Corticosteroid treatment is associated with increased filamentous fungal burden in allergic fungal disease

doi:10.1016/j.jaci.2017.09.039

Journal of Allergy and Clinical Immunology

Volume 142, Issue 2, August 2018, Pages 407-414

https://doi.org/10.1016/j.jaci.2017.09.039 Get rights and content

Background

Allergic diseases caused by fungi are common. The best understood conditions are allergic bronchopulmonary aspergillosis and severe asthma with fungal sensitization. Our knowledge of the fungal microbiome (mycobiome) is limited to a few studies involving healthy individuals, asthmatics, and smokers. No study has yet examined the mycobiome in fungal lung disease.

Objectives

The main aim of this study was to determine the mycobiome in lungs of individuals with well-characterized fungal disease. A secondary objective was to determine possible effects of treatment on the mycobiome.

Methods

After bronchoscopy, ribosomal internal transcribed spacer region 1 DNA was amplified and sequenced and fungal load determined by real-time PCR. Clinical and treatment variables were correlated with the main species identified. Bronchopulmonary aspergillosis (n = 16), severe asthma with fungal sensitization (n = 16), severe asthma not sensitized to fungi (n = 9), mild asthma patients (n = 7), and 10 healthy control subjects were studied.

Results

The mycobiome was highly varied with severe asthmatics carrying higher loads of fungus. Healthy individuals had low fungal loads, mostly poorly characterized Malasezziales. The most common fungus in asthmatics was Aspergillus fumigatus complex and this taxon accounted for the increased burden of fungus in the high-level samples. Corticosteroid treatment was significantly associated with increased fungal load (P < .01).

Conclusions

The mycobiome is highly variable. Highest loads of fungus are observed in severe asthmatics and the most common fungus is Aspergillus fumigatus complex. Individuals receiving steroid therapy had significantly higher levels of Aspergillus and total fungus in their bronchoalveolar lavage.

Section snippets

Sample collection and processing

Patients were identified using the exclusion and inclusion criteria defined in the supplemental Methods (in this article's Online Repository at www.jacionline.org). Briefly, 64 individuals were identified with 58 agreeing to bronchoscopy (Table I and see Table E1 in this article's Online Repository at www.jacionline.org). Bronchoalveolar lavage (BAL) samples were collected using local guidelines and British Thoracic Society standard procedures.²⁰ After bronchoscopy, all collected samples were

Recruitment of patients to the study

This was an observational study conducted between November 2011 and November 2013 at the National Aspergillosis Centre and the North West Severe Asthma Centre based at the Manchester University NHS Foundation Trust (Wythenshawe). Sixty-four adults (31 female and 33 male) 22 to 75 years of age were enrolled. All current or previous smokers had <10 pack years. No bronchoscopy samples were obtained from 5 patients and DNA extraction was unsuccessful in 1. Therefore, 58 patients were included in

Discussion

To our knowledge, this is the first study to identify the composition of the mycobiome in lungs of individuals with fungal disease. We show differences in fungal load in groups of individuals receiving corticosteroid treatment and antifungal therapy. The lung mycobiome varies substantially between individuals but is always at low levels in healthy individuals and increased load is always due to higher levels of A fumigatus complex.

A fumigatus complex is the predominant fungus in the lung

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Citation Excerpt :
With this link between fungi and asthma severity, there has been increasing interest in the pulmonary fungal microbiome, or mycobiome. Analysis of lung mycobiome has demonstrated higher fungal loads in patients with asthma subtypes linked to fungal colonization, allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS), when compared with healthy controls.57,61 Patients with CRS also have distinct features of their microbial community architecture.
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: M.B. and P.B. receive support from Medical Research Council (MRC) grant MR/M02010X/1. M.F., M.B., and P.B. were funded by EU Framework 7 (FP7-2007-2013) under grant agreement HEALTH-F2-2010-260338 “ALLFUN.”

: Disclosure of potential conflict of interest: L. Chishimba has received grants from the University of Manchester, National Aspergillosis Centre, and Novartis; has received travel support from AstraZeneca and GlaxoSmithKline; and has received payment for lectures from Novartis and AstraZeneca. R. M. Niven has consultant arrangements with AstraZeneca, Boehringer, Boston, Chiesi, Novartis, Roche, TEVA Pharmaceutical Industries, and Vectura; has received payment for lectures from AstraZeneca, Boehringer, Boston, Chiesi, GlaxoSmithKline, Napp, Novartis, Roche, and TEVA; and has received travel support from Boehringer, Chiesi, Napp, Novartis, and TEVA. M. Bromley has a board membership with Syngenics Limited; has consultant arrangements with Synergy Health PLC (also known as Genon Laboratories Limited); is employed by the University of Manchester and Lariat Consulting LLP; and has received grants from the Biotechnology and Biological Sciences Research Council, Wellcome Trust, the Medical Research Council, the European Union, Innovate UK, DuPont, Hans Knoll Institute, and F2G Limited. L. Smyth is employed by University of Salford and has received a grant from Kidscan. D. W. Denning has received grants from Pfizer, Gilead, Merck Sharp Dohme, and Astellas; has received personal fees from Pfizer, Gilead, Merck Sharp Dohme, Basilea, Pulmocide, Dynamiker, Cidara, Syncexis, Astellas, Biosergen, Quintilles, Pulmatrix, and Pulmocide; and has a patent for assays for fungal infection. P. Bowyer has received a grant from the Medical Research Council (MR/M02010X/1) and has received payment for lectures from Gilead Ltd. The rest of the authors declare that they have no relevant conflicts of interest.

^∗: Livingstone Chishimba, PhD, is currently at Cardiff and Vale University Hospitals Health Board, Cardiff, United Kingdom.

View full text

Asthma and lower airway diseaseCorticosteroid treatment is associated with increased filamentous fungal burden in allergic fungal disease

Background

Objectives

Methods

Results

Conclusions

Section snippets

Sample collection and processing

Recruitment of patients to the study

Discussion

J Allergy Clin Immunol

J Mol Biol

Stud Mycol

J Allergy Clin Immunol

Hidden killers: human fungal infections

Sci Transl Med

The link between fungi and severe asthma: a summary of the evidence

Eur Respir J

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

Crit Rev Microbiol

Allergic bronchopulmonary aspergillosis: review of literature and proposal of new diagnostic and classification criteria

Clin Exp Allergy J

Fungal allergy in asthma-state of the art and research needs

Clin Transl Allergy

High-frequency triazole resistance found in nonculturable Aspergillus fumigatus from lungs of patients with chronic fungal disease

Clin Infect Dis

Volume dependency for culture of fungi from respiratory secretions and increased sensitivity of Aspergillus quantitative PCR

Mycoses

Randomized controlled trial of oral antifungal treatment for severe asthma with fungal sensitization: the Fungal Asthma Sensitization Trial (FAST) study

Am J Respir Crit Care Med

Selective protection against conidia by mononuclear and against mycelia by polymorphonuclear phagocytes in resistance to Aspergillus: observations on these two lines of defense in vivo and in vitro with human and mouse phagocytes

J Clin Invest

The lung mycobiome in the next-generation sequencing era

Virulence

Infectious diseases

The ambitious ‘95-95 by 2025’ roadmap for the diagnosis and management of fungal diseases

Thorax

The diagnostic criteria for allergic bronchopulmonary aspergillosis in children with poorly controlled asthma need to be re-evaluated

Acta Paediatr Oslo Nor 1992

Fungi and allergic lower respiratory tract diseases

J Allergy Clin Immunol

Aspergillus fumigatus proteases, Asp f 5 and Asp f 13, are essential for airway inflammation and remodelling in a murine inhalation model

Clin Exp

Hydrocortisone-enhanced growth of Aspergillus spp.: implications for pathogenesis

Microbiol Read Engl

Fungal infections: corticosteroids

Different oral corticosteroid regimens for acute asthma

Cochrane Database Syst Rev

Asthma and lower airway disease
Corticosteroid treatment is associated with increased filamentous fungal burden in allergic fungal disease