Airborne fungi infections Dr David W. Denning FRCP FRCPath Scientific Advisor to the Fungal Research...
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Transcript of Airborne fungi infections Dr David W. Denning FRCP FRCPath Scientific Advisor to the Fungal Research...
Airborne fungi infections
Dr David W. Denning FRCP FRCPath
Scientific Advisor to the Fungal Research Trust
Clinician, Wythenshawe Hospital
Head, Antifungal Testing Laboratory
Faculty, University of Manchester
WWW.aspergillus.man.ac.uk
Airborne fungal infections
Fungi are all around us in the air and yeasts (ie Candida) live in our guts
Exposure to fungi is one of life’s certainties
Introductions
Aspergillus –
38 species have caused disease
Common in the environment
www.aspergillus.man.ac.uk
Aspergillus niger Aspergillus fumigatus
Aspergillus spore head
Spores 3uM across (i.e. easily are drawn into the lungs)
The supporting cast
Alternaria
Penicillium
Cladosporium
Airborne fungi and their ‘diseases’
Aspergillus
Alternaria
Cladosporium
Penicillium
Others
Invasive (life- threatening) infection
Chronic infection
Allergy/asthma
Where are airborne fungi found?
• Outside air
• Home
• Hospital
Aspergillus and compost
Airborne fungi and pillows
Airborne fungi and pillows
Feather pillow Synthetic pillow
Fungus in the bedroom
We have been examining pillows for fungi:
Pillow typeNo pillows
Mean cfu/g pillowPredominant species *
Synthetic 3 8.6 x 102 - 2 x103A. fumigatus
R. rubra
Feather 3 1.8 x102 - 1.8 x103A. fumigatus
R. rubra*Other common species were other Aspergillus spp., Penicillium spp., Cladosporium spp.
What this means is that each ‘old’ pillow contains ~1 million fungal spores
Woodcock et al, Allergy 2005 In press
Airborne fungi on clothes and fabrics
Airborne fungi
Common sources of airborne fungi
Outside air – especially Cladosporium
After thunderstorms – esp Alternaria
In homes – esp Aspergillus and outdoor fungi
In hospitals – esp Aspergillus
Airborne fungi
Airborne fungi and hospital construction
Airborne fungi and hospital computers
Airborne fungi on air conditioning systems in hospital (intake ducts)
Airborne fungi in hospital
Airborne fungi in hospital
Outside room Inside room
Airborne fungi in hospital
Airborne fungi in hospital after continous air filtration
Outside room Inside room
Invasive aspergillosisChronic pulmonary aspergillosisAllergic aspergillosis
ABPASevere asthma association
Invasive aspergillosisChronic pulmonary aspergillosisAllergic aspergillosis
ABPASevere asthma association
Life-threatening aspergillosis
24 year old with genetic immune defect
Predicted numbers of invasive Aspergillus infections in the UK
Patient Number (2002)
% invasive aspergillosis
Range Expected cases invasive aspergillosis
Bone marrow Tx 793 8.10% 2.8-15.1% 64
Solid organ Tx 2,697 2.2-2.8% 0.8-16(lung)% 62-78
Leukaemia 15,802 6.50% 2.0-9.6% 1,027
Solid tumour (neutropenic)
27,824 1% 1 study only 278
Advanced cancer 127,766 1.86% 1.3-2.2% 2,376
ICU ~200,000 3.62% 2.7-3.7% 7,240
AIDS <400 0.60% 0.02-4.0% 2
Total 10,992
Actual cases
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Invasive aspergillosisChronic pulmonary aspergillosisAllergic aspergillosis
ABPASevere asthma association
Chronic pulmonary aspergillosis
30 year old smoker with no immune defect
January 2001
Chronic pulmonary aspergillosis
30 year old smoker with no immune defect
April 2003
Predicted numbers of chronic lung Aspergillus infections in the UK
Those at riskPrior TB (?5%)Sarcoidosis with cavitation (12% of all) Lung damage (pneumothorax etc)
Prevalence rate in the UK ???? 200-1000 cases
Incurable currently (require life-long treatment)
Invasive aspergillosisChronic pulmonary aspergillosisAllergic aspergillosis
ABPASevere asthma association
ABPA
Plug in airways Airway clear after removal
ABPA with airway obstruction
Mild asthma with shortness of breath
Predicted numbers of ABPA patients in the UK
Those at riskAdults with asthma = 4,100,000 on treatmentCystic fibrosis = 2,700 adults
Prevalence rate in the UK~ 1% of asthmatics = 41,000 patients~15% adult CF patients = 405 patients
Invasive aspergillosisChronic pulmonary aspergillosisAllergic aspergillosis
ABPASevere asthma association
Severe asthma with fungal sensitisation
Histamine House dust mite Cat
Cladosporium
Dog
GrassNegativeControl
Aspergillusfumigatus
AlternariaCandida Penicillium
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)
Fungus at home
Environmental data
• Mouldy housing associated with worse asthma
• Wheezing in children associated with damp housing
• Mouldy and damp school associated with asthma symptoms and emergency room visits
• Highest concentration of Aspergillus fumigatus is at home
Airborne fungal fragments
Fungal fragment
Diffusing allergen leeching out of fungus in contact with liquid
Hospital admission with asthmatic attacks and mould allergy
Allergen Asthma, no admission (n=82) Asthma, 2+ admission (n=46)
House dust mite 56 % 67 %
Grass pollen 46 % 63 %
Cat 37 % 59 %
Dog 18 % 48 %
Any non fungal allergen 70% 74%
O’Driscoll et al, BMC Pulm Med 2005;18:4
Allergen Asthma, no admission (n=82) Asthma, 2+ admission (n=46)
Aspergillus 7 % 37 %
Alternaria 5 % 26 %
Cladosporium 1 % 41 %
Penicillium 2 % 30 %
Candida 10 % 33 %
Any fungal allergen 16% 76%
Hospital admission with asthmatic attacks and mould allergy
O’Driscoll et al, BMC Pulm Med 2005;18:4
Severe asthma and moulds
Severe asthma – 235 (21%) of all asthmatics
Zureik et al, Br Med J 2002;325:411
Increasing frequency of fungal skin test positivity in severe asthma
Odds ratio
Predicted numbers of severe asthmatics with fungal sensitisation in the UK
Those at riskAdults with asthma = 4,100,000 on treatmentSevere asthma = 5-21%Mould allergic = 35-50%
Prevalence rate in the UKLower number = 71,750 patientsUpper number = 430,500 patients
~40,000 adults admitted to hospital in the UK each year with asthmaAdmissions reduced to 25% with antifungal therapy in 14 patients (pre antifungal - 1.63 admissions per year, post antifungal 0.4)
Conclusions
Fungi are all around us in the air
Exposure to airborne fungi is one of life’s certainties
Many people in the UK have infection or allergy due to fungi, and additional research and care is required for these patients.
Ascertainment of national caseload would be useful