This document summarizes research on primary immunodeficiencies that cause increased susceptibility to fungal infections. It describes how innate and adaptive immunity normally defend against fungi through pattern recognition receptors, cytokines, and T cell responses. Deficiencies in the CARD9 protein, STAT1 and STAT3 genes, and the IL-17 and IL-22 pathways are highlighted as causing chronic mucocutaneous candidiasis by impairing Th17 responses. Autoantibodies against IL-17 and IL-22 in autoimmune polyendocrine syndrome type I can also phenocopy these genetic defects. Understanding these immunodeficiencies provides insight into antifungal immunity and opportunities for new therapies.

1. Unravelling Fungal Immunity
through Primary Immune
Deficiencies
Suda Sibunruang, M.D.

2. Picture from www.kids.nationalgeographic.com

3. Lilic D. Current Opinion in Microbiology 2012,15:420–6

4. Outline
• Introduction
• Immunity to fungi
- Innate immune response
- Adaptive immune response
• Primary immunodeficiencies with
susceptibility to fungal infections

5. Pfaller MA, Diekema DJ. Critical Reviews in Microbiology 2010;36:1–53
Emerging importance of fungal infections
Increase >200% in number of sepsis cases caused by fungal organisms
with mortality rate in invasive fungal infections of 30–70%

6. Pfaller MA, Diekema DJ. Critical Reviews in Microbiology 2010;36:1–53

7. Vinh DC. Lancet Infect Dis 2011;11:780-92
Medical mycology and fungal immunology

8. • Epidermis and epithelium act
as a physical barrier
reinforced by antimicrobial
peptides (defensins, cathelicidins,
S100 proteins)
• If this barrier is breached,
fungi are recognized and
processed by both innate and
adaptive immune system
Vinh DC. Lancet Infect Dis 2011;11:780-92
Lilic D. Current Opinion in Microbiology 2012,15:420–6

9. Innate immunity
• Recognize ‘pathogen associated molecular
patterns’ (PAMPs), initiating a rapid,
conserved response that activates
inflammatory cells
• Triggering signaling pathways, which result in
targeted cytokine production, recruitment
and polarization of relevant T, B and natural
killer (NK) lymphocyte
Lilic D. Current Opinion in Microbiology 2012,15:420–6

10. Abbas AK et al. Cellular and Molecular immunology. 2014 Eighth Edition
• Transmembrane PRRs,
Toll-like receptors (TLRs) and
C-type lectin receptors are both involved
in antifungal immunity
• Cytosolic receptors, such as
retinoic acid–inducible gene I
and nucleotide-binding oligomerization
domain (NOD) proteins, sense intracellular
bacteria and viruses

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Engelhardt KR et al. J Allergy Clin Immunol 2012;129:294–305
Structure of the fungal cell wall
Different components of cell wall are recognized
by different receptors
TLR 4
MINCLE

12. Romani L. Nat Rev Immunol 2004;4:1-23
These forms express different antigens
β glucan is exposed exclusively
at bud and birth scars of
blastoconidia and being
recognized by dectin 1
α mannans in both yeast and
hyphal forms are recognized
by dectin-2

13. Engelhardt KR et al. J Allergy Clin Immunol 2012;129:294–305
(spleen tyrosine
Kinase)
(caspase recruitment
domain–containing
protein 9)
(B-cell lymphoma/
leukemia 10)
(Mucosa-associated lymphoid
tissue lymphoma translocation
protein 1)
(NLR family,pyrin
domain containing 3
Inflammasome)

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15. Plato A. et al. Semin Immunopathol 2015;37:97–106

16. Engelhardt KR et al. J Allergy Clin Immunol 2012;129:294–305
Production of proinflammatory
cytokines and chemokines

17. Engelhardt KR et al. J Allergy Clin Immunol 2012;129:294–305
TH17-priming cytokines signal through STAT3->
Transcription factor retinoic acid–related
orphan receptor γt
Upregulation of
chemokine receptors

18. Puel A. et al. Curr Opin Allergy Clin Immunol 2012;12:616–22
Gain-of-function STAT1 mutations shift cellular response
toward TH17 cell–inhibiting cytokines

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Local cytokine milieu
from innate immune cells

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Neutrophils: the final killers
3 main mechanisms to kill microbes
• Phagocytosis
• Degranulation and activation of
oxidative burst
• Neutrophil extracellular traps
Thus, neutropenia (<1,500) is more severe and
predisposes to systemic fungal infection
Traps consist of a web of
DNA and histones and
contain granule-derived
proteins with
antimicrobial activity

24. Romani L. Nat Rev Immunol 2011;11:275-88

25. Primary immune
deficiencies with
susceptibility to fungal
infections

26. Primary immune deficiencies (PIDs)
• Conventional PIDs were defined by an overt
immunological phenotype resulting in a
broad susceptibility to a range of
microorganisms
• Non-conventional PIDs include selective
susceptibilities to weakly pathogenic and/or
opportunistic microorganisms (atypical
mycobacteria, herpes simplex, pneumococci)
as well as opportunistic fungi
Lilic D. Current Opinion in Microbiology 2012,15:420–6

27. Parvaneh N. et al. J Allergy Clin Immunol 2013;131:314-23
Ochs HD et al. Ann Allergy Asthma Immunol 2014;112:489-95
New genes associated with PIDs are discovered at increasing velocity
19 novel single-gene defects were described within 1 year
of the last IUIS report published in 2011

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34. Ferwerda B. et al. N Engl J Med 2009;361:1760-7
Human Dectin-1 Deficiency and
Mucocutaneous Fungal Infections
Dutch
Homozygous nonsense mutation (Y238X) in
DECTIN1 resulted in lost of capability to bind
β-glucan or C. albicans

35. Ferwerda B. et al. N Engl J Med 2009;361:1760-7
Both monocytes and macrophages
showed poor in vitro production of IL-6,
IL-17, and TNF-α on stimulation with β-glucan
Phagocytosis and killing
of C.albicans were normal

36. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

37. Glocker EO. et al. N Engl J Med 2009;361:1727-35
A Homozygous CARD9 Mutation in a Family
with Susceptibility to Fungal Infections
4 patients from a large consanguineous family from Iran
3 died from invasive candida infections of
brain in early childhood
• Recurrent oral candidiasis
• Vaginal candidiasis
• Angular cheilitis
• Tinea corporis
• Dermatophytosis

38. Glocker EO. et al. N Engl J Med 2009;361:1727-35
Q295X mutation and lack of CARD9 expression

39. Glocker EO. et al. N Engl J Med 2009;361:1727-35
Low numbers of IL-17–producing T cells

40. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

41. Marodi L. et al. J Allergy Clin Immunol 2012;130:1019-27
Submental staphylococcal abscess in a 7-month-old girl and
nail candidiasis in her mother from a family with AD-HIES
and R382W mutation in STAT3

42. Conti HR. et al. Mucosal Immunol 2011;4:448-55
Oral candidiasis is encouraged by reduced antifungal activity in saliva of STAT3-
deficient patients with reduced expression of antimicrobial effectors, such as
β-defensin 2 and histatins

43. Conti HR. et al. Mucosal Immunol 2011;4:448-55

44. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

45. Puel A. et al. Curr Opin Allergy Clin Immunol 2012;12:616–22
Gain-of-function STAT1 acts in 2 ways with regard to impaired generation of TH17 cells:
• cytokines that antagonize development of TH17 cells, such as IL-27, IFN- are increased
• cytokines that normally promote TH17 differentiation through activation of STAT3
are shifted toward STAT1
IFN- production has been reported as both normal and decreased.
Interestingly, they are not particularly susceptible to intracellular microorganisms that provoke a
Th1 protective immune response
accumulation of phosphorylated
STAT1 in nucleus
STAT1 gain-of-function mutations,
leading to an IPEX-like presentation

46. Plantinga TS. et al. Medical Mycology 2012;50:785–94
Varying symptoms, sometimes reminiscent of HIES,
but frequently have associated hypothyroidism and
oral/oesophageal squamous cell cancer

47. van de Veerdonk FL. et al. N Engl J Med 2011;365:54-61
STAT1 Mutations in Autosomal Dominant
Chronic Mucocutaneous Candidiasis
14 patients from 5 families of
Dutch and British decent
Patients’ PBMCs showed poor production of TH17 cytokines
(IL-17/IL-22, respectively) in response to C.albicans

48. van de Veerdonk FL. et al. N Engl J Med 2011;365:54-61
CMC, severe oropharyngeal chronic candidiasis, and severe dermatophytosis,
together with autoimmune phenomena, such as hypothyroidism and autoimmune
hepatitis. One patient also had squamous cell carcinoma

49. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

50. de Beaucoudrey L. et. al. Medicine (Baltimore) 2010; 89: 381–402
Revisiting Human IL-12Rβ1 Deficiency:
A Survey of 141 Patients From 30 Countries
23% of patients
had associated CMC

51. de Beaucoudrey L. et. al. J Exp Med 2008;205:1543-50
IL-12R1 deficiency impairs development
of IL-17 producing T cells
Interestingly, other
known mutations that
disrupt IFN- mediated
immunity resulting
in MSMD are not associated
with increased incidence
of CMC

52. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

53. Zepp J et. al. Trends in Immunology 2011;32:1-8

54. Eyerich K. et al. J Invest Dermatol 2008;128:2640-5
Patients with Chronic Mucocutaneous Candidiasis
Exhibit Reduced Production of Th17-Associated
Cytokines IL-17 and IL-22
In 2008, Eyerich et al. studied a group of patients with
isolated CMC in whom no other infectious or autoimmune
manifestations occurred and showed a smaller proportion of
IL-17–producing T cells and low levels of IL-17

55. Eyerich K. et al. J Invest Dermatol 2008;128:2640-5

56. Puel A. et al. Science 2011;332:65-8
Chronic mucocutaneous candidiasis in humans with inborn
errors of interleukin-17 immunity
2 genetic defects leading to CMC
• AD deficiency of IL-17F
• AR deficiency of the IL-17RA

57. Puel A. et al. Science 2011;332:65-8

58. Kisand K. and Peterson P. Curr Opin Pediatr 2013;25:715–21

59. Browne SK. Annu. Rev. Immunol. 2014;32:635–57

60. Plantinga TS. et al. Medical Mycology 2012;50:785–94
Ochs HD et al. Ann Allergy Asthma Immunol 2014;112: 489-95
autoimmune regulator
Phenocopies of PIDDs is a new category that was first presented in IUIS 2014 update.
This category includes conditions that resemble PIDDs and are not due to germline mutations.
A typical example would be autoantibodies against IL-17 or IL-22 in APECED,
which is similar to IL-17 pathway defects and leads to CMC

61. Kisand K. et. al. Eur J Immunol 2011;41:1517-27

62. Ng WF et. al. J Allergy Clin Immunol 2010;126:1006-15

63. Ng WF et. al. J Allergy Clin Immunol 2010;126:1006-15
Normal or even increased
IL-17 production

64. Ng WF et. al. J Allergy Clin Immunol 2010;126:1006-15

65. Puel A. J Exp Med 2010;207:291-7
Autoantibodies against IL-17A, IL-17F,
and IL-22 in patients with chronic
mucocutaneous candidiasis and autoimmune
polyendocrine syndrome type I
Plasma of 33 patients with APECED,
29/33 had CMC, and found neutralizing IgG
autoantibodies against IL-17A (67%), IL-17F (94%), and IL-22
(91%) but not against other cytokines, such as IL-1b, IL-6,
IL-23, and IL-26. All patients had autoantibodies against at least
1 of these cytokines. This also included patients without CMC

66. Autoantibodies to IL 17A, 17F, and 22
• Sometimes demonstrably preceding mycosis,
suggesting a causative role in, rather than a result
of, infection
• Moreover, autoantibodies to other cytokines
were not recorded, except for interferons α and ω
• Antibodies against IL 17 and 22 are not known in
other autoimmune disorders, suggesting that
association between these neutralizing
autoantibodies and CMC in APECED is specific
Vinh DC. Lancet Infect Dis 2011;11:780-92

67. Translating basic research
into clinical practices
• New antifungal drugs
• Immune therapies; PRR agonism or
antagonism
• Vaccines
• Functional genomics; risk assessment of
patients at highest risk of developing a
life- threatening infection
Romani L. Nat Rev Immunol 2011;11:275-88

68. Lilic D. Current Opinion in Microbiology 2012,15:420–6
Take home messages

69. Thank you for your attention