therapeutic benefit of these cytokines as activators of antifungal defense in the context of innate defects.
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Affiliation(s)
- Orchi Dutta
- Graduate School of Biomedical Sciences, Rutgers Biomedical and Health Sciences, Newark, NJ, United States.,Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Vanessa Espinosa
- Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Keyi Wang
- Graduate School of Biomedical Sciences, Rutgers Biomedical and Health Sciences, Newark, NJ, United States.,Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Samantha Avina
- Graduate School of Biomedical Sciences, Rutgers Biomedical and Health Sciences, Newark, NJ, United States.,Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
| | - Amariliz Rivera
- Department of Pediatrics, Center for Immunity and Inflammation, Rutgers Biomedical and Health Sciences, Newark, NJ, United States
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Dellière S, Sze Wah Wong S, Aimanianda V. Soluble mediators in anti-fungal immunity. Curr Opin Microbiol 2020; 58:24-31. [PMID: 32604018 DOI: 10.1016/j.mib.2020.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Abstract
Although soluble mediators of our innate immune system have a substantial impact on invading microbes, their role against fungal pathogens has been underexplored. Constituting the humoral immunity, soluble mediators comprise the complement system, collectins, acute-phase proteins, antibodies and antimicrobial peptides. These components can prevent fungal infection either by directly interacting with invading microbes, leading to their aggregation (microbistatic), destruction (microbicidal) or linking them to cellular immunity. The composition of soluble-mediator varies with human body-fluids, resulting in different antifungal mechanisms. Moreover, cellular immune system deploys both oxidative and non-oxidative mechanisms to destroy extracellular or internalized fungal pathogens; however, cellular immune activation is mainly influenced as well as regulated by soluble mediators. This review outlines the antifungal mechanism employed, directly or indirectly, by soluble mediators, and in response, the evading strategies of the fungal pathogens.
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Affiliation(s)
- Sarah Dellière
- Institut Pasteur, Molecular Mycology Unit, UMR2000, CNRS, Paris, France; Parasitology-Mycoloy Laboratory, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand-Widal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
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34
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Sheth U, Dande P. Pityriasis capitis: Causes, pathophysiology, current modalities, and future approach. J Cosmet Dermatol 2020; 20:35-47. [PMID: 32416039 DOI: 10.1111/jocd.13488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/07/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Pityriasis capitis commonly known as dandruff is one of the most common and widely seen dermatological disease that affects majority of the world population. It is more than superficial flaking, as it leads to significant structural changes in the stratum corneum and inflammatory biomarkers. Various intrinsic and extrinsic factors, such as Malassezia yeast, host epidermal conditions, sebaceous secretion, and abnormal immune responses, are found to contribute to the pathogenesis. Regardless of wide research, detail understanding, and treatment modalities, it still remains to be a cause of concern due to its recurring nature. AIMS The objective of this study is to enhance the understanding of its wide causes, pathophysiology, current treatment, and future approach. METHODS The article also aims at evaluating various promising anti-dandruff agents that can be further researched to become the leads in anti-dandruff therapy. RESULTS & CONCLUSION The article summarizes the current knowledge on dandruff and present new facts and evidences in order to spread awareness, create potential for new herbal treatment options, and effectively control the most commercially exploited scalp disorder.
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Affiliation(s)
- Umang Sheth
- SVKM's NMIMS, School of Pharmacy & Technology Management, Shirpur Campus, Shirpur, India
| | - Payal Dande
- SVKM's NMIMS, School of Pharmacy & Technology Management, Shirpur Campus, Shirpur, India
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35
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Bai G, Wang H, Han W, Cui N. T-Bet Expression Mediated by the mTOR Pathway Influences CD4 + T Cell Count in Mice With Lethal Candida Sepsis. Front Microbiol 2020; 11:835. [PMID: 32431684 PMCID: PMC7214724 DOI: 10.3389/fmicb.2020.00835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/07/2020] [Indexed: 11/13/2022] Open
Abstract
The sustained high morbidity and mortality of Candida sepsis are mainly caused by compromise of host immunity. Clinically, it is often manifested as a significant decrease in CD4+ T cell count, although the mechanism is unclear. We established a lethal mice Candida sepsis model and used Murine Sepsis Score to group mice with different disease severity to establish the influence of T-bet expression on CD4+ T cell count in Candida sepsis. We found that CD4+ T cell count decreased in Candida-infected compared to uninfected mice, and the degree of decrease increased with aggravation of sepsis. Expression of T-bet similarly decreased with worsening of sepsis, but it was significantly enhanced in candidiasis in comparison of naïve state. To clarify its possible mechanism, we measured the activity of mammalian target of rapamycin (mTOR), which is a key regulator of T-bet expression. The mTOR pathway was activated after infection and its activity increased with progression of sepsis. We used mice with T-cell-specific knockout of mTOR or tuberous sclerosis complex (TSC)1 to further inhibit or strengthen the mTOR signaling pathway. We found that mTOR deletion mice had a higher CD4+ T cell count by regulating T-bet expression, and the result in TSC1 deletion mice was reversed. These results demonstrate that T-bet expression mediated by the mTOR pathway influences the CD4+ T cell count in mice with Candida sepsis.
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Affiliation(s)
- Guangxu Bai
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Hao Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Wen Han
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
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36
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Abstract
Aspergillus fumigatus is a saprotrophic fungus; its primary habitat is the soil. In its ecological niche, the fungus has learned how to adapt and proliferate in hostile environments. This capacity has helped the fungus to resist and survive against human host defenses and, further, to be responsible for one of the most devastating lung infections in terms of morbidity and mortality. In this review, we will provide (i) a description of the biological cycle of A. fumigatus; (ii) a historical perspective of the spectrum of aspergillus disease and the current epidemiological status of these infections; (iii) an analysis of the modes of immune response against Aspergillus in immunocompetent and immunocompromised patients; (iv) an understanding of the pathways responsible for fungal virulence and their host molecular targets, with a specific focus on the cell wall; (v) the current status of the diagnosis of different clinical syndromes; and (vi) an overview of the available antifungal armamentarium and the therapeutic strategies in the clinical context. In addition, the emergence of new concepts, such as nutritional immunity and the integration and rewiring of multiple fungal metabolic activities occurring during lung invasion, has helped us to redefine the opportunistic pathogenesis of A. fumigatus.
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Affiliation(s)
- Jean-Paul Latgé
- School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Georgios Chamilos
- School of Medicine, University of Crete, Heraklion, Crete, Greece
- Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, Heraklion, Crete, Greece
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37
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Wang H, Bai G, Cui N, Han W, Long Y. T-cell-specific mTOR deletion in mice ameliorated CD4 + T-cell survival in lethal sepsis induced by severe invasive candidiasis. Virulence 2019; 10:892-901. [PMID: 31668132 PMCID: PMC6844314 DOI: 10.1080/21505594.2019.1685151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/06/2019] [Accepted: 09/08/2019] [Indexed: 12/27/2022] Open
Abstract
The mammalian target of rapamycin (mTOR) pathway can mediate T-cell survival; however, the role of this pathway in T-cell survival during fungal sepsis is unclear. Here, we investigated the role of the mTOR pathway in CD4+ T-cell survival in a mouse model of rapidly progressive lethal sepsis induced by severe invasive candidiasis and explored the possible mechanism. The decrease in CD4+ T-cell survival following fungal sepsis was ameliorated in mice with a T-cell-specific mTOR deletion, whereas it was exacerbated in mice with a T-cell-specific tuberous sclerosis complex (TSC)1 deletion. To explore the mechanism further, we measured expression of autophagy proteins light chain 3B and p62/sequestosome 1 in CD4+ T cells. Both proteins were increased in T-cell-specific mTOR knockout mice but lower in T-cell-specific TSC1 knockout mice. Transmission electron microscopy revealed that T-cell-specific mTOR knockout mice had more autophagosomes than wild-type mice following fungal sepsis. CD4+ T-cell mTOR knockout decreased CD4+ T-cell apoptosis in fungal sepsis. Most notably, the T-cell-specific mTOR deletion mice had an increased survival rate after fungal sepsis. These results suggest that the mTOR pathway plays a vital role in CD4+ T-cell survival during fungal sepsis, partly through the autophagy-apoptosis pathway.
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Affiliation(s)
- Hao Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Guangxu Bai
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Na Cui
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science; Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Wen Han
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China
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Wu X, Shen Y. Management of human immunodeficiency virus-associated cryptococcal meningitis: Current status and future directions. Mycoses 2019; 62:874-882. [PMID: 31365770 DOI: 10.1111/myc.12977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022]
Abstract
Cryptococcal meningitis (CM) is one of the most common opportunistic infections of acquired immunodeficiency syndrome (AIDS), as well as an important cause of hospitalisation and death. In recent years, the mortality of CM has remained high in HIV/AIDS population, with up to 30%, including within developed countries. The treatment usually encompasses controls of Cryptococcus, HIV, and increased intracranial pressure. Recent progress on the management of HIV-associated CM mainly centres in optimising induction regimens, looking for appropriate timing of initiating antiretroviral therapy and prevention of symptomatic onset and adverse consequences. This review compared several international guidelines combined with the results from some clinical researches to illustrate the similarities, differences and potential in CM treatment. The present practice is still far from satisfactory, and there remains much to explore due to our limited understanding of the pathogenesis of HIV-associated CM. Thus, screening and monitoring should be strengthened, and better therapies in line with the actual situation of each country should be discovered.
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Affiliation(s)
- Xueyun Wu
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Yinzhong Shen
- Department of Infection and Immunity, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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Li LY, Zhang HR, Jiang ZL, Chang YZ, Shao CZ. Overexpression of Dendritic Cell-Specific Intercellular Adhesion Molecule-3-Grabbing Nonintegrin in Dendritic Cells Protecting against Aspergillosis. Chin Med J (Engl) 2019; 131:2575-2582. [PMID: 30381591 PMCID: PMC6213851 DOI: 10.4103/0366-6999.244103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Dendritic cells (DCs) play an important role in host defense against pathogen infection. DC-specific intercellular adhesion molecule-3-grabbing nonintegrin (SIGN) is a group II C-type lectin receptor and specifically expressed on the surface of DCs. This study aimed to determine whether DC-SIGN affects intracellular signaling activation, Th1/Th2 imbalance and aspergillus immune evasion in aspergillus infection, and explore the application of DC-SIGN-modified DCs in immunotherapy. Methods: DCs were first obtained from the mononuclear cells of peripheral blood. The interferon (IFN)-γ and dexamethasone (Dex) were used to stimulate DCs. The expression of DC-SIGN, Th1 and Th2 cytokines, and the capacity of DCs in stimulating T cells proliferation and phagocytosis, and nuclear factor (NF)-κB activation were analyzed. In addition, adenovirus expression vector Ad-DC-SIGN was generated to transfect DCs. Mannan was used to block DC-SIGN signaling for confirming the involvement of DC-SIGN function in Aspergillus fumigatus (Af)-induced DCs maturation. The unpaired, two-tailed Student's t-test was used in the comparisons between two groups. Results: Exogenous IFN-γ could activate Af-induced DCs and promote the Th0 cells toward Th1 profile (interleukin [IL]-12 in IFN-γ/Af group: 50.96 ± 4.38 pg/ml; control/Af group: 29.70 ± 2.00 pg/ml, t = 10.815, P < 0.001). On the other hand, Dex inhibited the secretion of Th2 cytokines (IL-10 in Dex/Af group: 5.27 ± 0.85 pg/ml; control/Af group: 15.14 ± 1.40 pg/ml, t = 14.761, P < 0.001)), and successfully caused immunosuppression. After transfection with Ad-DC-SIGN, DCs have improved phagocytosis (phagocytosis rates in Ad-DC-SIGN group: 74.0% ± 3.4%; control group: 64.7% ± 6.8%, t = 3.104, P = 0.013). There was more Th1 cytokine secreted in the Af-induced DC-SIGN modified DCs (IL-12 in Ad-DC-SIGN/Af group: 471.98 ± 166.31 pg/ml; control/Af group: 33.35 ± 5.98 pg/ml, t = 6.456, P = 0.001), correlated to the enhanced NF-κB activation. Conclusion: Overexpressing DC-SIGN in DCs had a protective function on aspergillosis.
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Affiliation(s)
- Li-Yang Li
- Department of Pulmonary Medicine, Shanghai Institute of Respiratory Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Hao-Ru Zhang
- Laboratory of Molecular Iron Metabolism, The Key Laboratory of Animal Physiology, Biochemistry and Molecular Biology of Hebei Province, College of Life Science, Hebei Normal University, Shijiazhuang, Hebei 050024, China
| | - Zhi-Long Jiang
- Department of Pulmonary Medicine, Shanghai Institute of Respiratory Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yan-Zhong Chang
- Laboratory of Molecular Iron Metabolism, The Key Laboratory of Animal Physiology, Biochemistry and Molecular Biology of Hebei Province, College of Life Science, Hebei Normal University, Shijiazhuang, Hebei 050024, China
| | - Chang-Zhou Shao
- Department of Pulmonary Medicine, Shanghai Institute of Respiratory Diseases, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Immunomodulatory Effects of Drugs for Effective Cancer Immunotherapy. JOURNAL OF ONCOLOGY 2018; 2018:8653489. [PMID: 30498512 PMCID: PMC6222238 DOI: 10.1155/2018/8653489] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 10/10/2018] [Indexed: 12/12/2022]
Abstract
Recent advances in cancer immunotherapy, including immune checkpoint inhibitors or adoptive T cell therapies, have contributed to better outcomes in cancer patients. However, there are still many cancers with no cure. Therefore, combinations of several treatment strategies are being explored, and enhancing anticancer immunity will play an important role to combat the disease. There have been several reports on the immune-modulatory effects of commonly used drugs, namely, statin, metformin, and angiotensin receptor blockers (ARBs), which suggest that these drugs could enhance immunity against cancer cells. Other anticancer drugs, such as anthracyclines, thalidomides, lenalidomides, and hypomethylating drugs, could also strengthen the immune system to attack cancer cells at a relatively low dose. Hence, these drugs might contribute to better outcomes in cancer patients.
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