No abstract

Aspergillus fumigatus (AF) is a ubiquitous mold and is the most common cause of invasive aspergillosis, an important source of morbidity and mortality in immunocompromised hosts. Using cytokine flow cytometry, we assessed the magnitude of functional CD4 ؉ and CD8 ؉ T-cell responses following stimulation with Aspergillus antigens. Relative to those seen with cytomegalovirus (CMV) or superantigen stimulation, responses to Aspergillus antigens were near background levels. Subsequently, we confirmed that gliotoxin, the most abundant mycotoxin produced by AF, was able to suppress functional T-cell responses following CMV or staphylococcal enterotoxin B (SEB) stimulation. Additional studies demonstrated that crude AF filtrates and purified gliotoxin inhibited antigen-presenting cell function and induced the preferential death of monocytes, leading to a marked decrease in the monocyte-lymphocyte ratio. Analysis of caspase-3 activation confirmed that gliotoxin preferentially induced apoptosis of monocytes; similar effects were observed in CD83 ؉ monocyte-derived dendritic cells. Importantly, the physiologic effects of gliotoxin in vitro were observed below concentrations recently observed in the serum of patients with invasive aspergillosis. These studies suggest that the production of gliotoxin by AF may constitute an important immunoevasive mechanism that is mediated by direct effects on antigenpresenting cells and both direct and indirect effects on T cells. IntroductionAspergillus fumigatus (AF) is the most common cause of invasive aspergillosis (IA) and a major source of infection-related mortality in immunocompromised patients, such as allogeneic stem cell transplant (SCT) recipients. 1,2 In these patients prophylactic antifungal therapy has been found to have little effect on disease incidence. 1,[3][4][5] Despite advances in early diagnosis and new antifungal agents, 3,6,7 IA remains a leading cause of death in this patient population, with an attributable mortality rate ranging from 30% to 80%. 8 AF is among the most ubiquitous of those fungi with airborne conidia (spores) and is commonly found in human domiciles. Pulmonary infection by AF, the predominant type of IA, is acquired through the inhalation of Aspergillus conidia, while the invasion stage of the disease is characterized by hyphal destruction of pulmonary tissue. 1 The mediocre efficacy of antifungals in the setting of profound immunosuppression contributes to the poor prognosis of this opportunistic infection. The development of effective strategies to improve AF-specific immune reconstitution should greatly influence the natural history of IA.Historically, there was a biphasic distribution of IA following bone marrow transplantation (BMT); IA was most common in the pre-engraftment period associated with neutropenia, with a second peak in incidence associated with acute and/or chronic graft-versushost disease (GVHD). 5 However, recent reports have indicated late-onset IA predominates after allogeneic SCT, often in concomitance with the occurrence o...

Epidemiologic investigation of invasive fungal diseases (IFDs) in allogeneic hematopoietic stem cell transplantation (allo-HSCT) may be useful to identify subpopulations who might benefit from targeted treatment strategies. The Gruppo Italiano Trapianto Midollo Osseo (GITMO) prospectively registered data on 1858 consecutive patients undergoing allo-HSCT between 2008 and 2010. Logistic regression analysis was performed to identify risk factors for proven/probable IFD (PP-IFD) during the early (days 0 to 40), late (days 41 to 100), and very late (days 101 to 365) phases after allo-HSCT and to evaluate the impact of PP-IFDs on 1-year overall survival. The cumulative incidence of PP-IFDs was 5.1% at 40 days, 6.7% at 100 days, and 8.8% at 12 months post-transplantation. Multivariate analysis identified the following variables as associated with PP-IFDs: transplant from an unrelated volunteer donor or cord blood, active acute leukemia at the time of transplantation, and an IFD before transplantation in the early phase; transplant from an unrelated volunteer donor or cord blood and grade II-IV acute graft-versus-host disease (GVHD) in the late phase; and grade II-IV acute GVHD and extensive chronic GVHD in the very late phase. The risk for PP-IFD was significantly higher when acute GVHD was followed by chronic GVHD and when acute GVHD occurred in patients undergoing transplantation with grafts from other than matched related donors. The presence of PP-IFD was an independent factor in long-term survival (hazard ratio, 2.90; 95% confidence interval, 2.32 to 3.62; P < .0001). Our findings indicate that tailored prevention strategies may be useful in subpopulations at differing levels of risk for PP-IFDs.

Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a multisystemic autosomal recessive disease due to primary thymidine phosphorylase (TP) deficiency. To restore TP activity, we performed reduced intensity allogeneic stem cell transplantations (alloSCTs) in two patients. In the first, alloSCT failed to engraft, but the second achieved mixed donor chimerism, which partially restored buffy coat TP activity and lowered plasma nucleosides. Thus, alloSCT can correct biochemical abnormalities in the blood of patients with MNGIE, but clinical efficacy remains unproven.Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an autosomal recessive disease caused by mutations in the ECGF1 gene encoding thymidine phosphorylase (TP). 1-3 The disease is characterized by ophthalmoplegia, gastrointestinal dysmotility, cachexia, peripheral neuropathy, and leukoencephalopathy and typically causes death in early to mid-adulthood. 1,3,4 Laboratory studies reveal defects of the respiratory chain and mitochondrial DNA (mtDNA) alterations. 1,3,4