Powerpoint on aspergillosis

1. The extraordinary spectrum of diseases
caused by Aspergillus
David W. Denning
Wythenshawe Hospital
University of Manchester

2. The genus Aspergillus - importance to humanity
on the negative side:
cause invasive and allergic disease
in humans and other animals:
A. fumigatus
cause plant and food spoilage and
produce mycotoxins:
A. flavus and A. parasiticus
www.aspergillus.man.ac.uk

3. The genus Aspergillus - importance to humanity
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. sydowi
lovastatin: A. terreus
fumagillin: A. fumigatus
www.aspergillus.man.ac.uk

4. Aspergillus Life-cycle
Spores inhaled Germination
Mass of hyphae Hyphal elongation
(plateau phase) and branching
www.aspergillus.man.ac.uk

5. The genus Aspergillus – ~180 species,
38 have caused disease (able to grow at 37C)
Common in the environment
Aspergillus
A. nidulans – may be amphotericin B resistant fumigatus
conidial head
A. niger A. flavus -sometimes to AmB of azole resistance
A. fumigatus low frequency
A. terreus – resistant amphotericin B resistant
www.aspergillus.man.ac.uk

6. CLASSIFICATION OF ASPERGILLOSIS
Invasive aspergillosis
• Acute (<1 month course)
Airways/nasal • Subacute/chronic necrotising (1-3 months)
exposure to
airborne Chronic aspergillosis (>3 months)
Aspergillus
• Chronic cavitary pulmonary
• Aspergilloma of lung
• Chronic fibrosing pulmonary
• Chronic invasive sinusitis
Persistence • Maxillary (sinus) aspergilloma
without disease
- colonisation of
the airways or Allergic
nose/sinuses • Allergic bronchopulmonary (ABPA)
• Extrinsic allergic (broncho)alveolitis (EAA)
• Asthma with fungal sensitisation
• Allergic Aspergillus sinusitis (eosinophilic
fungal rhinosinusitis)

7. 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.

8. Interaction of Aspergillus with the host
A unique microbial-host interaction
Frequency of aspergillosis
Frequency of aspergillosis
Acute IA
ABPA
Allergic sinusitis
Subacute IA
Tracheobronchitis
Aspergilloma
Chronic cavitary
Chronic fibrosing
Immune dysfunction Normal Immune hyperactivity
immune
function
. www.aspergillus.man.ac.uk

9. Changing incidence of fatal invasive
mycoses in non-HIV patients in USA
0.8
Rate per 100,000 population
0.2 0.4 0.6
Candidiasis
Aspergillosis
0.0
1981 1986 1991 1996
McNeil et al, Clin Infect Dis 2001;33:641

10. Invasive pulmonary aspergillosis
IPA Normal lung
IPA occurs in ~7%
of acute leukaemia
patients, 10-15%
allogeneic BMT
patients
www.aspergillus.man.ac.uk

11. Unequivocal ‘Halo sign’ surrounding a nodule
Halo sign
Herbrecht, Denning et al, NEJM 2002;347:408-15.

12. 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

13. 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?
Gillies & Campbell, www.aspergillus.man.ac.uk

14. How does Aspergillus fumigatus cause
thrombosis (clotting of vessels) and
also bleeding?
Interaction of
conidia and
endothelial cell Internalisation of
projections conidia (and hyphae)
by endothelial cells
with injury apparent
at 4 hours
Filler et al, Blood 2004;103:2134; Paris et al, Infect Immun 1997;65:1510.

15. 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
www.aspergillus.man.ac.uk

16. Early diagnosis of invasive aspergillosis
is important
Treatment started <10d >11d
Mortality 40% 90%
Von Eiff et al, Respiration 1995;62:241-7.

17. 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.

18. 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

19. Outcome from invasive aspergillosis –
amphotericin B therapy
Survival Functions by Site of Infection
1.0
.9
.8
Sinusitis (n =17)
.7
.6
Multi-site (n =11)
.5
Aspe rgilloma (n =10)
.4
.3
.2 Pu lmonary (n =83)
.1
CNS o r Dissemin ated (n =35)
0.0
0 30 60 90 120 150 180 210 240 270 300 330 360
Days
Lin et al, Clin Infect Dis 2001;32:358

20. Sub-acute invasive aspergillosis in AIDS
www.aspergillus.man.ac.uk

21. 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
www.aspergillus.man.ac.uk

22. 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.

23. Chronic necrotising pulmonary aspergillosis
Right upper lobe showing circular
Right lobe shows huge cavity
shadow partly filled by a mass. PT MS
containing some debris, with
1996
+ve aspergillus precipitins.Pt
MS 1999
Right upper lobe. Patient has Same lobe shows expansion of
diabetes and pulmonary the shadow, still partially filled
mycobacterium avium- shows small with a mass. Pt MS 1998
cavitary lesion PT MS 1995.
Denning, Clin Microbiol Infect 2001;7(Suppl 2):25-31.

24. CLASSIFICATION OF ASPERGILLOSIS
Invasive aspergillosis
• Acute (<1 month course)
Airways/nasal • Subacute/chronic necrotising (1-3 months)
exposure to
airborne Chronic aspergillosis (>3 months)
Aspergillus
• Chronic cavitary pulmonary
• Aspergilloma of lung
• Chronic fibrosing pulmonary
• Chronic invasive sinusitis
Persistence • Maxillary (sinus) aspergilloma
without disease
- colonisation of
the airways or Allergic
nose/sinuses • Allergic bronchopulmonary (ABPA)
• Extrinsic allergic (broncho)alveolitis (EAA)
• Asthma with fungal sensitisation
• Allergic Aspergillus sinusitis (eosinophilic
fungal rhinosinusitis)

25. Aspergillus and airways
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)
Langley, ATS 2004

26. Aspergillus tracheobronchitis
Autopsy drawing of a
‘normal’ 3 year old
who died over 10 days
Wheaton, Path Trans 1890; 41:34-37

27. Aspergillus tracheobronchitis
Review of 58 patients in literature for normal and
immuno compromised patients - risk factors
%
None (ie normal) 25
Heart / Lung transplant 18
Solid tumour 15
BMT 13
Leukaemia 13
HIV/AIDS 8
Other 8
Kemper et al, Clin Infect Dis 1993; 17: 344

28. Aspergilloma
Fungus ball
Patient RT
December 2002

29. 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

30. 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

31. 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

32. Chronic cavitary pulmonary aspergillosis
(CCPA)
Patient RW
Patient RW September 1992
December 1991 Relapse in normal lung
Pre surgical resection
www.aspergillus.man.ac.uk

33. Chronic cavitary pulmonary aspergillosis
Patient RW
July 1993
www.aspergillus.man.ac.uk

34. Chronic Cavitary Pulmonary Aspergillosis
Patient JA
Jan 2001

35. Chronic Cavitary Pulmonary Aspergillosis
Patient JA
Feb 2002

36. Chronic Cavitary Pulmonary Aspergillosis
Patient JA
April 2003

37. Chronic Cavitary Pulmonary Aspergillosis
Patient JA
July 2003

38. Chronic cavitary pulmonary aspergillosis
Patient JP
June 1999
Denning DW et al, Clin Infect Dis 2003; 37:S265

39. Chronic Cavitary Pulmonary Aspergillosis, with
aspergilloma
Patient JP
July 2001
Denning DW et al, Clin Infect Dis 2003; 37:S265

40. Chronic Fibrosing Pulmonary Aspergillosis
Patient JP
April 2002
Denning DW et al, Clin Infect Dis 2003; 37:S265

41. Mannose Binding Lectin (MBL)- a key part
of the innate immune system
Di b
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aii s
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Crosdale et al J Infect Dis 2001;184:653

42. Mannose Binding Protein
Mutations
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
Eisen & Minchinton Clin Infect Dis 2003;37:1496

43. 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.

44. CLASSIFICATION OF ASPERGILLOSIS
Invasive aspergillosis
• Acute (<1 month course)
Airways/nasal • Subacute/chronic necrotising (1-3 months)
exposure to
airborne Chronic aspergillosis (>3 months)
Aspergillus
• Chronic cavitary pulmonary
• Aspergilloma of lung
• Chronic fibrosing pulmonary
• Chronic invasive sinusitis
Persistence • Maxillary (sinus) aspergilloma
without disease
- colonisation of
the airways or Allergic
nose/sinuses • Allergic bronchopulmonary (ABPA)
• Extrinsic allergic (broncho)alveolitis (EAA)
• Asthma with fungal sensitisation
• Allergic Aspergillus sinusitis (eosinophilic
fungal rhinosinusitis)

45. ALLERGIC BRONCHOPULMONARY
ASPERGILLOSIS – Key diagnostic criteria
ABPA possible
• Asthma
ABPA possible
• Blood eosinophilia (>1,000 / cu mm)
ABPA probable
• History of pulmonary infiltrates
ABPA almost certain
• Central bronchiectasis
• Precipitins against A. fumigatus positive If 3 tests +ve,
• Aspergillus IgE antibody >2x asthma control then ABPA very
• Aspergillus IgG antibody >2x asthma control likely,
If all 4 +ve the
• Total serum IgE concentration, >1000 iu/mL diagnosis
established
Rickett et al. Arch Intern Med 1983; 143: 1553; Patterson, Chest 2000;118:7

46. ABPA
After bronchoscopy
Before bronchoscopy
www.aspergillus.man.ac.uk

47. ABPA mucous plugging
www.aspergillus.man.ac.uk

48. ABPA - CT showing central bronchiectasis
www.aspergillus.man.ac.uk

49. 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.

50. 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.

51. 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

52. 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

53. A link between Aspergillus and asthma?

54. Fungal-associated asthma – evidence
Severe asthma linked
with fungal
sensitisation
Frequency of fungal
sensitisation
ABPA Fungal-associated
asthma
Treatment of ABPA High spore counts and
and pilot data asthmatic attacks

55. Spore counts and asthma attacks and
admission to hospital
All 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.

56. Fungus at home
Environmental 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.

57. Mild asthma – 564 (50%)
Moderate asthma – 333 (29%)
Severe asthma and moulds
Severe asthma – 235 (21%) – linked with
fungus skin test positivity
Zureik et al, Br Med J 2002;325:411

58. Asthma severity, house dust mites, cats
and moulds
Allergen No asthma Mild asthma Moderate Severe
n= 111 FEV1 >75% asthma FEV1 asthma FEV1
<90% >60% <75% >60%
n= 67 n= 42 n= 42
House dust 61% 71% 45% 77%
mite
Cats* 49% 51% 38% 35%
Moulds# 17% 19% 36% 31%
* P = 0.05
# p = 0.01
Langley, ATS 2004