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(BQ) Part 2 book “Current topics in medical mycology” has contents: Killer system interactions, allylamine antifungal drugs, teaching medical mycology in latin america, the'' need for a national mycoses reporting system,… and other contents.
5-Killer System Interactions L POLONELLI, G MORACE, S CONTI, M GERLONI, W MAGLIANI, AND C CHEZZI Viruses and Fungi Over the last few years, our concept of yeasts has changed vastly Once thought of as "E coli with a nucleus,"l these organisms currently represent cells of universal use by modern molecular biologists Retroviral elements, ubiquitin, calmodulin, actin, and tubulin are only some of the many biological elements that are being investigated in yeast cells Ras-related genes, strongly implicated in the transformation of normal mammalian to cancer cells, have also been discovered in yeasts, opening the way for exciting new cytological, biochemical, and experimental genetic strategies that were impossible to carry out in animal cells Cytoplasmic viruslike particles (VLPs) were first observed in diseased mushrooms Since then, viruses have been detected in more than 100 different fungal species In most of these species, the persistent viral infection produces no discernible effect on the fungal host's phenotype However, the finding that the antiviral and interferon-inducing activities of extracts (statolon, hellenin) from Penicillium species were due to the presence of double-stranded RNA (dsRNA) has sparked an explosion of interest in what has now become a new area for research in mycology.4 The hypovirulence of certain forms of Endothia parasitica, which may cause chestnut blight disease, has also been found to be related to the presence oflipid-rich cytoplasmic vesicles containing dsRNA Reduction of cytochrome oxidase and respiratory deficiency resulting in abnormal growth and morphology have been linked to specific dsRNA segments in Ophiostoma ulmi (which causes Dutch elm disease) The biological properties of the dsRNA genomes that are in capsid form in noninfectious VLPs within the fungal cytoplasm have proved to be unique These mycoviruses are apparently incapable of extracellular transmission through lysis of the host cell They are normally maintained at a relatively stable copy number and transmitted predominantly by the intracellular route In hyphomycetes, for example, transmission occurs through the How 137 138 Poionelli et aI of protoplasm toward the growing hyphal tip, whereas cytoplasmic mixing that occurs during budding, mating, or other means of cell fusion is responsible for the spread of these viruses in yeasts Another unusual characteristic of the dsRNA VLPs in fungi is that they generally produce no adverse effect on their hosts and, in some cases, may even be beneficial In this respect they may be compared with bacterial plasm ids, in that they act as nonessential extrachromosomal elements which can, however, be quite useful to their hosts In addition to conjugation behavior, enterotoxin production, and antibiotic resistance, bacterial plasmids encode the production of bacteriocins by certain strains that exert lethal effects on closely related strains The killer toxins produced by certain yeasts are extremely similar to the bacteriocins The killer characteristics of these yeasts are often compared with those of bacterial species associated with C factors The resemblance is even more striking between killer yeasts and Paramecium species carrying K particles In the latter case, a dominant nuclear gene has been found to be responsible for the organism's ability to maintain these particles The occurrence of similar phenomena in organisms with such widely divergent evolutionary histories is fascinating The Killer Phenomenon in Yeast The yeast killer phenomenon was first observed among Saccharomyces cerevisiae strains These strains secrete glycoproteins that have toxic effects on other, sensitive strains of this species as well as closely related ones The yeast's ability to produce a killer toxin, its immunity to the effects of that protein, and its resistance to those produced by other species are all encoded by satellite dsRNAs In S cerevisiae there are two main recognized killer systems (Kl and K2) which not elicit cross-immunity Kl is found in laboratory strains and is the most deeply investigated yeast killer system, whereas K2 is exclusively related to wine yeasts When no distinction is made, reference to the Kl killer system is generally intended In the type I system, cells may have one offour possible phenotypes: K+ R+ (killer), K- R- (sensitive), K- R+ (neutral), and K+ R- (suicidal) Two types of dsRNA have been (ound inside icosahedral VLPs of approximately 40 nm in diameter within wild killer strains of S cerevisiae: L dsRNA (4.9 kb) is present in approximately 1,000 copies per haploid cell, while the M dsRNA appears in about 100 copies Deletion of certain sequences of the latter results in suppressive S dsRNA.7 Both L and M dsRNA interact with mak (maintenance killer) genes, which are widely scattered over the chromosomal map of the yeast, and these genes are necessary for maintaining autoreplication of M dsRNA VLPs In fact, mutants that have 5-Killer System Interactions 139 lost certain mak genes also lose M dsRNA, though L dsRNA, which is also present in nonkiller yeast cells, is maintained Recessive mutations of other chromosomal genes, such as ski (superkiller), result in increased toxin production by the yeast, presumably because of the roles they play in the replication of M dsRNA.8 Other chromosomal genes are essential for the secretion (sec) and killer expression (kex) of the toxin as well as for the virus-mediated host immunity to the toxin (vpl [vacuolar protein localization], end [endocytosis], and rex [resistance expression] genes) although not necessarily for replication of the cytoplasmic killer genome The kex gene product is, however, also required for mating functions and meiotic sporulation The relationship between the L and M dsRNA genomes would be analogous to that between a helper and a defective virus rather than that of components of an interdependent segmented mycovirus genome In the S cerevisiae Kl and K2 killer systems, L dsRNA encodes the major capsid polypeptides of the VLPs The M and L types of dsRNA probably not exist within the same capsid, and although the polypeptide composition of the VLPs has not been completely described yet, particles containing L dsRNA reportedly include a large polypeptide of 75,000 Da and two smaller ones of 55,000 and 37,000 Da Whether or not the M dsRNA-containing particles are structurally identical to the L particles cannot be confirmed at this time However, in light of the cross-antigenicity observed between the two VLPs, it is likely that they share at least one polypeptide The M dsRNA is related to toxin activity, by encoding the killer as well as the immune phenotype Killer toxin-coding cDNA copies of the MdsRNA from S cerevisiae have been cloned, and a toxin precursor gene sequence has been identified 10.11 This sequence encodes a 35-kDa protein (preprotoxin), which contains a signal sequence-encoding region Either this molecule or a processed product (43-kDa protoxin) of glycosylation in the endoplasmic reticulum is responsible for immunity of the toxin-producing strain After digestion by specific proteolytic enzymes, the protoxin is processed in the Golgi apparatus or in secretory vesicles into the mature killer toxin, which in the S cerevisiae Kl killer system is composed of ~vo disulfide-linked a (9.5kDa) and {3 (9.0-kDa) polypeptide components 12.13 Mutation of various nuclear genes may drastically affect the yeast's ability to maintain killer dsRNA VLPs and its killer phenotype The study ofkillerresistant (kre) mutants has shed light on the mechanism by which killer toxins destroy sensitive yeast cells Strains of S cerevisiae that had been rendered resistant to S cerevisiae Kl killer toxin by mutation of the nuclear genes krel and kre2 were found to bind 35S-labeled killer toxin more weakly than wild, sensitive strains 14 Although killing activity is not yet fully understood, ATe know that rapid, energy-independent binding of the toxin to a (1,6)-{3-n-glucan-linked component of the cell wall occurs during the initial phase and that the products of either the krel or the kre2 nuclear gene are necessary to this process Mutations in the nuclear loci krel and 140 Poionelli et al kre2 result in a reduction and modification of (1,6)-J3-n-glucan content of the cell wall The initial binding to the wall, presumptively by the J3 subunit, might make the a subunit of the toxin somehow accessible by an energydependent process at a plasma membrane site where the toxic effect is manifested by ion leakage and cell death 15 When constant concentrations of sensitive cells were treated with sub saturating concentrations of killer toxin, linear rates of killing were observed, thus suggesting a single-hit process 16 Since krel and kre2 mutant spheroplasts are sensitive to the toxin, while those with mutation of the kre3 nuclear gene are resistant, even though normal cell wall binding occurs, it may be that the latter gene encodes for or is in some other way involved with the cytoplasmic membrane receptor site Two different hypotheses have been proposed for killer toxin resistance in the immune cell The immunity determinant (22-kDa) might alter or mask the plasma membrane receptor site, rendering its interaction with the a domains derived from exogenous killer toxin impossible Alternatively, the immunity determinant might mediate the relocation or removal of the receptor from the cytoplasmic membrane, a process in which vp2 and end genes might be involved,17 though protease production by immune strains for cleaving killer toxin should not be excluded Studies using artificial phospholipid bilayer membranes have revealed that the purified toxin from Pichia kluyveri, like the K1 and K2 S cerevisiae toxins, causes ion-permeable channels to form in the bilayer 18 The formation of pores and proton pumping is not part of the killing effect of a P mrakii toxin This basic polypeptide, composed of 88 amino acid residues, is devoid of mannosides and has an isoelectric point of 9.1 and a molecular size of 10,721 Da 19 It selectively inhibits the synthesis of J3-glucan in the cell wall of sensitive S cerevisiae cells 20 Cell wall synthesis of proteins, mannan, chitin, and the alkali-insoluble, acid-soluble polysaccharides is not affected by the toxin Like S cerevisiae, the corn smut pathogen Ustilago maydis secretes glycoprotein toxins 21 There are three different, though closely related, killer systems (PI, P4, and P6) which are associated with cytoplasmic dsRNAs in VLPS.22-24 The strains in one system kill those of the other two systems, though they are immune to their own toxins All three toxins consist of a 12.5-kDa and a 1O-kDa peptide chain linked by disulfide bonds only, and both polypeptides are essential for toxic activity Temperature-sensitive, nonkiller mutants secrete an inactive toxin which lacks the 1O-kDa polypeptide; when the missing peptide is added, the killer effects of the toxin are restored The two polypeptides appear to interact sequentially: the 1O-kDa component initiates the toxic effect by acting as a recognition element It interacts with a cell wall receptor to render the cell accessible to the catalytic effects of the 12.5-kDa polypeptide, which apparently induces endonucleolytic cleavage of nucleic acids The U maydis killer strains are lethal only for members of their own and very closely re- 5-Killer System Interactions 141 lated species and have no effect on yeast isolates that are sensitive to other killer yeasts The plasmids of both prokaryotic and eukaryotic microorganisms are usually covalently closed circular DNA molecules, though linear forms exist.25 The killer system of Kluyveromyces lactis, for example, is mediated by two linear dsDNA plasmids: pGKI-l (8.9 kb) and pGKI-2 (13.4 kb) There are approximately 100 copies of each in each haploid cell, and they are cytoplasmically inherited in a non-Mendelian fashion 26 The pGKI-l plasmid confers upon the host cell either the killer (gene located in the central part) or the immunity (gene located in the terminal part of the plasmid) phenotype Replication and maintenance of the pGKI-l plasmid are probably controlled by the pGKI-2 plasmid The K lactis killer toxin consists of three subunits: a glycosylated polypeptide with an approximate molecular size of 100,000 Da and two smaller nonglycosylated components of 30,000 and 27,500 Da These three proteins are produced by two distinct RNAs, each of which includes a signal sequence 27 The first two subunits are derived from a larger precursor The toxin inhibits adenylate cyclase in sensitive strains, causing them to arrest in the G phase of growth This arrest can be reversed by the addition of cyclic AMP, which is recognized as necessary for the initiation of a new mitotic cycle in normal cells While many aspects of the killer phenomenon in K lactis (such as pH and temperature range for toxin activity, spectrum of activity, and even mode of action) are different from those of S cerevisiae, killer cells of both species can be deprived of their toxic properties by physical and chemical curing processes (growth in cycloheximide or ethidium bromide or at elevated temperatures) Both dsRNA and dsDNA plasmids may be transferred, by protoplast fusion and transformation techniques, to (heterologous) nonkiller (sensitive) strains to confer the killer (and resistant) phenotype to the recipient cells K lactis dsDNA plasm ids can replicate autonomously and stably in the S cerevisiae new host and can coexist with the resident dsRNA, although they are incompatible with mitochondrial DNA.28 The resultant killer strains may produce larger amounts of killer toxin than the K lactis did Extracellular transmission of the dsRNA VLPs of S cerevisiae has also been demonstrated 29 The toxin of Pichia anomala (Fig 5-1a) has proven to be a potent killer of many different genera of yeasts, including many pathogenic species 3O The genetic basis and the mechanism of action have not yet been identified Studies of the saturation kinetics of this toxin in Candida albicans cells suggest the presence of a toxin receptor, probably located on the cell wa1l3l (Fig 5-1b) Killing activity against C albicans is greatest during the early exponential growth phase of P anomala, while the highest activity against Saccharomycodes ludwigii occurs during the late phase This would suggest that P anomala produces more than one active component Like the toxin of S cerevisiae, the P anomala toxin acts by binding to a Polonelli et aI 142 KILLER SYSTEM INTERACTIONS INDIRECT IMMUNOFLUORESCE 'CE OCCUI\IIE CE or PHE OME ON IOIOTYPIC VACCI ATION ~II.I.ER PfJyriIuU ~r.lih rt!mVery 1on YEAST KII.I.ER TOXI THERAPEUTIC EFFECT FIG 5-1 Killer system interactions For detailed descriptions, see text receptor site, but its range of activity is much broader, including microorganisms of various genera Unlike the toxin of K lactis, this toxin is not counteracted by cyclic AMP These phenomena suggest that the P anomala killer toxin has a unique mode of action 32 Hat-spored species that were formerly classified in the genus Hansenula have now been included in the genus Pichia, since identity of the two genera was demonstrated by DNA comparisons.33 Segregation of the recombinant killer phenotype from the meiotic tetrads of crosses between killer and nonkiller strains of P anomala have shown that one or more nuclear genes must be involved in expression of the killer character.34 The search for RNA or DNA plasmids in many other Pichia (former Hansenula) species have also failed to yield positive results (N Gunge, personal communication) Killer toxin-producing yeast isolates belonging to the pathogenic genera Cryptococcus and Torulopsis have been isolated from natural habitats, although the genetic determinants for their toxinogenesis and toxin bioaction modalities are still unknown.35 The field has been extensively reviewed in whole or in part by several authors.36- 41 These reviews have been very useful to the authors, and readers will find in them further references and sometimes alternative viewpoints The different susceptibilities of potential sensitive yeasts to the activity of 5-Killer System Interactions 143 potential killer yeasts must be attributed to different mechanisms of immunity In the S cerevisiae Kl system, binding of the killer toxin to the cell wall receptor is substantially reduced in krel and kre2 mutants,42 which are considered resistant Binding would thus seem to be a prerequisite for the sensitive phenotype 43 The Kl killer toxin is lethal for spheroplasts of Candida, Kluyveromyces, and Schwanniomyces isolates, though intact cells of the same microorganisms are toxin resistant Killer spheroplasts themselves also remain immune to their own toxin The Kl toxin is poorly retained by the cell wall of K iacUs, but the C albicans wall binds the toxin to more or less the same extent as that of sensitive S cerevisiae species Thus, yeast killer toxin specificity is defined by cell wall receptors which are necessary for binding but not sufficient for toxin action at the plasma membrane of the intact cells 44 It is possible that there are additional unidentified cell wall components for killer toxin activity that are missing in the wall of C albicans Alternatively, there could be some structural differences in the wall of this species which prevent the glucan receptor-bound toxin from reaching the plasma membrane Such observations emphasize the need for further study of the structure and protein transport systems of the yeast cell wall Saccharomyces cerevisiae strains carrying a 1.8-kb M dsRNA, which codes for polypeptide toxin and a resistance function, are resistant to S cerevisiae Kl killer toxin, though they not present a significant reduction in the number of (1,6)-J3-D-glucan cell wall receptors Remarkable amounts of killer toxin are retained by binding to the killer cell's own cell wall The chromosomal rexl gene is also involved in this form of resistance 45 Whether this phenomenon represents the mechanism of resistance or not, all resistant strains bind a certain amount of toxin to the cell walls, indicating that they contain receptors similar to those that exist in wild-type sensitive strains 42 Killer cells themselves present cell wall receptors for their own toxin, which act as a barrier to the toxin after it passes through the plasma membrane on its outward path Binding of the toxin by isolates that contain sterically compatible cell wall receptors might also reduce toxin activity against sensitive cells (unpublished data) In krel mutants, which lack such receptors, a superkiller phenotype results when M dsRNA is introduced Phenylmethylsulfonyl fluoride-sensitive protease in the cell wall may also degrade the toxin before it can be secreted In fact, mutation of the superkiller (skiS) gene, which controls this enzyme, results in the production of an active killer toxin more concentrated than that produced by the nonmutant strain 46 The various mechanisms of immunity invariably result in differential susceptibility of the yeasts to the toxins of defined killer strains In a reciprocal killer assay, yeast isolates were alternatively used as killer or sensitive strains Many strains exhibited both killer and susceptible behavior, depending on the strain they were matched against and the conditions under which the assay was performed 47 The production of inhibitory factors (killer toxins) can be assumed to play 144 Poionelli et al an important role in the modification of the ecosystems of natural habitats 34 and infected organisms (amensalism) Studies in animals have clearly shown that the killer yeast P anomala is able to secrete toxin in vivo in both immunosuppressed and normal mice after experimental infection 48 The use of selected killer yeasts during brewing processes has been considered to prevent the growth of contaminating strains It has been speculated, moreover, that the potential capacity of U maydis killer proteins to specifically inhibit U maydis sensitive strains could be used in the biological control of cereal smuts, if informational molecules for the production of toxin, introduced into the plant cell cytoplasm, could replicate and express their killing function 49 The Killer System as an Epidemiological Marker The impact of hospital-acquired yeast infections has been dramatically demonstrated over the last decade, and the need for a simple, reliable, and sensitive method for differentiating fungal strains beyond the species level has become increasingly pressing Several different methods have been used for this purpose: serotyping, morphologic differentiation, study of mating behavior, enzyme profiles, chemical analyses, and chemical assimilation or resistance patterns 50 The ultimate method for biotyping fungal isolates would be complete DNA base sequencing, but even if this approach was technologically feasible, it would probably result in the complete differentiation of all isolates tested, thus invalidating its use as an epidemiological marker First reported among S cerevisiae strains, the killer yeast phenomenon has subsequently been observed among many other yeast genera 51-53 Killer yeasts have been grouped according to their specificity for killing sensitive yeasts,54 and conversely, sensitive isolates of the same species have been differentiated on the basis of their differential susceptibility to the activity of various killer yeasts The killer typing system, using zone assays similar to those used in phage typing of Salmonella species, was first used to differentiate isolates of the pathogenic yeast species C albicans55 and subsequently applied to the epidemiological study of nosocomial infections caused by this yeast species 56 The adoption of simple test conditions allowed investigators to evaluate the susceptibility of these isolates to the activity of selected killer yeasts, primarily those of Pichia spp Under the same test conditions it was possible to extend the typing to other opportunistic species of yeasts (C ryptococcus neoformans, C glabrata, C parapsilosis, C pseudotropicalis, and C tropicalis) 30 On the basis of their susceptibilities to the panel of selected killer strains, these opportunistic yeasts could be grouped into reproducible categories that contained strains that were serotypically heterogeneous The ability of the killer yeasts to exert their toxic effects was naturally -Killer System Interactions 145 affected by temperature, pH, and composition of the growth medium, conditions that varied according to the requirements of the target species being studied To avoid some of these restrictions, isolated and partially purified toxins were used instead of streaked whole yeasts 57 The use of killer toxins in place of killer yeasts, although more laborious, improved the standardization of the system Killer toxins proved to be stable when partially purified, concentrated, and stored at 4°C, thus ensuring a high degree of test reproducibility A computer program automatically divided the C albicans isolates studied into groups according to their susceptibility to the killer toxins The program was designed to allow a maximum error of 5% in strain differentiation The computer-aided program permitted the biotyping of the investigated yeast isolates in terms of the group percentage of probable affinity Computer interpretation of the results eliminated subjective interpretation The storage of the data in the computer allowed a rapid comparison of any new result with the results of the groups coded previously, thus simplifying its application in epidemiological studies The original test conditions were also used to evaluate the occurrence of sensitivity of hyphomycetes, bacteria, and achlorophyllous microorganisms to the activity of recognized killer yeasts 58 Killer toxins appeared to be inhibitory to a wide variety of prokaryotic and eukaryotic microorganisms other than yeasts (Fig 5-1c) As expected, the highest activity was displayed by the isolates of Pichia spp tested All of the bacteria and fungi that were able to grow under the experimental conditions proved to be sensitive to at least one killer yeast tested The killing effect was expressed differently against the various species of bacteria and hyphomycetes and strains within the same species The inhibitory effect observed might not necessarily be caused by the killer toxins themselves but rather by other metabolic products If the killer phenomenon among yeasts, bacteria, aerobic actinomycetes, hyphomycetes, and achlorophyllous microorganisms could be confirmed with purified killer toxins, this would imply common cell wall binding receptors and bioaction modalities The differential susceptibility of bacteria and hyphomycetes to the killer strains could be used for epidemiological differentiation of strains within the same species in much the same way that bacteriocin typing of gram-negative and gram-positive bacteria is used 59,60 Gross morphology and microscopic features are inconsistent criteria for distinguishing intraspecific mycelial cultures Pleomorphism and lack of sporulation pose major difficulties to mycologists attempting the biotyping of mycelial fungi Unfortunately, with the possible exception of C albicans61 and C neoformans, 62 serologic differentiation of fungi has proven to be less discriminatory than serotyping of pathogenic bacteria The exoantigen technique has revealed two serotypes in Blastomyces dermatitidis,63 and antigenic variability among isolates of Sporothrix schenckii has been detected by indirect immunofluorescence 64 Monoclonal antibodies have proven to be very useful for serotyping yeastlike and mycelial 146 Polonelli et aI fungi by using the Western blot technique 65 •66 This immunological approach, however, requires reagents and technology that are not often available to small laboratories The toxic effect of numerous selected killer yeasts has been studied on Penicillium camemberti, S schenckii, Aspergillus niger, Pseudoallescheria boydii,67 and A fumigatus and related taxa 68 The killer system proved to be a reliable tool for the biotyping of these mycelial cultures Although different procedures have been developed for differentiating isolates of gram-positive and gram-negative bacterial species, fewer possibilities have been reported for distinguishing strains of slowly growing bacteria such as aerobic actinomycetes and mycobacteria The killer system, preViously standardized for yeasts and hyphomycetes, has been adapted to the specific growth conditions of the bacterial isolates The (modified) killer system proved to be a convenient and flexible biotyping method for strain differentiation of Nocardia asteroides, N brasiliensis, N otitidis caviarum, and Actinomadura madurae 69 as well as Acinetobacter calcoaceticus, Escherichia coli, Pseudomonas aeruginosa, Haemophilus injluenzae, Neisseria meningitidis (beyond the conventional serotype level), staphylococcus aureus, group A /3-hemolytic streptococci, Mycobacterium tubercolosis, M fortuitum, and M smegmatis 70 The specific growth conditions of each bacterial species under which killer yeasts could still exert their potential killer activity were identified, and there were remarkable variations in pH, temperature, and oxygen concentration It is likely, however, that more than one killer toxin is produced by the same yeast, each of which is active under different conditions Several typing systems, in addition to serotyping and antibiotic susceptibility, have, of course, been used for such bacterial species: phage susceptibility,71-73 enzyme production,74,75 bacteriocin production or susceptibility, 76, 77 DNA hybridization,78 and R plasmid analysis 79 Most of these methods, however, are too laborious to be reproduced with a large number of isolates in small microbiological laboratories The killer system, properly adapted to the growth requirements of the sensitive species, may be a convenient biotyping method for a large number of prokaryotic and eukaryotic microorganisms It requires no specific technical expertise and can be carried out using commercially available media and a set of suitable killer yeasts Antibiotic Potential of Yeast Killer Toxins Many of the etiologic agents of systemic mycoses have a parasitic form in infected tissues that is structurally and morphologically different from the one they present in the cultural phase The in vitro susceptibility to selected killer toxins of both the mycelial and yeast forms of S schenckii isolates were therefore evaluated comparatively80 (Fig 5-1d) 10 (II)-The Need for a Mycoses Reporting System CARL YN HALDE, MIRIAM VALESCO, AND MARTHA FLORES In recent years, human fungal infections have taken on a new dimension Many fungi that previously were considered normal flora, colonists, or environmental saprobes now threaten the lives of individuals, particularly those individuals with underlying debilitating diseases These compromised individuals, when infected by any systemic fungal pathogen, are likely to develop disseminated disease The rapidity of invasiveness of some of the opportunists, the paucity of effective, nontoxic antifungal drugs, and the lack of vaccines are serious challenges to the health of a growing segment of the population These individuals and communities suffering from serious systemic or opportunistic mycoses impact immediately on health care systems The extent of this impact, nationally, is largely unknown due to the lack of a national mycoses reporting system A comprehensive, prospective survey documenting the yearly incidence of the systemic and opportunistic mycoses in North America has never been attempted The need for such a national survey as well as an ongoing reporting system will be discussed, particularly as it involves vital members of the health care team: the clinician, health science educators, pharmaceutical and biomedical supply industries, the medical laboratory mycologist, and governmental health care agencies In the United States today, only a few state health departments require reporting of only a few of the systemic mycoses Usually, this information does not go beyond the state level Individuals seeking information about particular mycoses often have to go to regional, national, or even international meetings or communicate personally with researchers working on specific mycoses to obtain information on the frequency of each mycosis Although individual case reports can be found in the literature, very few comprehensive or cumulative mycoses reports are available Often even these communication systems not reach all those who are concerned about mycotic diseases Instances where a concerted effort has been made to document the incidence of mycoses are usually associated with outbreaks For example, the 259 260 Carlyn Halde, Miriam Valesco, and Martha Flores histoplasmosis epidemic following Earth Day in Ohio in 1970 involved over 384 students and facultyl It was eventually terminated by decontamination of the school courtyard soil Similar attempts to measure the incidence of systemic mycoses in the United States have involved reviewing hospital discharge records One such study compared hospitalization records of 1970 and 1976 and projected future incidence of specific mycoses based on increases observed in numbers of cases between the years3 Outbreaks and hospital case reviews such as these serve to heighten the awareness of an endemic mycosis but represent only a limited view of the true incidence of any particular mycoses The Clinician's Need for Mycoses Reporting Reporting of mycoses, whether by individual case reports or by outbreak, involves numerous members of the health care team Often clinicians are the first to suspect or recognize a case A mycosis in the differential diagnosis is more easily included if current information on morbidity of specific fungal diseases in their locality is readily available At present this information may only be available from infection control records in a hospital or from those local or reference laboratories providing a diagnostic mycology service As clinicians and other health care workers see more immigrant, transient, and highly mobile populations they will need current information also on the national and worldwide distribution of fungal disease With the ever widening spectrum of fungal diseases, it also becomes increasingly more difficult to maintain current knowledge of clinically significant fungi Clinicians could use a centralized reporting system as an educational tool to learn of newly recognized fungal pathogens, their clinical manifestations, and therapeutic outcomes Once alerted, a clinician may opt to learn more about the outcome of previously reported cases, the tests that assist in diagnosis, the name changes of pathogenic fungi, and the current drug therapy of choice These self-educational efforts are less likely to be rewarding where mycotic infections go unreported Thus a centralized reporting system could provide a valuable diagnostic and educational tool for clinicians and other health care workers The Health Education Institutions' Need for Reporting of Mycoses Health science educational institutions allocate a certain number of instructional hours to medical mycology based upon such factors as incidence of a disease in the given locality of the institution For example, since cases of coccidioidomycosis are now found nationwide due to winter tourism to 10 (H)-The Need for a Mycoses Reporting System 261 warmer southwestern areas , adequate clinical training about coccidioidomycosis needs to be included in the training of all medical students and residents Similarly, histoplasmosis, is now being reported in increasing frequency, nationally, in human immunodeficiency virus (HIV) antibody positive patients5 • Similarly, more information on this mycosis needs to be included in medical school curricula in all geographic areas As the number of environmental and plant pathogens find their way into the world of medical mycology, the need for medical mycologists trained in classical mycology becomes readily apparent There is a natural extension of knowledge from botanical mycology to medical mycology but there is a distinct dirth of training programs integrating the two disciplines at universities and other health science education institutions Clinically Significant fungi that prove difficult to identify in the medical mycology laboratory, may require the knowledge of taxonomy and familiarity with the techniques of botanical mycology to be more easily identified The documentation of such fungi in a national survey would point out the need for changes in curricula to more closely reflect the current need for classical mycology training programs at health science institutions Acquired immunodeficiency syndrome (AIDS) captured the interest of many medical research scientists, especially those at universities and health science institutions located in large cities where the incidence is high Opportunistic mycoses found in HIV antibody-positive individuals is well recognized as a harbinger of AIDS and now such infections are included in the diagnosis of AIDS6 Heretofore, funding for basic research on the mycoses has been difficult Now, however, due to AIDS funding, there is an invaluable opportunity to greatly expand our knowledge of the host-parasite relationship, virulence factors, and the genetic basis for unique physiologic, morphologic, metabolic, and taxonomic aspects of these fungi The newest technologies currently employed at many university research centers could be applied to the aforementioned aspects of mycotic disease in an ongoing attempt to both understand and to find effective therapeutic modalities for the opportunistic diseases associated with AIDS Hence, documentation of the increasing incidence of these mycoses in both HIV antibody-positive and -negative patients by a national survey would greatly assist granting agencies in directing funding towards these efforts The Pharmaceutical and Biomedical Supply Industries' Need for the Reporting of Mycoses Progress in the development of efficacious antifungal drugs has seriously lagged behind those advances made with antibacterial and antiviral agents Many pharmaceutical firms are reluctant to invest in the development of antifungal drugs The antifungal drug market may be uncertain, particularly where the incidence of many of the mycoses is unknown 262 earlyn Halde, Miriam Valesco, and Martha Flores A nationwide documentation of the incidence of mycoses would help point the drug industry in specific directions Development of new effective antifungal agents is critical in order to meet the difficult challenge of treating diseases caused by the well recognized as well as the newly emerging opportunistic fungi There is a simultaneous need for the development of both new drugs and improved methods for in vitro antifungal drug susceptibility testing7 • There is current work being done on the standardization of methods for determining drug susceptibility of yeasts as well as mold forms, such as Aspergillus scedosporium and Fusarium sp, to name a few of the current opportunists, but at present only a few laboratories are performing appropriate, well controlled anti-fungal drug tests Biomedical suppliers and manufacturers of antimicrobics have already demonstrated their ability to develop automated rapid methods for determining MICs for bacteria Similar efforts could be directed toward fungi and antifungal agents The laboratory supply industry, likewise, needs to develop media, reagents and kits for the isolation and identification of selected pathogenic fungi Research on and development of newer identification tools such as genetic probes, enzyme analysis, exoantigens, and serologic reagents must be encouraged Increasing the accuracy of diagnostic tests and shortening the time for confirmation of the diagnosis should be stressed Thus, if money is to be allocated by the pharmaceutical and biomedical supply industries for development of therapautic agents and laboratory identification tools, then reliable information concerning the incidence of these infections must become available The Medical Mycologists' Need for the Reporting of Mycoses A mycoses reporting system, which included morbidity and mortality reports, could become a useful liaison between the diagnostic laboratory and the clinician Mycologists working in a diagnostic laboratory, in addition to seeing commonly encountered pathogens and opportunists, may be alerted to unusual or rare species of fungi These reports could be useful to clinicians faced with difficult differential diagnoses Additionally, these reports could act as a communication network between mycologists working in different settings, providing assistance in identification when needed Reporting would also act as a powerful stimulus for self education on many levels, from laboratory director to technologist A mycoses reporting system may well act as a catalyst to encourage laboratories to initiate further training programs and workshops to increase the level of competence of their staff, to procure reference books and laboratory materials and equipment to improve their diagnostic service, and lastly to recognize the value of well trained personnel 10 (H}-The Need for a Mycoses Reporting System 263 The Government's Role No government morbidity and mortality reports on the mycoses are available as they are for measles or tuberculosis, for example The lack of know1edge of how many cases of systemic or opportunistic mycoses occur per year is disquieting in view of the growing segment of the population at risk from infection as alluded to earlier To maintain an effective reporting system, the cooperation of numerous individuals at many levels in the health care system is essential Initially, the clinicians recognize the case, the laboratory identifies the fungus, and the infection control staff, if the patient is hospitalized, may, one or all, report the case to the governmental public health authorities In an ideal system, this report goes from a city to a county to a state and finally to a national public health reporting center If communication systems are optimal, accumulated information is in turn fed back through the chain and clinicians and public health facilities are alerted in a timely manner This is an expensive system requiring careful documentation and can only be accomplished by a government subsidy Although mycoses are not currently required to be reported to national public health centers, the reporting system is in place for many of the communicable diseases A national mycoses survey would show the need for both additional government subsidy and for reporting guidelines which include fungi in the existing national reporting system Meeting the Need In 1988, the executive council of the Medical Mycological Society of the Americas discussed the need for reporting cases of mycoses The senior author (C.H.), together with the other two authors (M.V and M.F.), were designated the organizers of a survey to determine as many systemic and major opportunistic mycoses as possible during 1989 Hospital and public health laboratory staff were chosen to be the participating reporters Letters were sent to various laboratories and an announcement was placed in the Medical Mycological Society of the Americas Newsletter asking for mycoses data reporters To simplify reporting, only the name of the fungus, the site or specimen from which the initial isolation was made, and the date of its collection were requested Patient information was requested but was not always supplied by the survey reporter Sex and age of the patient, as well as the initials of the patient's name, were requested The latter was used to eliminate duplicate reports Whether the patient has AIDS or is HIV antibody positive is to be included in the 1990 survey Ninety-two hospital clinical laboratories, 20 state or provincial public health microbiology laboratories participated Participating laboratories were irregularly distributed throughout the United States and provinces of 264 Carlyn Halde, Miriam Valesco, and Martha Flores 10-1 Systemic fungal isolations from 124 hospital and public health laboratories during 1989" TABLE Fungus Cryptococcus neojornwns Coccidioides immitis Histoplasma capsulatum Blastomyces dernwtitidis Sporothrix schenckii Sex Number of cases Male Female Not reported 1,237 1,372 504 117 63 953 691 329 78 45 192 518 57 34 14 92 63 118 "1,255 reporting months Canada and not all reporters submitted data for the entire year The goal of achieving a statistically representative geographic distribution of reporters was not attained in the first year Data was placed on an IBM personal computer using dBase III plus, Ashton-Tate, 1985, software At the time of this writing, isolations of fungi for 1989 are being tabulated Preliminary findings for the systemic mycoses are shown in Table lO.1 Duplicate reports were eliminated where possible and identification of all fungi were accepted as reported This preliminary information was presented at the 1990 annual meeting of the American Society for Microbiology (Anaheim, CA), Abstract number F-14, ASM, Washington, D.C In summary, the reporting of mycoses should facilitate requests for research grants in many fields of basic and applied mycology In turn, findings from such research should enhance our knowledge of many important aspects of mycoses More importantly, such reporting may allow, for the first time, a more accurate picture of the incidence and significance of mycotic diseases in contemporary medicine Acknowledgement We wish to thank Dr Michael C Rinaldi for his helpful comments References Brodsky AL, Gregg MB, Loewenstein MS, et al Outbreak of histoplasmosis associated with the 1970 Earth Day activities Am J Med 54: 333-342, 1973 Hammerman KJ, Powell KE, Tosh FE The incidence of hospital cases of systemic mycotic infections Sabouraudia, 12: 33-45, 1974 Fraser DW, Ward JL, Ajello L, et al Aspergillosis and other systemic mycoses JAMA 242: 1631-1635, 1979 Harrell ER, Honeycutt WM Coccidioidomycosis: A traveling fungus disease Arch Dernwtol 87: 188-196, 1983 10 (H)-The Need for a Mycoses Reporting System 265 Minamoto G, Armstrong D Fungal infections in AIDS Histoplasmosis and Coccidioidomycosis Infect Dis Ciin North Am, 2:447-456, 1988 CDC Revision of the CDC Surveillance case definition for acquired immunodeficiency syndrome MMWR 36 (no SI):1-9, 1987 National Committee for Clinical Laboratory Standards 1985 Antifungal susceptibility testing; Committee Report NCCLS publication M20-CR Villanova, PA:NCCLS Index A ABPA (allergic bronchopulmonary aspergillosis), 72-75 Aculeacin A, 147 Aerial mycelium, 21-22 Aflatoxin B1, 207, 215 biosynthetic pathway of, 208 Aflatoxins, 213 Agar gel double diffusion, 69 Air crescents, 66 Albumin, plasma, binding of quinone mycotoxins to, 222-223 Alimentary toxic aleukia (ATA), 231, 237 Allylamine antifungal drugs, 158-181 Allylamines, 158, 194 Alternaria, 71 Alveolitis, extrinsic allergic, due to aspergilli,71-72 Amorolfine, 200 Amphotericin B in bronchopulmonary aspergillosis, 70,71,78-79 in fusarial infections, 244-245 for Scytalidium, 17 Anthraquinone pigments, 210 Antibiobodies, 152 Antibiotic activity of anti-idiotypic antibodies, 151-152 of yeast killer toxins, 146-147 Antibodies anti-idiotypic, see Anti-idiotypic antibodies monoclonal, see Monoclonal antibodies Antifungal drugs allylamine, 158-181 azole, see Azole antifungal drugs systemic, 195-197,200-202 Anti-idiotypic antibodies antibiotic activity of, 151-152 yeast killer toxins mimicking, 149150 Antimycotic activity in experimental animals, 164-166 Antimycotics, 70 Arthroconidia, 1, 8, 19-20, 23-24 Aspergillal fungus ball, 66-71, 73 Aspergillary bronchitis, 65 Aspergilli extrinsic allergic alveolitis due to, 7172 hypersensitivity to, 71-75 invasive infection due to, 75-80 saprobic colonization with, 65-71 Aspergillosis, 64 bronchial stump, 65 bronchopulmonary, see Bronchopulmonary aspergillosis disseminated, 73 nosocomial invasive, 75 pseudomembranous necrotizing bronchial, 65 pulmonary, see Pulmonary aspergillosis Aspergillus, 64-80 Aspergillus antigens, circulating, tests for, 78 Aspergillus candidus, 66 Aspergillus clavatus, 66, 71 267 268 Aspergillus flavus, 64, 66, 75, 77, 78, 215 Aspergillus jumigatus, 64, 66, 68, 7175,77-78,80 Aspergillus glaucus group, 75 Asperqillus nidulans, 66 Aspergillus niger, 64-67, 75, 77 Aspergillus terreus, 66, 75 Aspergillus versicolor, 66 Asthma, 71 extrinsic, 71 ATA (alimentary toxic aleukia), 231, 237 Averufin, 219 biosynthetic pathway of, 208 Azole antifungal drugs oral, skin distribution of, 90 skin kinetics of, 88-134 topical, skin distribution of, 88-90 Azole derivatives, 193 B Bacterial plasmids, 138 Bandlike shadows, 73 Basal layer (SB), 102 i3-glucan, 147 Bifonazole, 200 Bisanthraquinoid pigments, 209 Blastomyces dermatitidis, 145 Bronchial stump aspergillosis, 65 Bronchiectasis, 74 Bronchitis, aspergillary, 65 Bronchopulmonary aspergillosis, 64-80 allergic (ABPA), 72-75 amphotericin Bin, 70, 71, 78-79 C C factors, 138 Campesterol, 37 Candida epidemiologic typing of, 43-60 as nosocomial pathogens, 43-44 Candida albicans, 43-45, 47-60 Candida parapsilosis, 47 Candida stellatoidea, 56-57 Candida tropicalis, 44, 47-49, 52, 54, 55,59,60 Index Candidemia, 50-51 Candidiasis, nosocomial, 43-46 Carcinogenicity of quinone mycotoxins, 215-216 Castellani paint, 194 Cavernoscopic evacuation, 70 CHEF (contour-clamp homogeneous field gel electrophoresis), 56-57 Chlamydoconidia, 1, 20, 23, 232 Cholesterol biosynthesis, 173-174 CIE (counterimmunoelectrophoresis), 69 Clinical mycology, 254 Clotrimazole, 89 for Scytalidium, 16 Conidia, 232 Conidioma, 28-31 Contour-clamp homogeneous field gel electrophoresis (CHEF), 56-57 Counterimmunoelectrophoresis (CIE), 69 Cryptococcus, 142 Cultural mutation, 234 Cutinase, 239 Cyclodextrin formulation, 95 Cycloheximide, 2, 9, 10 Cyclopiroxolamine, 89-90 for Scytalidium, 16 Cytochrome P-450, 174-175 Cytoplasmic viruslike particles (VLPS), 137-138 D DE (dermis), 102 Deoxyversicolorin A, 212-214 Dermatophytes, chemical structures of pigments from, 211 onychomycoses due to, 198-203 superficial skin infections caused by, 189-203 Dermatophytoses, chronic, 196 Dermis (DE), 102 DEtBr typing (DNA typing with ethidium bromide staining), 47-51 Diabetes, 14 Dihydroxyanthraquinones, chemical structures of, 217 Index Dimethyl sulfoxide (DMSO) formulation,92,109 Dimethylskyrin, 210 Dimethylversicolorins, 212-214 Disseminated aspergillosis, 73 DMSO (dimethyl sulfoxide) formulation,92,109 DNA, genomic, restriction endonuclease analysis of, 46-51 DNA typing with ethidium bromide staining (DEtBr typing), 47-51 Dothiorella mangijerae, 18 Double-stranded RNA (ds RNA), 137 types of, 138-139 E Echinocandin B, 147 Econazole, 88-89 Efficacy, therapeutic, 131 Electrophoretic techniques, 56-57 Embolotherapy, 70 Emodin, 210, 218 end genes, 139 Endothia parasitica, 137 Enzyme electrophoresis, multilocus, 59 Epidemiologic typing, 40 of Candida species, 43-60 Epidemiological marker, killer system as,144-146 Epidermomycoses, 11 Epidermophyton, Epidermophyton jloccosum, Ergosterol, 37, 170 Ergosterol biosynthesis, 167 inhibition of, 167-170 Erythematous skin lesions, 242-243 Ethidium bromide staining, DNA typing with (DEtBr typing), 47-51 Exosporina jawcetti, 12 Extrinsic allergic alveolitis due to aspergilli,71-72 Extrinsic asthma, 71 F Farmer's lung, 71 Field-inversion gel electrophoresis (FlGE), 56-57 269 Flavoskyrin, 209 Floccosin, 211 Fluconazole in aspergillosis, 79 Fronding hyphae, 36 Fumonisins, 239 Fungal growth, inhibiting, 168 Fungal keratitis, 240 Fungi, viruses and, 137-138 Fungus ball, aspergillal, 66-71, 73 Fusarium, 77, 231-234 disseminated multiorgan infections, 241-245 toxin production, 237-239 virulence factors, 236-239 Fusarium-caused hyalohyphomycosis, 231-245 Fusarium graminearum, 238 Fusarium monilijorme, 237-239, 241 Fusarium oxysporum, 236, 241 Fusarium solani, 234-235, 239-242, 245 Fusarium sporotrichioides, 231, 237, 238 G Genotoxicity in HPC/DNA repair assay, 213-214 Gloved-finger shadows, 73 Griseofulvin, 131-132 for Scytalidium, 16 in tinea barbae, 192 in tinea capitis, 190-191 H Hairless mouse skin, 91-92 Hansenula, 142, 149 Hemoptysis in aspergillosis, 67, 69 Hendersonula, 4, 18, 30-31 Hendersonula toruloidea, 1-18,35-36 Scytalidium synanamorph of, 3-4, 12 Hepatocyte primary culture, see HPC entries Hospital-acquired, see Nosocomial entries HPC (hepatocyte primary culture), 213 Index 270 HPC/DNA repair assay, genotoxicity in, 213-214 Hyalohyphomycosis,74 Fusarium-caused,231-245 Hypersensitivity to aspergilli, 71-75 Hyphae, fronding, 36 Hyphal coils, 24-25 Hyphomycetes, 137-138 Hypovirulence, 137 I Idiotypic vaccination, 152 Imidazole derivatives, 193 Imidazoles, topical, 200 Immunity determinant, 140 Immunoblot fingerprinting, 57-59 IPA (invasive pulmonary aspergillosis), 75-79 Iridosporin, 211 Isoenzyme profiling, 59 Isoenzymes, 59 Itraconazole, 191, 201-202 in aspergillosis, 79 buildup of, 129-130 oral,93-94, 123-130, 131-133 for Scytalidium, 16 in tinea, 195-196 topical, 91-93, 109, 113-117, 130131 K K particles, 138 K1 and K2 killer systems, 138-139 K1 toxin, 143 Keratin, 199 affected, elimination of, 199 Keratitis, fungal, 240 Kerions, scalp, 189 Ketoconazole, 193 long-term administration of, 120 oral, 93, 116, 118-123, 131-133 for Scytalidium, 16, 17 for tinea capitis, 191 topical, 91-93, 94-109, 110-112, 130-131 Killer cells, 143 Killer phenomenon in yeast, 138-144 Killer system as epidemiological marker, 144-146 modified, 146 Killer system interactions, 137-152 Killer systems K1 and K2, 138-139 Killer toxins, 145 yeast, see Yeast killer toxins Killer yeasts, 144-145 Kluyveromyces lactis, 141 kre mutants, 139-140 KTl,148 KT4, 148-149 L L dsRNA, 138-139 Latin America, 255 teaching medical mycology in, 251256 Lung scans, strontium, 67 Luteoskyrin, 209, 215, 217 Luteosporin, 211, 212, 217-218 M M dsRNA, 138-139 MAbs, see Monoclonal antibodies Macroconidia, 232-233 Magenta paint, 194 Malasseziajurjur, 147 Malt worker's lung, 71 Medical mycology, 253 postgraduate teaching of, 254-255 suggested strategies for improvement of teaching of, 253-256 teaching, in Latin America, 251-256 Mesoconidia, 232-233 Miconazole, 89, 200 Microconidia, 232-233 Microsporum, Microsporum audouinii, 190 microsporum canis, 190-192 Microsporum cookei, 210 Minimum inhibitory concentrations (MICs),158 Mitochondrial DNA (mtDNA) sequences, 52-53 Mitochondrial function, toxicity of quinone mycotoxin to, 216-219 Index 271 "Moccasin foot" appearance, Monoclonal antibodies (MAbs), 148 neutralizing yeast killer toxins, 148149 Mouse skin, hairless, 91-92 mtDNA (mitochondrial DNA) sequences, 52-53 Multilocus enzyme electrophoresis, 59 Mushroom worker's lung, 71 Mutagenicity test, Salmonella-microsome, 212-213 Mutation, cultural, 234 Mycelium, aerial, 21-22 Mycetoma, 17 Mycology clinical, 254 medical, see Medical mycology Mycoses, 251 Mycotic diseases, 254 Mycotoxicoses, 207 Mycotoxins, quinone, see Quinone mycotoxins Mycoviruses, 137 Nosocomial candidiasis, 43-46 Nosocomial invasive aspergillosis, 75 Nosocomial pathogens, Candida as, 4344 Nosocomial yeast infections, 144 N Naftifine, 90, 158, 194 antifungal action in vitro, 158-162 antimycotic activity in experimental animals, 164-165 clinical applications of, 176-177 as epoxidase inhibitor, 172-173 fungicidal action, 162, 164 inhibiting fungal growth, 168 pharmacokinetics of, 175-176 topical therapy with, 177-178 Nail bed excision, 199 Nail darkening, Nail infection by Scytalidium, 1-38 Scytalidium clinical disease, 4-16 National mycoses reporting system, 259-264 Nattrassia, 18, 30 Nattrassia mangijerae, 4, 30-32, 36-38 Scytalidium anamorph of, 19,2031,33-38 Necrotizing pulmonary aspergillosis, chronic, 79-80 P PAGE (polyacrylamide gel electrophoresis), 46, 57-59 Papulocandin B, 147 Parallel line shadows, 73 Paronychia, PEG (polyethylene glycol) formulation, 89 Penicillium, 137 Penicillium griseojulveum, 190 Penicillium islandicum, 215 Perihilar pseudoadenopathy, 73 Phaeohyphomycosis,74 subcutaneous, 17 Phosphorylation, oxidative, 216 Physion, 210 Pichia, 142, 149 Pichia anomala, 141-142, 144 Pichia kluyveri, 140 Pityriasis versicolor, 122 Polyacrylamide gel electrophoresis (PAGE), 46, 57-59 Polyethylene glycol (PEG) formulation, 89 o OFAGE (orthogonal-field alternation gel electrophoresis), 56-57 Ohrysophanol,210 Oil/water system, 95 Onycholysis, Onychomycosis, 178 due to dermatophytes, 198-203 Ophiostoma ulmi, 137 Ophthalmitis, 240-241 Orthogonal-field alternation gel electrophoresis (OFAGE), 56-57 Osteomyelitis, 241 Oxalic acid, 67, 77 Oxiconazole, 89 Oxidative phosphorylation, 216 272 Polyhydroxyanthraquinones, 213 Prednisone in bronchopulmonary aspergillosis, 74 Preprotoxin, 139 Protoxin, 139 Pseudoadenopathy, perihilar, 73 Eseudomembranous necrotizing bronchial aspergillosis, 65 Pulmonary aspergillal fungus ball, 6671,73 Pulmonary aspergillosis chronic necrotizing, 79-80 invasive (IPA), 75-79 Pulsed-field electrophoretic techniques, 56-57 Pycnidia, 27 Pyoderma, 178 Q Quinone mycotoxins binding of, to plasma albumin, 222223 carcinogenicity of, 215-216 reduction-oxidation reaction of, 220221 toxic actions of, 207-223 toxicity of, to mitochondrial function, 216-219 R Ras-related genes, 137 rDNA probe, Saccharomyces, 51 Reduction-oxidation reaction of quinone mycotoxins, 220-221 Reporting of mycoses clinician's need for, 259 health education institutions' need for, 260 pharmaceutical and biomedical supply industries' need for, 260 medical mycologists' need for, 261 Restriction endonuclease analysis of genomic DNA, 46-51 Restriction fragment length polymorphisms (RFLPs), 48, 51 rex genes, 139 RFLPs (restriction fragment length polymorphisms), 48, 51 Index Ribosomal repeat unit, 51 Ring shadows, 73 Rubrofusarin, 213 Rubroskyrin, 209 Rubrosporin, 211 Rubrosulphin, 211 Rugulosin, 209 S S dsRNA, 138-139 Sabouraud's dextrose agar, Saccharomyces cerevisiae, 138-139 Saccharomyces rDNA probe, 51 Salmonella-microsome mutagenicity test, 212-213 Saperconazole in aspergillosis, 79 Saprobic colonization with aspergilli, 65-71 SB (basal layer), 102 SC, see Stratum corneum entries SCH 39304 in aspergillosis, 79 Scopulariopsis brevicaulis, Scytalidium, 2, 18-19 skin and nail infections by, 1-38 Scytalidium anamorph of Nattressia mangijerae, 19,20-31,33-38 Scytalidium circinatum, 19 Scytalidium dimidiatum, Scytalidl!um hyalinum, 2-11, 13-16, 18-19,31-38 Scytalidium lignicola, 1, 3-4, 19-21, 23,33 Scytalidium synanamorph of Hendersonula toruloidea, 3-4, 12 SDZ 87-469 antifungal action in vitro, 159-162 antimycotic activity in experimental animals, 166 as epoxidase inhibitor, 172-173 fungicidal action, 162 Sebum, 132, 195 sec genes, 139 SG (stratiIm granulosum), 102 Side chain methylation technique, 169 ski genes, 139 Skin distribution of oral antifungals, 90 of topical antifungals, 88-90 Index Skin infection by Scytalidium, 1-38 Scytalidium clinical disease, 4-16 superficial, treatment of, 189-203 Skin kinetics, 88 of azole antifungal drugs, 88-134 Skin lesions, 14 erythematous, 242-243 Skin morphology, 102 Skyrin,210 Southern hybridization analysis, 51-56 Sporothrix schenckii, 145 Squalene accumulation, 171 Squalene epoxidase, 173-174 inhibition of, 171-173 Squalene epoxidation, 170 SS (stratum spinosum), 102 Sterigmatocystin, biosynthetic pathway of,208 Sterol patterns, 37 Strain delineation, rationale for, 44-45 Stratum corneum (sq, 102 Stratum corneum plasma level ratios, 133 Stratum granulosum (SG), 102 Stratum spinosum (SS), 102 Stromata, 27 Strontium lung scans, 67 Sweat, 195 Sweat glands, 122 T Teaching medical mycology in Latin America, 251-256 Terbinafine, 158, 192, 194, 202-203 antifungal action in vitro, 158-162 antimycotic activity in experimental animals, 164-166 antiprotozoal activity, 166 clinical applications of, 176-177 as epoxidase inhibitor, 172-173 fungicidal action, 162-164 inhibiting fungal growth, 168 oral therapy with, 179-181 pharmacokinetics of, 175-176 in tinea, 196 topical therapy with, 178-179 Terconazole, 193 Therapeutic efficacy, 131 273 Tinea barbae, 192 Tinea capitis, oral therapy, 190-192 topical therapy, 189-190 Tinea corporis, 192-197 chronic, 197 Tinea cruris, 192-197 Tinea faciei, 192-197 Tinea imbricata, 197 Tinea manus acute, 197-198 chronic, 198 Tinea nigra, Tinea pedis, 177 acute, 197-198 chronic, 197,198 Tinea unguium, 198-203 Tioconazole, 200 Toe web infection, Tolnaftate, 193 Torula dimidiata, 12 Torulopsis, 142 Torulopsis (Candida) glabrata, 52, 56 Toxin receptor, 141 Tram-line shadows, 73 Trichophyton, Trichophyton interdigitale, Trichophyton rubrum, 2, 5, 20, 191 Trichophyton schoenleinii, 190 Trichophyton tonsurans, 190 Trichophyton verrucosum, 16-17, 191 Trichothecenes, 237, 239 Turkey X-disease, 207 U Ubiquinone, 207 Undecylenic acid creams, 194 Ustilago maydis, 140, 144 V Vaccination, idiotypic, 152 Versicolorin A, 207, 219 Versicolorins, 212-214 biosynthetic pathway of, 208 Viomellein, 211 Viopurpurin, 211 274 Vioxanthin, 211 Viruses, fungi and, 137-138 Viruslike particles, cytoplasmic (VLPs), 137-138 vpl genes, 39 W Whitfield's ointment, 193 Wood's lamp examination, 190 X Xanthomegnin, 210, 211, 212, 217 absorption spectrum of, 222 redox reaction of, 220-221 Xanthomegnin shunt, 220-221 Index Y Yeast, 137 killer, 144-145 killer phenomenon in, 138-144 Yeast infections, nosocomial, 144 Yeast killer toxins antibiotic potential of, 146-147 microbial receptors for, 150-151 mimicking anti-idiotypic antibodies, 149-150 monoclonal antibodies neutralizing, 148-149 Z Zygomycosis, 17 Zymosterol,37 ... Naftifine Terbinafine SDZ 87-469a Reference(s) 1.6-> 128 0 .2- 3.1 25 2: :20 0 50 -20 0 1.0-100 16 -20 0 50- 128 1.0-> 128 4.0-64 0.8-300 6 .25 -> 128 0.1-0.8 6 .25 -100 2: :100 50 -2: :100 0.1-3.1 0.5-50 20 - 128 0 .25 -> 128 ... albicans Guinea pig Guinea pig Guinea pig Guinea pig Guinea pig Guinea pig (skin) Guinea pig (skin) Rat (vaginal) 0.06% 2% 0.5% mglkg 40 mglkg 2% 1% 4%a Reference 11 54 11 11 12 11 12 11 • In one... 19 21 23 25 27 29 31 *dorsal surface of external ear days FIG 6-5 Antimycotic activity of terbinafine in comparison with griseofulvin in vivo, using the skin temperature test The ears of guinea