Re-drawing the Maps for Endemic Mycoses

Mycopathologia - Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within...     

Serologic Detection of Coccidioidomycosis Antibodies in Northeast Brazil

Coccidioidomycosis is a systemic infection caused by Coccidioides spp. The disease is endemic in Brazil but its incidence is underreported as it is not a notifiable disease. This article presents the results of a serologic survey carried out with 229 volunteers in northeast Brazil by the immunodiffusion (ID) test with commercial Coccidioides spp. antigens. The commercial ID test detected 15 individuals without clinical diagnosis of the disease and two individuals in treatment for coccidioidomycosis. Regarding the epidemiological data, most of the positive individuals were male, between 18 and 65 years of age and were engaged in armadillo hunting. Three women who had never participated in armadillo hunts also displayed positive results for coccidioidal antibodies. Besides armadillo hunts, exposure to environmental dust in endemic areas may account for the serologic response detected in the study. The data from this study suggest the importance of performing epidemiological surveys for coccidioidomycosis in order to understand the prevalence of this disease in Brazil.     

Reversal of coccidioidal anergy in vitro by dendritic cells from patients with disseminated coccidioidomycosis

Coccidioides immitis is a pathogenic, dimorphic fungus found in the southwestern United States and is the causative agent of coccidioidomycosis. Extrathoracic dissemination of coccidioidomycosis is associated with a lack of cellular immunity. Dendritic cells (DCs) have been shown to initiate and modulate cellular immune responses. To determine whether DCs could modulate or initiate the immune response in this disease, monocyte-derived DCs were generated from coccidioidal Ag nonresponsive patients with disseminated coccidioidomycosis and healthy nonimmune individuals. DCs generated from both groups demonstrated phenotypes characteristic of DCs and stimulated strong allogeneic MLR. DCs from patients and healthy nonimmune individuals pulsed with the coccidioidal Ag preparation T27K induced lymphocyte proliferation. Mature DCs were much more efficient than immature DCs in these stimulations. Furthermore, restimulation of T27K-primed PBMC with Ag-pulsed DCs generated a C. immitis-specific cellular immune response in PBMC from patients with disseminated coccidioidomycosis as well as healthy nonimmune individuals. These results show that 1) DCs have the capacity to stimulate specific cellular immune responses from patients with disseminated coccidioidomycosis who are nonresponsive to coccidioidal Ag and healthy nonimmune individuals in vitro; 2) DCs can be used to screen coccidioidal Ags as candidates for human vaccine development; and 3) DC therapy may be useful in the treatment of disseminated coccidioidomycosis.     

球孢子菌病的流行病学、临床表现及诊治进展

球孢子菌病是球孢子菌感染人类所致的疾病。传统认为其流行区域仅限于美洲部分地区,但随着全球人口流动,非疫区的输入性病例报道日渐增多。一些新近研究也对其传统流行病学观念提出了挑战。此外,球孢子菌病的临床表现多样,从轻微的自限性呼吸道感染到严重的全身播散性感染均可发生,给诊断带来了很大的困难。因此,尽管中国并非传统概念上的球孢子菌病疫区,国内感染病工作者仍有必要对其现状有所了解。本文针对球孢子菌病的流行现状及诊疗进展进行综述。     

Antigens of Coccidioides posadasii as an Important Tool for the Immunodiagnosis of Coccidioidomycosis

Serologic diagnosis has been presented as a safe alternative for coccidioidomycosis. However, commercial kits based on coccidioidal antibodies available in the USA are considered too expensive for laboratories outside that country. In this study, we describe the preparation of antigens for detection of human coccidioidal antibodies by the immunodiffusion test (ID) and enzyme immunoassay (EIA). Antigens were tested against serum samples from patients with coccidioidomycosis, histoplasmosis and paracoccidioidomycosis, as well as healthy individuals. The highest reactivity in the ID tests was seen in the F0-90 antigen. In the EIAs, the best results were obtained with the F60-90 antigen. None of the serum samples from healthy individuals were recognized by any of the antigen extracts tested by ID or EIA. In conclusion, the F0-90 and F60-90 antigens have the potential to be commercially employed in presumptive diagnosis of coccidioidomycosis by ID or EIA, respectively. The tests could improve serological diagnosis of coccidioidomycosis in South America.     

Mannose-Binding Lectin Serum Levels are Low in Persons with Clinically Active Coccidioidomycosis

Background  Mannose-binding lectin (MBL) is a circulating collectin that is part of the innate immune response. We explored the serum levels of MBL in persons with different forms of coccidioidomycosis. Methods  Serum MBL was measured by ELISA from samples obtained from healthy donors with immunity to Coccidioides, and those with various forms of active coccidioidomycosis. Blood cell specimens from a subgroup of subjects with active coccidioidomycosis were examined for single nucleotide polymorphisms of the MBL gene and promoter regions. Results  The control group comprised 29 healthy immune subjects. Patient groups with active coccidioidomycosis consisted of 20 patients with symptomatic primary pulmonary coccidioidomycosis, 26 with non-meningeal disseminated coccidioidomycosis, and nine with coccidioidal meningitis. The group with active coccidioidomycosis was significantly older and more likely to be male than the control group (for both, P < 0.001). The mean ± SEM level of serum MBL in the healthy controls was 169.4 ± 28.6 ng/ml, significantly higher than the 79.2 ± 10.9 ng/ml for all active groups (P < 0.001). Moreover, the active coccidioidomycosis group was significantly more likely to have serum MBL level ≤70 ng/ml compared to the control group (P = 0.001). Genetic analysis in 27 subjects with active coccidioidomycosis revealed marked variation based on race and ethnicity. Among a subgroup of 10 white, non-hispanic men with active coccidioidomycosis, there was a significant association between the H and P haplotypes and MBL levels ≤70 ng/ml (P < 0.036 and P < 0.035, respectively). Conclusions  These data suggest that there is an association between low serum MBL levels and symptomatic coccidioidomycosis.     

Serologic testing for symptomatic coccidioidomycosis in immunocompetent and immunosuppressed hosts

Serologic studies are an important diagnostic tool in the clinical evaluation and follow-up of persons with coccidioidomycosis. Numerous types of serologic tests are available, including immunodiffusion, enzyme immunoassay, and complement fixation. We conducted a retrospective review of the results of 1,797 serologic tests spanning 12 months from the onset of coccidioidomycosis in 298 immunocompetent and 62 immunosuppressed persons with symptomatic infection. Using the onset of symptoms as a reference point, we plotted the positive or negative serologic results over time for both groups. Compared with the immunocompetent group, immunosuppressed persons had lower rates of seropositivity for every type of test during the first year after onset of symptoms for coccidioidomycosis, although many results did not achieve statistical significance. Combining the results of these tests increased the sensitivity of the serologic evaluation in immunocompromised patients. Immunosuppressed persons have the ability to mount a serologic response to coccidioidomycosis, but in some circumstances, multiple methods may be required to improve detection.     

Coccidioidomycosis in Northern California—An Outbreak among Archeology Students near Red Bluff

An outbreak of coccidioidomycosis occurred among 39 archeology students in the summer of 1972. The students excavated Indian ruins near Red Bluff in Tehama County, California, 20 miles north of the previously recognized northernmost limit of endemicity. At least 17 persons contracted an illness clinically compatible with a diagnosis of coccidioidomycosis. Coccidioidomycosis was documented by skin test conversion as well as by specific serologic reactions. Coccidioides immitis was also isolated from two soil samples taken at the excavation site. In light of its ecological requirements, it is doubtful that C. immitis will be recovered much farther north than Red Bluff. The occupational hazard of coccidioidomycosis to archeologists and others employed in known endemic areas remains a substantial threat to health.     

CORTISONE IN COCCIDIOIDOMYCOSIS

Cortisone administered orally, in low dosages for brief periods, promptly suppressed the allergic manifestations accompanying primary pulmonary coccidioidomycosis in 19 cases. There was no interference with the coccidioidin skin test reaction or with the usual serologic pattern.Dissemination of the disease as a sequel to the administration of cortisone and/or corticotropin has not been reported. A survey of physicians and of the known instances of disseminated coccidioidomycosis in Kern County failed to reveal any such episode.In none of the cases in which the authors gave cortisone in the presence of coccidioidomycosis was there any complication or undesirable sequel—specifically, no subsequent dissemination of the disease.The data presented are not to be interpreted as a therapeutic recommendation, but as a contribution to the information available concerning the effects of these drugs in infectious diseases.     

Coccidioidomycosis: An Update

Coccidioidomycosis is the oldest of the major mycoses. In recent years the incidence of the disease has increased in California and Arizona, which may be partially due to the massive migration to the endemic region. The endemic region for the disease lays exclusively in the Western Hemisphere, between the 40° latitudes north and south. The disease manifests in one of four clinical syndromes: acute pulmonary, chronic pulmonary and acute or chronic disseminated coccidioidomycosis. Serologic tests identifying anticoccidioidal antibodies are the most frequently employed assays for diagnosis. Primary coccidioidomycosis is usually self-limited; therapy of primary disease is recommended when symptoms persist for more than 6 weeks, for severe acute cases and for patients with impaired cellular immunity. Chronic pulmonary coccidioidomycosis and all forms of disseminated coccidioidomycosis require antifungal therapy. The drugs of choice are either fluconazole or itraconazole.     

Agar-Gel Precipitin-Inhibition Test for Coccidioidomycosis: II. Serological Test Antigen Studies in Agar-Gel

In this study of saprophytic and parasitic growth-phase extracts of Coccidioides immitis, an antigen from the spherule culture supernatant fluid detected a specific antibody in heretofore serologically negative suspect coccidioidomycosis human sera when diffused in agar-gel. This antigen-antibody reaction occurred also in some of the serologically positive human coccidioidomycosis sera. This study indicates that this antigen-antibody reaction should be utilized as a possible routine serological test for complete serodiagnosis.     

Primary cutaneous coccidioidomycosis; the criteria for diagnosis and a report of a case

Study was made of a case of coccidioidomycosis known to have resulted from primary inoculation of the organisms into the skin. Clinical observations and laboratory data were obtained at the time of clinical illness and for a period of five years thereafter. From the information thus obtained and correlation of it with what already was known of coccidioidomycosis, it was concluded that the disease originates very rarely as the result of primary cutaneous inoculation. In most instances lesions suspected to be of this type have actually resulted by dissemination of the organisms to the skin from a previously unrecognized pulmonary focus. Primary cutaneous coccidioidomycotic lesions closely resemble the primary cutaneous lesions (chancres) in other infectious granulomata, such as syphilis, tuberculosis and sporotrichosis. Spontaneous involution should occur within three months and then there should be immunity to reinfection in all but one or two per thousand instances. From these observations certain criteria were evolved by which to determine in a case of coccidioidomycosis with cutaneous manifestations whether or not the infecting organism entered through the skin.     

PRIMARY CUTANEOUS COCCIDIOIDOMYCOSIS—The Criteria for Diagnosis and a Report of a Case

Study was made of a case of coccidioidomycosis known to have resulted from primary inoculation of the organisms into the skin. Clinical observations and laboratory data were obtained at the time of clinical illness and for a period of five years thereafter. From the information thus obtained and correlation of it with what already was known of coccidioidomycosis, it was concluded that the disease originates very rarely as the result of primary cutaneous inoculation. In most instances lesions suspected to be of this type have actually resulted by dissemination of the organisms to the skin from a previously unrecognized pulmonary focus.Primary cutaneous coccidioidomycotic lesions closely resemble the primary cutaneous lesions (chancres) in other infectious granulomata, such as syphilis, tuberculosis and sporotrichosis. Spontaneous involution should occur within three months and then there should be immunity to reinfection in all but one or two per thousand instances.From these observations certain criteria were evolved by which to determine in a case of coccidioidomycosis with cutaneous manifestations whether or not the infecting organism entered through the skin.     

Coccidioidomycosis

Coccidioidomycosis is an endemic fungal infection whose incidence and impact have been increasing in the southwestern United States. Advances in understanding its epidemiology and mycology are continuing. New diagnostic tests have been developed and experience with newer therapeutic agents continues to accumulate, but numerous clinical questions remain. Timely recognition and diagnosis of coccidioidomycosis are still problematic. With the rise in incidence, changing demographics, an aging population, and the increase in immunocompromised patients, coccidioidomycosis continues to be a fungal infection worthy of further study. This review summarizes the pathogenesis of coccidioidomycosis; the epidemiologic, diagnostic, and therapeutic approaches for coccidioidal infections; and the management challenges of select at-risk populations.     

A direct comparison of oral treatments with BAY-n-7133, BAY-1-9139 and ketoconazole in experimental murine coccidioidomycosis

Two new experimental antifungal azole drugs were compared with ketoconazole for the management of experimental murine coccidioidomycosis. The first, BAY-n-7133, a triazole, was superior to the second, BAY-1-9139, an imidazole derivative. Neither BAY drug was as effective as ketoconazole in early fulminant coccidioidomycosis of mice, in later disseminated disease and in deep-seated chronic disease. A possible limitation of BAY-n-7133 in the mouse model was its reported capacity to induce enzyme changes that accelerated its clearance from serum. Induction of such an enzyme response in human beings has been reported not to occur.     

Strategies to Combat Coccidioidomycosis: Are We Making Any Progress?

Coccidioidomycosis is caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. One of the endemic mycoses, this organism has been found solely in the semiarid to arid life zones of the southwestern United States, Mexico, and parts of Central America and South America. Clinical manifestations of disease vary greatly between patients and are largely dependent upon both the extent of exposure and the immune status of the host. The incidence of coccidioidomycosis continues to rise within the United States. Primary coccidioidal pneumonia accounts for close to 25% of all community-acquired pneumonia within endemic regions, reflecting the substantial burden of disease and health care costs associated with this infection. Although most patients with coccidioidomycosis resolve their initial infection without long-term complications, a minority of patients develop complications of disease ranging from asymptomatic pulmonary nodules to life-threatening disease such as meningitis. This review focuses on the epidemiology, clinical manifestations, spectrum of disease, and treatment options currently available for coccidioidomycosis.     

Review of human and animal cases of coccidioidomycosis diagnosed in Canada

The first Canadian case of coccidioidomycosis in a human was reported in 1952 and 11 more cases since then. This study provides details of other cases of coccidioidomycosis that have been diagnosed in Canada. Based on clinical details, isolation of Coccidioides immitis, detection of a specific antibody (F band) for coccidioidomycosis by macro- or microimmunodiffusion tests, concurrently used with the complement fixation procedure, and histopathological findings, 116 more cases of this disease were verified. The great majority (94%) of these cases were diagnosed in the western Canadian provinces of British Columbia, Alberta, Saskatchewan and Manitoba, and the others in Quebec, Ontario and Nova Scotia (5,1, and 1 cases, respectively). Available information indicates that the C. immitis infections were contracted during visits to endemic areas in the United States (Arizona, California and New Mexico), Mexico, and Bolivia. Pulmonary infections were the most common type of coccidioidomycosis (93%) followed by the disseminated or meningeal types C. immitis infections occurred in individuals with or without predisposing factor(s) and were more common in males than in females. The exoantigen procedure was very useful and reliable in the accurate and rapid identification of suspected C. immitis isolates. Two cases of coccidioidomycosis were reported in animals in Ontario, Canada.     

Peter Brian Medawar

Patients with coccidioidomycosis manifest a wide variety of severity of infection. Patients with unifocal and particularly multifocal dissemination manifest a defect in host defense mechanisms. This study focuses on the in vitro response to PHA as an indicator of immunoregulatory mechanisms. Study subjects are divided into four groups: Group I—17, patients with active disseminated coccidioidomycosis and lesions in multiple organs; Group II—15, patients with active disseminated coccidioidomycosis and a single lesion; Group III—16, patients with active coccidioidomycosis confined to the lungs; and Group IV—18, patients in whom coccidioidomycosis is inactive. The response to PHA was heterogeneous, even within groups. When cells were cultured in the presence of indomethacin or R020-5720, Group I cells demonstrated highly significant augmentation of the response to PHA (P < 0.002), whereas cells from Groups II to IV were unaffected. When adherent cells were removed by passage through a nylon wool column, the effect of indomethacin could no longer be demonstrated. Direct measurement of prostaglandin production (PGE₂ and PGF_2α) and thromboxane suggest that there is no difference in the quantity of these compounds produced by unstimulated or PHA-stimulated cells by Group I versus Group IV cells (P = 0.2-0.4). Indomethacin or R020-5720 markedly inhibit the production of these compounds. Studies of the effect of exogenous prostaglandin on PHA-stimulated cells suggest that Group I cells may be more inhibited by PGF_1α and PGF_2α compared to Group IV cells. The data demonstrate that PHA cultures of cells from Group I patients are suppressed. The suppressor cell can be removed by adherence to nylon wool and is inhibited by indomethacin or R020-5720.     

SERUM PROTEIN PROFILES IN COCCIDIOIDOMYCOSIS

Serum protein analysis is a valuable addition to the present methods for evaluating the status of the individual patient with coccidioidomycosis. The albumin protein and albumin glycoprotein decrease and gamma protein increases in relation to severity of infection. In 40 patients with coccidioidomycosis, changes in individual protein fractions could be significantly correlated with conventional laboratory tests, such as the complement fixation test, erythrocyte sedimentation rate and hematocrit.Changes in the alpha, glycoprotein concentration, the erythrocyte sedimentation rate and the hematocrit value appear to be related to the degree of inflammation, while the changes in the gamma protein and the beta, glycoprotein appear to be related to the specific antibody response.