A global view on fungal infections in humans and animals: opportunistic infections and microsporidioses

After cardiovascular diseases, infectious diseases are the second most common cause of death worldwide. Although these infections are caused mainly by viruses or bacteria, a systematically growing prevalence of human and animal opportunistic fungal infections is noticeable worldwide. More attention is being paid to this problem, especially due to the growing frequency of recalcitrant and recurrent mycoses. The latter are classically divided into superficial, which are the most common type, subcutaneous, and systemic. This work discusses opportunistic fungal pathogens without proven horizontal transmission between different animal species including humans and microsporidia as spore-forming unicellular parasites related to fungi; however, with a yet undetermined taxonomic position. The review also mentions aetiological agents, risk factors, epidemiology, geographical distribution, and finally symptoms characteristic for individual disease entities. This paper provides insight into fungal infections from a global perspective and simultaneously draws attention to emerging pathogens, whose prevalence is continuously increasing. Finally, this work also takes into consideration the correct nomenclature of fungal disease entities and the importance of secondary metabolites in the pathogenesis of fungal infections.     

Susceptibility testing of dermatophytes

The dermatophytes are a specialized group of fungi that infect the keratinized tissues of humans (hair, nails, and skin) and cause superficial infections. Although several studies have been conducted to develop methods to determine the susceptibilities of yeast and filamentous fungi, similar studies for dermatophytes have only recently taken place. We review how susceptibility testing of dermatophytes was developed and how it has already been applied to clinical samples. We also review recent advances in the development of disk diffusion and colorimetric methodologies for determining the antifungal susceptibility of dermatophytes. With several agents now available for treating infections due to dermatophytes, susceptibility testing will serve as a valuable tool for clinicians as they choose the most appropriate treatment option. Studies are still needed to establish interpretive breakpoints for antifungal agents used in the treatment of superficial fungal infections.     

Fungal infections in the immunocompromised host

In recent years many remarkable changes occurred in our way of life, producing opportunities for microbes. All these changes are related to the recent emergence of previously unrecognized diseases, or the resurgence of diseases that, at least in developed countries, were thought to be under control. This concept is reviewed regarding fungal infections and their agents in the immunocompromised host. The changing pattern of these infections, the portals of entry of fungi into the human host, fungal pathogenicity and the main predisposing factors are analyzed. Opportunistic fungal infections in cancer, organ transplant and acquired immunodeficiency syndrome patients are reviewed, specially candidiasis and aspergillosis.     

Relevant Animal Models in Dermatophyte Research

Dermatophytoses are common superficial fungal infections affecting both humans and animals. They are provoked by filamentous fungi called dermatophytes specialized in the degradation of keratinized structures, which allows them to induce skin, hair and nail infections. Despite their high incidence, little investigation has been performed for the understanding of these infections compared to fungal opportunistic infections and most of the studies were based on in vitro experiments. The development of animal models for dermatophyte research is required to evaluate new treatments against dermatophytoses or to increase knowledge about fungal pathogenicity factors or host immune response mechanisms. The guinea pig has been the most often used animal model to evaluate efficacy of antifungal compounds against dermatophytes, while mouse models were preferred to study the immune response generated during the disease. Here, we review the relevant animal models that were developed for dermatophyte research and we discuss the advantages and disadvantages of the selected species, especially guinea pig and mouse.     

Major challenges and perspectives in the diagnostics and treatment of dermatophyte infections

Dermatophytes are the aetiological factors of a majority of superficial fungal infections. What distinguishes them from other pathogenic filamentous fungi is their unique ability to degrade keratin. The remarkable ability of this group of fungi to survive in different ecosystems results from their morphological and ecological diversity as well as high adaptability to changing environmental conditions. Paradoxically, despite the progress in medicine, the prevalence of dermatophyte infections is increasing from year to year. At the beginning of the third millennium, practical diagnostic and therapeutic options are still very limited. This review focuses on understanding the major problems in this aspect of dermatophyte infections and indicates future strategies and perspectives for novel approaches to identification and drugs for elimination of dermatophytes. Particular importance is placed on development of a strategy for a diagnostic pathway and implementation of rapid and reliable diagnostics methods designed by international teams. Furthermore, among compounds that currently arouse great interest, representatives of terpenoids, alkaloids, saponins, flavonoids and essential oils deserve attention. Many of these compounds are undergoing clinical trials as potential antifungal agents, and future research should focus on attempts at determination of the applicability of tested substances. Finally, the advantages and disadvantages in implementation of new diagnostic paths and medicinal substances for routine use are indicated.     

Opportunistic zygomycotic infections

This is a literature review of 361 opportunistic fungal infections caused by the Zygomycetes. The clinical and laboratory diagnosis, pathogenesis, management, treatment, and outcome of infection are discussed. The Zygomycetes are a group of opportunistic fungi (orders Mucorales and Entomophthorales) which cause severe infections which may be fatal. Early clinical recognition, prompt diagnostic procedures, control of underlying disease and treatment with high doses of amphotericin B and aggressive surgery increases survival in an otherwise lethal infection.     

Antifungal Resistance Mechanisms in Dermatophytes

Although fungi do not cause outbreaks or pandemics, the incidence of severe systemic fungal infections has increased significantly, mainly because of the explosive growth in the number of patients with compromised immune system. Thus, drug resistance in pathogenic fungi, including dermatophytes, is gaining importance. The molecular aspects involved in the resistance of dermatophytes to marketed antifungals and other cytotoxic drugs, such as modifications of target enzymes, over-expression of genes encoding ATP-binding cassette (ABC) transporters and stress-response-related proteins are reviewed. Emphasis is placed on the mechanisms used by dermatophytes to overcome the inhibitory action of terbinafine and survival in the host environment. The relevance of identifying new molecular targets, of expanding the understanding about the molecular mechanisms of resistance and of using this information to design new drugs or to modify those that have become ineffective is also discussed.     

The distribution of ringworm infections amongst Nigerian nomadic Fulani herdsmen

There are very few medical reports on the nomadic peoples of the world. In Nigeria such reports are nonexistent. The present work has looked at the distribution of ringworm infections among the Nigerian nomadic Fulani herdsmen. An examination of their infected herds of cattle revealed similarities in the species of dermatophytes isolated from the herdsmen and those isolated from their cattle. Some of the leaves of the plants that lined the cattle tracks normally used by both the herdsmen and their cattle yielded some of the species of dermatophytes isolated from the herdsmen and their cattle. The possible origins of the dermatophytes that caused the ringworm infections amongst the nomads are discussed.     

Fungal toxins as a parasitic factor responsible for the establishment of fungal infections

Although the mechanism of fungal infections, particularly that of opportunistic fungus infections, has been studied extensively, much still remains to be clarified. As is the case for certain bacterial infections, it has long been assumed by numerous investigators that some toxins, enzymes and other metabolites produced in vitro as well as in vivo by pathogenic fungi or their cellular constituents might be responsible for the establishment of fungal infections. However, there are very few papers which deal with isolation and/or characterization of pathogenic fungus-derived toxins, particularly those of high molecular weight, to sufficiently meet various criteria for toxins including etiopathological ability. Likewise, it has been speculated that certain enzymes produced by pathogenic fungi are related to the pathogenesis of infections with the fungi implicated, but no direct evidence has been provided.It is commonly held by researchers concerned with medical mycology that the lowering of specific and/or nonspecific resistance of a host to pathogenic fungi is a prerequisite for the establishment of infections, particularly opportunistic infections. However, it is also accepted that if a given fungus possesses no parasite factors (e.g. toxigenicity, invasiveness and others), it would be unable to initiate infection even when the host is in a severe immunodeficient state. This is supported by our recent studies working with Saccharomyces cerevisiae and some other so-called nonpathogenic yeasts (unpublished data). Based on these considerations, the author and his co-workers have attempted to isolate several high and low molecular weight toxins in a pure state from virulent strains of Candida albicans and Aspergillus fumigatus as opportunist. Studies have also been made on the etiopathological roles of some successfully isolated toxins in infections with the fungi implicated (46).In addition to our experimental results, general concepts in fungal toxins, particularly those related to such toxins as isolated in our laboratory are outlined. Since opportunistic fungus infections have created a global problem because of their world-wide prevalence, a sharp demarcation between the so-called pathogenic and nonpathogenic fungi has become vague. Despite this situation, two terms are conventionally used throughout this paper.The author thanks Drs. H. Yamaguchi and K. Uchida, Y. Yamamoto, T. Hiratani, and Y. Nozu for their collaboration during these studies.     

Studying fungal pathogens of humans and fungal infections: fungal diversity and diversity of approaches

Seminal work by Louis Pasteur revealed the contribution of fungi – yeasts and microsporidia to agroindustry and disease in animals, respectively. More than 150 years later, the impact of fungi on human health and beyond is an ever-increasing issue, although often underestimated. Recent studies estimate that fungal infections, especially those caused by Candida, Cryptococcus and Aspergillus species, kill more than one million people annually. Indeed, these neglected infections are in general very difficult to cure and the associated mortality remains very high even when antifungal treatments exist. The development of new antifungals and diagnostic tools that are both necessary to fight fungal diseases efficiently, requires greater insights in the biology of the fungal pathogens of humans in the context of the infection, on their epidemiology, and on their role in the human mycobiota. We also need a better understanding of the host immune responses to fungal pathogens as well as the genetic basis for the increased sensitivity of some individuals to fungal infections. Here, we highlight some recent progress made in these different areas of research, in particular based on work conducted in our own laboratories. These progresses should lay the ground for better management of fungal infections, as they provide opportunities for better diagnostic, vaccination, the development of classical antifungals but also strategies for targeting virulence factors or the host.     

深部真菌感染临床特点分析

目的了解深部真菌感染患者的性别、年龄、感染部位、住院科室、菌种分布及真菌耐药情况,为临床防治真菌感染提供研究依据。方法收集荆州市中心医院2009年1月至2009年12月微生物实验室分离的真菌446株,采用科马嘉显色琼脂及API220C Aux鉴定系统鉴定,并使用ATMTMFUNGUS3真菌药敏卡进行体外药敏试验。结果临床真菌感染男性占72%,以老年患者为主,大于60岁者占54.9%;感染的真菌主要分布于呼吸内科和ICU,分别占35.5%、24.9%;主要感染部位为呼吸道,占91.3%;主要菌种为白假丝酵母菌、热带念株菌、近平滑假丝酵母菌、光滑念株菌和克柔念株菌,分别占64.2%、13.2%、9.6%、7.6%和5.4%;合并细菌感染的感染真菌100株,占22.2%,细菌中以革兰阴杆性菌为主,占96%;药敏试验结果显示真菌对各抗真菌药具有较好的敏感性。结论临床真菌感染已日益突出,以呼吸科及ICU患者老年男性为主,儿童真菌感染亦不容忽视,感染菌种以白假丝酵母菌和热带念株菌为主,临床应加强对这些真菌感染的预防和监测,防止真菌感染。     

Photodynamic inactivation for controlling Candida albicans infections

Antimicrobial photodynamic therapy (APDT) combines a non-toxic dye, termed photosensitizer, which is activated by visible light of appropriate wavelength which will produce reactive oxygen species (ROS). These ROS will react with cellular components inducing oxidative processes, leading to cell death. A wide range of microorganisms, have already showed susceptibility to APDT. Therefore, this treatment might consist in an alternative for the management of fungal infections that is mainly caused by biofilms, since they respond poorly to conventional antibiotics and may play a role in persistent infections. Biofilms are the leading cause of microbial infections in humans, thus representing a serious problem in health care. Candida albicans is the main type of fungi able to form biofilms, which cause superficial skin and mucous membrane infections as well as deep-seated mycoses, particularly in immunocompromised patients. In these patients, invasive infections are often associated with high morbidity and mortality. Furthermore, the increase in antifungal resistance has decreased the efficacy of conventional therapies. Treatments are time-consuming and thus demanding on health care budgets. Additionally, current antifungal drugs only have a limited spectrum of action and toxicity. The use of APDT as an antimicrobial topical agent against superficial and cutaneous diseases represents an effective method for eliminating microorganisms.     

How to diagnose and treat fungal infections in chronic prostatitis

Epidemiologic changes that include immune-compromised patients and drug-resistant fungi have caused an increase in nosocomial infections by Candida albicans and non-albicans Candida species. Other fungi, aspergilla and Cryptococcus (environmental contaminants), are opportunistic invaders of the immune-compromised (transplant, HIV) patients. The environmental fungi Coccidioides immitis (dry arid areas), Histoplasma capsulatum (Avian-infested areas), and Blastomyces dermatitidis (aquatic areas) can cause infections in immune-competent and immune-deficient patients. Each fungus can cause changes in the prostate that mimic bacterial infection, benign prostatic hypertrophy, or neoplasm. Diagnosis can be established by urine cultures or needle biopsy of the prostate. Prostate surgery for carcinoma or benign enlargement may detect latent fungal infection. Different fungal species can have divergent clinical manifestations and require different treatment. In some cases, asymptomatic, localized, fungal prostatitis can be cured by removal of the infected gland. Symptomatic and disseminated infection may require prostatectomy and systemic antifungal therapy.     

Sequenced dermatophyte strains: growth rate, conidiation, drug susceptibilities, and virulence in an invertebrate model

Although dermatophytes are the most common cause of fungal infections in the world, their basic biology is not well understood. The recent sequencing and annotation of the genomes of five representative dermatophyte species allows for the creation of hypotheses as to how they cause disease and have adapted to their distinct environments. An understanding of the microbiology of these strains will be essential for testing these hypotheses. This study is the first to generally characterize these five sequenced strains of dermatophytes for their microbiological aspects. We measured the growth rate on solid medium and found differences between species, with Microsporum gypseum CBS118893 having the fastest growth and Trichophyton rubrum CBS118892 the slowest. We also compared different media for conidia production and found that the highest numbers of conidia were produced when dermatophytes were grown on MAT agar. We determined the Minimum Inhibitory Concentration (MIC) of nine antifungal agents and confirmed susceptibility to antifungals commonly used as selectable markers. Finally, we tested virulence in the Galleria mellonella (wax moth) larvae model but found the results variable. These results increase our understanding of the microbiology and molecular biology of these dermatophyte strains and will be of use in advancing hypothesis-driven research about dermatophytes.     

Fungal infections following treatment with monoclonal antibodies and other immunomodulatory therapies

Tumor necrosis factor (TNF) is a proinflammatory cytokine involved in a wide range of important physiologic processes and has a pathologic role in some diseases. TNF antagonists (infliximab, adalimumab, etanercept) are effective in treating inflammatory conditions. Antilymphocyte biological agents (rituximab, alemtuzumab), integrin antagonists (natalizumab, etrolizumab and vedolizumab), interleukin (IL)-17A blockers (secukinumab, ixekizumab) and IL-2 antagonists (daclizumab, basiliximab) are widely used after transplantation and for gastroenterological, rheumatological, dermatological, neurological and hematological disorders. Given the putative role of these host defense elements against bacterial, viral and fungal agents, the risk of infection during a treatment with these antagonists is a concern. Fungal infections, both opportunistic and endemic, have been associated with these biological therapies, but the causative relationship is unclear, especially among patients with poor control of their underlying disease or who are undergoing steroid therapy. Potential recipients of these drugs should be screened for latent endemic fungal infections. Cotrimoxazole prophylaxis could be useful for preventing Pneumocystis jirovecii infection in patients over 65 years of age who are taking TNF antagonists, antilymphocyte biological agents or who have lymphopenia and are undergoing concomitant steroid therapy. As with other immunosuppressant drugs, TNF antagonists and antilymphocyte antibodies should be discontinued for patients with active infectious disease.     

Diversity Patterns,Ecology and Biological Activities of Fungal Communities Associated with the Endemic Macroalgae Across the Antarctic Peninsula

We surveyed diversity patterns and engaged in bioprospecting for bioactive compounds of fungi associated with the endemic macroalgae, Monostroma hariotii and Pyropia endiviifolia, in Antarctica. A total of 239 fungal isolates were obtained, which were identified to represent 48 taxa and 18 genera using molecular methods. The fungal communities consisted of endemic, indigenous and cold-adapted cosmopolitan taxa, which displayed high diversity and richness, but low dominance indices. The extracts of endemic and cold-adapted fungi displayed biological activities and may represent sources of promising prototype molecules to develop drugs. Our results suggest that macroalgae along the marine Antarctic Peninsula provide additional niches where fungal taxa can survive and coexist with their host in the extreme conditions. We hypothesise that the dynamics of richness and dominance among endemic, indigenous and cold-adapted cosmopolitan fungal taxa might be used to understand and model the influence of climate change on the maritime Antarctic mycota.     

Human infections due to nematode helminths nowadays: epidemiology and diagnostic tools

An update on the epidemiology of intestinal and tissue roundworms, in the world as well as in Italy, is presented. This analysis indicates that the most important changes happened in developed countries, where two main phenomena have been registered. The improvements occurred in social, economic, hygienic and sanitary conditions resulted in decrease of intestinal geohelminth prevalence but, besides, the changes happened at level of other factors, like environment, climate and human behaviour, promote more and more the opportunity for infections due to animal nematode species, which in people induce tissue syndromes. Therefore, the easier circulation of zoonoses among humans constitutes the main remark, which has to be strongly taken into account in countries like Italy, in that it is an emerging sanitary problem, important both for the number of people involved, and for the difficulties induced by their diagnosis. The general trend of "traditional" and "new" nematode infections that can affect humans is analysed, changes in the distribution patterns are tentatively explained, and available diagnostic tools are summarised.     

Mycological study of 100 cases of ungual lesions of Rosario city (Republica Argentina)

The aim of present work was to analyze several diagnostic methods of nail infections relating to various etiological agents with the different types of lesions and their probable predisposing causes. One hundred nail samples were studied including the following laboratory test: Direct microscopic exams with 40% KOH, direct exams in fluorescence microscope with calcoflúor white and mycological cultures. One or more of these methods gave positive results in 65% of the samples tested. The fungi isolated by culture were the following: Candida (predominantly non-albicans, which appeared in 70.8% of the cases), dermatophytes (25% of the cases) and opportunistic fungi (4.2%). Females showed a higher incidence of fungal infection. Candida were more frequent in finger nails, while dermatophytes occurred mainly in toe nails. The clinical characteristic of the lesions produced by Candida were: tricophytoid type (67%) and periungeal type (33%). On the other hand, dermatophytes and opportunistic fungi produced distal subungual type lesions. Since correlation between direct examination and cultures is not always found in mycological studies, based in our present results we suggest that, although they must always be carried out, both should be repeated with the addition of direct examination with calcoflúor in the cases in which the diagnosis is difficult.     

Keratinophilic fungi isolated from children's sandpits in the Nablus area,West Bank of Jordan

The keratinophilic fungi of 29 sandpits from kindergarten schools and public parks in the city of Nablus was analysed to evaluate their role in the epidemiology of diseases caused by these fungi. Seventy two species were recovered 28 of which were common to both kindergartens and public parks sandpits. High percentage (57.4%) of fungal isolates found had been identified as the causes of various types of mycoses. Eight species of dermatophytes and closely related fungi were recovered, of which the followings were the most commonly found species in sandpits: Chrysosporium keratinophilum (20.7%), Microsporum gypseum (17.2%), Trichophyton mentagrophytes (6.9%), and C. evolceanui (6.9%).