H. S. Randhawa

Isolation of multiple-triazole-resistant Aspergillus fumigatus strains carrying the TR/L98H mutations in the cyp51A gene in India

OBJECTIVES Azole resistance in Aspergillus fumigatus isolates impacts on the management of aspergillosis since azoles are primary agents used for prophylaxis and therapy. We report the emergence of resistance to triazoles in two A. fumigatus isolates from patients in Delhi, India. METHODS One hundred and three A. fumigatus isolates, collected from 85 patients suspected of bronchopulmonary aspergillosis during 2005-10, were investigated for susceptibility to itraconazole, voriconazole, posaconazole and isavuconazole. We undertook a mixed-format real-time PCR assay for the detection of mutations leading to triazole resistance in A. fumigatus. The resistant isolates were compared with 25 Dutch TR/L98H-positive isolates by microsatellite analysis. RESULTS Of the 103 A. fumigatus isolates tested, only 2 had high MIC values of itraconazole (>16 mg/L), voriconazole (2 mg/L), posaconazole (2 mg/L) and isavuconazole (8 mg/L). The resistant A. fumigatus isolates exhibited the TR/L98H genotype and showed identical patterns by microsatellite typing, but were different from 25 Dutch TR/L98H isolates. CONCLUSIONS We report for the first time from India the occurrence of TR/L98H mutations in the cyp51A gene (responsible for reduced azole susceptibility) in two A. fumigatus isolates from patients with chronic respiratory disease who had not previously been exposed to azoles. The presence of TR/L98H is consistent with a route of resistance development through exposure to azole compounds in the environment. Given the emergence of azole resistance in environmental strains, continued surveillance of resistance in clinical A. fumigatus strains is desirable for successful therapy of aspergillosis.

New Clonal Strain of Candida auris, Delhi, India

A new clonal strain of Candida auris is an emerging etiologic agent of fungemia in Delhi, India. In 12 patients in 2 hospitals, it was resistant to fluconazole and genotypically distinct from isolates from South Korea and Japan, as revealed by M13 and amplified fragment length polymorphism typing.

Long-distance dispersal and recombination in environmental populations of Cryptococcus neoformans var. grubii from India

The basidiomycete yeast Cryptococcus neoformans is a cause of significant morbidity and mortality in immunocompromised hosts throughout the world. The sporadic nature of the infection and the limited empirical evidence for direct human-to-human transmission have led to the belief that infections in humans are predominantly caused by the inhalation of basidiospores from environmental sources. Therefore, analysing the structure of environmental populations of C. neoformans can significantly increase our understanding of its ecology, evolution and epidemiology. Decaying wood is a rich source of organic and inorganic compounds and is known to be a suitable ecological niche for many micro-organisms, including C. neoformans. However, relatively little is known about the population structure of C. neoformans sampled from decaying wood. In this study, we analysed samples of C. neoformans var. grubii colonizing decaying wood in tree hollows of nine tree species in five geographical locations (Delhi, Bulandshahar, Hathras, Amritsar and Amrouli) in north-western India. Multilocus sequence typing was conducted using five gene fragments for each of 78 isolates. All isolates belonged to mating type alpha. Population-genetic analyses identified no evidence for significant differentiation among populations belonging to either different geographical areas or different host tree species. Interestingly, despite the lack of mating type a strains in our survey, we found unambiguous evidence for recombination in our population analyses. Our results are consistent with the hypothesis of long-distance dispersal and recombination in environmental populations of this species in India.

Allergic bronchopulmonary mycosis due to fungi other than Aspergillus: a global overview

Abstract Allergic bronchopulmonary mycosis (ABPM) is a hypersensitivity-mediated disease of worldwide distribution. We reviewed 143 reported global cases of ABPM due to fungi other than aspergilli. The commonest etiologic agent was Candida albicans, reported in 60% of the cases, followed by Bipolaris species (13%), Schizophyllum commune (11%), Curvularia species (8%), Pseudallescheria boydii species complex (3%) and rarely, Alternaria alternata, Fusarium vasinfectum, Penicillium species, Cladosporium cladosporioides, Stemphylium languinosum, Rhizopus oryzae, C. glabrata, Saccharomyces cerevisiae and Trichosporon beigelii. India accounted for about 47% of the globally reported cases of ABPM, attributed predominantly to C. albicans, followed by Japan (16%) where S. commune predominates, and the remaining one-third from the USA, Australia and Europe. Notably, bronchial asthma was present in only 32% of ABPM cases whereas its association with development of allergic bronchopulmonary aspergillosis (ABPA) is known to be much more frequent. The cases reviewed herein revealed a median IgE value threefold higher than that of ABPA, suggesting that the etiologic agents of ABPM incite a stronger immunological response than that by aspergilli in ABPA. ABPM is currently underdiagnosed, warranting comprehensive basic and clinical studies in order to elucidate its epidemiology and to devise a more effective therapy.

A survey of soil inhabiting dermatophytes and related keratinophilic fungi of India

The first comprehensive survey of soil-inhabiting dermatophytes and related keratinophilic fungi of India is reported. Of the 485 soil samples examined by hair baiting 45·9% yielded keratinophilic fungi. Among the species isolated were Keratinophyton terreum (32·3%), Microsporum gypseum (11·7%) and one of its cleistocarpic states, Nannizzia incurvata, Ctenomyces serratus (2·4%), Trichophyton evolceanui (2·0%), Keratinomyces ajelloi (1·2%), Chrysosporium tropicum (0·6%) and Microsporum cookei (0·2%). Mixed growth was noted in 14% of the soil samples. In general keratinophilic fungi were met with in a great variety of soil sources. However, soils from shady and moist sites rich in organic or keratin matter or both appeared to be more suitable than others. Saline soils, barren roadside soils, dry river sand and beach sand proved to be poor sources of keratinophilic fungi.

Decaying wood in tree trunk hollows as a natural substrate for Cryptococcus neoformans and other yeast-like fungi of clinical interest

The occurrence of Cryptococcus neoformans var. neoformans and other yeast-like fungi of clinical interest in decaying wood inside tree trunk hollows, bark and other plant materials is reported. The var. neoformans was isolated from 3 of 45 (6.6%) wood and one of 390 Eucalyptus bark samples. Two of the positive wood samples came from a tree trunk hollow of Butea monosperma (Family: Papilionaceae) growing in Roshan Ara Garden, Old Delhi whereas the third was from a trunk hollow of Tamarindus indica (Family: Papilionaceae) growing outside of Talkatora Garden, New Delhi. The solitary positive Eucalyptus bark sample originated from Amritsar. The isolations of var. neoformans from decaying wood inside trunk hollows of B. monosperma and T. indica constitute the first record of the natural occurrence of this pathogen in association with these trees. The observation reinforces the recent evidence for decaying wood inside trunk hollows of some trees to be a new natural habitat of the variety neoformans. Besides, in consonance with their essentially saprobic character, a number of other yeast-like fungi were sporadically isolated. This includes, Cryptoccus laurentiiCryptococcus albidusCandida lusitaniaeC. guilliermondiiC. kruseiC. tropicalisC. zeylanoidesTrichosporon cutaneumRhodotorula mucilaginosaR. glutinisGeotrichum capitatumG. klebahnii and Sporobolomyces salmonicolor.Cryptococcus neoformans var. gattii was not found in any of the 702 samples of plant materials, including the bark and detritus of Eucalyptus camaldulensis and E. tereticornis trees. A more extensive environmental survey, covering divergent climatic regions, is warranted to identify the natural reservoirs of var. gattii in India.

Decayed wood of Syzygium cumini and Ficus religiosa living trees in Delhi/New Delhi metropolitan area as natural habitat of Cryptococcus neoformans.

The isolation is reported of Cryptococcus neoformans var. gattii and C. n. var. neoformans from decayed wood inside trunk hollows of Syzygium cumini and of C. n. var. neoformans from Ficus religiosa trees in the Delhi/New Delhi metropolitan area. Fourteen of sixty-six (21%) S. cumini trees investigated proved to be positive, seven for each variety. The two varieties never co-occurred in the same hollow. C. n. var. neoformans was also isolated from three of seventeen Ficus religiosa-trees. Two of these isolates originated from decayed wood and one from bark. The C. n. var. gattii and C. n. var. neoformans isolates belonged to serotype B and serotype A, respectively. The data strongly supported colonization of S. cumini by both varieties and of F. religiosa trees by C. n. var. neoformans. Evidence of this was found by repeated isolations. For example, in 36/44 (82%) samples for C. n. var. gattii and 22/27 (81%) samples for C. n. var. neoformans, and by a high population density in the tested wood debris (maximally 6 x 10(5) colony-forming units per gram [c.f.u./g] for C. n. var. gattii and 8 x 10(4) c.f.u./g for C. n. var. neoformans). No eucalypt trees were seen near the positive S. cumini and F. religiosa trees. The densities of C. neoformans in these trees exceeded those found previously in Eucalyptus camaldulensis and in other tree species more rarely reported to be sources of C. neoformans in India. S. cumini and F. religiosa appear not to have been reported to date as sources for either C. n. var. gattii or C n. var. neoformans. Our results add to the recently emerging evidence that the natural habitat of C. n. var. gattii and C. n. var. neoformans is not specific to woody or other debris of particular tree species, but instead is more generalized.

Schizophyllum commune as an emerging fungal pathogen: a review and report of two cases.

We report Schizophyllum commune as the aetiological agent of one case each of allergic broncho‐pulmonary mycosis (ABPM) and pulmonary fungal ball, and present a literature review. The fungus was characterised by clamp connections, hyphal spicules, and formation of basidiocarps with basidiospores. The phenotypic identification was confirmed by sequencing of the ITS region. To‐date, ABPM and pulmonary fungal ball to S. commune have been reported exclusively from Japan and North America respectively. Of the 71 globally reported cases due to S. commune, 45 (63%) were bronchopulmonary, 22 (31%) sinusitis and 4 extrapulmonary. Taken together, cases of bronchopulmonary disease and sinusitis numbered 67 (94%), indicating the respiratory tract as the primary target of disease. Concerning the country‐wise distribution, Japan topped the list with 33 cases (46%), followed by Iran – 7 cases (10%), U.S.A. – 6 cases (9%), and a lower prevalence of 1.4–6% for the remaining 12 countries. The preponderance of the disease in Japan may be attributed to its greater awareness vis‐à‐vis that in other countries rather than to any geographical/climatic factors. We believe that the burden of S. commune‐incited disease is currently underestimated, warranting comprehensive prospective studies to determine its prevalence.

In vitro antifungal susceptibility profiles and genotypes of 308 clinical and environmental isolates of Cryptococcus neoformans var. grubii and Cryptococcus gattii serotype B from north-western India

Cryptococcus neoformans and Cryptococcus gattii are aetiological agents of cryptococcosis, a major opportunistic systemic mycosis of increasing global importance. This study reports the antifungal susceptibility profiles of clinical and environmental isolates of C. neoformans var. grubii, genotype VNI/AFLP1 (n = 246), and C. gattii serotype B, genotype VGI/AFLP4 (n = 62), originating from patients and environmental sources in north-western India. All of the C. neoformans var. grubii and C. gattii isolates were mating type α. Using the broth microdilution method, both species were found to be susceptible to the antifungals tested except for two clinical C. neoformans var. grubii isolates that were resistant to 5-flucytosine (MIC >64 µg ml⁻¹). Data on the geometric mean of MICs revealed that C. gattii was significantly less susceptible than C. neoformans var. grubii to fluconazole, itraconazole and voriconazole (P<0.0001). In addition, the MIC₉₀ of C. gattii was twofold higher than that of C. neoformans var. grubii for fluconazole, itraconazole and voriconazole. However, no statistically significant difference in susceptibility of the two Cryptococcus species was observed against amphotericin B and 5-flucytosine. Furthermore, the environmental C. neoformans var. grubii isolates were significantly less susceptible to fluconazole, itraconazole and 5-flucytosine (P<0.0001) than the clinical isolates. A continued surveillance of antifungal susceptibility of clinical and environmental strains of C. neoformans and C. gattii is desirable to monitor the emergence of any resistant strains in order to ensure more successful therapy of cryptococcosis.

The expanding host tree species spectrum of Cryptococcus gattii and Cryptococcus neoformans and their isolations from surrounding soil in India.

This study reports the widespread prevalence of Cryptococcus neoformans and Cryptococcus gattii in decayed wood inside trunk hollows of 14 species representing 12 families of trees and from soil near the base of various host trees from Delhi and several places in the Indian states of Uttar Pradesh, Haryana, Tamil Nadu and Chandigarh Union Territory. Of the 311 trees from which samples were obtained, 64 (20.5%) were found to contain strains of the C. neoformans species complex. The number of trees positive for C. neoformans var grubii (serotypeA) was 51 (16.3%), for C. gattii (serotype B) 24 (7.7%) and for both C. neoformans and C. gattii 11 (3.5%). The overall prevalence of C. neoformans species complex in decayed wood samples was 19.9% (111/556). There was no obvious correlation between the prevalence of these two yeast species and the species of host trees. The data on prevalence of C. gattii (24%) and C. neoformans (26%) in soil around the base of some host trees indicated that soil is another important ecologic niche for these two Cryptococcus species in India. Among our sampled tree species, eight and six were recorded for the first time as hosts for C. neoformans var grubii and C. gattii, respectively. A longitudinal surveillance of 8 host tree species over 0.7 to 2.5 years indicated long term colonization of Polyalthia longifolia, Mimusops elengi and Manilkara hexandra trees by C. gattii and/or C. neoformans. The mating type was determined for 153 of the isolates, including 98 strains of serotype A and 55 of serotype B and all proved to be mating type alpha (MAT alpha). Our observations document the rapidly expanding spectrum of host tree species for C. gattii and C. neoformans and indicate that decayed woods of many tree species are potentially suitable ecological niches for both pathogens.