FUNGAL INFECTIONS and ANTIFUNGAL AGENTS

AIMS & OBJECTIVES To provide an overview of the medically important fungal infections List and classify Antifungal drug classes with their modes of action Make some key learning points through illustrated cases

The Fungal Kingdom Diverse groups of eukaryotic organisms that find nourishment from living or dead organic matter Their classification is based on their structural appearance During evolution relied on both sexual and asexual reproduction Both forms important for identification

FUNGI Saccharomyces cerevisiae is the model organism for studying yeast genetics Many seen as harmless environmental organisms Of the 50-250,000 fungal species less than 200 cause human disease and only a dozen or so on a regular basis

Fungi of medical importance: Classification Based on the colony morphology, vegetative hyphae that produce a mycelium and specialised aerial hyphae that bear spores (conidia) Yeasts: unicellular fungi reproduce by budding Moulds (filamentous): produce hyphae and mycelium Dimorphic: grow as moulds (environment) or yeasts (in human host)

YEAST: Blastospore; hyphae; pseudohyphae MOULD: Mycelium; hyphae

Some examples Yeast: Candida albicans, Cryptococcus neoformans Mould: Aspergillus, Penicillium, Fusarium, Dermatophytes Dimorphic: Histoplasma capsulatum

Types of diseases caused by human fungal pathogens Mycotoxicosis: due to ingestion of the toxic metabolites of mould fungi eg, poisonous toadstools

Mycotoxins Aspergillus flavus A ochraceus Fusarium moniliforme F graminearum Aflatoxin(hepatic ca) Ochratoxin (renal tox) Fumonisins (oesophageal ca) Deoxynivalenol (gastrointestinal toxicity)

Allergic lung disease Due to inhalation of fungal spores eg, A fumigatus, causing a type I or type III hypersensitivity reaction A clinical example is called allergic bronchopulmonary aspergillosis Farmers lung is another example

Fungi of medical importance Candida albicans Other Candida sp. Cryptococcus Dermatophytes Aspergillus spp Zygomycetes Dimorphic fungi Dematiaceous fungi Candida albicans x 6049

Classification of human fungal infections Superficial: ringworm (dermatophytes) , thrush (Candida species), dandruff (Pityrosporum) Subcutaneous: involve the dermis of the skin, deep tissues or bone. Usually found in tropics/sub-tropics where caught walking barefoot eg, mycetoma Systemic: due to pathogenic (Histoplasma) or opportunistic (Aspergillus) fungi

Dermatophytes (the cause of RINGWORM) Infection of scalp (Tinea capitis), trunk (Tinea corporis) or nails (Tinea unguium) Causative fungi are Trichophyton, Epidermophyton, Microsporum Geophilic, zoophylic, anthropophylic Clinically red patches on skin, or scalp, scaly, hair loss Athletes foot an example

Some other skin fungal infections Seborrhoeic dermatitis (Pitysporum) Pityriasis versicolor (Pitysporum) Candidiasis (Candida albicans)

Vaginal Candidiasis (Thrush) Common in women of child bearing years Symptoms are itchy vaginal discharge Diagnosed by vaginal examination (white plaques) and microscopy/culture Treat: topical pessary Or Fluconazole

SYSTEMIC (DEEP/INVASIVE) FUNGAL INFECTIONS: MAJOR EXAMPLES Candidiasis Aspergillosis Cryptococcosis Other mould infections Endemic mycoses Emerging fungal infections

ILLUSTRATION OF SOME CASES

CANDIDIASIS: CASE 1 A 70-year old man has colonic surgery for carcinoma of colon Recovery is in the ITU He develops high fevers which don’t respond to antibiotics An organism is grown from blood cultures which is seen on gram stain

Candida blastospores (yeast) In blood

Candidaemia

GERM TUBE

CANDIDIASIS:CASE 1……….. Candida albicans is identified He is treated with a systemic antifungal drug called amphotericin B intravenously He develops rigors each time the drug is given and after 7 days treatment although he is improving kidney failure develops and he requires haemofiltration Treatment is changed to fluconazole

SYSTEMIC (invasive) CANDIDIASIS Increasing in incidence Risk factors are prior colonisation of mucosal surfaces, antibiotics, major surgery, leukaemia, vascular catheters Main pathogenic species is Candida albicans (others are C tropicalis, C glabrata, C krusei)

Distribution of Nosocomial Bloodstream Pathogens in a Large Teaching Hospital 26% 9% 5.5% 17% 6% 4.5% 19.5% Crowe et al: Eur J Clin Microbiol Infect Dis 1998

Distribution of candidaemia by species (Hammersmith Hospital 1997-2000) 2% 6% 44% 8% 14% N=50 24%

General patterns of susceptibility of Candida species Fluco Itraco Vorico Flucy AmB Candins C. albicans S C. tropicalis C. parapsilosis S (- I?) C. glabrata SDD - R S - I S – I C. krusei R I - R C. lusitaniae S - R Pappas et al CID 2004; 38: 161-189

Interpretive breakpoints for isolates of Candida species MIC range (g/ml) Drug Susceptible Intermediately susceptible Resistant Fluconazole ≤8 16-32 (SDD) >32 Itraconazole ≤0.125 0.25-0.5 (SDD) > 0.5 Flucytosine ≤4 8.16 >16 Pappas et al CID 2004; 38: 161-189

Candida biofilms (on vascular catheter): a source of candidaemia Courtesy of Dr J Douglas

Clinical manifestations of candidaemia/invasive candidiasis Infective endocarditis (heart valve surgery, IVDAs) Endophthalmitis Embolic skin lesions (petechial rash) Hepatic, renal, cerebral, meningeal infection

ANOTHER CASE………. Case no 2: a man who is HIV antibody positive He complains of difficulty with swallowing and retrosternal burning Endoscopy reveals white plaques on the oesophageal mucosa typical of Candida (thrush)

FINALLY: SOME LEARNING POINTS ABOUT CANDIDIASIS In immunocompromised relapses often occur unless underlying problem is removed Candida endocarditis often requires surgery Fluconazole resistance has been reported in AIDS cases because of the high fungal load Disseminated candidiasis is difficult to diagnose

Antifungal Drugs Currently licensed for systemic therapy POLYENES: examples: amphotericin B, nystatin: Including 3 lipid formulations of amB (Ambisome) AZOLES: Imidazoles: miconazole, ketoconazole Triazoles: fluconazole, itraconazole, voriconazole FLUORINATED PYRIMIDINE: flucytosine ALLYLAMINE: terbinafine CANDINS: new antifungal class

NUCLEIC ACID SYNTHESIS CELL WALL SYNTHESIS Caspofungin Anidualfungin Micafungin MEMBRANE FUNCTION Amphotericin B Nyststin NUCLEIC ACID SYNTHESIS 5-Flucytosine ERGOSTEROL SYNTHESIS Azoles: Fluconazole, itraconazole, voriconazole ALLYLAMINE: Terbinafine Targets of action of antifungal drugs

AMPHOTERICIN B vs FLUCONAZOLE Polyene antifungal Inhibits cell membrane Broad spectrum Not absorbed Causes rigors Causes kidney damage Resistance rare Azole antifungal Inhibits cytochrome p450 ( ergosterol) Broad spectrum Orally absorbed Few side effects No kidney damage Resistance occurs

Caspofungin New class Fungicidal Broad spectrum Few side effects not Cryptococcus Few side effects o.d. regimen No cross resistance with azoles & polyenes

Mechanism of Action CANDINS Fungal cell wall Phospholipid bilayer b-(1,6)-glucan Fungal cell wall Phospholipid bilayer of the fungal cell membrane b-(1,3)-glucan Ergosterol b-(1,3)-glucan synthase CANDINS

Antifungal drug resistance Rare in Candida albicans except in AIDS patients Some fungi are inherently resistant to antifungal: aspergillus and fluconazole Others acquire resistance following exposure eg, C albicans in oropharyngeal infection in an AIDS patient

Drug sensitive cell Azole drug Resistance mechanisms Drug resistant cell mediated by efflux or Mutation in target ERG11 gene

Acquired Resistance to Fluconazole in HIV-associated Oropharyngeal Candidiasis Fluconazole quickly became established as the drug of choice Effective doses have ranged between 50mg and 400mg Since the late 1980’s there have been many reports of clinical failure

ASPERGILLOSIS Saprophytic (aspergilloma), allergic (ABPA) and invasive forms of this infection Environmental fungus Aspergillus is the pathogen Acquired by inhalation Pulmonary disease is main feature Difficult to diagnose & high mortality

Conidia Hypha and “fruiting head” Of Aspergillus

How Aspergillus infection is acquired Airborne conidia Alveolar macrophage

ASPERGILLOSIS: CASE STUDY A 23-year old man suffering from acute myeloid leukaemia undergoes a therapeutic bone marrow transplant There follows a long period of neutropenia He complains of pleuritic chest pain, breathlessness and has a fever Antibiotics make no difference

ASPERGILLOSIS CASE CONT’D……... Chest x ray is performed: infiltrates This is followed by a CT scan He also undergoes bronchoscopy which reveals some white plaques The patient dies despite amphotericin B therapy (there was no recovery of his bone marrow)

Risk groups for Invasive Aspergillosis Syndromes/treatments with severe neutropenia Haematological malignancy Chronic immunosuppression Solid organ transplantation AIDS Chronic granulomatous disease Chronic lung diseases: sarcoidosis

Another mould infection: Zygomycosis Patients with Haematological malignancy at risk Diabetic patients also susceptible Rhinocerebral infection a feature Eye swelling and cellulitis also seen Antifungal therapy not effective Due to several related mould fungi eg, Rhizopus

ANOTHER SYTEMIC FUNGAL INFECTION: CRYPTOCOCCOSIS A man who had a kidney transplant is receiving immunosuppression with prednisone and azathioprine He develops headache over several days, followed be photophobia and neck stiffness Spinal fluid is obtained which reveals a high count of lymphocytes

CASE CONT’D……….. A special stain called India ink reveals the presence of round cells surrounded by haloes as illustrated These haloes are the capsule of the yeast Cryptococcus neoformans A silver stain of a skin biopsy also shows many yeast cells

Cryptococcosis (India ink stain)

CRYPTOCOCCOSIS A major opportunistic infection in AIDS Also occurs in chronically immunosuppressed patients eg, organ transplant Causes insidious meningitis with lymphocytes in spinal fluid Treatment is amphotericin B + flucytosine (as in IDSA treatment guidelines)

ENDEMIC MYCOSES Histoplasmosis (H capsulatum, H duboisii) Blastomycosis (B dermatitidis) Coccidioidomycosis (C immitis) Paracoccidioidomycosis

HISTOPLASMOSIS Has a specific geographical distribution For example it is endemic in some mid west states in USA Evidence of endemicity is from skin testing of healthy population May cause a self-limiting flu-like illness in immunocompetent Severe pneumonia in immunocompromised

Emerging fungal pathogens Increasingly being seen in severely immunocompromised Susceptibility to antifungals unpredictable Often these are environmental organisms Fusarium is reported to be the 4th most common opportunist fungus in some US centres

SUMMARY POINTS Superficial fungal infections are a not uncommon presenting complaint in primary care Invasive fungal infections are associated with compromised patients and are seen in hospital practice Limited antifungal therapies make them more difficult to treat than bacterial infection