Invasive Fungal Infections in the Child with Chronic Granulomatous Disease

Invasive fungal infections (IFI) are a major threat for patients with chronic granulomatous disease (CGD) which is an inherited disorder of NADPH oxidase. The absence of a functional NADPH oxidase complex affects the display of an efficient antimicrobial effect as well as a controlled inflammatory response. Invasive aspergillosis caused by either Aspergillus fumigatus or A. nidulans is the most common IFI. Aspergillus nidulans infections seem to display a unique interaction with the CGD host and are seldom reported in other immunocompromised hosts. The occurrence of mucormycosis in the CGD host is mainly noted in the setting of treatment of inflammatory complications with immunosuppressive drugs. Candida infections are infrequently seen and show an age-dependent clinical presentation mainly affecting infants and young children. Furthermore, the child with CGD is susceptible to a wide range of fungal pathogens, indicating the need to determine the causative fungus, often by invasive diagnostic approaches, to guide optimal and rational treatment. Currently, it is becoming more and more clear that the exaggerated inflammatory response to fungal infection in the CGD host is leading in the pathogenesis, and antiinflammatory treatment might become as important as antifungal treatment in this specific host.     

Clinical Characteristics and Immunogenetics of BCGosis/BCGitis in Chinese Children: A 6 Year Follow-Up Study

In this study, the clinical and immunogenetical features in a cohort of Chinese patients with BCGosis/BCGitis were investigated. For the patients with abnormal immunological functions, Sanger sequencing was used to identify the involved genes. There were 74 confirmed cases of BCGosis/BCGitis during 2007–2012. Classified by infected tissues and organs, no cases only had local infection, 39 patients had a regional infection, 21 patients had a distant infection and 14 patients had a disseminated infection. Thirty-two patients (43.2%) had definitive primary immunodeficiency diseases (PID) and chronic granulomatous disease (CGD) is the most common PID (n = 23, accounted for 71.9% of all PID patients). For CGD patients, based on the anti-tuberculosis treatment, administration of rhIFN-γ resulted in better control of BCGosis/BCGitis. The results indicate that PIDs are associated with susceptibility to BCG disease. For children with BCGosis/BCGitis, immune function evaluation is necessary, and IFN-γ treatment for BCGosis/BCGitis patients with CGD is effective.     

Chronic granulomatous disease,a heterogeneous syndrome

Chronic granulomatous disease (CGD) is a clinical syndrome, the unifying characteristics of which are a severe predisposition to bacterial and fungal infections, an impaired ability of phagocytic leukocytes to kill certain microorganisms and the failure of these cells to produce microbicidal oxygen metabolites. In CGD the causal biochemical defect and the mechanism of genetic transmission vary from family to family. At least six different molecular defects have been found to underly the X-linked and at least three other the autosomal recessive form of CGD. Diagnosis of carriers is possible in most instances, and prenatal diagnosis by fetoscopic placental vessel puncture has become feasible.     

Bacillus Calmette-Guerin Infection in NADPH Oxidase Deficiency: Defective Mycobacterial Sequestration and Granuloma Formation

Patients with chronic granulomatous disease (CGD) lack generation of reactive oxygen species (ROS) through the phagocyte NADPH oxidase NOX2. CGD is an immune deficiency that leads to frequent infections with certain pathogens; this is well documented for S. aureus and A. fumigatus, but less clear for mycobacteria. We therefore performed an extensive literature search which yielded 297 cases of CGD patients with mycobacterial infections; M. bovis BCG was most commonly described (74%). The relationship between NOX2 deficiency and BCG infection however has never been studied in a mouse model. We therefore investigated BCG infection in three different mouse models of CGD: Ncf1 mutants in two different genetic backgrounds and Cybb knock-out mice. In addition, we investigated a macrophage-specific rescue (transgenic expression of Ncf1 under the control of the CD68 promoter). Wild-type mice did not develop severe disease upon BCG injection. In contrast, all three types of CGD mice were highly susceptible to BCG, as witnessed by a severe weight loss, development of hemorrhagic pneumonia, and a high mortality (∼50%). Rescue of NOX2 activity in macrophages restored BCG resistance, similar as seen in wild-type mice. Granulomas from mycobacteria-infected wild-type mice generated ROS, while granulomas from CGD mice did not. Bacterial load in CGD mice was only moderately increased, suggesting that it was not crucial for the observed phenotype. CGD mice responded with massively enhanced cytokine release (TNF-α, IFN-γ, IL-17 and IL-12) early after BCG infection, which might account for severity of the disease. Finally, in wild-type mice, macrophages formed clusters and restricted mycobacteria to granulomas, while macrophages and mycobacteria were diffusely distributed in lung tissue from CGD mice. Our results demonstrate that lack of the NADPH oxidase leads to a markedly increased severity of BCG infection through mechanisms including increased cytokine production and impaired granuloma formation.     

Human polymorphonuclear leukocytes inhibit Aspergillus fumigatus conidial growth by lactoferrin-mediated iron depletion

Aspergillus fumigatus, a common mold, rarely infects humans, except during prolonged neutropenia or in cases of chronic granulomatous disease (CGD), a primary immunodeficiency caused by mutations in the NADPH oxidase that normally produces fungicidal reactive oxygen species. Filamentous hyphae of Aspergillus are killed by normal, but not CGD polymorphonuclear leukocytes (PMN); however, the few studies on PMN-mediated host defenses against infectious conidia (spores) of this organism have yielded conflicting results, some showing that PMN do not inhibit conidial growth, with others showing that they do, most likely using reactive oxygen species. Given that CGD patients are exposed daily to hundreds of viable A. fumigatus conidia, yet considerable numbers of them survive years without infection, we reasoned that PMN use ROS-independent mechanisms to combat Aspergillus. We show that human PMN from both normal controls and CGD patients are equipotent at arresting the growth of Aspergillus conidia in vitro, indicating the presence of a reactive oxygen species-independent factor(s). Cell-free supernatants of degranulated normal and CGD neutrophils both suppressed fungal growth and were found to be rich in lactoferrin, an abundant PMN secondary granule protein. Purified iron-poor lactoferrin at concentrations occurring in PMN supernatants (and reported in human mucosal secretions in vivo) decreased fungal growth, whereas saturation of lactoferrin or PMN supernatants with iron, or testing in the presence of excess iron in the form of ferritin, completely abolished activity against conidia. These results demonstrate that PMN lactoferrin sequestration of iron is important for host defense against Aspergillus.     

Increased nitric oxide production by neutrophils from patients with chronic granulomatous disease on trimethoprim-sulfamethoxazole.

Chronic granulomatous disease (CGD) is an inherited disease characterized by severe and recurrent bacterial and fungal infections. Phagocytic cells of CGD patients are unable to produce superoxide anion, and their efficiency in bacterial killing is significantly impaired. In these patients, the prophylactic and therapeutic validity of a long-term use of trimethoprim-sulfamethoxazole (TMP-SMX) has been well established. However a role of nitric oxide (NO) produced by phagocytic cells from CGD patients is unknown, and the mechanism of TMP-SMX in CGD is unclear. We have directly measured NO production in whole human blood by using 4,5-diaminofluorescein as a novel fluorescent indicator for intracellular NO. Intracellular NO production of gated neutrophils increased time dependently when stimulated by lipopolysaccharide (LPS) and calcium ionophore. Although all polymorphonuclear leukocyte (PMN) specimens from patients with CGD failed to generate hydrogen peroxide, NO production by CGD PMNs was significantly increased compared with that of control PMNs (p<0.05). TMP-SMX with LPS significantly increased compared with LPS-stimulated samples at clinical (n=5, p<0.05) and 10-fold clinical concentrations (n=5, p<0.01). TMP-SMX with LPS in CGD PMNs significantly increased the production of NO in comparison with the LPS stimulation at 10-fold clinical concentrations (n=5, p<0.05). In conclusion, our data indicate the possibility that NO production by neutrophils from patients with CGD treated with TMP-SMX has a role of bactericidal activity instead of O(2)(-) in host defense mechanism.     

某医院皮肤科就诊患者真菌感染的流行病学调查

目的探讨延安市某医院2006—2010年皮肤科门诊患者真菌感染的菌群分布、特点及变迁情况,为临床防治真菌感染提供研究依据。方法采用回顾性调查方法,收集5年来该院皮肤科门诊患者的所有真菌检查的病例资料,对标本来源、菌群分布及菌种变迁进行调查和分析。结果5年中真菌感染阳性率为9．98％-44．05％,男性感染率高于女性,浅部真菌感染率高于深部真菌,差异均有统计学意义（P〈0．005）;60岁以上患者占38．18％,感染以白假丝酵母菌为主但所占比例5年间下降了16．86％（P〈0．05）,而其他假丝酵母菌所占比例则呈上升趋势。结论5年来该院真菌感染菌群分布发生了变迁;真菌感染以老年男性为主,儿童真菌感染亦不容忽视,临床应加强对这些真菌感染的预防和监测,防止真菌感染。     

Reactive oxygen species produced by the NADPH oxidase 2 complex in monocytes protect mice from bacterial infections

Chronic granulomatous disease (CGD) is an inherited disorder characterized by recurrent life-threatening bacterial and fungal infections. CGD results from defective production of reactive oxygen species by phagocytes caused by mutations in genes encoding the NADPH oxidase 2 (NOX2) complex subunits. Mice with a spontaneous mutation in Ncf1, which encodes the NCF1 (p47(phox)) subunit of NOX2, have defective phagocyte NOX2 activity. These mice occasionally develop local spontaneous infections by Staphylococcus xylosus or by the common CGD pathogen Staphylococcus aureus. Ncf1 mutant mice were more susceptible to systemic challenge with these bacteria than were wild-type mice. Transgenic Ncf1 mutant mice harboring the wild-type Ncf1 gene under the human CD68 promoter (MN(+) mice) gained the expression of NCF1 and functional NOX2 activity specifically in monocytes/macrophages, although minimal NOX2 activity was also detected in some CD11b(+)Ly6G(+) cells defined as neutrophils. MN(+) mice did not develop spontaneous infection and were more resistant to administered staphylococcal infections compared with MN(-) mice. Most strikingly, MN(+) mice survived after being administered Burkholderia cepacia, an opportunistic pathogen in CGD patients, whereas MN(-) mice died. Thus, monocyte/macrophage expression of functional NCF1 protected against spontaneous and administered bacterial infections.     

The X+ chronic granulomatous disease as a fabulous model to study the NADPH oxidase complex activation

Chronic granulomatous disease (CGD) is a rare inherited disorder in which phagocytes lack NADPH oxidase activity. Patients with CGD suffer from recurrent bacterial and fungal infections because of the absence of superoxide anions (O2- degrees ) generatingsystem. The NADPH oxidase complex is composed of a membranous cytochrome b558, cytosolic proteins p67phox, p47phox, p40phox and two small GTPases Rac2 and Rap1A. Cytochrome b558 consists of two sub-units gp91phox and p22phox. The most common form of CGD is due to mutations in CYBB gene encoding gp91phox. In some rare cases, the mutated gp91phox is normally expressed but is devoided of oxidase activity. These variants called X+ CGD, have provided interesting informations about oxidase activation mechanisms. However modelization of such variants is necessary to obtain enough biological material for studies at the molecular level. A cellular model (knock-out PLB-985 cells) has been developed for expressing recombinant mutated gp91phox for functional analysis of the oxidase complex. Recent works demonstrated that this cell line genetically deficient in gp91phox is a powerful tool for functional analysis of the NADPH oxidase complex activation.     

重型肝炎患者肝移植术后真菌感染临床分析

目的分析重型肝炎肝移植受体术后真菌感染情况,进一步探讨其易感因素和防治措施。方法回顾性分析我院器官移植中心2003年3月至2006年2月间89例重型肝炎肝移植患者的临床资料并进行讨论。结果89例重型肝炎肝移植患者中21例出现术后真菌感染,感染率为23.6%,较其他病种肝移植更高,其中12例为白念珠菌(57.1%),6例为光滑念珠菌(28.6%),1例为近平滑念珠菌,1例为克柔念珠菌,1例为热带念珠菌。真菌感染多发生在术后1周内,感染部位以呼吸系统为主。结论重型肝炎肝移植患者术后真菌感染以念珠菌属的早期呼吸道感染为主。术前肝性脑病与术后发生真菌感染之间存在相关关系。而一般的白念珠菌感染不会显著地影响重型肝炎肝移植患者的预后。预防性使用抗真菌药物在重型肝炎肝移植术后真菌感染的治疗中具有重要意义。     

Chromoblastomycosis – A clinical and mycological study of 71 cases from Sri Lanka

Chromoblastomycosis, a well-documented chronic fungal infection, represents a specific clinical entity with typical warty cutaneous nodules and a worldwide distribution. Although more prevalent in tropical and subtropical regions, only a few reports are available from Sri Lanka or from Asia. Five etiologic agents of chromoblastomycosis have been recognized worldwide. Of these the majority of infections have been caused by Fonsecaea pedrosoi. During the period from 1952 to 1962, only twelve culturally proven cases of this disease had been recorded from Sri Lanka. The fungus responsible was F. pedrosoi. The present report presents a study of the clinical and mycological features of 71 Sri Lankan patients with chromoblastomycosis for the 16-year period from 1978 to 1993. It documents three etiological agents. Culture identification was made in 69 cases. The three fungal species were Fonsecaea pedrosoi (64), Phialophora verrucosa (3) and a fungus compatible morphologically with F. compacta (2). The isolation of a fungus morphologically compatible with F. compacta is of significance since only 12 cases have been documented in the world's literature so far. This revised version was published online in June 2006 with corrections to the Cover Date.     

院内深部真菌感染92例临床分析

目的探讨院内深部真菌感染的临床表现、感染相关因素及诊断治疗措施.方法对1993年1月至2002年12月间经微生物检查证实的92例院内深部真菌感染的病例临床资料进行回顾性分析.结果在92例患者中,肺部疾病26例,糖尿病19例,血液病及肿瘤19例,外科手术后13例,消化系统疾病6例,慢性肾脏病6例,风湿性疾病3例.主要感染真菌为白色念珠菌和酵母菌.感染相关因素:长时间应用广谱抗生素病人65例,应用糖皮质激素22例,应用免疫抑制剂18例,应用气管切开或气管内插管以及中心静脉留置导管17例,进行血液净化治疗的9例.治疗痊愈59例(64.1%),好转10例(10.9%),死亡23例(25%).结论白色念珠菌是院内深部真菌感染的主要致病菌株,有逐年增加趋势,病死率高.与长时间应用广谱抗生素及免疫抑制剂等有相关性.     

激素治疗大疱性疾病引起真菌感染回顾性分析

目的研究糖皮质激素治疗大疱性疾病患者发生医院真菌感染的病原菌分类、危险因素和防治对策。方法收集67例大疱性类天疱疮和38例天疱疮患者糖皮质激素治疗的临床资料,计算医院真菌感染率,分析相关危险因素。结果大疱性疾病患者糖皮质激素治疗出现医院真菌感染率达32.38%,口腔真菌感染率为27.61%,肺部真菌感染率为13.33%,主要病原菌分别为白念珠菌(69.77%),热带念珠菌(11.63%)和近平滑念珠菌(6.98%)。糖皮质激素剂量、免疫抑制剂、抗生素、住院日及糖尿病病史明显增加真菌感染危险,其中免疫抑制剂、抗生素和糖尿病病史为独立危险因素。结论糖皮质激素治疗大疱性疾病患者院内真菌感染发生率高,免疫抑制剂、抗生素和糖尿病病史是其主要危险因素。     

21例淋巴瘤合并肺部侵袭性真菌感染的回顾性临床分析

摘要 目的：探讨淋巴瘤合并肺部侵袭性真菌感染( IPFI ) 的高危因素、临床特征和诊疗方案。方法：回顾性分析2019-2020年血液科收治的淋巴瘤合并IPFI患者的临床资料。结果：化疗后出现IPFI的淋巴瘤患者共计21例,总发病率为2.7%,平均年龄60岁,男性占77.8%,其中确诊5例、临床诊断7例、拟诊8例,确诊患者的病原菌为白色念珠菌（80%）和曲霉菌（20%）。肺部CT影像特征不典型,大多表现为弥漫、散在的斑片状絮样密度增高影、结节影,双肺受累多见,在接受一线抗真菌治疗后有18例患者缓解,总有效率为90.4%,其中原发病终末期患者及合并细菌感染患者死亡率高,预后差。结论：老年、男性、原发病控制不佳、高强度或大剂量化疗以及糖皮质激素的使用可能是淋巴瘤IPFI的高危因素,早期临床症状和影像学检查缺乏特异性,常规病原学检出率仍较低,1-3-β-D-葡聚糖试验（G试验）、半乳甘露聚糖试验（GM试验）结合肺部CT检查有助于早期诊断,一线抗真菌药物的使用可显著改善患者预后。     

ICU患者深部真菌感染调查

目的了解院内ICU患者深部真菌感染的临床和病原学特点。方法在2006年1月至2008年1月期间,对217例ICU患者进行前瞻性研究。结果2年期间ICU共分离出29株真菌,以白色念珠菌和热带念珠菌为主,其发生与2种以上广谱抗生素联合运用,糖皮质激素的使用,导尿管、气管插管和深静脉留置针的使用有关。结论警惕上述ICU患者深部真菌感染的相关危险因素对临床防治深部真菌病具有重要意义。     

Regulation of innate immunity by NADPH oxidase

NADPH oxidase is a critical regulator of both antimicrobial host defense and inflammation. Activated in nature by microbes and microbial-derived products, the phagocyte NADPH oxidase is rapidly assembled, and generates reactive oxidant intermediates (ROIs) in response to infectious threat. Chronic granulomatous disease (CGD) is an inherited disorder of the NADPH oxidase characterized by recurrent and severe bacterial and fungal infections, and pathology related to excessive inflammation. Studies in CGD patients and CGD mouse models indicate that NADPH oxidase plays a key role in modulating inflammation and injury that is distinct from its antimicrobial function. The mechanisms by which NADPH oxidase mediates killing of pathogens and regulation of inflammation have broad relevance to our understanding of normal physiological immune responses and pathological states, such as acute lung injury and bacterial or fungal infections.     

Fungal Thyroiditis: An Overview

The authors review the epidemiology, clinical manifestations, diagnosis, and treatment of fungal thyroiditis cases previously reported in the medical literature. Aspergillus was by far the most common cause of fungal thyroiditis. Immunocompromised patients, such as those with leukemia, lymphoma, autoimmune diseases, and organ-transplant patients on pharmacological immunosuppression were particularly at risk. Fungal thyroiditis was diagnosed at autopsy as part of disseminated infection in a substantial number of patients without clinical manifestations and laboratory evidence of thyroid dysfunction. Local signs and symptoms of infection were indistinguishable from other infectious thyroiditis and included fever, anterior cervical pain, thyroid enlargement sometimes associated with dysphagia and dysphonia, and clinical and laboratory features of transient hyperthyroidism due to the release of thyroid hormone from follicular cell damage, followed by residual hypothyroidism. Antemortem diagnosis of fungal thyroiditis was made by direct microscopy and culture of a fine-needle aspirate, or/and biopsy in most cases. Since most patients with fungal thyroiditis had disseminated fungal infection with delay in diagnosis and treatment, the overall mortality was high.     

医院获得性真菌尿路感染的临床特点

目的 :了解我院真菌尿路感染现状 ,探讨防治对策。方法 :回顾分析 1998～ 2 0 0 0年我院医院感染调查中 73例真菌尿路感染的临床特点。结果 :平均年龄 5 4 4 9岁 ,≥ 6 0岁占 4 2 4 7% ,平均住院日5 4 76d ;见于多种基础疾病 ,与恶性肿瘤、长期卧床、危重疾病有关 ;发生真菌感染前抗生素使用率 10 0 % ,78 0 8%联用两种以上抗生素 ,平均使用抗生素时间为 (35± 14 )d ;感染前应用激素者 2 7,4 0 % ,化疗16 4 4 % ,导尿等泌尿操作 4 7 95 % ;临床表现不典型 ,抗真菌治疗效果欠佳 ,病死率 2 4 6 6 %。结论 :年龄大、住院时长、长期卧床及需长期应用抗生素者 ,无论是否导尿 ,均易发生真菌尿路感染 ,应随时监测 ,以便及时采取综合治疗措施 ,降低病死率。     

Acute dacryocystitis: another clinical manifestation of sporotrichosis

Sporotrichosis associated with exposure to domestic cats is hyperendemic in Rio de Janeiro, Brazil. A review of the clinical records at our institute revealed four patients with clinical signs of dacryocystitis and a positive conjunctival culture for Sporothrix who were diagnosed with Sporothrix dacryocystitis. Three patients were children (< 13 years of age) and one patient was an adult. Two patients reported contact with a cat that had sporotrichosis. Dacryocystitis was associated with nodular, ulcerated lesions on the face of one patient and with granulomatous conjunctivitis in two patients; however, this condition manifested as an isolated disease in another patient. All of the patients were cured of the fungal infections, but three patients had chronic dacryocystitis and one patient developed a cutaneous fistula. Sporotrichosis is usually a benign disease, but may cause severe complications when the eye and the adnexa are affected. Physicians, especially ophthalmologists in endemic areas, should be aware of the ophthalmological manifestations and complications of sporotrichosis.     

A novel bacterium associated with lymphadenitis in a patient with chronic granulomatous disease

Chronic granulomatous disease (CGD) is a rare inherited disease of the phagocyte NADPH oxidase system causing defective production of toxic oxygen metabolites, impaired bacterial and fungal killing, and recurrent life-threatening infections. We identified a novel gram-negative rod in excised lymph nodes from a patient with CGD. Gram-negative rods grew on charcoal-yeast extract, but conventional tests could not identify it. The best 50 matches of the 16S rRNA (using BLAST) were all members of the family Acetobacteraceae, with the closest match being Gluconobacter sacchari. Patient serum showed specific band recognition in whole lysate immunoblot. We used mouse models of CGD to determine whether this organism was a genuine CGD pathogen. Intraperitoneal injection of gp91(phox -/-) (X-linked) and p47 (phox -/-) (autosomal recessive) mice with this bacterium led to larger burdens of organism recovered from knockout compared with wild-type mice. Knockout mouse lymph nodes had histopathology that was similar to that seen in our patient. We recovered organisms with 16S rRNA sequence identical to the patient's original isolate from the infected mice. We identified a novel gram-negative rod from a patient with CGD. To confirm its pathogenicity, we demonstrated specific immune reaction by high titer antibody, showed that it was able to cause similar disease when introduced into CGD, but not wild-type mice, and we recovered the same organism from pathologic lesions in these mice. Therefore, we have fulfilled Koch's postulates for a new pathogen. This is the first reported case of invasive human disease caused by any of the Acetobacteraceae. Polyphasic taxonomic analysis shows this organism to be a new genus and species for which we propose the name Granulobacter bethesdensis.