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Direct Detection of Exophiala and Scedosporium Species in Sputa of Patients with Cystic fibrosis Min Chen1,2,3,∗, Nahid Kondori4, Shuwen Deng7, A

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Direct Detection of Exophiala and Scedosporium Species in Sputa of Patients with Cystic fibrosis Min Chen1,2,3,∗, Nahid Kondori4, Shuwen Deng7, A Medical Mycology, 2017, 0, 1–8 doi: 10.1093/mmy/myx108 Advance Access Publication Date: 0 2017 Original Article Original Article Direct detection of Exophiala and Scedosporium species in sputa of patients with cystic fibrosis Min Chen1,2,3,∗, Nahid Kondori4, Shuwen Deng7, A. H. G. Gerrits van den Ende2, M. Lackner5, Wanqing Liao1 and G. S. de Hoog1,2,3,6,∗ 1Department of Dermatology, Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Medical Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, 200003, China, 2Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands, 3Institute of Biodiversity and Ecosystem Dynamics, University of Amsterdam, Amsterdam, The Netherlands, 4Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Sweden, 5Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria, 6Peking University First Hospital, Research Center for Medical Mycology, Beijing, China; Department of Basic Biology, University of Parana,´ Curitiba, Brazil and 7Department of Medical Microbiology, People’s Hospital of Suzhou National New & Hi-Tech Industrial Development Zone, Jiangsu, China ∗To whom correspondence should be addressed. Min Chen. E-mail: [email protected] G. S. de Hoog. E-mail: [email protected] Received 26 June 2017; Revised 31 August 2017; Accepted 5 October 2017; Editorial Decision 17 September 2017 Abstract Detection of species of Exophiala and Scedosporium in the respiratory tracts of cystic fibrosis (CF) patients remains controversial because of highly variable results. The results of our study suggested a significantly higher prevalence and more complex colonization than previously estimated. Approximately 17% (27/162) of clinical sputum samples were found to be positive for Exophiala dermatitidis and 30% (49/162) were positive for Sce- dosporium apiospermum / S. boydii species complex determined by reverse line blot (RLB) hybridization. In contrast, only 14.2% (23/162) and 1.2% (2/162) of clinical sputa were positive for E. dermatitidis and S. apiospermum / S. boydii species complex when tested by culture, respectively. Molecular detection methods, such as loop-mediated isothermal amplification (LAMP) or reverse line blot (RLB) hybridization, have the potential to be- come powerful alternatives to selective culture, providing a more realistic understanding on the prevalence of E. dermatitidis and S. apiospermum / S. boydii species complex in the respiratory tract of CF patients. Key words: Exophiala dermatitidis, Scedosporium, cystic fibrosis, sputum. Introduction among Caucasian populations.1 CF is caused by mutations Affecting over 70,000 individuals worldwide, cystic fibro- in the CF transmembrane conductance regulator (CFTR) sis (CF) is the most common genetically inherited disease protein, which leads to the production of thick and sticky C The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal 1 Mycology. All rights reserved. For permissions, please e-mail: [email protected] Downloaded from https://academic.oup.com/mmy/advance-article-abstract/doi/10.1093/mmy/myx108/4714805 by University of Leeds user on 16 January 2018 2 Medical Mycology, 2017, Vol. 00, No. 00 bronchial mucus that may facilitate microbial accumula- detection of E. dermatitidis in clinical samples was not tion and colonization.2,3 In addition to bacteria such as conducted frequently to date. Therefore, we compared the Staphylococcus aureus and Pseudomonas aeruginosa,sev- detection of E. dermatitidis, S. apiospermum, and S. boydii eral fungi colonize the respiratory tracts of CF patients,3,4 from CF sputa by two molecular approaches (polymerase though their prevalence and pathogenicity remain contro- chain reaction [PCR]-RLB and LAMP) and culture.20 The versial.5,6 Aspergillus fumigatus is the filamentous fungus aim of this study is to improve our understanding of the most commonly isolated from CF patients and is capable prevalence of E. dermatitidis, S. apiospermum, and S. boy- of precipitating a chronic allergic inflammatory response dii in the respiratory tracts of CF patients. or invasive infection after lung transplantation.4 However, the fungal biota colonizing the lungs of CF patients are more complex and include various non-Aspergillus fila- Methods 7–9 mentous fungi such as Scedosporium apiospermum and Clinical specimens Exophiala dermatitidis.4,10–12 In the genus Scedosporium, Between September and December 2012, a total of 162 spu- S. apiospermum,andS. boydii have recently been aggre- tum specimens from 103 CF patients were collected by the gated as the ‘S. apiospermum complex’ because of their ge- Department of Clinical Microbiology, Sahlgrenska Univer- netic similarity and the lack of clinical differences observed sity Hospital, Sweden. Each sample was divided into two between sibling species.13,14 portions: one part for the isolation of conventional or semi- The black yeast E. dermatitidis is another filamentous selective culture, the other part for molecular detection by fungus regularly involved in colonizing the respiratory tract PCR-RLB and LAMP assays. of CF patients.7–12 Persistent colonization and repeated infection with E. dermatitidis or S. apiospermum / S. boydii may occur in CF patients over decades.10–12 Sce- Isolation of fungi from sputum samples dosporium species are resistant to many antifungal agents by culture including amphotericin B.15 In addition to Aspergillus and Candida, patients with CF were observed to be colonized Approximately 1 ml of sputum specimens from each CF by E. dermatitidis or Scedosporium; however, this may be patients was routinely cultured on Sabouraud glucose agar an artifact because published studies that detected them in (SGA), CHROMagar Candida, maltose agar, and ECA combination are scant. In addition, culture only has a lim- plates. Sputum was liquefied by the addition of pancreatin ited sensitivity, these species usually remain undetected be- (10 mg/ml) in a volume ratio of 1/1, vortexed and incu- ◦ cause they are easily outcompeted by Aspergillus and Can- bated at 20 C for 5 min prior to culture. Cultures were ◦ dida species.15,17 Possible correlations with underlying dis- then incubated at 30 C and examined for fungal growth eases remain uncertain because of limited amount of data for up to 20 days. Isolated fungi were identified to the available. An exceptionally high recovery rate of approx- species level using morphological criteria, the ability to ◦ imately 20% of E. dermatitidis was recently reported by grow at present at 42 C and on mycobiotic agar plates sup- incubating sputa on erythritol-chloramphenicol agar (ECA) plemented with cycloheximide. A set of reference strains medium from Sweden, but conventional culture-based diag- included 46 strains (Table 1)ofE. dermatitidis and an- nosis strategies are hampered by the mucoid consistency of other 22 Exophiala species that are taxonomically close CF sputum or bronchoalveolar lavage (BAL) specimens.18 to E. dermatitidis were obtained from Westerdijk Fungal Thus, frequencies of accompanying fungi may be under- Biodiversity Institute, Utrecht, The Netherlands, for evalu- estimated,12,18 though recent applications of semi-selective ation of sensitivity and specificity of designed E. dermati- media, which inhibit rapidly growing Aspergillus and Can- tidis species-specific primer sets of RLB and LAMP assays 23,24 dida, enable fungi with delayed growth to be revealed.19,20 according to the previous analysis. All reference strains ◦ Detection by culture still requires viable cells in the sam- were grown on potato dextrose agar (PDA) at 30 Cfor ples and highly skilled laboratory technicians for successful 7 days prior to use. cultivation. Molecular techniques have improved detection and thereby our understanding of fungal colonization of the Molecular detection respiratory tracts of CF patients.21,22 Among these meth- Genomic DNA from reference strains was extracted us- ods, loop-mediated isothermal amplification (LAMP)21 and ing cetyltrimethylammonium bromide (CTAB) as described reverse line blot (RLB) hybridization7,21 have shown added previously.14 To extract fungal DNA directly from clini- value to elucidation of the epidemiology of less common cal sputum, a High Pure PCR Template Preparation Kit colonizers in the CF patient population.7,21,22 Molecular (Roche Inc., Mannheim, Germany) was used according to Downloaded from https://academic.oup.com/mmy/advance-article-abstract/doi/10.1093/mmy/myx108/4714805 by University of Leeds user on 16 January 2018 Chen et al. 3 Ta b l e 1 . Fungal isolates (n = 46) analyzed with PCR-RLB and LAMP assays for detection of E. dermatitidis. Serial number Strains Species Source PCR-RLB detection LAMP detection 1 CBS 207.35 Exophiala dermatitidis Clinical strain ++ 2 CBS 424.67 Exophiala dermatitidis Clinical strain ++ 3 CBS 632.69 Exophiala dermatitidis Environmental strain ++ 5 CBS 314.90 Exophiala dermatitidis Environmental strain ++ 7 CBS 292.49 Exophiala dermatitidis Environmental strain ++ 8 CBS 109140 Exophiala dermatitidis Environmental strain ++ 9 CBS 109146 Exophiala phaeomuriformis Environmental strain - - 11 CBS 134012 Exophiala phaeomuriformis Environmental strain - - 12 CBS 124194 Exophiala phaeomuriformis Environmental strain - - 13 CBS 121744 Exophiala phaeomuriformis Environmental strain - - 14 CBS 120563 Exophiala phaeomuriformis Clinical strain - - 15 CBS 120555 Exophiala
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