Abstract
Background
Aspergillus fumigatus is the species section Fumigati most frequently isolated from the respiratory tract of cystic fibrosis (CF) patients. Recent studies suggest that mutations in the Cyp51 gene, particularly TR34/L98H, are responsible for azole resistance.
Objectives and Methods
The focus of this study was on section Fumigati isolates isolated from the respiratory tract samples of CF patients. More specifically, the goal was to detect A. fumigatus isolates, test their antifungal susceptibility to itraconazole, voriconazole and posaconazole, and finally determine the presence of TR34/L98H and other mutations in the isolates Cyp51A gene.
Results and Conclusions
A set of 31 isolates of Aspergillus section Fumigati were obtained from the sputum samples of 6 CF patients and subsequently identified to species level by microsatellite genotyping. All isolates were determined as A. fumigatus and involved 14 different genotypes. The minimal inhibitory concentrations to the three azoles were determined by the E-test method, and the Cyp51A gene was sequenced. One of the genotypes was found to be resistant to all azoles but no mutations were detected in the Cyp51A gene, especially the TR34/L98H mutation. Therefore, mutations in genes other than Cyp51A or other distinct mechanisms may be responsible for this reported multiazole resistance found in a Turkish CF patient.
Similar content being viewed by others
References
Müller FM, Seidler M. Characteristics of pathogenic fungi and antifungal therapy in cystic fibrosis. Expert Rev Anti Infect Ther. 2010;8:957–64.
Bauernfeind A, Bertele RM, Harms K. Qualitative and quantitative microbiological analysis of sputa of 102 patients with cystic fibrosis. Infection. 1987;15:270–7.
Blyth CC, Harun A, Middleton PG. Detection of occult Scedosporium species in respiratory tract specimens from patients with cystic fibrosis by use of selective media. J Clin Microbiol. 2010;48:314–6.
Speirs JJ, van der Ent CK, Beekman JM. Effects of Aspergillus fumigatus colonization on lung function in cystic fibrosis. Curr Opin Pulm Med. 2012;18:632–8.
Alcazar-Fuoli L, Mellado E, Alastruey-Izquierdo A, et al. Aspergillus section Fumigati: antifungal susceptibility patterns and sequence-based identification. Antimicrob Agents Chemother. 2008;52(4):1244–51.
Yaguchi T, Horie Y, Tanaka R, et al. Molecular phylogenetics of multiple genes on Aspergillus section Fumigati isolated from clinical specimens in Japan. J Med Mycol. 2007;48:37–46.
Ullmann AJ, Aguado JM, Arikan-Akdagli S, et al. Diagnosis and management of Aspergillus diseases: executive summary of the 2017 ESCMID-ECMM-ERS guideline. Clin Microbiol Infect. 2018;24:e1–38.
Balajee SA, Gribskov J, Brandt M, et al. Mistaken identity: Neosartorya pseudofisheri and its anamorph masquerading as Aspergillus fumigatus. J Clin Microbiol. 2005;43:5996–9.
Khare R, Gupta S, Arif S, et al. Misidentification of Neosartorya pseudofischeri as Aspergillus fumigatus in a lung transplant patient. J Clin Microbiol. 2004;52:2722–5.
Denning DW, Perlin DS. Azole resistance in Aspergillus: a growing public health menace. Future Microbiol. 2011;6(11):1229–32.
Howard SJ, Cerar D, Anderson MJ, et al. Frequency and evolution of Azole resistance in Aspergillus fumigatus associated with treatment failure. Emerg Infect Dis. 2009;15(7):1068–76.
Morio F, Aubin GG, Danner-Boucher I, et al. High prevalence of triazole resistance in Aspergillus fumigatus, especially mediated by TR/L98H, in a French cohort of patients with cystic fibrosis. J Antimicrob Chemother. 2012;67:1870–3.
Snelders E, van der Lee HA, Kuijpers J, et al. Emergence of azole resistance in Aspergillus fumigatus and spread of a single resistance mechanism. PLoS Med. 2008;5(11):e219.
Amorim A, Guedes-Vaz L, Araujo R. Susceptibility to five antifungals of Aspergillus fumigatus strains isolated from chronically colonised cystic fibrosis patients receiving azole therapy. Int J Antimicrob Agents. 2010;35:396–9.
Terpstra PD, van WEstreenen MJ, Croughs P, et al. Filamentous fungi in the Netherlands among CF patients. Trends in medical mycology, 5th ed. 2011.
Burgel PR, Baixench MT, Amsellem M, et al. High prevalence of azole-resistant Aspergillus fumigatus in adults with cystic fibrosis exposed to itraconazole. Antimicrob Agents Chemother. 2012;56(2):869–74.
Hamprecht A, Morio F, Bader O, et al. Azole resistance in Aspergillus fumigatus in patients with cystic fibrosis: a matter of concern? Mycopathologia. 2018;183:151–60.
Seufert R, Sedlacek L, Kahl B, et al. Prevalence and characterization of azole-resistant Aspergillus fumigatus in patients with cystic fibrosis: a prospective multicentre study in Germany. J Antimicrob Chemother. https://doi.org/10.1093/jac/dky147.
Ozmerdiven GE, Ak S, Ener B, et al. First determination of azole resistance in Aspergillus fumigatus strains carrying the TR34/L98H mutations in Turkey. J Infect Chemoter. 2015;21:581–6.
Larone DH. Medically important fungi: a guide to identification. 5th ed. Washington, DC: ASM Press; 2011.
De Hoog GS, Guarro J, Gene J. Atlas of clinical fungi. 2nd ed. Washington, DC: ASM Press; 2001.
Aspergillus & aspergillosis website. Accessed January 2018. http://www.aspergillus.org.uk/content/dna-extraction-%E2%80%93-miniprep-spores-pcr.
Araujo R, Pina-Vaz C, Rodrigues AG, et al. Simple and highly discriminatory microsatellite-based multiplex PCR for Aspergillus fumigatus strain typing. Clin Microbiol Infect. 2009;15:260–6.
Araujo R, Gungor O, Amorim A. Single-tube PCR coupled with mini-sequencing assay for the detection of cyp51A and cyp51B polymorphisms in Aspergillus fumigatus. Future Microbiol. 2015;10(11):1797–804.
Clinical and Laboratory Standards Institute (CLSI). Reference method for broth dilution antifungal susceptibility testing of filamentous fungi; approved standard. 2nd ed. Document M38-A2 Wayne, PA: CLSI; 2008.
Mortensen KL, Jensen RH, Johansen HK, et al. Aspergillus species and other molds in respiratory samples from patients with cystic fibrosis: a laboratory-based study with focus on Aspergillus fumigatus azole resistance. J Clin Microbiol. 2011;49:2243–51.
Gungor O, Tamay Z, Guler N, et al. Frequency of fungi in respiratory samples from Turkish cystic fibrosis patients. Mycoses. 2013;56:123–9.
Fischer J, van Koningsbruggen-Rietschel S, Rietschel E, et al. Prevalence and molecular characterization of azole resistance in Aspergillus spp. isolates from German cystic fibrosis patients. J Antimicrob Chemother. 2014;69:1533–6.
Pasquoletto AC. Aspergillosis: from diagnosis to prevention. Berlin: Springer; 2010.
Symoens F, Haase G, Pihet M, et al. Unusual Aspergillus species in patients with cystic fibrosis. Med Mycol. 2010;48(Suppl 1):10–6.
Lestrade PP, van der Velden WJFM, Bouwman F, et al. Epidemiology of invasive aspergillosis and triazole-resistant Aspergillus fumigatus in patients with haematological malignancies: a single-centre retrospective cohort study. J Antimicrob Chemother. 2018;73(5):1389–94.
De Valk HA, Klaassen CHW, Yntema JB, et al. Molecular typing and colonization patterns of Aspergillus fumigatus in patients with cystic fibrosis. J Cyst Fibros. 2009;8:110–4.
Vanhee LME, Symoens F, Bouchara JP, et al. High-resolution genotyping of Aspergillus fumigatus isolates recovered from chronically colonized patients with cystic fibrosis. Eur J Clin Microbiol Infect Dis. 2008;27:1005–7.
Chazalet V, Debeaupuis JP, Sarfati J, et al. Molecular typing of environmental and patient isolates of Aspergillus fumigatus from various hospital settings. J Clin Microbiol. 1998;36:1494–500.
Araujo R, Amorim A, Gusmão L. Genetic diversity of Aspergillus fumigatus in indoor hospital environments. Med Mycol. 2010;48:832–8.
Araujo R, Amorim A, Gusmão L. Microbial forensics: Do Aspergillus fumigatus strains present local or regional differentiation? Forensic Sci Int Genet Suppl Series. 2009;2:297–9.
Prigitano A, Esposto MC, Biffi A, et al. Triazole resistance in Aspergillus fumigatus isolates from patients with cystic fibrosis in Italy. J Cyst Fibros. 2017;16(1):64–9.
Rath PM, Ratjen F, Ansorg R. Genetic diversity among isolates of Aspergillus fumigatus in patients with cystic fibrosis. Zentralbl Bakteriol. 1997;285(3):450–5.
Rivero-Menendez O, Alastruey-Izquierdo A, Mellado E, et al. Triazole resistance in Aspergillus spp.: A worldwide problem? J Fungi (Basel). 2016;2(3):21.
Stensvold CR, Jorgensen LN, Arendrup MC. Azole-resistant invasive aspergillosis: relationship to agriculture. Curr Fungal Infect Rep. 2012;6:178–91.
Bader O, Weig M, Reichard U, et al. Cyp51A-based mechanisms of Aspergillus fumigatus azole drug resistance present in clinical samples from Germany. Antimicrob Agents Chemother. 2013;57:3513–7.
Garczewska B, Jarzynka S, Kus J, et al. Fungal infection of cystic fibrosis-single center experience. Pneumonol Alergol Pol. 2016;84:151–9.
Guegan H, Chevrier S, Belleguic C, et al. Performance of molecular approaches for Aspergillus detection and azole resistance surveillance in cystic fibrosis. Front Microbiol. 2018;27(9):531.
Arendrup MC, Mavridou E, Mortensen KL, et al. Development of azole resistance in Aspergillus fumigatus during azole therapy associated with change in virulence. PLoS ONE. 2010;5:e10080. https://doi.org/10.1371/journal.pone.0050034.
Camps SM, Dutilh BE, Arendrup MC, et al. Discovery of a hapE mutation that causes azole resistance in Aspergillus fumigatus through whole genome sequencing and sexual crossing. PLoS ONE. 2012;7:e50034. https://doi.org/10.1371/journal.pone.0050034.
Albarrag AM, Anderson MJ, Howard SJ, et al. Interrogation of related clinical pan-azole-resistant Aspergillus fumigatus strains: G138C, Y431C, and G434C single nucleotide polymorphisms in cyp51A, upregulation of cyp51A, and integration and activation of transposon Atf1 in the cyp51A promoter. Antimicrob Agents Chemother. 2011;55:5113–21.
Slaven JW, Anderson MJ, Sanglard D, et al. Increased expression of a novel Aspergillus fumigatus ABC transporter gene, atrF, in the presence of itraconazole in an itraconazole resistant clinical isolate. Fungal Genet Biol. 2002;36:199–206.
Bowyer P, Mosquera J, Anderson M, et al. Identification of novel genes conferring altered azole susceptibility in Aspergillus fumigatus. FEMS Microbiol Lett. 2012;332:10–9.
Acknowledgements
This work was supported by the Research Fund of Istanbul University, Project No. 47641 and Federation of European Microbiological Societies (FEMS) Research Fellowship 2015-0048. i3S was partially financed by FEDER—Fundo Europeu de Desenvolvimento Regional funds through the COMPETE 2020—Operacional Programme for Competitiveness and Internationalisation (POCI), Portugal 2020, and by Portuguese funds through FCT—Fundação para a Ciência e a Tecnologia/Ministério da Ciência, Tecnologia e Inovação in the framework of the project “Institute for Research and Innovation in Health Sciences” (POCI-01-0145-FEDER-007274). As control isolates, itraconazole sensitive (V089-25) and itraconazole resistant (V089-27) isolates obtained from Paul E. Verweij (Radboud University Nijmegen Medical Center) were used.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
This article does not contain any studies with human participants or animals performed by any of the authors. This study received approval from Istanbul University, Istanbul Medical Faculty, Clinical Research Ethics Committee to be conducted (15.08.2014/1251).
Informed Consent
For this type of study formal consent is not required.
Additional information
Handling editor: Patrick CY Woo.
Özge Güngör and Zayre Erturan: Members of the ECMM/ISHAM Working group on Fungal Respiratory Infections in Cystic Fibrosis (Fri-CF).
Rights and permissions
About this article
Cite this article
Güngör, Ö., Sampaio-Maia, B., Amorim, A. et al. Determination of Azole Resistance and TR34/L98H Mutations in Isolates of Aspergillus Section Fumigati from Turkish Cystic Fibrosis Patients. Mycopathologia 183, 913–920 (2018). https://doi.org/10.1007/s11046-018-0297-y
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11046-018-0297-y