The extraordinary spectrum of diseases caused by Aspergillus David W. Denning Wythenshawe Hospital University of Manchester
May 17, 2015
The extraordinary spectrum of diseases caused by Aspergillus
David W. DenningWythenshawe Hospital
University of Manchester
The genus Aspergillus - importance to humanity
www.aspergillus.man.ac.uk
cause invasive and allergic diseasein humans and other animals:
A. fumigatus
cause plant and food spoilage and produce mycotoxins:
A. flavus and A. parasiticus
on the negative side:
The genus Aspergillus - importance to humanity
www.aspergillus.man.ac.uk
on the positive side:
composting
well-established model organism in cell biology and genetics:A. nidulans
food production:enzymes and organic acids: A. niger East Asian foods: A. oryzae and A. sojae
pharmaceuticals:echinocandins: A. nidulans and A. sydowilovastatin: A. terreusfumagillin: A. fumigatus
Spores inhaled Germination
Mass of hyphae (plateau phase)
Hyphal elongation and branching
Aspergillus Life-cycle
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A. nidulans – may be amphotericin B resistant
The genus Aspergillus – ~180 species,
38 have caused disease (able to grow at 37C)
Common in the environment
A. nigerA. terreus – resistant to AmBA. flavus -sometimes amphotericin B resistant
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A. fumigatus low frequency of azole resistance
Aspergillus fumigatus
conidial head
CLASSIFICATION OF ASPERGILLOSIS
Persistence without disease - colonisation of the airways or nose/sinuses
Airways/nasal exposure to airborne Aspergillus
Invasive aspergillosis• Acute (<1 month course)• Subacute/chronic necrotising (1-3
months)
Chronic aspergillosis (>3 months)• Chronic cavitary pulmonary• Aspergilloma of lung• Chronic fibrosing pulmonary• Chronic invasive sinusitis • Maxillary (sinus) aspergilloma
Allergic• Allergic bronchopulmonary (ABPA)• Extrinsic allergic (broncho)alveolitis
(EAA)• Asthma with fungal sensitisation• Allergic Aspergillus sinusitis
(eosinophilic fungal rhinosinusitis)
Immunosuppression and infection
• Inhalation of aspergillus spores is a common daily occurrence. A healthy immune system would normally remove the spores and no symptoms or infection would occur.
• In individuals whose immune system may be suppressed either because of illness eg AIDS, cancer patients or drugs, spores may germinate and resulting tissue or systemic aspergillus invasion can result.
• Individuals with allergies such as asthma, can also be vulnerable to aspergillus disease.
Interaction of Aspergillus with the host
A unique microbial-host interaction
Immune dysfunction
Frequency
of a
sperg
illosis
Immune hyperactivity
Frequency
of
asp
erg
illosi
s
Acute IA
Subacute IA
Tracheobronchitis AspergillomaChronic cavitaryChronic fibrosing
ABPAAllergic sinusitis
. www.aspergillus.man.ac.uk
Normal immune function
Changing incidence of fatal invasive mycoses in non-HIV
patients in USA
Rate
per
100,0
00 p
opula
tion
0.0
0.2
0.4
0.6
0.8
1981 1986 19911996
CandidiasisAspergillosis
McNeil et al, Clin Infect Dis 2001;33:641
Invasive pulmonary aspergillosis
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Normal lungIPA
IPA occurs in ~7% of acute
leukaemia patients, 10-15% allogeneic BMT
patients
Unequivocal ‘Halo sign’ surrounding a nodule
Herbrecht, Denning et al, NEJM 2002;347:408-15.
Halo sign
Recent examples of the frequency of invasive aspergillosis
Underlying condition Incidence Reference/year
Acute myeloid leukaemia
8% Cornet, 2002
Acute lymphatic leukaemia
6.3% Cornet, 2002
Allogeneic HSCT 11-15% Grow, 2002; Marr, 2002
Lung transplantation 6.2-12.8% Minari, 2002; Singh,2003
Heart-lung transplantation
11% Duchini, 2002
Small bowel tranplantation
11% Duchini, 2002
AIDS 2.9% Libanore, 2002
Gillies & Campbell, www.aspergillus.man.ac.uk
Bleeding as an aspect of disseminated invasive aspergillosis
Fumagillin is anti-angiogenic
A haemolysin described from Aspergillus fumigatus
Other factors that contribute to thrombosis or a coagulopathy?
How does Aspergillus fumigatus cause thrombosis (clotting of vessels) and also bleeding?
Filler et al, Blood 2004;103:2134; Paris et al, Infect Immun 1997;65:1510.
Interaction of conidia and
endothelial cell projections
Internalisation of conidia (and hyphae) by
endothelial cells with injury
apparent at 4 hours
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Cerebral aspergillosis (abscess) in chronic lymphocytic leukaemia
Dissemination via the blood stream
to the brain occurs in ~5% of cases of
invasive aspergillosis, and
in ~40% of allogeneic bone marrow (HSCT)
recipients
Early diagnosis of invasive aspergillosis is important
Treatment started <10d >11dMortality 40% 90%
Von Eiff et al, Respiration 1995;62:241-7.
Sputum Cultures for Fungus
Bacteriological media inferior to fungal media – 32% higher yield on fungal
media
A four day A. fumigatus culture on malt extract agar (above). Light microscopy
pictures are taken at 1000x, stained with lacto-phenol cotton blue.
Aspergillus Antigen Test
• Diagnosis or surveillance? • Only blood, or BAL, CSF etc• Best OD cut-off - 0.7• False positives in kids / antibiotics• False negative with antifungal
prophylaxis• Not as useful for non-hematology• Not useful if pre-existing antibody
Herbrecht et al, J Clin Microbiol 2002;20:1898-906; and others
Outcome from invasive aspergillosis – amphotericin B therapy
Survival Functions by Site of Infection
Days
3603303002702402101801501209060300
Cu
mu
lativ
e S
urv
iva
l Ra
te
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
CNS or Disseminated
Pulmonary (n=83)
Aspergilloma (n=10)
Multi-site (n=11)
Sinusitis (n=17)
(n=35)
Lin et al, Clin Infect Dis 2001;32:358
Sub-acute invasive aspergillosis in AIDS
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Sub-acute invasive aspergillosis
• Less immunocompromised patients• Slower progression of disease (> 1
month)• Cavitary or nodular pulmonary disease
typical • Vascular invasion less common• Dissemination less common• Antigen testing less useful• Antibody testing may be helpful in
diagnosis
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Chronic necrotizing aspergillosis(CNPA)
Chronic necrotizing pulmonary aspergillosis (CNPA) is a subacute process usually found in patients with some degree of immunosuppression.
Usually it is associated with underlying lung disease, alcoholism, or chronic corticosteroid therapy. Because it is uncommon, CNPA often remains unrecognized for weeks or months and causes a progressive cavitary pulmonary infiltrate.
Right upper lobe. Patient has diabetes and pulmonary
mycobacterium avium- shows small cavitary lesion PT MS 1995.
Chronic necrotising pulmonary aspergillosis
Denning, Clin Microbiol Infect 2001;7(Suppl 2):25-31.
Right upper lobe showing circular shadow partly filled by a mass. PT
MS 1996
Same lobe shows expansion of the shadow, still partially
filled with a mass. Pt MS 1998
Right lobe shows huge cavity containing some
debris, with +ve aspergillus precipitins.Pt
MS 1999
CLASSIFICATION OF ASPERGILLOSIS
Persistence without disease - colonisation of the airways or nose/sinuses
Airways/nasal exposure to airborne Aspergillus
Invasive aspergillosis• Acute (<1 month course)• Subacute/chronic necrotising (1-3
months)
Chronic aspergillosis (>3 months)• Chronic cavitary pulmonary• Aspergilloma of lung• Chronic fibrosing pulmonary• Chronic invasive sinusitis • Maxillary (sinus) aspergilloma
Allergic• Allergic bronchopulmonary (ABPA)• Extrinsic allergic (broncho)alveolitis
(EAA)• Asthma with fungal sensitisation• Allergic Aspergillus sinusitis
(eosinophilic fungal rhinosinusitis)
Aspergillus and airways
Langley, ATS 2004
Types of aspergillosis of the airways• Colonisation (no disease – could be at risk)• Obstructing Aspergillus tracheobronchitis /Mucus
impaction (non-invasive)
• Aspergillus bronchitis/tracheobronchitis (superficially invasive only)
• Ulcerative Aspergillus tracheobroncitis (locally invasive) (lung
transplants – at anastomosis)• Pseudomembranous Aspergillus tracheobronchitis
(Extensive disease, locally invasive, associated with IPA and may disseminate)
Aspergillus tracheobronchitis
Autopsy drawing of a ‘normal’ 3 year old who died over 10 days
Wheaton, Path Trans 1890; 41:34-37
Aspergillus tracheobronchitis
Review of 58 patients in literature for normal and immuno compromised patients - risk factors
%None (ie normal) 25Heart / Lung transplant 18Solid tumour 15BMT 13Leukaemia 13HIV/AIDS 8Other 8
Kemper et al, Clin Infect Dis 1993; 17: 344
Aspergilloma
Patient RTDecember 2002
Fungus ball
Chronic pulmonary aspergillosis – pre-existing disease
All 18 patients had prior pulmonary disease
9 TB, 5 with atypical mycobacteria
13 smokers or ex-smokers
All 18 non-immunocompromised
3 excess alcohol
Denning DW et al, Clin Infect Dis 2003; 37:S265
Chronic pulmonary aspergillosis - presentation
Weight loss 16 / 18 (89%)Cough 15 / 18 (83%)Shortness of breath 9 / 18 (50%)Haemoptysis 9 / 18 (50%)Fatigue / malaise 5 / 18 (28%)Chest pain 3 / 18 (17%)Sputum production ++ 3 / 18 (17%)Fever 2 / 18 (11%)
Denning DW et al, Clin Infect Dis 2003; 37:S265
Chronic pulmonary aspergillosis - serology
All 18 patients had positive Aspergillus precipitins (1+ - 4+)
All 18 patients had elevated inflammatory markers, CRP, PV and / or ESR
14 of 18 (78%) had elevated total IgE (>20), 13 >200 and 7 >400
9 of 14 (67%) had Aspergillus specific IgE (RAST)
Denning DW et al, Clin Infect Dis 2003; 37:S265
Chronic cavitary pulmonary aspergillosis (CCPA)
Patient RWSeptember 1992 Relapse in normal lung
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Patient RWDecember 1991 Pre surgical resection
Chronic cavitary pulmonary aspergillosis
Patient RWJuly 1993
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Chronic Cavitary Pulmonary Aspergillosis
Patient JAJan 2001
Chronic Cavitary Pulmonary Aspergillosis
Patient JAFeb 2002
Chronic Cavitary Pulmonary Aspergillosis
Patient JAApril 2003
Chronic Cavitary Pulmonary Aspergillosis
Patient JAJuly 2003
Chronic cavitary pulmonary aspergillosis
Patient JP June 1999
Denning DW et al, Clin Infect Dis 2003; 37:S265
Chronic Cavitary Pulmonary Aspergillosis, with aspergilloma
Patient JP July 2001
Denning DW et al, Clin Infect Dis 2003; 37:S265
Chronic Fibrosing Pulmonary Aspergillosis
Patient JPApril 2002
Denning DW et al, Clin Infect Dis 2003; 37:S265
Mannose Binding Lectin (MBL)- a key part of the innate immune system
Disulphide bondInteraction with
collectin receptor
Interaction withMASP
Exon 1
Exon 2
Exon 3
Exon 4
CRD
Ca binding site2+
Crosdale et al J Infect Dis 2001;184:653
Mannose Binding Protein
5 mutations described 2 in promoter region (less important)3 in open reading frame (M52, M54, M57)
Codon 54 mutation present in 16% of Caucasian homozygous in 2%
Defects associated with bacterial infections in children and hepatitis B carriage
Mutations
Eisen & Minchinton Clin Infect Dis 2003;37:1496
CCPA and human gene defects
• 8 of 11 (72%) had low MBL genotypes p=<0.05
(compared to normal controls)
• 8 of 17 (47%) had low MBL genotypes p=0.0002
• 32% and 21.5% frequency of 2 SPA2 mutations, compared with normals (18% and 11%) (p=0.021 and p=0.044)
• not related to coeliac disease (<1 in 30)Crosdale et al J Infect Dis 2001;184:653; Vaid et al, unpublished.
CLASSIFICATION OF ASPERGILLOSIS
Persistence without disease - colonisation of the airways or nose/sinuses
Airways/nasal exposure to airborne Aspergillus
Invasive aspergillosis• Acute (<1 month course)• Subacute/chronic necrotising (1-3
months)
Chronic aspergillosis (>3 months)• Chronic cavitary pulmonary• Aspergilloma of lung• Chronic fibrosing pulmonary• Chronic invasive sinusitis • Maxillary (sinus) aspergilloma
Allergic• Allergic bronchopulmonary (ABPA)• Extrinsic allergic (broncho)alveolitis
(EAA)• Asthma with fungal sensitisation• Allergic Aspergillus sinusitis
(eosinophilic fungal rhinosinusitis)
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS – Key diagnostic criteria
• Asthma• Blood eosinophilia (>1,000 / cu
mm)• History of pulmonary infiltrates• Central bronchiectasis
Rickett et al. Arch Intern Med 1983; 143: 1553; Patterson, Chest 2000;118:7
ABPA possibleABPA possibleABPA probable
ABPA almost certain
• Precipitins against A. fumigatus positive• Aspergillus IgE antibody >2x asthma control• Aspergillus IgG antibody >2x asthma control• Total serum IgE concentration, >1000 iu/mL
If 3 tests +ve, then ABPA very likely, If all 4 +ve the diagnosis established
ABPA
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Before bronchoscopy
After bronchoscopy
ABPA mucous plugging
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ABPA - CT showing central bronchiectasis
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ABPA and surfactant
5 surfactant proteins in man, SPA1, SPA2, SPB, SPC and SPD – all ‘collectin’ family
Mason et al, Am J Physiol 1998;275:L1-13.
ABPA – surfactant defects
2 exonic polymorphisms, and 2 intronic polymorphisms in SP-A2 associated with ABPA
A1660G = OR of 4.78; or if combined with G1649C = OR 10.4
Also associated with higher peripheral eosinophilia
Saxena et al, J Allergy Clin Immunol 2003;111:1001-7.
Eosinophilic fungal rhinosinusitis or allergic fungal sinusitis
Patient with chronic symptoms of nasal obstruction, loss of smell and nasal polyps
Ponikau et al, Mayo Clinic Proc 1999;74:877 & WWW.aspergillus.man.ac.uk
Eosinophilic fungal rhinosinusitis(link with airborne fungi - ?which most important
= Myelin basic protein, highly toxic to local epithelium
Ponikau et al, Mayo Clinic Proc 1999;74:877
A link between Aspergillus and asthma?
Fungal-associated asthma – evidence
Fungal-associated asthma
ABPA
Treatment of ABPAand pilot data
Severe asthma linked with fungal
sensitisation
Frequency of fungal sensitisation
High spore counts and asthmatic attacks
Spore counts and asthma attacks and admission to hospitalAll circumstantial evidence
• Thunderstorm asthma – linked to Alternaria
• Asthma deaths (Chicago) linked to high ambient spores counts and season (summer autumn) when spore counts highest
• Asthma hospital admission linked to high ambient spore counts (Derby, New Orleans, Ottawa
• Asthma hospital attendance linked to high spore counts , but not pollen counts (Canada)
• Asthma symptoms increased on days of high spore counts (California, Pennsylvania)
O'Hollaren, N Engl J Med 1991; 324: 359; Newson, Occup Environ Med 2000; 57: 786-92.
Fungus at homeEnvironmental data• Mouldy housing associated with worse
asthma, with a correlation between asthma severity and degree of dampness in the home and separately with visible mould growth
• In Germany bronchial reactivity in children was associated with damp housing
• Mouldy and damp school associated with asthma symptoms and emergency room visits
• Highest concentration of Aspergillus fumigatus is at home
Williamson, Thorax 1997;52:229. Taskinen, Acta Paediatr 1999; 88:1373.
Severe asthma and moulds
Mild asthma – 564 (50%)
Moderate asthma – 333 (29%)
Severe asthma – 235 (21%) – linked with fungus skin test positivity
Zureik et al, Br Med J 2002;325:411
Asthma severity, house dust mites, cats and moulds
Langley, ATS 2004
Allergen No asthman= 111
Mild asthma FEV1 >75%
<90%n= 67
Moderate asthma FEV1
>60% <75%n= 42
Severe asthma FEV1
>60% n= 42
House dust mite
61% 71% 45% 77%
Cats* 49% 51% 38% 35%
Moulds# 17% 19% 36% 31%
* P = 0.05# p = 0.01