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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.

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airborne fungi infections

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

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

slide4

Aspergillus –

38 species have caused disease

Common in the environment

Aspergillus fumigatus

Aspergillus niger

www.aspergillus.man.ac.uk

aspergillus spore head

Aspergillus spore head

Spores 3uM across (i.e. easily are drawn into the lungs)

slide6

The supporting cast

Alternaria

Cladosporium

Penicillium

airborne fungi and their diseases

Airborne fungi and their ‘diseases’

Invasive (life- threatening) infection

Chronic infection

Allergy/asthma

Aspergillus

Alternaria

Cladosporium

Penicillium

Others

where are airborne fungi found outside air home hospital
Where are airborne fungi found?

Outside air

Home

Hospital

airborne fungi and pillows1

Airborne fungi and pillows

Feather pillow

Synthetic pillow

slide12

Fungus in the bedroom

We have been examining pillows for fungi:

*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

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 in hospital1

Airborne fungi in hospital

Outside room

Inside room

slide23
Invasive aspergillosis

Chronic pulmonary aspergillosis

Allergic aspergillosis

ABPA

Severe asthma association

slide24
Invasive aspergillosis

Chronic pulmonary aspergillosis

Allergic aspergillosis

ABPA

Severe asthma association

life threatening aspergillosis

Life-threatening aspergillosis

24 year old with genetic immune defect

slide27
Invasive aspergillosis

Chronic pulmonary aspergillosis

Allergic aspergillosis

ABPA

Severe asthma association

chronic pulmonary aspergillosis

Chronic pulmonary aspergillosis

January 2001

30 year old smoker with no immune defect

chronic pulmonary aspergillosis1

Chronic pulmonary aspergillosis

April 2003

30 year old smoker with no immune defect

slide30

Predicted numbers ofchronic lung Aspergillus infections in the UK

Those at risk

Prior 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)

slide31
Invasive aspergillosis

Chronic pulmonary aspergillosis

Allergic aspergillosis

ABPA

Severe asthma association

slide32

ABPA

Plug in airways

Airway clear after removal

abpa with airway obstruction

ABPA with airway obstruction

Mild asthma with shortness of breath

slide34

Predicted numbers ofABPA patients in the UK

Those at risk

Adults with asthma = 4,100,000 on treatment

Cystic fibrosis = 2,700 adults

Prevalence rate in the UK

~ 1% of asthmatics = 41,000 patients

~15% adult CF patients = 405 patients

slide35
Invasive aspergillosis

Chronic pulmonary aspergillosis

Allergic aspergillosis

ABPA

Severe asthma association

slide37

Aspergillus

fumigatus

Alternaria

Cladosporium

Candida

Penicillium

Negative

Control

Grass

Histamine

House dust mite

Cat

Dog

slide38

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)
slide39

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

Airborne fungal fragments

Fungal fragment

Diffusing allergen leeching out of fungus in contact with liquid

slide41

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

slide42

Hospital admission with asthmatic attacks and mould allergy

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%

O’Driscoll et al, BMC Pulm Med 2005;18:4

slide43

Severe asthma and moulds

Severe asthma – 235 (21%) of all asthmatics

Odds ratio

Increasing frequency of fungal skin test positivity in severe asthma

Zureik et al, Br Med J 2002;325:411

slide44

Predicted numbers ofsevere asthmatics with fungal sensitisation in the UK

Those at risk

Adults with asthma = 4,100,000 on treatment

Severe asthma = 5-21%

Mould allergic = 35-50%

Prevalence rate in the UK

Lower number = 71,750 patients

Upper number = 430,500 patients

~40,000 adults admitted to hospital in the UK each year with asthma

Admissions reduced to 25% with antifungal therapy in 14 patients (pre antifungal - 1.63 admissions per year, post antifungal 0.4)

conclusions

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