Polymerase Chain Reaction Screening for Fungemia and/or Invasive Fungal Infections in Patients with Hematologic Malignancies

INTRODUCTION: Invasive fungal infections (IFIs) are a life-threatening complication in patients with hematologic malignancies, mainly in acute leukemia patients, following chemotherapy. IFI incidence is increasing, and associated mortality remains high due to unreliable diagnosis. Antifungal drugs are often limited by inadequate antimicrobial spectrum and side effects. Thus, the detection of circulating fungal DNA has been advocated as a rapid, more sensitive diagnostic tool. PATIENTS AND METHODS: Between June 01 and January 03, weekly blood samples (1,311) were screened from 193 patients undergoing intensive myelosuppressive or immunosuppressive therapy. IFI cases were classified according to European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. Fungal DNA was extracted from whole blood and amplified using polymerase chain reaction (PCR) published primers that bind to the conserved regions of the fungal 18S rRNA gene sequence. In our study, two or more consecutive positive samples were always associated with fungal disease. RESULTS: PCR screening predicted the development of IFI to be 17 days (median). This test had a specificity of 91.1% and a sensitivity of 75%. IFI incidence was 7.8%. DISCUSSION: Therefore, our results confirm the potential usefulness of PCR serial screening and the clinical applicability in everyday routine. PCR screening offers a noninvasive repeatable aid to the diagnosis of IFI.

The use of mannan antigen and anti-mannan antibodies in the diagnosis of invasive candidiasis: recommendations from the Third European Conference on Infections in Leukemia.

INTRODUCTION: Timely diagnosis of invasive candidiasis (IC) remains difficult as the clinical presentation is not specific and blood cultures lack sensitivity and need a long incubation time. Thus, non-culture-based methods for diagnosing IC have been developed. Mannan antigen (Mn) and anti-mannan antibodies (A-Mn) are present in patients with IC. On behalf of the Third European Conference on Infections in Leukemia, the performance of these tests was analysed and reviewed. METHODS: The literature was searched for studies using the commercially available sandwich enzyme-linked immunosorbent assays (Platelia™, Bio-Rad Laboratories, Marnes-la-Coquette, France) for detecting Mn and A-Mn in serum. The target condition of this review was IC defined according to 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. Sensitivity, specificity and diagnostic odds ratios (DOR) were calculated for Mn, A-Mn and combined Mn/A-Mn testing. RESULTS: Overall, 14 studies that comprised 453 patients and 767 controls were reviewed. The patient populations included in the studies were mainly haematological and cancer cases in seven studies and mainly intensive care unit and surgery cases in the other seven studies. All studies but one were retrospective in design. Mn sensitivity was 58% (95% confidence interval [CI], 53-62); specificity, 93% (95% CI, 91-94) and DOR, 18 (95% CI 12-28). A-Mn sensitivity was 59% (95% CI, 54-65); specificity, 83% (95% CI, 79-97) and DOR, 12 (95% CI 7-21). Combined Mn/A-Mn sensitivity was 83% (95% CI, 79-87); specificity, 86% (95% CI, 82-90) and DOR, 58 (95% CI 27-122). Significant heterogeneity of the studies was detected. The sensitivity of both Mn and A-Mn varied for different Candida species, and it was the highest for C. albicans, followed by C. glabrata and C. tropicalis. In 73% of 45 patients with candidemia, at least one of the serological tests was positive before the culture results, with mean time advantage being 6 days for Mn and 7 days for A-Mn. In 21 patients with hepatosplenic IC, 18 (86%) had Mn or A-Mn positive test results at a median of 16 days before radiological detection of liver or spleen lesions. CONCLUSIONS: Mn and A-Mn are useful for diagnosis of IC. The performance of combined Mn/A-Mn testing is superior to either Mn or A-Mn testing.

PTX3 Polymorphisms and Invasive Mold Infections After Solid Organ Transplant.

Donor PTX3 polymorphisms were shown to influence the risk of invasive aspergillosis among hematopoietic stem cell transplant recipients. Here, we show that PTX3 polymorphisms are independent risk factors for invasive mold infections among 1101 solid organ transplant recipients, thereby strengthening their role in mold infection pathogenesis and patients' risk stratification.

Gypsy moths (Lymantria dispar) in the Niagara Region : population density variation, introduction of an entomopathogenic fungus (Entomophaga maimaiga) and occurrence of nuclear polyhedrosis virus

The gypsy moth, Lymantria dispar, a major defoliator of broad leaf trees, was accidentally introduced into North America in 1869. Much interest has been generated regarding the potential of using natural pathogens for biological control of this insect. One of these pathogens, a highly specific fungus, Entomophaga maimaiga, was accredited with causing major epizootics in populations of gypsy moth across the north-eastern United States in 1989 and 1990 and is thought to be spreading northwards into Canada. This study examined gypsy moth population densities in the Niagara Region. The fungus, .E.. maimaiga, was artificially introduced into one site and the resulting mortality in host populations was noted over two years. The relationship between fungal mortality, host population density and occurrence of another pathogen, the nuclear polyhedrosis virus (NPV), was assessed. Gypsy moth population density was assessed by counting egg masses in 0.01 hectare (ha) study plots in six areas, namely Louth, Queenston, Niagara-on-the-Lake, Shorthills Provincial Park, Chippawa Creek and Willoughby Marsh. High variability in density was seen among sites. Willoughby Marsh and Chippawa Creek, the sites with the greatest variability, were selected for more intensive study. The pathogenicity of E. maimaiga was established in laboratory trials. Fungal-infected gypsy moth larvae were then released into experimental plots of varying host density in Willoughby Marsh in 1992. These larvae served as the inoculum to infect field larvae. Other larvae were injected with culture medium only and released into control plots also of varying host density. Later, field larvae were collected and assessed for the presence of .E.. maimaiga and NPV. A greater proportion of larvae were infected from experimental plots than from control plots indicating that the experimental augmentation had been successful. There was no relationship between host density and the proportion of infected larvae in either experimental or control plots. In 1992, 86% of larvae were positive for NPV. Presence and intensity of NPV infection was independent of fungal presence, plot type or interaction of these two factors. Sampling was carried out in the summer of 1993, the year after the introduction, to evaluate the persistence of the pathogen in the environment. Almost 50% of all larvae were infected with the fungus. There was no difference between control and experimental plots. Data collected from Willoughby Marsh indicated that there was no correlation between the proportion of larvae infected with the fungus and host population density in either experimental or control plots. About 10% of larvae collected from a nearby site, Chippawa Creek, were also positive for .E.. maimaiga suggesting that low levels of .E.. maimaiga probably occurred naturally in the area. In 1993, 9.6% of larvae were positive for NPV. Again, presence or absence of NPV infection was independent of fungal presence plot type or interaction of these two factors. In conclusion, gypsy moth population densities were highly variable between and within sites in the Niagara Region. The introduction of the pathogenic fungus, .E.. maimaiga, into Willoughby Marsh in 1992 was successful and the fungus was again evident in 1993. There was no evidence for existence of a relationship between fungal mortality and gypsy moth density or occurrence of NPV. The results from this study are discussed with respect to the use of .E.. maimaiga in gypsy moth management programs.

Effect of fatty acids on hyphal growth in the pathogenic yeast Candida albicans

Candida albicans est une levure pathogène qui, à l’état commensal, colonise les muqueuses de la cavité orale et du tractus gastro-intestinal. De nature opportuniste, C. albicans cause de nombreuses infections, allant des candidoses superficielles (muguet buccal, vulvo-vaginite) aux candidoses systémiques sévères. C. albicans a la capacité de se développer sous diverses morphologies, telles que les formes levures, pseudohyphes et hyphes. Des stimuli environnementaux mimant les conditions retrouvées chez l’hôte (température de 37°C, pH neutre, présence de sérum) induisent la transition levure-à-hyphe (i.e. morphogenèse ou filamentation). Cette transition morphologique contribue à la pathogénicité de C. albicans, du fait que des souches présentant un défaut de filamentation sont avirulentes. Non seulement la morphogenèse est un facteur de virulence, mais elle constituerait aussi une cible pour le développement d’antifongiques. En effet, il a déjà été démontré que l’inhibition de la transition levure-à-hyphe atténuait la virulence de C. albicans lors d’infections systémiques. Par ailleurs, des études ont démontré que de nombreuses molécules pouvaient moduler la morphogenèse. Parmi ces molécules, certains acides gras, dont l’acide linoléique conjugué (CLA), inhibent la formation d’hyphes. Ainsi, le CLA posséderait des propriétés thérapeutiques, du fait qu’il interfère avec un déterminant de pathogénicité de C. albicans. Par contre, avant d’évaluer son potentiel thérapeutique dans un contexte clinique, il est essentiel d’étudier son mode d’action. Ce projet vise à caractériser l’activité anti-filamentation des acides gras et du CLA et à déterminer le mécanisme par lequel ces molécules inhibent la morphogenèse chez C. albicans. Des analyses transcriptomiques globales ont été effectuées afin d’obtenir le profil transcriptionnel de la réponse de C. albicans au CLA. L’acide gras a entraîné une baisse des niveaux d’expression de gènes encodant des protéines hyphes-spécifiques et des régulateurs de morphogenèse, dont RAS1. Ce gène code pour la GTPase Ras1p, une protéine membranaire de signalisation qui joue un rôle important dans la transition levure-à-hyphe. Des analyses de PCR quantitatif ont confirmé que le CLA inhibait l’induction de RAS1. De plus, le CLA a non seulement causé une baisse des niveaux cellulaires de Ras1p, mais a aussi entraîné sa délocalisation de la membrane plasmique. En affectant les niveaux et la localisation cellulaire de Ras1p, le CLA nuit à l’activation de la voie de signalisation Ras1p-dépendante, inhibant ainsi la morphogenèse. Il est possible que le CLA altère la structure de la membrane plasmique et affecte indirectement la localisation membranaire de Ras1p. Ces travaux ont permis de mettre en évidence le mode d’action du CLA. Le potentiel thérapeutique du CLA pourrait maintenant être évalué dans un contexte d’infection, permettant ainsi de vérifier qu’une telle approche constitue véritablement une stratégie pour le traitement des candidoses.

Développement de nouvelles formulations d’antifongiques et évaluation de l’activité sur Candida spp. et Aspergillus spp.

Les travaux effectués dans le cadre de cette thèse de doctorat avaient pour but de mettre au point des nouvelles formulations d’antifongiques sous forme de nanoparticules polymériques (NP) en vue d’améliorer l’efficacité et la spécificité des traitements antifongiques sur des souches sensibles ou résistantes de Candida spp, d’Aspergillus spp et des souches de Candida albicans formant du biofilm. Dans la première partie de ce travail, nous avons synthétisé et caractérisé un polymère à base de polyester-co-polyéther branché avec du poly(éthylène glycol) (PEG-g-PLA). En plus d’être original et innovant, ce co-polymère a l’avantage d’être non-toxique et de posséder des caractéristiques de libération prolongée. Trois antifongiques couramment utilisés en clinique et présentant une biodisponibilité non optimale ont été choisis, soient deux azolés, le voriconazole (VRZ) et l’itraconazole (ITZ) et un polyène, l’amphotéricine B (AMB). Ces principes actifs (PA), en plus des problèmes d’administration, présentent aussi d’importants problèmes de toxicité. Des NP polymériques encapsulant ces PA ont été préparées par une technique d’émulsion huile-dans-l’eau (H/E) suivie d’évaporation de solvant. Une fois fabriquées, les NP ont été caractérisées et des particules de d’environ 200 nm de diamètre ont été obtenues. Les NP ont été conçues pour avoir une structure coeur/couronne avec un coeur constitué de polymère hydrophobe (PLA) et une couronne hydrophile de PEG. Une faible efficacité de chargement (1,3% m/m) a été obtenue pour la formulation VRZ encapsulé dans des NP (NP/VRZ). Toutefois, la formulation AMB encapsulée dans des NP (NP/AMB) a montré des taux de chargement satisfaisants (25,3% m/m). En effet, le caractère hydrophobe du PLA a assuré une bonne affinité avec les PA hydrophobes, particulièrement l’AMB qui est le plus hydrophobe des agents sélectionnés. Les études de libération contrôlée ont montré un relargage des PA sur plusieurs jours. La formulation NP/AMB a été testée sur un impacteur en cascade, un modèle in vitro de poumon et a permis de démontrer le potentiel de cette formulation à être administrée efficacement par voie pulmonaire. En effet, les résultats sur l’impacteur en cascade ont montré que la majorité de la formulation s’est retrouvée à l’étage de collecte correspondant au niveau bronchique, endroit où se situent majoritairement les infections fongiques pulmonaires. Dans la deuxième partie de ces travaux, nous avons testé les nouvelles formulations d’antifongiques sur des souches planctoniques de Candida spp., d’Aspergillus spp. et des souches de Candida albicans formant du biofilm selon les procédures standardisées du National Committee for Clinical Laboratory Standards (NCCLS). Les souches choisies ont démontré des résistances aux azolés et aux polyènes. Les études d’efficacité in vitro ont permis de prouver hors de tout doute que les nouvelles formulations offrent une efficacité nettement améliorée comparée à l’agent antifongique libre. Pour mettre en lumière si l’amélioration de l’efficacité antifongique était due à une internalisation des NP, nous avons évalué le comportement des NP avec les cellules de champignons. Nous avons procédé à des études qualitatives de microscopie de fluorescence sur des NP marquées avec de la rhodamine (Rh). Tel qu’attendu, les NP ont montré une localisation intracellulaire. Pour exclure la possibilité d’une simple adhésion des NP à la surface des levures, nous avons aussi confirmé leur internalisation en microscopie confocale de fluorescence. Il est important de noter que peu d’études à ce jour ont mis l’accent sur l’élaboration de nouvelles formulations d’antifongiques à base de polymères non toxiques destinées aux traitements des mycoses, donnant ainsi une grande valeur et originalité aux travaux effectués dans cette thèse. Les résultats probants obtenus ouvrent la voie vers une nouvelle approche pour contourner les problèmes de résistances fongiques, un problème de plus en plus important dans le domaine de l’infectiologie.

Micoses sistémicas

Este trabalho teve como objetivo a análise das micoses sistémicas, no que respeita à sua identificação, morfologia dos agentes patogénicos que lhes dão origem, onde são endémicas, os sintomas que apresentam, os métodos de diagnóstico e as terapêuticas disponíveis para cada patologia. As micoses sistémicas são infeções causadas por fungos patogénicos primários que têm o trato respiratório como porta de entrada, e a partir daí podem disseminar-se por todo o organismo. Os agentes antifúngicos são usados no tratamento destas infeções, em que, no caso das infeções sistémicas, predominam o uso de cetoconazol (polieno), fluconazol e itraconazol (azóis). Existem ainda estudos que demonstram que as vacinas atenuadas podem ser usadas na profilaxia destas infeções. Com este trabalho conclui-se que as infeções fúngicas estão longe de ser extintas, uma vez que se verifica cada vez mais a existência de resistências por parte dos fungos aos fármacos, sendo o diagnóstico e a terapêutica usada dois parâmetros fundamentais para um tratamento eficaz.

Attempts at a peptide vaccine against paracoccidioidomycosis, adjuvant to chemotherapy

Chemotherapy is the basis of treatment of paracoccidioidomycosis in its various forms. Depending on the Paracoccidioides brasiliensis virulence, the status of host immunity, the degree of tissue involvement and fungal dissemination, treatment can be extended for long periods with an alarming frequency of relapses. Association of chemotherapy with a vaccine to boost the cellular immune response seemed a relevant project not only to reduce the time of treatment but also to prevent relapses and improve the prognosis of anergic cases. The candidate immunogen is the gp43 major diagnostic antigen of P. brasiliensis and more specifically its derived peptide P10, carrying the CD4(+) T-cell epitope. Both gp43 and P10 protected Balb/c mice against intratracheal infections with virulent P. brasiliensis strain. P10 as single peptide or in a multiple-antigen-peptide (MAP) tetravalent construction was protective without adjuvant either by preimmunization and intratracheal challenge or as a therapeutic agent in mice with installed infection. P10 showed additive protective effects in drug-treated mice stimulating a Th-1 type immune response with high IFN-gamma and IL-12. P10 and few other peptides in the gp43 were selected by Tepitope algorithm and actually shown to promiscuously bind several prominent HLA-DR molecules suggesting that a peptide vaccine could be devised for a genetically heterogenous population. P10 was protective in animals turned anergic, was effective in a DNA minigene vaccine, and increased the protection by monoclonal antibodies in Balb/c mice. DNA vaccines and peptide vaccines are promising therapeutic tools to be explored in the control of systemic mycoses.

Metallopeptidase inhibitors arrest vital biological processes in the fungal pathogen Scedosporium apiospermum

P>Scedosporium apiospermum is an emerging agent of opportunistic mycoses in humans. Previously, we showed that mycelia of S. apiospermum secreted metallopeptidases which were directly linked to the destruction of key host proteins. In this study, we analysed the effect of metallopeptidase inhibitors on S. apiospermum development. As germination of inhaled conidia is a crucial event in the infectious process of S. apiospermum, we studied the morphological transformation induced by the incubation of conidia in Sabouraud-dextrose medium at 37 degrees C. After 6 h, some conidia presented a small projection resembling a germ-tube. A significant increase, around sixfold, in the germ-tube length was found after 12 h, and hyphae were exclusively observed after 24 h. Three distinct metallopeptidase inhibitors were able to arrest the transformation of conidia into hyphae in different ways; for instance, 1,10-phenanthroline (PHEN) completely blocked this process at 10 mu mol l-1, while ethylenediamine tetraacetic acid (EDTA) and ethylene glycol-bis (beta-aminoethyl ether; EGTA) only partially inhibited the differentiation at up to 10 mmol l-1. EGTA did not promote any significant reduction in the conidial growth, while PHEN and EDTA, both at 10 mmol l-1, inhibited the proliferation around 100% and 65%, respectively. The secretion of polypeptides into the extracellular environment and the metallopeptidase activity secreted by mycelia were completely inhibited by PHEN. These findings suggest that metallo-type enzymes could be potential targets for future therapeutic interventions against S. apiospermum.

Fungicidal effect of photodynamic therapy against fluconazole-resistant Candida albicans and Candida glabrata

P>Although photodynamic therapy (PDT) has shown great promise for the inactivation of Candida species, its effectiveness against azole-resistant pathogens remains poorly documented. This in vitro study describes the association of Photogem (R) (Photogem, Moscow, Russia) with LED (light emitting diode) light for the photoinactivation of fluconazole-resistant (FR) and American Type Culture Collection (ATCC) strains of Candida albicans and Candida glabrata. Suspensions of each Candida strain were treated with five Photogem (R) concentrations and exposed to four LED light fluences (14, 24, 34 or 50 min of illumination). After incubation (48 h at 37 degrees C), colonies were counted (CFU ml-1). Single-species biofilms were generated on cellulose membrane filters, treated with 25.0 mg l-1 of Photogem (R) and illuminated at 37.5 J cm-2. The biofilms were then disrupted and the viable yeast cells present were determined. Planktonic suspensions of FR strains were effectively killed after PDT. It was observed that the fungicidal effect of PDT was strain-dependent. Significant decreases in biofilm viability were observed for three strains of C. albicans and for two strains of C. glabrata. The results of this investigation demonstrated that although PDT was effective against Candida species, fluconazole-resistant strains showed reduced sensitivity to PDT. Moreover, single-species biofilms were less susceptible to PDT than their planktonic counterparts.

Antifungal activity of tri- and tetra-thioureido amino derivatives against different Candida species

The in vitro antifungal activity of six thioureido substituted amines (P1-P6) was evaluated against Candida species, including Candida albicans, C. glabrata, C. krusei and C. parapsilosis. These tri- and tetra-thioureido amino derivatives with different methylation levels were synthesised through easy synthetic routes to evaluate their antifungal properties against Candida species. Among all studied derivatives, the tri-(2-thioureido-ethyl)-amine (P1) was the most active compound inhibiting C. albicans and C. glabrata at a concentration of 0.49 mu g ml(-1); P3, the N,N `,N ``,N ```-hexamethyl-derivative, also showed inhibitory activity against C. albicans and C. glabrata, but in higher concentrations (250 mu g ml(-1)). The N,N `,N ``,N ```-tetramethylated amine (P5) only inhibited the growth of C. glabrata, but its corresponding N,N `,N ``,N ```-octamethyl derivative (P6) was also active against C. glabrata (125 mu g ml(-1)) and it was the only compound active against C. parapsilosis. P2 and P4 showed no significant antifungal activity. The structure-activity relationship of the thioureido-substituted derivatives indicates that the molecular branching and the alkylation levels can influence the antifungal activity. This study demonstrated that thioureido derivatives exhibited significant antifungal activity against Candida species and that they can be considered as a very promising bioactive lead compound to develop novel antifungal agents.