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• W1996599043 abstract "Aspergillus P. Micheli ex Haller is a genus of filamentous microfungi usually saprotrophs, ubiquitous, occurring in the environment. There are 339 species of Aspergillus 1. In medical mycology, Aspergillus spp. have been described as agents of both systemic and superficial infections. Aspergillus may cause a broad spectrum of systemic diseases in humans, ranging from hypersensitivity reactions to direct angioinvasion. Superficial and local infections include otomycosis, tracheobronchitis, primary and secondary cutaneous infections and onychomycosis (s1). In fact, Aspergillus spp are the second most commonly recovered species among non-dermatophytic moulds in Europe (s2). Aspergillus spp. occurring in onychomycosis are often the same as involved in systemic infections, such as Aspergillus flavus, A. nidulans, A. terreus and A. versicolor (s3–s9). Recently, a number of Aspergillus onychomycosis have been described and several Aspergillus species (A. sclerotiorum, A. tamari, A. sydowii, A. persii; A. nomius) have now been identified as onychomycosis agents (s6, 2-5). As opportunistic Aspergillus spp. have recently been reported as being capable of expanding their habitat by attacking human tissues, also in immunocompetent patients, it is necessary to recognize the species in order to administrate specific therapies. We diagnosed onychomycosis, caused by A. melleus, in a 68-year-old Caucasian man through morphological and molecular identification. He presented with an extensive involvement of the nail plate with pseudo-leukonychia dots localized in the proximal portion of the fourth toenail on the right foot, developed several years before (Fig. 1). The patient underwent several unsuccessful treatments (topical treatments and itraconazole pulse therapy) during 3 years. We performed a direct microscopic examination and macro- and micromorphological fungal identification with modified Sabouraud medium and Czapek yeast agar. Then, the fungal sequence was obtained by DNA amplification and deposited and compared to those available in the GenBank database (http://www.ncbi.nlm.nih.gov/). Drug susceptibility tests were performed (microdilution and Sensititre YeastOne® methods). Fungal identification and drug susceptibility methods are described in Data S1. Direct microscopic examination revealed mycelial filaments (Fig. S1). Colony diameters at 7 days were (mm) as follows: CYA25 25–50; MEA 30–56; CYA37 20–40; CYA20S 57–65; and CZ 15–35. In CYA 25°C, the colony was golden yellow, plane or radially sulcate, and velutinous, with white vegetative mycelium and abundant conidial structures; colony reverse varied from pale orange to brown; soluble pigment presented as pale brown; and numerous sclerotia presented as yellow to pale brown. Microscopic character sizes are reported using three numbers corresponding to the minimum/average/maximum values. Conidial heads were biseriate and radiate; stipes appeared as light brown, roughened and 200/380/750 μm in length; spherical vesicles were 18/22/40 μm. Conidia were globose to subglobose, smooth to finely roughened and 2.8/3.3/4.2 μm. The strain was identified as Aspergillus melleus, a species belonging to the subgenus Circumdati 1, 6 section Circumdati, the A. ochraceus group 7. The Circumdati section traditionally encompasses species with predominantly biseriate sterigmata and small, yellow buff to ochre conidia; sclerotia that do not turn black 6; and ubiquinone systems Q-9, Q-10, and Q-10 (H2) (s12–s14). Our sequence clusters (Fig. 2) with the A. melleus sequences present in the data set. Microdilution method revealed that voriconazole (MIC = 0.12 μg/ml), posaconazole (MIC = 0.125 μg/ml), itraconazole (MIC = 0.25 μg/ml), amphotericin B (MIC = 2 μg/ml) and terbinafine (MIC = 0.5 μg/ml) showed a clear antifungal activity. The YeastOne® panel showed that A.melleus was susceptible to voriconazole (MIC = 0.5 μg/ml), posaconazole (MIC = 0.5 μg/ml), itraconazole (MIC = 0.25 μg/ml) and amphotericin B (MIC = 1 μg/ml) and resistant to flucytosine, anidulafungin, caspofungin, micafungin and fluconazole. Aspergillus spp. usually affect immunocompromised hosts, but are becoming increasingly prevalent in healthy people. This apparent emergence might be an artefact of improved diagnostic techniques or of an increased awareness that these fungi are potential aetiologic agents (s20). As they are not usually keratinolytic, they are usually found as secondary invaders of the nail plait (s21,s22). Aspergillus melleus has never been described as a pathogen for humans before. According to the phylogenetic tree (Fig. 2), our sequence from MUT 4199 falls in a clade (the A. melleus clade) together with four A. melleus sequences retrieved from GenBank (type strain NRRL 5103 included), The pairwise identity value of the β-tubulin sequences of the entire A. melleus clade is 99.2%. Aspergillus melleus is quite common in soils and in the rhizosphere of tropical, subtropical or warm temperate regions. It has also been isolated from peanuts and different types of corn (s23). A.melleus and other Circumdati are known for their production of mycotoxins 8, 9. They can also cause infections, although infrequently. A. ochraceus, A. sclerotiorum and A. persii have been described as agents of onychomycosis 4, 8, 9. A. westerdijkiae, A. insulicola A. tritici and A. pallidofulvus have also been recognized as pathogens for humans 6. Other species of the same section, such as A. tanneri, have been described as causing invasive infections (s15). Unfortunately, a standard treatment for onychomycosis due to Aspergillus spp. has not been established and a perfect cure is rather difficult to obtain. Aspergillus spp. are reported to have excellent susceptibility to itraconazole followed by miconazole, ketoconazole, tioconazole, fenticonazole and terbinafine (s25). Some authors have described Aspergillus as being resistant to terbinafine (s21,s22,s24). In our case, there was an agreement between the two methods used and a good susceptibility to azoles, amphotericine and terbinafine was shown (except for fluconazole). Moreover, the microdilution revealed sensitivity to terbinafine. However, our patient did not fully respond to therapy with itraconazole probably due to various factors, possibly poor compliance with prescribed therapies. Nevertheless, correlation between in vitro susceptibility and therapeutic success is lower than the correlation between in vitro resistance and clinical failure (s21,s24). In conclusion, we describe the first case of Aspergillus melleus as a pathogen for humans. As Aspergillus spp. infections are becoming increasingly prevalent, their identification is necessary to investigate their characteristics and to select strategies for a correct management of these infections. MZ, AFA and AV designed the research study, analysed the data and wrote the paper; EC and AP revised the paper. The authors thank Massimo Drosera, Carmela Sgrò and Prof. Agostino Persi. The authors declare no conflict of interests. Data S1. Materials and Methods. Data S2. Supplementary References. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article." @default.
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• W1996599043 title "<i>O</i>nychomycosis <i>from Aspergillus melleus</i>, a Novel Pathogen for Humans. Fungal Identification and <i>in vitro</i> Drug Susceptibility" @default.
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