John N Galgiani
- Director, Valley Fever Center for Excellence
- Professor, Medicine
- Professor, BIO5 Institute
Dr. Galgiani has focused his career on Arizona’s special problems with Valley Fever. His work has included studies of the impact of Valley Fever on the general population and on special groups such as organ transplant recipients and patients with AIDS. For 19 years, as part of the NIH-sponsored Mycoses Study Group, Dr. Galgiani has been the project director of a coccidioidomycosis clinical trials group. Through collaboration, this group has evaluated new therapies for Valley Fever more rapidly and with greater clarity than might otherwise have been possible by investigators working in isolation. Dr. Galgiani has also been involved with efforts to prevent Valley Fever through vaccination. His group discovered and patented a recombinant antigen which is the basis for a vaccine candidate suitable for further development and clinical trials. He is currently leading a program to develop a live, avirulent vaccine candidate discovered by others at the UA. He is also the project leader for developing a new drug, nikkomycin Z, for treating Valley Fever. With NIH and FDA grant awards, clinical trials with this drug were resumed in 2007. Dr. Galgiani is also Chief Medical Officer of Valley Fever Solutions, Inc, a start-up company founded to assist in the drug’s development.
In 1996, the Arizona Board of Regents accepted Dr. Galgiani’s proposal to establish the Valley Fever Center for Excellence for the Arizona universities. Based at the University of Arizona, the Center is pledged to spread information about Valley Fever, help patients with the severest complications of this disease, and to encourage research into the biology and diseases of its etiologic agent. The Center maintains a website (www.VFCE.Arizona.edu) and answers inquiries from health care professionals located in Arizona, other parts of the United States, and even from other countries. The Valley Fever Corridor Project, begun in 2009, intends to facilitate communication among Arizona clinicians to also improve patient care. Research is increasing into the environmental biology of the fungus within its desert soil habitat as well as how the fungus caused disease and the body’s immunity controls it. Since Arizona has the only medical schools situated directly within the endemic region for Valley Fever, it is quite appropriate that Arizona lead in solving this problem. As Director of the Center, Dr. Galgiani is working for its full implementation as a means of ensuring an institutional commitment to accomplish this goal.
- M.D. Medicine
- Northwestern Medical School, Chicago, Illinois, United States
- B.S. Biology
- Stanford University, Palo Alto, California, United States
- Chief Medical Officer, Valley Fever Solutions, Inc (2007 - Ongoing)
- Director, Valley Fever Center for Excellence, University of Arizona, Tucson, Arizona (1996 - Ongoing)
- Professor with Tenure, University of Arizona, Tucson, Arizona (1990 - Ongoing)
- Associate Professor with Tenure, University of Arizona, Tucson, Arizona (1984 - 2009)
- Chief, Section of Infectious Diseases, Southern Arizona VA Health Care System (1978 - 2009)
- Assistant Professor of Medicine, University of Arizona, Tucson, Arizona (1978 - 1984)
- Fellow, Stanford University, Palo Alto, California (1974 - 1976)
- Infectious Diseases Society of America, Spring 1987
- American College of Physicians, Spring 1982
- Public Health Service Award
- Arizona Medical Society, Summer 2012
- Arizona Medical Association, Spring 2012
- Innovation Day Leading Edge Researcher
- University of Arizona, Fall 2008
- Founders Day Award
- UA COM-Tucson, Fall 2003
- University of Arizona College of Medicine, Fall 2003
- Achievement Award
- Coccidioidomycosis Study Group, Spring 2001
Licensure & Certification
- Board Certification, American Board of Internal Medicine (1978)
- Medical Licensure, Arizona, Arizona Medical Board (1978)
- Medical Licensure, California, Medical Board of California (1973)
No activities entered.
- Brown, H. E., Comrie, A. C., Tamerius, J., Khan, M., Tabor, J. A., & Galgiani, J. N. (2014). Climate, wind storms, and the risk of valley fever (coccidioidomycosis). In The Influence of Global Environmental Change on Infectious Disease Dynamics(pp Chapter A12). Washington, D.C.: The National Academies Press.
- Galgiani, J. N., Ampel, N. M., Blair, J. E., Catanzaro, A., Geertsma, F., Hoover, S. E., Johnson, R. H., Kusne, S., Lisse, J., MacDonald, J. D., Meyerson, S. L., Raksin, P. B., Siever, J., Stevens, D. A., Sunenshine, R., & Theodore, N. (2016). 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 63(6), e112-46.More infoIt is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.
- Galgiani, J. N., Ampel, N. M., Blair, J. E., Catanzaro, A., Geertsma, F., Hoover, S. E., Johnson, R. H., Kusne, S., Lisse, J., MacDonald, J. D., Meyerson, S. L., Raksin, P. B., Siever, J., Stevens, D. A., Sunenshine, R., & Theodore, N. (2016). Executive Summary: 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Treatment of Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 63(6), 717-22.More infoIt is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which eventually resolves whether or not antifungal therapy is administered, to a variety of pulmonary and extrapulmonary complications. Additional recommendations address management of coccidioidomycosis occurring for special at-risk populations. Finally, preemptive management strategies are outlined in certain at-risk populations and after unintentional laboratory exposure.
- Narra, H. P., Shubitz, L. F., Mandel, M. A., Trinh, H. T., Griffin, K., Buntzman, A. S., Frelinger, J. A., Galgiani, J. N., & Orbach, M. J. (2016). A Coccidioides posadasii CPS1 Deletion Mutant Is Avirulent and Protects Mice from Lethal Infection. Infection and immunity, 84(10), 3007-16.More infoThe CPS1 gene was identified as a virulence factor in the maize pathogen Cochliobolus heterostrophus Hypothesizing that the homologous gene in Coccidioides posadasii could be important for virulence, we created a Δcps1 deletion mutant which was unable to cause disease in three strains of mice (C57BL/6, BALB/c, or the severely immunodeficient NOD-scid,γc(null) [NSG]). Only a single colony was recovered from 1 of 60 C57BL/6 mice following intranasal infections of up to 4,400 spores. Following administration of very high doses (10,000 to 2.5 × 10(7) spores) to NSG and BALB/c mice, spherules were observed in lung sections at time points from day 3 to day 10 postinfection, but nearly all appeared degraded with infrequent endosporulation. Although the role of CPS1 in virulence is not understood, phenotypic alterations and transcription differences of at least 33 genes in the Δcps1 strain versus C. posadasii is consistent with both metabolic and regulatory functions for the gene. The in vitro phenotype of the Δcps1 strain showed slower growth of mycelia with delayed and lower spore production than C. posadasii, and in vitro spherules were smaller. Vaccination of C57BL/6 or BALB/c mice with live Δcps1 spores either intranasally, intraperitoneally, or subcutaneously resulted in over 95% survival with mean residual lung fungal burdens of
- Noble, J. A., Nelson, R. G., Fufaa, G. D., Kang, P., Shafir, S. C., & Galgiani, J. N. (2016). Effect of Geography on the Analysis of Coccidioidomycosis-Associated Deaths, United States. Emerging infectious diseases, 22(10), 1821-3.More infoBecause coccidioidomycosis death rates vary by region, we reanalyzed coccidioidomycosis-associated mortality in the United States by race/ethnicity, then limited analysis to Arizona and California. Coccidioidomycosis-associated deaths were shown to increase among African-Americans but decrease among Native Americans and Hispanics. Separately, in a Native American cohort, diabetes co-varied with coccidioidomycosis-associated death.
- Martirosyan, N. L., Skoch, J. M., Zaninovich, O., Zoccali, C., Galgiani, J. N., & Baaj, A. A. (2015). A paradigm for the evaluation and management of spinal coccidioidomycosis. Surgical neurology international, 6, 107.More infoCoccidioidomycosis is a fungal infection that is endemic to parts of the Southwestern United States. When infection involves the spine, the treatment strategies can be challenging. We have devised a management protocol for spinal coccidioidomycosis based on a review of the literature and our experience.
- Shubitz, L. F., Trinh, H. T., Galgiani, J. N., Lewis, M. L., Fothergill, A. W., Wiederhold, N. P., Barker, B. M., Lewis, E. R., Doyle, A. L., Hoekstra, W. J., Schotzinger, R. J., & Garvey, E. P. (2015). Evaluation of VT-1161 for Treatment of Coccidioidomycosis in Murine Infection Models. Antimicrobial agents and chemotherapy, 59(12), 7249-54.More infoCoccidioidomycosis, or valley fever, is a growing health concern endemic to the southwestern United States. Safer, more effective, and more easily administered drugs are needed especially for severe, chronic, or unresponsive infections. The novel fungal CYP51 inhibitor VT-1161 demonstrated in vitro antifungal activity, with MIC50 and MIC90 values of 1 and 2 μg/ml, respectively, against 52 Coccidioides clinical isolates. In the initial animal study, oral doses of 10 and 50 mg/kg VT-1161 significantly reduced fungal burdens and increased survival time in a lethal respiratory model in comparison with treatment with a placebo (P < 0.001). Oral doses of 25 and 50 mg/kg VT-1161 were similarly efficacious in the murine central nervous system (CNS) model compared to placebo treatment (P < 0.001). All comparisons with the positive-control drug, fluconazole at 50 mg/kg per day, demonstrated either statistical equivalence or superiority of VT-1161. VT-1161 treatment also prevented dissemination of infection from the original inoculation site to a greater extent than fluconazole. Many of these in vivo results can be explained by the long half-life of VT-1161 leading to sustained high plasma levels. Thus, the efficacy and pharmacokinetics of VT-1161 are attractive characteristics for long-term treatment of this serious fungal infection.
- Wack, E. E., Ampel, N. M., Sunenshine, R. H., & Galgiani, J. N. (2015). The Return of Delayed-Type Hypersensitivity Skin Testing for Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 61(5), 787-91.More infoA skin test that detects dermal hypersensitivity in persons with past infection with Coccidioides species is again available for clinical use. Nearly all of the clinical studies with similar materials were published prior to the 1990s, and as a result, many practicing physicians will be unfamiliar with how skin testing for coccidioidomycosis might be useful in patient management or as a research tool. We review clinical and epidemiological studies with past skin test antigens, the composition of past and current skin test preparations with particular attention to differences in the preservatives, and how the current preparation could be used today.
- Navalkar, K. A., Johnston, S. A., Woodbury, N., Galgiani, J. N., Magee, D. M., Chicacz, Z., & Stafford, P. (2014). Application of immunosignatures for diagnosis of valley fever. Clinical and vaccine immunology : CVI, 21(8), 1169-77.More infoValley fever (VF) is difficult to diagnose, partly because the symptoms of VF are confounded with those of other community-acquired pneumonias. Confirmatory diagnostics detect IgM and IgG antibodies against coccidioidal antigens via immunodiffusion (ID). The false-negative rate can be as high as 50% to 70%, with 5% of symptomatic patients never showing detectable antibody levels. In this study, we tested whether the immunosignature diagnostic can resolve VF false negatives. An immunosignature is the pattern of antibody binding to random-sequence peptides on a peptide microarray. A 10,000-peptide microarray was first used to determine whether valley fever patients can be distinguished from 3 other cohorts with similar infections. After determining the VF-specific peptides, a small 96-peptide diagnostic array was created and tested. The performances of the 10,000-peptide array and the 96-peptide diagnostic array were compared to that of the ID diagnostic standard. The 10,000-peptide microarray classified the VF samples from the other 3 infections with 98% accuracy. It also classified VF false-negative patients with 100% sensitivity in a blinded test set versus 28% sensitivity for ID. The immunosignature microarray has potential for simultaneously distinguishing valley fever patients from those with other fungal or bacterial infections. The same 10,000-peptide array can diagnose VF false-negative patients with 100% sensitivity. The smaller 96-peptide diagnostic array was less specific for diagnosing false negatives. We conclude that the performance of the immunosignature diagnostic exceeds that of the existing standard, and the immunosignature can distinguish related infections and might be used in lieu of existing diagnostics.
- Shubitz, L. F., Trinh, H. T., Perrill, R. H., Thompson, C. M., Hanan, N. J., Galgiani, J. N., & Nix, D. E. (2014). Modeling nikkomycin Z dosing and pharmacology in murine pulmonary coccidioidomycosis preparatory to phase 2 clinical trials. The Journal of infectious diseases, 209(12), 1949-54.More infoNikkomycin Z (NikZ) is a chitin synthase inhibitor with activity against Coccidioides species that is being developed as a first-in-class orphan product for treatment of coccidioidomycosis. It has previously been shown to reduce lethal respiratory infections in mice to undetectable levels when treatment is begun 48 hours after infection. The studies described here focus on bracketing NikZ doses for phase 2 and 3 clinical trials, using an established mouse respiratory infection as a model and starting treatment 120 hours after infection. A dose of 80 mg/kg/day, divided into 2 doses, nearly eradicated infection, and larger doses did not improve fungal clearance. Increasing the duration of treatment from 1 week to 3 weeks resulted in a greater percentage of culture-negative mice. Comparative data show that plasma levels of NikZ that nearly eradicate Coccidioides in mice are achievable in patients and provide a plausibly effective dose range for initial phase 2 clinical studies.
- Galgiani, J. N. (2013). Elements of style in managing coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 56(11), 1586-8.
- Nguyen, C., Barker, B. M., Hoover, S., Nix, D. E., Ampel, N. M., Frelinger, J. A., Orbach, M. J., & Galgiani, J. N. (2013). Recent advances in our understanding of the environmental, epidemiological, immunological, and clinical dimensions of coccidioidomycosis. Clinical microbiology reviews, 26(3), 505-25.More infoCoccidioidomycosis is the endemic mycosis caused by the fungal pathogens Coccidioides immitis and C. posadasii. This review is a summary of the recent advances that have been made in the understanding of this pathogen, including its mycology, genetics, and niche in the environment. Updates on the epidemiology of the organism emphasize that it is a continuing, significant problem in areas of endemicity. For a variety of reasons, the number of reported coccidioidal infections has increased dramatically over the past decade. While continual improvements in the fields of organ transplantation and management of autoimmune disorders and patients with HIV have led to dilemmas with concurrent infection with coccidioidomycosis, they have also led to advances in the understanding of the human immune response to infection. There have been some advances in therapeutics with the increased use of newer azoles. Lastly, there is an overview of the ongoing search for a preventative vaccine.
- Sampaio, E. P., Hsu, A. P., Pechacek, J., Bax, H. I., Dias, D. L., Paulson, M. L., Chandrasekaran, P., Rosen, L. B., Carvalho, D. S., Ding, L., Vinh, D. C., Browne, S. K., Datta, S., Milner, J. D., Kuhns, D. B., Long Priel, D. A., Sadat, M. A., Shiloh, M., De Marco, B., , Alvares, M., et al. (2013). Signal transducer and activator of transcription 1 (STAT1) gain-of-function mutations and disseminated coccidioidomycosis and histoplasmosis. The Journal of allergy and clinical immunology, 131(6), 1624-34.More infoImpaired signaling in the IFN-γ/IL-12 pathway causes susceptibility to severe disseminated infections with mycobacteria and dimorphic yeasts. Dominant gain-of-function mutations in signal transducer and activator of transcription 1 (STAT1) have been associated with chronic mucocutaneous candidiasis.
- Shubitz, L. F., Roy, M. E., Nix, D. E., & Galgiani, J. N. (2013). Efficacy of Nikkomycin Z for respiratory coccidioidomycosis in naturally infected dogs. Medical mycology, 51(7), 747-54.More infoNikkomycin Z (NikZ) is a chitin synthase inhibitor with antifungal efficacy against Coccidioides spp. and other endemic fungi. Dogs suffer a rate and range of natural coccidioidomycosis similar to humans and were considered an excellent model for initially testing NikZ against naturally acquired disease. Twelve dogs with coccidioidal pneumonia that had been present for an average of three months were treated with 250 mg (5-15 kg) or 500 mg (> 15-30 kg) twice daily for 60 days. Nine dogs completed the course of treatment and seven dogs had improvement in disease based on radiographs, clinicopathological parameters, physical examination findings, and subjective assessment by owners; three dogs had resolution or near resolution of disease. Based on this small study, NikZ shows efficacy to treat naturally acquired coccidioidomycosis and merits further development for trials in humans.
- Muhammed, M., Feldmesser, M., Shubitz, L. F., Lionakis, M. S., Sil, A., Wang, Y., Glavis-Bloom, J., Lewis, R. E., Galgiani, J. N., Casadevall, A., Kontoyiannis, D. P., & Mylonakis, E. (2012). Mouse models for the study of fungal pneumonia: a collection of detailed experimental protocols for the study of Coccidioides, Cryptococcus, Fusarium, Histoplasma and combined infection due to Aspergillus-Rhizopus. Virulence, 3(3), 329-38.More infoMouse models have facilitated the study of fungal pneumonia. In this report, we present the working protocols of groups that are working on the following pathogens: Aspergillus, Coccidioides, Cryptococcus, Fusarium, Histoplasma and Rhizopus. We describe the experimental procedures and the detailed methods that have been followed in the experienced laboratories to study pulmonary fungal infection; we also discuss the anticipated results and technical notes, and provide the practical advices that will help the users of these models.
- Stafford, P., Halperin, R., Legutki, J. B., Magee, D. M., Galgiani, J., & Johnston, S. A. (2012). Physical characterization of the "immunosignaturing effect". Molecular & cellular proteomics : MCP, 11(4), M111.011593.More infoIdentifying new, effective biomarkers for diseases is proving to be a challenging problem. We have proposed that antibodies may offer a solution to this problem. The physical features and abundance of antibodies make them ideal biomarkers. Additionally, antibodies are often elicited early in the ontogeny of different chronic and infectious diseases. We previously reported that antibodies from patients with infectious disease and separately those with Alzheimer's disease display a characteristic and reproducible "immunosignature" on a microarray of 10,000 random sequence peptides. Here we investigate the physical and chemical parameters underlying how immunosignaturing works. We first show that a variety of monoclonal and polyclonal antibodies raised against different classes of antigens produce distinct profiles on this microarray and the relative affinities are determined. A proposal for how antibodies bind the random sequences is tested. Sera from vaccinated mice and people suffering from a fugal infection are individually assayed to determine the complexity of signals that can be distinguished. Based on these results, we propose that this simple, general and inexpensive system could be optimized to generate a new class of antibody biomarkers for a wide variety of diseases.
- Taroumian, S., Knowles, S. L., Lisse, J. R., Yanes, J., Ampel, N. M., Vaz, A., Galgiani, J. N., & Hoover, S. E. (2012). Management of coccidioidomycosis in patients receiving biologic response modifiers or disease-modifying antirheumatic drugs. Arthritis care & research, 64(12), 1903-9.More infoCoccidioidomycosis (valley fever) is an endemic fungal infection of the American Southwest, an area with a large population of patients with rheumatic diseases. There are currently no guidelines for management of patients who develop coccidioidomycosis while under treatment with biologic response modifiers (BRMs) or disease-modifying antirheumatic drugs (DMARDs). We conducted a retrospective study of how both concurrent diseases were managed and the patient outcomes at 2 centers in Tucson, Arizona.
- Hector, R. F., Rutherford, G. W., Tsang, C. A., Erhart, L. M., McCotter, O., Anderson, S. M., Komatsu, K., Tabnak, F., Vugia, D. J., Yang, Y., & Galgiani, J. N. (2011). The public health impact of coccidioidomycosis in Arizona and California. International journal of environmental research and public health, 8(4), 1150-73.More infoThe numbers of reported cases of coccidioidomycosis in Arizona and California have risen dramatically over the past decade, with a 97.8% and 91.1% increase in incidence rates from 2001 to 2006 in the two states, respectively. Of those cases with reported race/ethnicity information, Black/African Americans in Arizona and Hispanics and African/Americans in California experienced a disproportionately higher frequency of disease compared to other racial/ethnic groups. Lack of early diagnosis continues to be a problem, particularly in suspect community-acquired pneumonia, underscoring the need for more rapid and sensitive tests. Similarly, the inability of currently available therapeutics to reduce the duration and morbidity of this disease underscores the need for improved therapeutics and a preventive vaccine.
- Shubitz, L. F., Dial, S. M., & Galgiani, J. N. (2011). T-lymphocyte predominance in lesions of canine coccidioidomycosis. Veterinary pathology, 48(5), 1008-11.More infoCoccidioidomycosis is a systemic fungal infection endemic to the southwestern United States. Although cell-mediated immunity is considered critical in control of the infection, little is known of the cellular population in naturally occurring lesions. To characterize the lymphocytic infiltration, archived formalin-fixed, paraffin-embedded tissues (subcutis, pericardium/heart, lung, bone, and synovium) from 18 dogs with coccidioidomycosis were studied with immunohistochemistry for CD3 and CD79a. In nearly all lesions, T lymphocytes were more numerous than B lymphocytes and were distributed throughout the lesion with concentration in the periphery of granulomas, whereas B lymphocytes were mostly confined to the periphery of granulomas. The predominance of T lymphocytes in lesions of canine coccidioidomycosis was independent of the tissue evaluated, the number of intralesional organisms, and the nature or severity of the inflammatory response.
- Vinh, D. C., Schwartz, B., Hsu, A. P., Miranda, D. J., Valdez, P. A., Fink, D., Lau, K. P., Long-Priel, D., Kuhns, D. B., Uzel, G., Pittaluga, S., Hoover, S., Galgiani, J. N., & Holland, S. M. (2011). Interleukin-12 receptor β1 deficiency predisposing to disseminated Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 52(4), e99-e102.
- Neafsey, D. E., Barker, B. M., Sharpton, T. J., Stajich, J. E., Park, D. J., Whiston, E., Hung, C., McMahan, C., White, J., Sykes, S., Heiman, D., Young, S., Zeng, Q., Abouelleil, A., Aftuck, L., Bessette, D., Brown, A., FitzGerald, M., Lui, A., , Macdonald, J. P., et al. (2010). Population genomic sequencing of Coccidioides fungi reveals recent hybridization and transposon control. Genome research, 20(7), 938-46.More infoWe have sequenced the genomes of 18 isolates of the closely related human pathogenic fungi Coccidioides immitis and Coccidioides posadasii to more clearly elucidate population genomic structure, bringing the total number of sequenced genomes for each species to 10. Our data confirm earlier microsatellite-based findings that these species are genetically differentiated, but our population genomics approach reveals that hybridization and genetic introgression have recently occurred between the two species. The directionality of introgression is primarily from C. posadasii to C. immitis, and we find more than 800 genes exhibiting strong evidence of introgression in one or more sequenced isolates. We performed PCR-based sequencing of one region exhibiting introgression in 40 C. immitis isolates to confirm and better define the extent of gene flow between the species. We find more coding sequence than expected by chance in the introgressed regions, suggesting that natural selection may play a role in the observed genetic exchange. We find notable heterogeneity in repetitive sequence composition among the sequenced genomes and present the first detailed genome-wide profile of a repeat-induced point mutation (RIP) process distinctly different from what has been observed in Neurospora. We identify promiscuous HLA-I and HLA-II epitopes in both proteomes and discuss the possible implications of introgression and population genomic data for public health and vaccine candidate prioritization. This study highlights the importance of population genomic data for detecting subtle but potentially important phenomena such as introgression.
- Ostrosky-Zeichner, L., Casadevall, A., Galgiani, J. N., Odds, F. C., & Rex, J. H. (2010). An insight into the antifungal pipeline: selected new molecules and beyond. Nature reviews. Drug discovery, 9(9), 719-27.More infoInvasive fungal infections are increasing in incidence and are associated with substantial mortality. Improved diagnostics and the availability of new antifungals have revolutionized the field of medical mycology in the past decades. This Review focuses on recent developments in the antifungal pipeline, concentrating on promising candidates such as new azoles, polyenes and echinocandins, as well as agents such as nikkomycin Z and the sordarins. Developments in vaccines and antibody-based immunotherapy are also discussed. Few therapeutic products are currently in active development, and progression of therapeutic agents with fungus-specific mechanisms of action is of key importance.
- Stern, N. G., & Galgiani, J. N. (2010). Coccidioidomycosis among scholarship athletes and other college students, Arizona, USA. Emerging infectious diseases, 16(2), 321-3.More infoTo compare coccidioidomycosis case rates among groups of young adults in a disease-endemic region, we reviewed medical charts for serologic testing and coding. Case rates were higher for scholarship athletes than for other students and paralleled 5x more serologic testing. Our findings underscore the need to routinely test patients for coccidioidomycosis.
- Ampel, N. M., Dionne, S. O., Giblin, A., Podany, A. B., & Galgiani, J. (2009). Mannose-binding lectin serum levels are low in persons with clinically active coccidioidomycosis. Mycopathologia, 167(4), 173-80.More infoMannose-binding lectin (MBL) is a circulating collectin that is part of the innate immune response. We explored the serum levels of MBL in persons with different forms of coccidioidomycosis.
- Ampel, N. M., Giblin, A., Mourani, J. P., & Galgiani, J. N. (2009). Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 48(2), 172-8.More infoStudies that assess the value of initiating oral antifungal therapy to treat primary pulmonary coccidioidomycosis have not been published previously.
- Nix, D. E., Swezey, R. R., Hector, R., & Galgiani, J. N. (2009). Pharmacokinetics of nikkomycin Z after single rising oral doses. Antimicrobial agents and chemotherapy, 53(6), 2517-21.More infoNikkomycin Z is an antifungal drug that inhibits chitin synthase. This agent is under development as an orphan product for treatment of coccidioidomycosis. Safety and pharmacokinetics of nikkomycin Z were evaluated in healthy male subjects following single, rising oral doses ranging from 250 mg to 2,000 mg. A total of 12 subjects were recruited and divided into two groups. Group 1 (n = 6) received two out of three doses of 250 mg, 1,000 mg, or 1,750 mg and a placebo randomly in place of one of the doses. Group 2 (n = 6) received two out of three doses of 500 mg, 1,500 mg, or 2,000 mg and a placebo in place of one of the doses. Subjects were confined to the study unit overnight prior to dosing, and 12 blood samples were collected over 24 h postdosing while subjects were confined. Subjects returned for additional blood samples and safety evaluations at 48 h and 72 h after each dose. There was a 2-week washout period between doses. Plasma drug concentrations were determined using a validated high-performance liquid chromatography method. Nikkomycin Z was absorbed after oral administration, reaching a maximum concentration in serum of 2.21 microg/ml at 2 h postdose and an area under the concentration-time curve from 0 h to infinity of 11.3 microg x h/ml for the 250-mg dose. Pharmacokinetics appeared linear over the range of 250 to 500 mg; however, relative bioavailability was about 62 to 70% for the 1,000-mg dose and 42 to 47% for doses between 1,500 and 2,000 mg. The mean terminal half-life ranged from 2.1 to 2.5 h and was independent of dose. No serious or dose-related adverse events were observed. This study provides a basis for pharmacokinetic simulations and continued studies of nikkomycin Z administered in multiple doses.
- Sharpton, T. J., Stajich, J. E., Rounsley, S. D., Gardner, M. J., Wortman, J. R., Jordar, V. S., Maiti, R., Kodira, C. D., Neafsey, D. E., Zeng, Q., Hung, C., McMahan, C., Muszewska, A., Grynberg, M., Mandel, M. A., Kellner, E. M., Barker, B. M., Galgiani, J. N., Orbach, M. J., , Kirkland, T. N., et al. (2009). Comparative genomic analyses of the human fungal pathogens Coccidioides and their relatives. Genome research, 19(10), 1722-31.More infoWhile most Ascomycetes tend to associate principally with plants, the dimorphic fungi Coccidioides immitis and Coccidioides posadasii are primary pathogens of immunocompetent mammals, including humans. Infection results from environmental exposure to Coccidiodies, which is believed to grow as a soil saprophyte in arid deserts. To investigate hypotheses about the life history and evolution of Coccidioides, the genomes of several Onygenales, including C. immitis and C. posadasii; a close, nonpathogenic relative, Uncinocarpus reesii; and a more diverged pathogenic fungus, Histoplasma capsulatum, were sequenced and compared with those of 13 more distantly related Ascomycetes. This analysis identified increases and decreases in gene family size associated with a host/substrate shift from plants to animals in the Onygenales. In addition, comparison among Onygenales genomes revealed evolutionary changes in Coccidioides that may underlie its infectious phenotype, the identification of which may facilitate improved treatment and prevention of coccidioidomycosis. Overall, the results suggest that Coccidioides species are not soil saprophytes, but that they have evolved to remain associated with their dead animal hosts in soil, and that Coccidioides metabolism genes, membrane-related proteins, and putatively antigenic compounds have evolved in response to interaction with an animal host.
- Vinh, D. C., Masannat, F., Dzioba, R. B., Galgiani, J. N., & Holland, S. M. (2009). Refractory disseminated coccidioidomycosis and mycobacteriosis in interferon-gamma receptor 1 deficiency. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 49(6), e62-5.More infoSevere coccidioidomycosis is rare, and specific genetic susceptibility to the disease remains unidentified. We describe a patient with disseminated recalcitrant coccidioidomycosis with autosomal dominant interferon-gamma receptor 1 deficiency caused by a heterozygous IFNGR1 818del4 mutation. Therefore, the interleukin-12/interferon-gamma axis appears to be critical for control of coccidioidomycosis.
- Galgiani, J. N. (2008). Vaccines to prevent systemic mycoses: holy grails meet translational realities. The Journal of infectious diseases, 197(7), 938-40.
- Shubitz, L. F., Dial, S. M., Perrill, R., Casement, R., & Galgiani, J. N. (2008). Vaccine-induced cellular immune responses differ from innate responses in susceptible and resistant strains of mice infected with Coccidioides posadasii. Infection and immunity, 76(12), 5553-64.More infoSusceptibility to Coccidioides spp. varies widely in humans and other mammals and also among individuals within a species. Among strains of mice with various susceptibilities, immunohistopathology revealed that C57BL/6 mice were highly susceptible to the disease following intranasal infection, DBA/2n mice were intermediate, and Swiss-Webster mice were innately resistant. Resistant Swiss-Webster mice developed prominent perivascular/peribronchiolar lymphocytic cuffing and well-formed granulomas with few fungal elements and debris in the necrotic center, surrounded by a mantle of macrophages, lymphocytes, and fibrocytes. Susceptible C57BL/6 mice became moribund between 14 and 18 days postinfection, with overwhelming numbers of neutrophils and spherules and very few T cells, the drastic reduction of which was associated with failure and death, while intermediate DBA/2n mice controlled the fungal burden but demonstrated progressive lung inflammation with prominent suppuration, and they deteriorated clinically. Vaccinated C57BL/6 mice had an early and robust lymphocyte response, which included significantly higher Mac2(+), CD3(+), and CD4(+) cell scores on day 18 than those of innately resistant SW mice and DBA/2n mice; they also had prominent perivascular/peribronchiolar lymphocytic infiltrates not present in their unvaccinated counterparts, and they appeared to be resolving lesions by day 56 compared to the other two strains, based on significantly lower disease scores and observably smaller and fewer lesions with few spherules and neutrophils.
- Catanzaro, A., Cloud, G. A., Stevens, D. A., Levine, B. E., Williams, P. L., Johnson, R. H., Rendon, A., Mirels, L. F., Lutz, J. E., Holloway, M., & Galgiani, J. N. (2007). Safety, tolerance, and efficacy of posaconazole therapy in patients with nonmeningeal disseminated or chronic pulmonary coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 45(5), 562-8.More infoCoccidioidomycosis can be difficult to treat with available therapies, particularly in patients with progressive or disseminated disease. Posaconazole is a new azole antifungal with potent activity against Coccidioides species, the causative agent of coccidioidomycosis.
- Galgiani, J. N. (2007). Coccidioidomycosis: changing perceptions and creating opportunities for its control. Annals of the New York Academy of Sciences, 1111, 1-18.More infoThe perceptions of coccidioidomycosis as a medical problem has undergone sequential and dramatic metamorphoses since its first description more than a century ago. First thought to be rare and lethal, coccidioidomycosis was subsequently found to be common and often mild. During World War II, its overall impact upon large populations came sharply into focus and the consequences for public health became clearer. Early treatments had significant limitations and toxicities, and therefore treatment of coccidioidomycosis was reserved for only the sickest patients. Since then, safer oral therapies have become commonplace. Despite their availability, there has been no investigation of their use in the less severe and much more common early infections. Even newer drugs such as nikkomycin Z, which might actually cure infections, until very recently have had trouble finding a sponsor to move it through clinical trials. Perceptions once formed by the understanding of coccidioidomycosis as a medical problem now appear to hinder the future study of newer therapeutic opportunities. It is suggested in this review that it is time to revisit and possibly change these perceptions if we are to improve our care of patients.
- Johnson, S. M., Lerche, N. W., Pappagianis, D., Yee, J. L., Galgiani, J. N., & Hector, R. F. (2007). Safety, antigenicity, and efficacy of a recombinant coccidioidomycosis vaccine in cynomolgus macaques (Macaca fascicularis). Annals of the New York Academy of Sciences, 1111, 290-300.More infoThe safety, immunogenicity and efficacy of recombinant Ag2/PRA106 + CSA chimeric fusion protein (CFP) vaccine in ISS/Montanide adjuvant-administered intramuscular (IM) was assessed in adult female cynomolgus macaques challenged with Coccidioides posadasii. Animals received three immunizations with either 5 microg CFP, 50-microg CFP, or adjuvant alone and were challenged 4 weeks following the final immunization. Although significant antibody response was produced in response to vaccination, there were no discernable adverse effects, suggesting that the vaccine was well tolerated. Upon intratracheal challenge, all animals showed evidence of disease. Two animals that received 5-microg doses of CFP were euthanatized prior to the study's end because of severe symptoms. Animals vaccinated with 50-microg doses of CFP showed evidence of enhanced sensitization compared to adjuvant controls and animals vaccinated with 5-microg doses of CFP. This was based on higher serum anti-CFP titers, enhanced secretion of interferon-gamma (IFN-gamma) from stimulated bronchoalveolar lavage mononuclear cells (BALMC), reduced pulmonary radiologic findings following intratracheal challenge, reduced terminal complement fixation titers, and reduced necropsy findings. Overall the vaccine was well tolerated, induced sensitization, and resulted in a protective response when given at the higher 50-microg dose. Additional experiments may be needed to optimize the vaccination and to confer greater protection against lethal challenge.
- Li, L., Schmelz, M., Kellner, E. M., Galgiani, J. N., & Orbach, M. J. (2007). Nuclear labeling of Coccidioides posadasii with green fluorescent protein. Annals of the New York Academy of Sciences, 1111, 198-207.More infoCoccidioidomycosis is a mild to life-threatening disease in otherwise healthy humans and other mammals caused by the fungus Coccidioides spp. Understanding the development of the unique dimorphic life cycle of Coccidioides spp. and its role in pathogenesis has been an area of research focus. However, nuclear behavior during the saprobic and parasitic life cycle has not been studied intensively. In this study, green fluorescent protein (GFP) was fused to histone H1 and introduced into Coccidioides posadasii (C. posadasii) strain Silveira to monitor the nuclear behavior of the fungus during the saprobic and parasitic stages of the life cycle. We constructed an Agrobacterium tumefaciens-mediated transformation (ATMT) vector that had in its T-DNA region a hygromycin-resistance gene as well as the fused histone H1-GFP gene under the control of the histone H3 promoter of C. posadasii. More than 30 hygromycin-resistant transformants were obtained and 23 were purified to homozygosity through multiple passages of the original transformants on hygromycin-containing media. One strain (VFC1420) transformed with a single copy of the fusion histone H1-GFP gene was selected for cytological studies. Strong nuclear-localized GFP signals were observed in arthroconidia, hyphae, as well as in spherules and endospores developed in vitro. Thus GFP can be used to study the expression pattern of potential virulence genes identified in serial analysis of gene expression (SAGE) or expressed sequence tags (EST) libraries, and could be a useful tool to monitor disease development in the murine model.
- Rohrbough, J. G., Galgiani, J. N., & Wysocki, V. H. (2007). The application of proteomic techniques to fungal protein identification and quantification. Annals of the New York Academy of Sciences, 1111, 133-46.More infoThe number of sequenced genomes has increased rapidly in the last few years, supporting a revolution in bioinformatics that has been leveraged by scientists seeking to analyze the proteomes of numerous biological systems. The primary technique employed for the identification of peptides and proteins from biological sources is mass spectrometry (MS). This analytical process is usually in the form of whole-protein analysis (termed "top-down" proteomics) or analysis of enzymatically produced peptides (known as the "bottom-up" approach). This article will focus primarily on the more common bottom-up proteomics to include topics such as sample preparation, separation strategies, MS instrumentation, data analysis, and techniques for protein quantification. Strategies for preparation of samples for proteomic analysis, as well as tools for protein and peptide separation will be discussed. A general description of common MS instruments along with tandem mass spectrometry (MS/MS) will be given. Different methodologies of sample ionization including matrix-assisted laser desorption ionization (MALDI) and electrospray ionization (ESI) will be discussed. Data analysis methods including database search algorithms and tools for protein sequence analysis will be introduced. We will also discuss experimental strategies for MS protein quantification using stable isotope labeling techniques and fluorescent labeling. We will introduce several fungal proteomic studies to illustrate the use of these methods. This article will allow investigators to gain a working knowledge of proteomics along with some strengths and weaknesses associated with the techniques presented.
- Dionne, S. O., Podany, A. B., Ruiz, Y. W., Ampel, N. M., Galgiani, J. N., & Lake, D. F. (2006). Spherules derived from Coccidioides posadasii promote human dendritic cell maturation and activation. Infection and immunity, 74(4), 2415-22.More infoPrevious studies have shown that dendritic cells (DC) pulsed with T27K, an antigenic preparation derived from spherules (of Coccidioides posadasii), activate peripheral blood mononuclear cells (PBMC) from nonimmune subjects as well as from patients with disseminated coccidioidomycosis. In this study, we have assessed the interaction between human DC and C. posadasii spherules in order to better understand the initial response between Coccidioides and the human host. Whole autoclaved spherules induced lymphocyte transformation in PBMC obtained from immune but not from nonimmune donors. Immature DC (iDC) bound fluorescein isothiocyanate-labeled spherules in a time- and temperature-dependent manner. This binding was blocked by the addition of mannan, suggesting mannose receptor involvement in the DC-Coccidioides interaction. Binding was subsequently associated with ingestion and intracellular processing of spherules. Coculturing of spherules with iDC was associated with the development of mature DC that were morphologically, phenotypically, and functionally similar to those induced by tumor necrosis factor alpha and prostaglandin E2. Finally, spherules incubated with iDC induced activation of PBMC from nonimmune donors. These data indicate that human DC are capable of binding, internalizing, and presenting antigens from Coccidioides spherules and suggest that DC may play a critical early role in the formation of a cellular immune response in human coccidioidomycosis.
- Mandel, M. A., Galgiani, J. N., Kroken, S., & Orbach, M. J. (2006). Coccidioides posadasii contains single chitin synthase genes corresponding to classes I to VII. Fungal genetics and biology : FG & B, 43(11), 775-88.More infoCoccidioides posadasii is a dimorphic fungal pathogen of humans and other mammals. The switch between saprobic and parasitic growth involves synthesis of new cell walls of which chitin is a significant component. To determine whether particular subsets of chitin synthases (CHSes) are responsible for production of chitin at different stages of differentiation, we have isolated six CHS genes from this fungus. They correspond, together with another reported CHS gene, to single members of the seven defined classes of chitin synthases (classes I-VII). Using Real-Time RT-PCR we show their pattern of expression during morphogenesis. CpCHS2, CpCHS3, and CpCHS6 are preferentially expressed during the saprobic phase, while CpCHS1 and CpCHS4 are more highly expressed during the parasitic phase. CpCHS5 and CpCHS7 expression is similar in both saprobic and parasitic phases. Because C. posadasii contains single members of the seven classes of CHSes found in fungi, it is a good model to investigate the putatively different roles of these genes in fungal growth and differentiation.
- Orsborn, K. I., Shubitz, L. F., Peng, T., Kellner, E. M., Orbach, M. J., Haynes, P. A., & Galgiani, J. N. (2006). Protein expression profiling of Coccidioides posadasii by two-dimensional differential in-gel electrophoresis and evaluation of a newly recognized peroxisomal matrix protein as a recombinant vaccine candidate. Infection and immunity, 74(3), 1865-72.More infoCoccidioides posadasii and Coccidioides immitis are dimorphic, soil-dwelling pathogenic ascomycetes endemic to the southwestern United States. Infection can result from inhalation of a very few arthroconidia, but following natural infection, long-lived immunity is the norm. Previous work in the field has shown that spherule-derived vaccines afford more protection than those from mycelia. We have used two-dimensional differential in-gel electrophoresis coupled with nano-high-performance liquid chromatography-tandem mass spectrometry to directly assess both absolute abundance and differential expression of proteins in the spherule and the mycelial phases of C. posadasii with the intent to identify potential vaccine candidates. Peptides derived from 40 protein spots were analyzed and a probable identity was assigned to each. One spherule-abundant protein, identified as Pmp1, showed homology to allergens from Aspergillus fumigatus and other fungi, all of which exhibit similarity to yeast thiol peroxidases. Recombinant Pmp1 was reactive with serum from individuals with both acute and protracted disease, and evoked protection in two murine models of infection with C. posadasii. These results demonstrate the utility of proteomic analysis as a point of discovery for protective antigens for possible inclusion in a vaccine candidate to prevent coccidioidomycosis.
- Shubitz, L. F., Galgiani, J. N., Tian, Z., Zhong, Z., Timmermans, P., & Katz, L. (2006). Efficacy of ambruticin analogs in a murine model of coccidioidomycosis. Antimicrobial agents and chemotherapy, 50(10), 3467-9.More infoAmbruticin S, an antifungal cyclopropyl-pyran acid, showed curative effects against murine coccidioidal infection. Two analogs of this compound with greater in vitro potency were tested against lethal murine Coccidioides infection. Both improved the survival of mice over that of controls; one resulted in near-sterilization of infection.
- Shubitz, L. F., Yu, J., Hung, C., Kirkland, T. N., Peng, T., Perrill, R., Simons, J., Xue, J., Herr, R. A., Cole, G. T., & Galgiani, J. N. (2006). Improved protection of mice against lethal respiratory infection with Coccidioides posadasii using two recombinant antigens expressed as a single protein. Vaccine, 24(31-32), 5904-11.More infoTwo recombinant antigens which individually protect mice from lethal intranasal infection were studied in combination, either as a mixture of two separately expressed proteins or as a single chimeric expression product. Mice vaccinated with either combination survived longer than mice given single antigens. Immunized mice also exhibited specific IgG immunoglobulins and yielded splenocytes which produced interferon-gamma in response to either antigen. The chimeric antigen has the practical advantage of offering enhanced protection from multiple components without increasing production costs.
- Valdivia, L., Nix, D., Wright, M., Lindberg, E., Fagan, T., Lieberman, D., Stoffer, T., Ampel, N. M., & Galgiani, J. N. (2006). Coccidioidomycosis as a common cause of community-acquired pneumonia. Emerging infectious diseases, 12(6), 958-62.More infoThe early manifestations of coccidioidomycosis (valley fever) are similar to those of other causes of community-acquired pneumonia (CAP). Without specific etiologic testing, the true frequency of valley fever may be underestimated by public health statistics. Therefore, we conducted a prospective observational study of adults with recent onset of a lower respiratory tract syndrome. Valley fever was serologically confirmed in 16 (29%) of 55 persons (95% confidence interval 16%-44%). Antimicrobial medications were used in 81% of persons with valley fever. Symptomatic differences at the time of enrollment had insufficient predictive value for valley fever to guide clinicians without specific laboratory tests. Thus, valley fever is a common cause of CAP after exposure in a disease-endemic region. If CAP develops in persons who travel or reside in Coccidioides-endemic regions, diagnostic evaluation should routinely include laboratory evaluation for this organism.
- Galgiani, J. N., Ampel, N. M., Blair, J. E., Catanzaro, A., Johnson, R. H., Stevens, D. A., Williams, P. L., & , I. D. (2005). Coccidioidomycosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 41(9), 1217-23.
- Kellner, E. M., Orsborn, K. I., Siegel, E. M., Mandel, M. A., Orbach, M. J., & Galgiani, J. N. (2005). Coccidioides posadasii contains a single 1,3-beta-glucan synthase gene that appears to be essential for growth. Eukaryotic cell, 4(1), 111-20.More info1,3-beta-Glucan synthase is responsible for the synthesis of beta-glucan, an essential cell wall structural component in most fungi. We sought to determine whether Coccidioides posadasii possesses genes homologous to known fungal FKS genes that encode the catalytic subunit of 1,3-beta-glucan synthase. A single gene, designated FKS1, was identified, and examination of its predicted protein product showed a high degree of conservation with Fks proteins from other filamentous fungi. FKS1 is expressed at similar levels in mycelia and early spherulating cultures, and expression decreases as the spherules mature. We used Agrobacterium-mediated transformation to create strains that harbor DeltaFKS1::hygB, a null allele of FKS1, and hypothesize that Fks1p function is essential, due to our inability to purify this allele away from a complementing wild-type FKS1 allele in a heterokaryotic strain. The heterokaryon appears normal with respect to growth rate and arthroconidium production; however, microscopic examination of strains with DeltaFKS1::hygB alleles revealed abnormal swelling of hyphal elements.
- Park, B. J., Sigel, K., Vaz, V., Komatsu, K., McRill, C., Phelan, M., Colman, T., Comrie, A. C., Warnock, D. W., Galgiani, J. N., & Hajjeh, R. A. (2005). An epidemic of coccidioidomycosis in Arizona associated with climatic changes, 1998-2001. The Journal of infectious diseases, 191(11), 1981-7.More infoReports of coccidioidomycosis cases in Arizona have increased substantially. We investigated factors associated with the increase.
- Bennett, J. E., Kauffman, C., Walsh, T., de Pauw, B., Dismukes, W., Galgiani, J., Glauser, M., Herbrecht, R., Lee, J., Pappas, P., Powers, J., Rex, J., Verweij, P., & Viscoli, C. (2003). Forum report: issues in the evaluation of diagnostic tests, use of historical controls, and merits of the current multicenter collaborative groups. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 36(Suppl 3), S123-7.More infoThis forum report contains conclusions about 3 different issues relevant to conducting clinical trials in deep mycoses. (1) Trials of diagnostic tests for deep mycoses must define the population appropriate for testing and the clinical question being asked. The unanswered question for the serum Aspergillus galactomannan assay is whether knowledge of results can change use of empirical therapy to treat febrile patients at high risk of invasive aspergillosis. (2) Use of historical controls is suboptimal but offers a pragmatic solution for studying rare mycoses; use of contemporaneous controls, matched for critical variables and evaluated by a blinded data review committee using detailed criteria, appears optimal. (3) Established groups of independent investigators, such as the European Organization for Research on Treatment of Cancer's Invasive Fungal Infections Group and National Institute of Allergy and Infectious Diseases's Bacteriology and Mycology Study Group, provide a pool of experienced investigators, defined operating rules, impartiality, and specialized expertise. Considering the enormous investment required for adequately powered efficacy trials of antifungal agents and the importance of these trials to guide clinical practice, use of collaborative groups outweighs the extra administrative time that is sometimes required.
- Bennett, J. E., Powers, J., Walsh, T., Viscoli, C., de Pauw, B., Dismukes, W., Galgiani, J., Glauser, M., Herbrecht, R., Kauffman, C., Lee, J., Pappas, P., Rex, J., & Verweij, P. (2003). Forum report: issues in clinical trials of empirical antifungal therapy in treating febrile neutropenic patients. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 36(Suppl 3), S117-22.More infoThere is inferential evidence that some patients with prolonged neutropenia and fever not responding to antibacterial agents are at sufficient risk of deep mycoses to warrant empirical therapy, although superiority of an antifungal agent over placebo has not been conclusively demonstrated. Amphotericin B deoxycholate, liposomal amphotericin B, and intravenous itraconazole followed by oral itraconazole solution are licensed in the United States for this indication. Fluconazole and voriconazole have given favorable results in clinical trials of patients with low and high risk of deep mold infections, respectively. Design features that can profoundly influence outcome of empirical trials are (1) inclusion of low-risk patients, (2) failure to blind the study, (3) obscuration of antifungal effects by changing antibacterial antibiotics, (4) failure to balance both arms of the study in terms of patients with prior antifungal prophylaxis or with severe comorbidities, (5) the merging of end points evaluating safety with those of efficacy, and (6) choice of different criteria for resolution of fever.
- Bennett, J. E., Powers, J., de Pauw, B., Dismukes, W., Galgiani, J., Glauser, M., Herbrecht, R., Kauffman, C., Lee, J., Pappas, P., Rex, J., Verweij, P., Viscoli, C., & Walsh, T. (2003). Forum report: issues in the design of trials of drugs for the treatment of invasive aspergillosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 36(Suppl 3), S113-6.More infoA recent trial of drugs for invasive aspergillosis was used as a background for discussing critical features in the design of antifungal trials. The study under discussion allowed stopping either drug without classifying the patient as having treatment failure, so the trial should be understood as a comparison of 2 treatment strategies, not just 2 drugs. Although the study was a noninferiority trial, the outcome permitted a claim of superiority. Use of the category of "probable" in addition to "proven" aspergillosis permitted inclusion of patients for whom the diagnosis was less certain but who were still early enough in the disease progression to respond to therapy. Different opinions still exist about some of the criteria for the diagnosis of "probable" aspergillosis. A blinded data review committee was helpful in evaluating efficacy in this unblinded trial but had limited value in assessing toxicity. An understanding of these features of design of antifungal drug trials is important in applying the results to clinical practice.
- Chiller, T. M., Galgiani, J. N., & Stevens, D. A. (2003). Coccidioidomycosis. Infectious disease clinics of North America, 17(1), 41-57, viii.More infoCoccidioides, a fungus, is endemic to specific parts of the Western Hemisphere. This article examines the prevalence, pathogenesis and host defense, clinical manifestations, diagnosis, and treatment of coccidioidomycosis.
- Abuodeh, R. O., Galgiani, J. N., & Scalarone, G. M. (2002). Molecular approaches to the study of Coccidioides immitis. International journal of medical microbiology : IJMM, 292(5-6), 373-80.More infoThe study of the molecular biology of Coccidioides sp. is only just beginning. As the importance of coccidioidomycosis grows as a public health problem, our need for understanding of pathogenesis, immune responses, and improved antifungal therapy also increases in proportion. Tools have now become available to study gene manipulation in this pathogen and this will allow molecular approaches to be used. Genetic experiments will also be accelerated by the availability of the whole coccidioidal genome, expected to be made public in the spring of 2003 (see http://www.tigr.org/tdb/tgi/cigi/GenInfo.html). Thus, there seems to be several reasons to expect considerable progress in the coming years.
- Peng, T., Shubitz, L., Simons, J., Perrill, R., Orsborn, K. I., & Galgiani, J. N. (2002). Localization within a proline-rich antigen (Ag2/PRA) of protective antigenicity against infection with Coccidioides immitis in mice. Infection and immunity, 70(7), 3330-5.More infoSubunits of a proline-rich coccidioidal antigen (Ag2/PRA) of Coccidioides immitis were analyzed by comparison as vaccines in mice. The optimal dose of plasmid vaccine encoding full-length Ag2/PRA was determined to be between 10 and 100 microg. Mice vaccinated with plasmids encoding amino acids (aa) 1 to 106 were as protective as full-length Ag2/PRA (aa 1 to 194). The subunit from aa 27 to 106 was significantly but less protective. Plasmids encoding aa 90 to 151 or aa 90 to 194 were not protective. Analogous results were obtained with recombinant vaccines of the same amino acid sequences. In addition, mixtures of aa 90 to 194 with either aa 1 to 106 or aa 27 to 106 did not enhance protection compared to the active single-recombinant subunits alone. Humoral response of total immunoglobulin G (IgG) and subclasses IgG1 and IgG2a were detectable in subunit vaccinations but at significantly (100-fold) lower concentrations than after vaccination with plasmids encoding full-length Ag2/PRA. Since virtually all protection by vaccination with full-length Ag2/PRA can be accounted for in the first half of the protein (aa 1 to 106), this subunit could make a multicomponent vaccine more feasible by reducing the quantity of protein per dose and the possibility of an untoward reactions to a foreign protein.
- Shubitz, L., Peng, T., Perrill, R., Simons, J., Orsborn, K., & Galgiani, J. N. (2002). Protection of mice against Coccidioides immitis intranasal infection by vaccination with recombinant antigen 2/PRA. Infection and immunity, 70(6), 3287-9.More infoSubcutaneous vaccination with recombinant antigen 2/PRA (rAg2/PRA) protected BALB/c mice against intranasal infection with Coccidioides immitis. Subcutaneously vaccinated C57BL/6 mice and intranasally vaccinated BALB/c mice were protected against larger numbers of infecting spores. Weight loss correlated with lethality, but histologic appearance did not. These studies support rAg2/PRA vaccination to prevent coccidioidomycosis.