Exserohilum Rostratum Research Articles

Clinical Response, Outbreak Investigation, and Epidemiology of the Fungal Meningitis Epidemic in the United States: Systematic Review.

We conducted a systematic review of the 2012-2013 multistate fungal meningitis epidemic in the United States from the perspectives of clinical response, outbreak investigation, and epidemiology. Articles focused on clinical response, outbreak investigation, and epidemiology were included, whereas articles focused on compounding pharmacies, legislation and litigation, diagnostics, microbiology, and pathogenesis were excluded. We reviewed 19 articles by use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework. The source of the fungal meningitis outbreak was traced to the New England Compounding Center in Massachusetts, where injectable methylprednisolone acetate products were contaminated with the predominant pathogen, Exserohilum rostratum. As of October 23, 2013, the final case count stood at 751 patients and 64 deaths, and no additional cases are anticipated. The multisectoral public health response to the fungal meningitis epidemic from the hospitals, clinics, pharmacies, and the public health system at the local, state, and federal levels led to an efficient epidemiological investigation to trace the outbreak source and rapid implementation of multiple response plans. This systematic review reaffirms the effective execution of a multisectoral public health response and efficient delivery of the core functions of public health assessment, policy development, and service assurances to improve population health.

Facing the Increasingly Looming Challenges from Environmental Fungal (Molds and Yeast) Contamination

In an unprecedented and extraordinary case of a deadly multi-state meningitis outbreak in the fall of 2012, 64 people died and 751 cases were treated across 20 states within the USA, according to the Centers for Disease Control and Prevention (CDC)[1]. Exserohilum rostratum , a fungus commonly found in the environment, was identified as the predominant organism in the patients with meningitis and was associated with the growth in the meninges [2]. One of the early patients from the outbreak was infected with Aspergillus fumigatus

4-Dechloro-14-deoxy-oxacyclododecindione and 14-deoxy-oxacylododecindione, two inhibitors of inducible connective tissue growth factor expression from the imperfect fungus Exserohilum rostratum

Connective tissue growth factor (CTGF/CCN2), a member of the CCN superfamily of secreted cysteine-rich glycoproteins, is a central mediator of tissue remodeling and fibrosis. CTGF is suggested to be an important down-stream effector of transforming growth factor-beta (TGF-β) signaling and has therefore reached considerable pathophysiological relevance because of its involvement in the pathogenesis of fibrotic diseases, atherosclerosis, skin scarring, and other conditions with excess production of connective tissue. In a search for inhibitors of inducible CTGF expression from fungi, two new macrocyclic lactones, namely 4-dechloro-14-deoxy-oxacyclododecindione (1) and 14-deoxy-oxacylododecindione, (2) along with the previously described congener oxacyclododecindione (3) were isolated from fermentations of the imperfect fungus Exserohilum rostratum. The structure of the compounds were elucidated by a combination of one- and two-dimensional NMR spectroscopy and mass spectrometry. Compounds 1 and 2 turned out to inhibit TGF-β induced CTGF promoter activity in transiently transfected HepG2 cells in a dose-dependent manner with IC50 values of 1.8μM and 336nM, respectively, and also antagonized TGF-β induced cellular effects including CTGF mRNA levels, CTGF protein expression and tube formation.

Outbreak of fungal infections associated with contaminated methylprednisolone acetate: an update.

In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.

Exserohilum rostratum: characterization of a cross-kingdom pathogen of plants and humans.

Pathogen host shifts represent a major source of new infectious diseases. There are several examples of cross-genus host jumps that have caused catastrophic epidemics in animal and plant species worldwide. Cross-kingdom jumps are rare, and are often associated with nosocomial infections. Here we provide an example of human-mediated cross-kingdom jumping of Exserohilum rostratum isolated from a patient who had received a corticosteroid injection and died of fungal meningitis in a Florida hospital in 2012. The clinical isolate of E. rostratum was compared with two plant pathogenic isolates of E. rostratum and an isolate of the closely related genus Bipolaris in terms of morphology, phylogeny, and pathogenicity on one C3 grass, Gulf annual rye grass (Lolium multiflorum), and two C4 grasses, Japanese stilt grass (Microstegium vimineum) and bahia grass (Paspalum notatum). Colony growth and color, as well as conidia shape and size were the same for the clinical and plant isolates of E. rostratum, while these characteristics differed slightly for the Bipolaris sp. isolate. The plant pathogenic and clinical isolates of E. rostratum were indistinguishable based on morphology and ITS and 28S rDNA sequence analysis. The clinical isolate was as pathogenic to all grass species tested as the plant pathogenic strains that were originally isolated from plant hosts. The clinical isolate induced more severe symptoms on stilt grass than on rye grass, while this was the reverse for the plant isolates of E. rostratum. The phylogenetic similarity between the clinical and plant-associated E. rostratum isolates and the ability of the clinical isolate to infect plants suggests that a plant pathogenic strain of E. rostratum contaminated the corticosteroid injection fluid and was able to cause systemic disease in the affected patient. This is the first proof that a clinical isolate of E. rostratum is also an effective plant pathogen.

Development of Technology and Popularization of Biological Control Agents for Integrated Management of Coconut Leaf Rot Disease*

Coconut is an important social crop of livelihood concern for millions of small- medium farmers. Leaf rot disease (due to a fungal complex-Colletotrichum gloeosoprioides, Exserohilum rostratum and Fusarium solani as major pathogens), in association with root (wilt), is a major problem of coconut in southern districts of Kerala besides certain districts in Tamil Nadu etc. Central Plantation Crops Research Institute (CPCRI) has evolved biological control technology for integrated management of leaf rot to improve the health of disease affected palms. Application of biocontrol agents in the disease affected areas was aimed for creation of widespread awareness on eco-friendly disease management, crop sustenance and in realizing human resource potential. Effective strains of biocontrol agents-Bacillus subtilis, Pseudomonas fluorescens and Trichoderma viride-were evolved, their multiplications in media including coconut water standardized and the antagonists’ processed into bioformulations (totally 2000 Kg. talc formulations evolved distributed/utilized). Coconut gardens and rural groups in various districts of southern Kerala (Thiruvananthapuram, Kollam, Alappuzha, Pathanamthitta, Kottayam, Idukki, Ernakulam and Thrissur), various blocks in Theni district besides specified blocks in Dindigul district of Tamil Nadu could be selected. Through effective contacts with extension-developmental agencies, coconut Research & Development (R&D) meetings etc. reached out to rural people and implemented the technology of mass production-use of biological control agents, and knowledge imparted to rural people. Conducted trainings and allied programmes by on-campus trainings (396 beneficiaries), off-campus trainings (1854 beneficiaries), household/field contacts of rural people (689 beneficiaries) and other awareness programmes encompassing lectures, interfaces etc. (661 beneficiaries) and enlightened women, rural people, youths etc. representing various locations (totally 3600 beneficiaries in three years). Field demonstrations of disease management with biological control agents in coconut gardens (55 units) besides clusters-compact gardens (1850 coconut palms) were also done. Also, promotional materials were made available to various stakeholders. An innovative participatory programme implementation approach for technology transfer was the outcome of the work. Creation of widespread awareness, percolation of knowledge on biocontrol agents to women and other rural people could be visualized that would go a long way.

The fungal lactone oxacyclododecindione is a potential new therapeutic substance in the treatment of lupus-associated kidney disease

Recently oxacyclododecindione (Oxa), a macrocyclic lactone isolated from the imperfect fungus Exserohilum rostratum, has been described as a potent transcription inhibitor of inducible proinflammatory and profibrotic genes in cell culture models. As kidney disease in systemic lupus erythematosus is characterized by aberrant expression of inflammatory mediators and infiltration of immune cells, we investigated the effect of Oxa in MRL-Fas(lpr) mice, a model of systemic lupus erythematosus. These mice develop a spontaneous T-cell and macrophage-dependent autoimmune disease including severe glomerulonephritis that shares features with human lupus. Comparable to the results of in vitro models, we found a reduced expression of the cytokines IFN-γ, IL-6, and TNF-α and the chemokines CCL2, RANTES, and CSF-1 on mRNA and protein level in the kidney of Oxa-treated MRL-Fas(lpr) mice. Accordingly, Oxa treatment reduced the infiltration of immune cells and the frequency of activated proinflammatory T cells in the kidney. Moreover, kidney disease, measured by histopathology, IgG and collagen deposition, and proteinuria, was ameliorated in Oxa-treated MRL-Fas(lpr) mice compared with the control group. Thus, Oxa is a new effective anti-inflammatory compound, which may serve as base structure for the development of new therapeutics for the treatment of chronic inflammatory and/or fibrotic diseases.

Drechslera rostrata a new mycoparasite of Syncephalastrum racemosum

<i>Drechslera rostrata</i> is reported here as a new mycoparasite of <i>Syncephalastrum racemosum</i>.

Methylprednisolone impairs conidial phagocytosis but does not attenuate hyphal damage by neutrophils against Exserohilum rostratum.

Exserohilum rostratum caused a multistate fungal meningitis outbreak following iatrogenic inoculation of contaminated methylprednisolone in the United States. To gain insight into the immunopathogenesis of this infection, we studied the innate host responses of human neutrophils against E. rostratum conidia and hyphae with or without methylprednisolone. The neutrophil-induced percentage fungal damage against conidia and hyphae was effector-to-target ratio dependent (≤55%). While methylprednisolone did not affect neutrophil-induced fungal damage by treatment of Exserohilum or neutrophils, it compromised phagocytosis of conidia (P < 0.05). These findings suggest that methylprednisolone-treated neutrophils may have altered phagocytic clearance of Exserohilum conidia, reducing host capacity to contain the invasive process.

Whole-genome analysis of Exserohilum rostratum from an outbreak of fungal meningitis and other infections.

Exserohilum rostratum was the cause of most cases of fungal meningitis and other infections associated with the injection of contaminated methylprednisolone acetate produced by the New England Compounding Center (NECC). Until this outbreak, very few human cases of Exserohilum infection had been reported, and very little was known about this dematiaceous fungus, which usually infects plants. Here, we report using whole-genome sequencing (WGS) for the detection of single nucleotide polymorphisms (SNPs) and phylogenetic analysis to investigate the molecular origin of the outbreak using 22 isolates of E. rostratum retrieved from 19 case patients with meningitis or epidural/spinal abscesses, 6 isolates from contaminated NECC vials, and 7 isolates unrelated to the outbreak. Our analysis indicates that all 28 isolates associated with the outbreak had nearly identical genomes of 33.8 Mb. A total of 8 SNPs were detected among the outbreak genomes, with no more than 2 SNPs separating any 2 of the 28 genomes. The outbreak genomes were separated from the next most closely related control strain by ∼136,000 SNPs. We also observed significant genomic variability among strains unrelated to the outbreak, which may suggest the possibility of cryptic speciation in E. rostratum.

Resolution of a fungal mycotic aneurysm after a contaminated steroid injection: a case report

BackgroundIn the past ten years there have been three separate outbreaks of fungal contaminated steroid injections from compounding pharmacies. The 2012 outbreak of central nervous system fungal infections associated with contaminated methylprednisolone produced by a United States compounding pharmacy has led to 750 infections (151 with meningitis and paraspinal infections and 325 cases with paraspinal infections without meningitis) and 64 deaths as of October 23, 2013. Exserohilum rostratum has been the predominant pathogen identified by culture, polymerase chain reaction or antibody tests. According to previous reports, cerebral involvement with phaeohyphomycosis has a high risk of morbidity and mortality.Case presentationWe report a 41 year-old Caucasian woman who received a lumbar methylprednisolone injection from a contaminated lot in August 2012. She was diagnosed with fungal meningitis by cerebrospinal fluid pleocytosis and positive (1, 3) beta-D-glucan after cultures and polymerase chain reaction were negative. Two weeks after onset of therapy, she developed a 4.1 mm superior cerebellar artery mycotic aneurysm associated with new stroke symptoms, which resolved with thirty-two weeks of antifungal treatment.ConclusionsThis is the rare case report of successful medical management of a cerebral mycotic aneurysm with stroke symptoms related to a presumed phaeohyphomycosis in an immunocompetent individual. Further studies are needed to determine the utility of cerebrospinal fluid (1, 3) beta-D-glucan in diagnosing and monitoring patients with meningitis thought to be related to fungal infection.

Methylprednisolone enhances the growth of Exserohilum rostratum in vitro, attenuates spontaneous apoptosis, and increases mortality rates in immunocompetent Drosophila flies.

High concentrations of methylprednisolone (0.32 mg/mL) accelerated growth and attenuated spontaneous apoptosis of Exserohilum rostratum in vitro. Injection of E. rostratum conidia preexposed to 0.32 mg/mL of methylprednisolone for 7 days in immunocompetent flies led to increased mortality and a higher fungal burden. Exposure to methylprednisolone could enhance the virulence of E. rostratum.

Mycoflora of grain maize (Zea mays L.) stored in traditional storage containers (gombisa and sacks) in selected woredas of Jimma zone, Ethiopia

Mycoflora of maize (Zea mays L.) grain (Variety: Bako Hybrid-660) stored in two traditional storage containers (Gombisa and Sacks) for 180 days was studied for mycoflora in two agro-ecologies, that is Intermediate and Lowland, with altitude ranges of 1500-2500 meters above sea level, and 1000-1500 meters above sea level, respectively, in Jimma zone, Ethiopia. The temperature and relative humidity were observed for identifying fungi species which can flourish and cause maximum deterioration to maize grains. Significant (P&lt;0.05) decreases in germination rate of the grains were observed with time under each storage method for both the low and intermediate altitude ranges. Germination percentage reduced from 98% and 97.5% to 68.5% and 80.5% for grains stored in Gombisa and Sacks, respectively. Storage type significantly (p&lt;0.05) affected seed germination under intermediate agro-ecology whereas no significant (p&gt;0.05) effect was observed under lowland agro-ecology due to storage container type. One sterile white mycelium and a total number of eight species of fungi viz., Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger, Aspergillus tereus, Cladosporium cladosporioides, Drechslera halodes, Fusarium oxysporum and Penicillium chrysogenum were identified from maize grain at the beginning and during storage. The most common fungi recorded from both agroecologies in the two storage structures were A. flavus, A. niger, D. halodes and F.oxysporum. These fungi were recorded from 90, 51, 72 and 44 percentage of the seed samples, respectively. In the districts of both intermediate and lowland agro-ecology these fungi were consistently recorded throughout 180 days, during storage. A. fumigatus was detected in3.6% of samples while C. cladosporioides observed in 15% of the samples. Fungal species A. tereus and Penicillium were recorded in 0.5% of samples in selected districts of Jimma. These fungal species were known to cause deterioration of maize and are a health risk to humans and animals due to the toxins they potentially produce.

In Vitro Studies of Exserohilum rostratum with Antifungal Drugs and Methylprednisolone

Exserohilum rostratum was the primary fungal species implicated in the recent nationwide outbreak of meningitis due to contaminated steroid injections ([1][1]). This species is an extremely rare cause of human infection, and optimal therapy is not known ([2][2]). Despite prolonged administration of

Exserohilum and the compounding pharmacy: pushing the envelope of virulence

Summary Microorganisms poorly pathogenic for man may become significant causes of morbidity and mortality when inadvertently inoculated into normally sterile sites. Compounding pharmacies in the USA, not strictly overseen by the US Food and Drug Administration but by individual states, have been implicated in a number of clusters of such events. Recognized in the fall of 2012, fungus-tainted corticosteroid manufactured by a Massachusetts compounding pharmacy has caused the largest outbreak of this kind, affecting 751 people with, to date, 64 deaths. The etiology of the cases of meningitis, perispinal infection and septic arthritis was found to be, mostly, Exserohilum rostratum, a very uncommon human fungal pathogen. Prevention of future outbreaks such as this one will require an overhaul of the control over these industrialized compounding pharmacies and, until then, making both clinicians and patients alike aware of this issue in order for them to make informed decisions about these products and the risk of their use.

Enhancing the efficiency of the bioagent Bacillus subtilis JF419701 against soil-borne phytopathogens by increasing the productivity of fungal cell wall degrading enzymes

This study was devoted to increasing the production of fungal cell wall degrading enzymes by Bacillus subtilis JF419701 to enhance its efficiency in the biological control process. In dual culture, B. subtilis JF419701 showed the highest antagonistic effect of the 256 bacterial strains tested against six soil-borne pathogens, Alternaria alternata, Exserohilum rostratum, Fusarium oxysporum, Macrophomina phaseolina, Pythium ultimum and Rhizoctonia solani. The production potentiality of the enzymes α-1,3-glucanase, β-1,3-glucanase, chitinase and protease by B. subtilis JF419701 was studied in vitro. Results proved that the maximum production of enzymes by this bacterium was achieved after a two-day incubation period at a slightly alkaline pH (8). The addition of colloidal chitin or S-glucan to the growth media enhanced the production of all the enzymes except protease, which was stimulated by casein. This study therefore recommends that to obtain an efficient and strong bioagent culture of B. subtilis JF419701, it is necessary to grow this micro-organism on a specific medium containing either chitin or its derivatives at pH 8 for two days.

Isolation and Identification of Streptomyces rochei Strain Active against Phytopathogenic Fungi

A total of 104 actinomycete isolates were recovered from farming soil samples collected from 11 states in Sudan. Upon screening for potential antifungal activity, an actinomycete isolate (R92) was found to be highly antagonistic against all of the tested phytopathogenic fungi. It was identified as Streptomyces rochei on the basis of its morphology, chemotaxonomy and 16S rDNA sequence analysis. In vivo antagonistic activities of the nbutanol extract of R92 culture were significant since the progress of Drechslera halodes leaf spot on sorghum and Alternaria alternata early blight on tomato was highly restricted and incidence of both diseases was greatly suppressed. Trials to evaluate the In vivo control efficacy of this extract under field conditions is recommended.

Anti-leishmanial Activities of Extracts and Isolated Compounds fromDrechslera rostrataandEurotium tonpholium

The fungal extract of Drechslera rostrata and Eurotium tonpholium showed a significant anti-leishmanial activity against Leishmania major; IC50 was 28.8 and 28.2 μg/mL, respectively. Seven compounds, five from D. rostrata (H1-H5) and two from E. tonpholium (H6 and H7), were isolated and identified using different spectroscopic analysis including (1) HNMR, (13) CNMR, Hetero-nuclear multiple bond connectivity (HMBC), Hetero-nuclear Multiple Quantum Correlation (HMQC), and EI-MS. The isolated compounds are: di-2-ethylhexyl phthalate (1), (22E)-5α,8α-epidioxyergosta-6,22-diene-3β-ol (2),1,3,8-trihydroxy-6-methyl-nthraquinone (3), aloe-emodine 8-O-glucopyranoside(4), 2R, 3R,4R,5R hexane 1, 2, 3, 4, 5, 6 hexole (Mannitol) (5), 1,8-dihydroxy-3-methoxy-6-methyl-anthraquinone (6) and 1, 4, 5-trihydroxy-7-methoxy-2-methyl-anthraquinone (7). However, compounds (1) and (6) showed activity against L. major with IC50 of 3.2 and 10.38 µg/mL, respectively. On the other hand, oral administration of the two extracts (100 mg/kg) and compounds 1 and 6 (50 mg/kg) showed very good activity when compared with the anti-leishmanial drug Pentostam (125 mg/kg). Interestingly, the complete heeling activity of the extracts and compounds (1) and (6) was obtained after 13-17 days of treatment, while complete healing activity of Pentostam was obtained after 28 days. No alteration on liver and kidney functions was recorded on animals treated with the two extracts for 15 consecutive days.

Lessons learned in the multistate fungal infection outbreak in the United States

The recent outbreak of fungal meningitis related to contaminated methylprednisolone acetate injections represents an important cause of morbidity and continues to be a significant public health problem in the United States. As of August 2013, there have been 749 cases and 63 deaths in 20 states associated with epidemic fungal meningitis, most of these because of Exserohilum rostratum. Clinical experience in managing these cases has grown dramatically in the last several months; most patients require at least 6 months of antifungal therapy for complicated disease. Most patients are treated with voriconazole, with or without liposomal amphotericin B, for central nervous system and paraspinal complications of the disease. For disease involving the sacroiliac and peripheral joints, voriconazole alone has been preferred. MRI spine imaging has identified several cases of asymptomatic disease, suggesting an aggressive diagnostic approach to exposed asymptomatic patients. Mortality remains low (<10%), but morbidity relating to persistent symptoms and treatment-associated toxicity is high. The ongoing fungal meningitis epidemic demonstrates an important achievement for the public health community. Important questions remain relating to the diagnosis, management, and long-term outcomes of these patients. Important research questions pertaining to specific risks influencing disease manifestations remain unanswered.

Exserohilum rostratum: Anatomy of a national outbreak of fungal meningitis

On 18 September 2012, an alert physician caring for a patient with fungal meningitis who had received an epidural methylprednisolone acetate injection approximately 6 weeks earlier, recognized its possible significance and reported this case to the Tennessee Department of Health, who in turn notified the Centers for Disease Control and Prevention. Shortly thereafter, additional cases of fungal meningitis were reported, and so began a large, unprecedented, multistate fungal meningitis outbreak. The predominant etiologic agent was Exserohilum rostratum, a black mould that was not known to have previously caused an outbreak of such devastating disease of this magnitude. The contaminated medication was prepared and distributed by a compounding pharmacy located in Massachusetts. This article reviews (i) the development and handling of the outbreak; (ii) the clinical manifestations and management of the infections; (iii) the detection, identification, and characteristics of E. rostratum, including the factors that might enhance its virulence; (iv) the regulatory concerns for microbiological quality control; and (v) what we have learned from this experience.