Aspergillus and Aspergillosis: an Introduction

Aspergillus and aspergillosis: an introduction

Malcolm Richardson Director© by author Mycology Reference Centre UHSM and University of ESCMID OnlineManchester Lecture Library Aspergillus and aspergillosis

ESCMID Online Lecture Library Aspergillus is in the air

ESCMID Online Lecture Library ASPERGILLOSIS

ESCMID Online Lecture Library

A short history of Aspergillus

• First catalogued by P. Michelli in 1729

• First known case of infection: 1815 (jackdaw) • 1842 (human)

• Occupational hazard amongst wig combers • (allergic disease of the lungs). © by author

ESCMID Online Lecture Library Sources of Infection

– Soil – Air; spores may be inhaled – Water / storage tanks in hospitals – Food – Compost and decaying vegetation – Fire proofing materials – Bedding, pillows – Ventilation and air© conditioning by author systems – Computer fans

ESCMID Online Lecture Library Members of the family • Genus of around 200 fungi (moulds) worlwide

• Filamentous fungus (opposed to single celled • fungus), reproduction by spores • A. fumigatus, A. flavus, A. niger, A. clavatus

ESCMID Online Lecture Library Where is Aspergillus found?

• Natural habitat: hay and compost.

• Aspergillus spores are easily airborne • (100-200 spores daily). • • Some species withstand heat (Aspergillus • fumigatus), commonly© by found author in compost.

ESCMID Online Lecture Library Pulmonary Aspergillosis

• Allergic Aspergillosis

• Noninvasive Local Colonization

ESCMID Online Lecture Library

ESCMID Online Lecture Library Allergic Aspergillosis

• Asthma bronchiale

• Allergic bronchopulmonary aspergillosis ABPA (Types I, III)

• Allergic Aspergillus sinusitis – AAS © by author • Allergic alveolitis ESCMID Online Lecture Library ABPA

• Hypersensitivity-reaction

• A. fumigatus

• Bronchial collapse,© by author bronchiectasis

• Lung infiltration by eosinophils ESCMID Online Lecture Library Noninvasive Local Colonization • Aspergilloma (cavities)

• Otomycosis

• Onchomycosis © by author • Eye infection ESCMID Online Lecture Library Aspergillus sinusitis

ESCMID Online Lecture Library

ESCMID Online Lecture Library Growth of Aspergillus

1-2 mm per hour

ESCMID Online Lecture Library Invasive Aspergillosis

• Rare, but life-threatening

• Progression speed varies

• Immunocompetency© by author

ESCMID• Pulmonary Online vs. Lecture disseminated Library EORTC-MSG Standards

• DEFINITE

• positive histology or culture

• PROBABLE

ESCMID Online Lecture Library

ESCMID Online Lecture Library Aspergilloma

ESCMID Online Lecture Library MORTALITY OF INVASIVE ASPERGILLOSIS IN RELATION TO UNDERLYING DISEASE Lin, Schranz, Teutsch Clin Infect Dis 2001;32:358

100

40 © by author 30

bone bone transplant marrow /lymphoma

kidney transplant kidney AIDS liver transplant liver

10 leukemia /heart lung

ESCMID Online Lecture Library

transplant The Helsinki experience: adults • 1989-1995 • 22 IPA allo BMT • Diagnosis 69-466 (median 131 days post Tx) • 16 (73%) definite or probable • Lung involvement: 90% • CNS: 41% • respiratory symptoms >50% • neurological symptoms 27% • Optimal diagnosis: tissue biopsy • BAL: 8/14 ”suggestive©” by author Jantunen et al. BMT 2000; 25: 867-871

ESCMID Online Lecture Library The Helsinki experience: children Invasive fungal infections in pediatric bone marrow transplant recipients: single center experience of 10 years • 148 BMT • 12/73 (16%) infection: allogeneic • 6/75 (8%) infection: autologous • 15/18 died, in 12 IFI as cause of death • 48 suspected infections • allogeneics: severe© GVHDby author major risk factor • steroid dose associated with IFI

HoviESCMID et al. Bone Marrow Online Transplantation Lecture 2000; Library 26: 999-1004. Pathophysiology of aspergillosis

ESCMID Online Lecture Library The life cycle of Aspergillus

Spores Germination

ESCMID Online Lecture Library Aspergillus in tea!

ESCMID Online Lecture Library Air sampling

ESCMID Online Lecture Library Air sampling: >1300 cfu/m3!

ESCMID Online Lecture Library Dust

ESCMID Online Lecture Library Dust collection

ESCMID Online Lecture Library Double door entry: HYKS

ESCMID Online Lecture Library Ceiling tiles: HYKS

ESCMID Online Lecture Library Nosocomial aspergillosis

ESCMID Online Lecture Library Invasive aspergillosis

ESCMID Online Lecture Library DEVELOPMENT OF ASPERGILLOSIS

INHALATION COLONIZATION INFECTION Dissemination

1 2 © by author3

ESCMID Online Lecture Library IPA: DISEASE PROGRESSION CAB CAB CAB CAB 0.3mg 0.5mg 0.8mg DC

Day 1 4© by author 7 10

2cms/day in vitro ESCMID Online Lecture Library Aspergillus: Risk of aspergillosis

Remission induction Consolidation Allogeneic BM SCT GVHD

Complete remission

Remission Remission induction induction © by author

Refractory Refractory Risk of aspergillosis ESCMID Online Lecture Library Aspergillus: Time to diagnosis of aspergillosis after BMT

20 Neutropenia Graft versus host disease

18 Wald et al. J Infect Dis 16 1997;175:1459 14

10 Cases 8 6 © by author 4

0 10 ESCMID20 30 40 50 Online60 70 80 Lecture90 100 110 120 Library 130 140 150 160 170 Days after transplant Assessment of risks following HSCT PRE- ENGRAFTMENT EARLY POST- LATE POST- TRANSPLANT ENGRAFTMENT ENGRAFTMENT Disease remote possible Probable disease proven likelihood41 °C °C 40

Temperature Temperature 37 Clinical

/L) features 6 High risk Persistent fever Tissue 10 Host factors Mucositis evidence

1x 10 1x Mycological

10 evidence features 1 © by author

treatment0.1 Prophylaxis Empirical Pre-emptive Specific Granulocytes (log Granulocytes -14 -7 0 7 14 21 28 6 8 10 12 6 9 12 ESCMIDTransplant DaysOnline LectureWeeks Library Months Risk periods for mycosis following HSCT PRE- ENGRAFTMENT EARLY POST- LATE POST- TRANSPLANT ENGRAFTMENT ENGRAFTMENT

°C °C 40

Temperature Temperature 37

36 /L) 6 neutropenia corticosteroids 10 1x 10 1x

10 Stem cells acute GvHD chronic GvHD low IgG 1 © by author

0.1 Granulocytes (log Granulocytes -14 -7 0 7 14 21 28 6 8 10 12 6 9 12 ESCMIDTransplant DaysOnline LectureWeeks Library Months Aspergillus: Risk factors for aspergillosis after BMT – building works

7.0 6.0 5.0 4.0 % % 3.0 2.0 1.0 © by author 0.0 Absent Present

ESCMID Online Lecture LibraryWald et al. J Infect Dis 1997;175:1459 Risk factors for aspergillosis after BMT – season 5.0

4.0

3.0

2.0

1.0 © by author 0.0 Winter Spring Summer Autumn

ESCMID Online Lecture LibraryWald et al. J Infect Dis 1997;175:1459 Risk factors for aspergillosis after BMT – building works

7.0 6.0 5.0 4.0 % % 3.0 2.0 1.0 © by author 0.0 Absent Present

ESCMID Online Lecture LibraryWald et al. J Infect Dis 1997;175:1459 The application of a quantitative risk assessment paradigm to the acquisition of nosocomial infection caused by Aspergillus species

•hazard identification •exposure assessment •dose-response relationship •risk characterisation •risk management© by author •communication Wilkinson 1998; HIS Electronic News Bulletin ESCMID Online Lecture Library Acceptable levels

• HEPA filtered air: 0 • Open ward:? • General hospital areas: ? • Outdoor air: highly variable/seasonal © by author

ESCMID Online Lecture Library Bioaerosols in the hospital environment • What are bioaerosols? • Can bioaerosols cause health problems • What are the sources of bioaerosols in hospital? • What measures can be taken to control bioaerosols in the hospital? • How can I control© the by cause author of bioaerosols?

ESCMID Online Lecture Library Building materials

Ceiling tiles, insulation, Aspergillus. painted surfaces, wallpaper Cladosporium

Carpet Alternaria Stachybotrys

Dust Alternaria © by author Cladosporium Penicillium

ESCMID Online Lecture Library Sources of Aspergillus spp.

• Environment • Food – long list! – Sharing of salt and pepper pots – autoclave pepper • standing water • ice-making machines • fomites © by author – carpets/furniture/fabrics/soft toys

ESCMID Online Lecture Library Fungal contamination of food distributed to neutropenic patients Food Contaminated Fungi samples (%)

Tea 100 A. fum, A. flavus Pepper 100 A. fum, A. niger

Freeze-dried soup 20 A. fum, A. niger Apricot 66 A. fum, A. flavus Kiwi 50 A. fum Banana 25 © by authorA. fum Grapefruit juice 15 A. fum Bouakline et al. JCM 2000; 38: 4272-4273.

ESCMID Online Lecture Library Kitchens as a source of A. niger infection • 3 cases of cutaneous infection: BMT unit • A. niger isolated: – surfaces – side vent of ice-maker – tea caddy • No isolates from ©bedroom by author • I patient infected with environmental strain Loudon et al., JHI 1996 ESCMID Online Lecture Library Aspergillosis due to carpet contamination • 13 cases of IA: July 1991 - March 1992 • construction • fire in adjacent building • open window • carpet tiles: Aspergillus spp. • shampoo cleaning replaced by water extraction: dramatic reduction in cases of IA • Carpet tiles: ?source© or by ?marker author of airborne spores Gerson et al., Infect Contr Hosp Epidemiol 1994 ESCMID Online Lecture Library Water as a source of filamentous fungi in a childhood bone marrow transplantation unit • 168 filtered water samples • 20 water-related surfaces: swabbed • Moulds recovered from all water samples – Aspergillus fumigatus • 60% taps • 75% main water supply • Water-related surfaces:© by 25% author positive for moulds (only 2 samples positive for A. fumigatus) Warris et al. JHI 2001; 47: 143-148. ESCMID Online Lecture Library Aspergillus species aerosols in hospitals: showering as a potential mode of exposure • Conidia can be isolated from hospital water supplies • gradient of aerosolized concentrations may exist between bathrooms and bedrooms in individual units • ?higher airborne spore concentrations when water is running© by author Anaissie et al., CID 2001; 33: 1546-1548.

ESCMID Online Lecture Library Aspergillus spp. aerosols in hospitals: showering as a potential mode of exposure

ESCMID Online Lecture Library Refinements of environmental assessment during an outbreak investigation of IA in a leukemia and BMT unit

• study stresses: – adequate pressure differentials between corridors and patient rooms – double-door entry into patient rooms – large-volume (1, 200 L) sampling superior © by author

Chloe et al. Infect Control Hosp Epidemiol 2000; 21: 18-23. ESCMID Online Lecture Library Assessment

• Structural survey • Air • Surfaces • Dust • Water analysis • Fabrics © by author • Carpets • Relative humidity ESCMID Online Lecture Library Dust!

• Fungal aerosols can vary widely between different locations and over short time periods • Indoor dust – deposited over long periods of time – will reflect long-term exposure history – easy and cheap© toby collect author

ESCMID Online Lecture Library

ESCMID Online Lecture Library Concentrations of airborne Aspergillus compared to the incidence of invasive aspergillosis: lack of correlation • 54-week air sampling period -3 • A. fumigatus and A. flavus: mean 1.83 cfu m • Individual samples: maximum: 11.6 cfu m-3 • No correlation with season or ward • 6 cases of IPA during sampling period • No association with fluctuations in air count Conclusion: “the available data do not provide a firm link© betweenby author hospital exposure and an increased incidence of aspergillosis” ESCMID Online Lecture Library Objectives of air sampling 1

• Correlation of outbreaks with hospital construction/demolition • identification of potential sources of nosocomial aspergillosis • prediction of contamination from outside sources © by author • identification of defects/breakdown in ventilation/filtration systems ESCMID Online Lecture Library Objectives of air sampling 2

• Monitoring of cleaning procedures • Efficacy of HEPA filters in LAF rooms • Monitoring of procedures to contain hospital building work from hospital wards/single-bedded© by author units

ESCMID Online Lecture Library A deadly dust may be in the wind during renovations Hospital infection control

• Deaths – despite aggressive control measures • ??Community-acquired aspergillosis • Put guidelines in the contract • one death should prompt inquiry • water may be source© of by Aspergillus author • Conduct regular walk-throughs

ESCMID Online Lecture Library Late onset of IA in BMT patients at a university hospital • 93 allogeneic and 149 autologous pts • 20 month period • 0% IA autologous • 15.1% allogeneic: overall incidence 5.8% • Median time to occurrence: 92 days • No de novo cases prior to engraftment • Survival 100 days from diagnosis 29% • Conclusions – shift towards late occurrence© by author – outpatient environment surveillance Grow et al., BMT 2002; 29: 15-19 ESCMID Online Lecture Library Is IA community-acquired?

• 70% of cases community-acquired (Patterson et al.) • hospital environmental control measures will not influence community-acquired cases • control/preventative measures © by author – surveillance of home environments – prophylaxis ESCMID Online Lecture Library Invasive mold infections in allogeneic BMT recipients • 94 adult patients • 15 cases invasive mould infections: – A. fumigatus 7/15 (47%) – Aspergillus species 5/15 • Median time to onset: 102 days (18-470) “Although these data suggest community rather then nosocomial acquition because of the late timing of clinically evident disease, the source of these pathogens remains speculative because detailed epidemiological surveys were not conducted during the ©study by period author”

Baddley et al. CID 2001; 32: 1319-1324.

ESCMID Online Lecture Library Patient’s house

ESCMID Online Lecture Library Nosocomially vs. community-acquired IA

Nosocomial Community-acquired • Due to break in, or • Due to occupational contamination of activities hospital water system • Due to leisure activities • Due to break in HEPA • Due to exposure to filtration system Aspergillus spores • Due to construction or (minimum effective demolition work in the© by authordose not known) hospital

ESCMID Online Lecture Library Praz-Christinaz et al. Transplant Infect Dis 2007; 9: 175-181 Diagnosis

• Consider it!

• Direct examination (sputum, BAL, tissue)

• Histology

• Antigen, Antibody

ESCMID Online• PCR for fungal Lecture DNA Library • various targets, sens ~ 100%, spec ~ 70%

Diagnosis of systemic fungal infection

Clinician Microbiologist

Infectious Disease Physician ESCMID Online LecturePharmaceutical Library Industry Aspergillus fumigatus

ESCMID Online Lecture Library Aspergillus fumigatus

ESCMID Online Lecture Library Aspergillus niger

ESCMID Online Lecture Library Aspergillus flavus

ESCMID Online Lecture Library Aspergillus nidulans

ESCMID Online Lecture Library Aspergillus terreus

ESCMID Online Lecture Library

Prevention is better than cure

• avoidance of exposure • prospective surveillance: standard protocol • prophylaxis • patient screening: ©nasal by authorswabs/BAL – Galactomannan ELISA – PCR ESCMID Online Lecture Library Non-culture approaches to fungal diagnosis

Candida Aspergillus Detection LA ELISA Cell wall Mannans Galactomannan 1,3-β-D-glucans 1,3-β-D-glucans RIA components chitin chitin Amebocyte lysate assay Spectrophotometry Cytoplasmic Enolase HSP-90 ELISA antigens Immunoblot

Metabolites arabinitol D-mannitol GLC Mass spectroscopy © by author Genomic DNA C-14 lanosterol C-14-lanosterol PCR sequences demethylase demethylase Chitin synthase Alkaline protease Actin Mitochondrial DNA Aspartate proteinase HSP-90 ESCMIDRibosomal RNA Online genes RibosomalLecture RNA genes Library Sensitivity testing

ESCMID Online Lecture Library Aspergillus, friend of mankind

• A. oryzae and A. sojae (soy sauce and miso)

• A. niger (citric acid)

• Washing powder, hard cheese, flavourings ESCMID Online Lecture Library Prevention is better than cure Avoid exposure in the hospital and in the home

ESCMID Online Lecture Library Surveillance strategy

•understand the ecology of Aspergillus •avoid exposure •risk assessment: hospitals and homes •prospective air and dust sampling •personal air samplers© by author

ESCMID Online Lecture Library