HI Con: I am very sorry about your friend's illness. As Harold suggested, Aspergillus is a nasty fungus that can cause extremely serious problems for individuals with immune weakness. Its sources however are difficult to pinpoint.. It is found just about everywhere fungus can grow. One study in Russia found 17 Aspergillus species in a hospital ward. My guess is that your friend (also our friend since he is an apple grower) may have gotten it from working in a damp environment with poor ventilation system. I will be sending you a recent review on aspergillus infection (abstract below). It suggests that the most common infection is caused by A. Fumigatus, with less common ones include A. niger, A. Flavus, and A. terreus. Either of these infections can be very serious unless it is diagnosed early and treated with either surgery or antifungal treatments. I have also attached an article on sources of Asp. infection for the group to read. Wish you all well and a happy holiday.. Mosbah Kushad, University of Illinois Clin Microbiol Infect. 2006 Dec;12(s7):24-39.
Update on invasive aspergillosis: clinical and diagnostic aspects. Munoz P, Guinea J, Bouza E. Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario 'Gregorio Maranon', Madrid, Spain. Apergillus is a ubiquitious mould that can cause a wide variety of clinical syndromes ranging from mere colonisation to fulminant invasive disease. Invasive aspergillosis (IA) is the most severe presentation of aspergillosis. The lung is usually the portal of entry, from which the pathogen may disseminate to almost any organ, often the brain and skin. The diagnosis remains a significant challenge. It is usually based on a combination of compatible clinical findings in a patient with risk-factors and isolation of the microorganism, radiological data, serological detection of antibodies or antigens, or histopathological evidence of invasion. Chest radiographic findings in patients with pulmonary Aspergillus may initially be normal in up to 10% of cases. Computed tomography scanning is probably the most useful imaging technique for the diagnosis of IA, since it may reveal lung lesions up to 5 days earlier than would radiograph techniques simply. Currently available laboratory diagnostic methods include several techniques: histopathological evidence of invasion; isolation of the microorganism and direct microscopy from clinical samples and non-invasive procedures (serological detection of antigens or nucleic material of Aspergillus; detection of antibodies). The histological diagnosis of IA requires the presence of invasion by fungus of the Aspergillus species. The truth is that, if no other variables are considered, the positive predictive value is very low, and most of the isolates of A. fumigatus do not represent proven or probable infection. Several molecules could be used as markers of infection, but two of them are of special interest: Aspergillus galactomannan (GM) and (1-->3)-beta-glucan (BG). GM has a high specificity (above 85%) and a reported sensitivity that varies widely (between 30% and 100%). BG, a main cell wall polysaccharide component of Aspergillus, can be colourimetrically detected and is useful in diagnosis, with a sensitivity ranging from 50% to 87.5%. A specific Aspergillus PCR assay has also been used in the diagnosis of IA and has shown very good results, with a sensitivity and specificity of 100% and 89%, respectively. **************************************************************************** ************************************************************************ Clinical implications of environmental sources for Aspergillus Journal Title: Medical Mycology | Vol: 43 | Issue: S1 | Coden: Medical Mycology Supplement 1 2005, 43, S59-S65 | Year: 2005 | PP: 59-65 Introduction Invasive filamentous fungal infections are a serious threat to immunocompromised patients, causing increased morbidity and mortality [1 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0001> -3 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0003> ]. Aspergillus fumigatus is the most frequent cause of invasive filamentous fungal infection in bone marrow transplant (BMT) patients, followed by Aspergillus flavus, A. terreus and A. niger [4 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0004> ,5 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0005> ]. Incidence rates of invasive aspergillosis depend principally on host factors. In transplant patients the incidence of invasive aspergillosis ranges from 0.7% to 8.4% depending on the organ transplanted. Lung and BMT recipients possess the highest incidence, whereas pancreas and kidney transplant patients have lower risk of developing invasive aspergillosis [6 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0006> ,7 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0007> ]. The incidence of invasive aspergillosis in patients with acute leukemia, chronic granulomatous disease, and AIDS are estimated at 5%-24%, 25%-40% and 0%-12%, respectively [2 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0002> ]. Aspergillus infections in immuncompromised hosts range from primary cutaneous aspergillosis (especially in neonates and children), rhinosinusitis, tracheobronchitis, pulmonary aspergillosis (the most common site of infection), cerebral aspergillosis to disseminated aspergillosis [2 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0002> ]. Clinical symptoms are non-specific and related to the localization of the infection. Furthermore, the clinical presentation varies among the different patient groups. The most immunocompromised patients are those least likely to have overt symptoms, and progression of the disease is usually fastest. Despite the incorporation of new diagnostic and therapeutic measures in management strategies, the number of patients with a favorable response remains low and mortality rates range from 50% to 90% depending mostly on the recovery of the host immune responses [2 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0002> ,8 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0009> ]. Therefore, prevention of invasive aspergillosis is of major importance. To develop preventive control measures, we need to have a clear understanding of how and where most infections are acquired. We have to take into account that the incidence of invasive aspergillosis differs among transplantation centers and may require different preventive measures in different institutions. Furthermore, the most appropriate control measures for the healthcare setting may differ from those advised for patients at home. Given the ubiquitous presence of Aspergillus spp. in our environment, the question arises if it is feasible to protect immunocompromised patients from this opportunistic mould. We may succeed to prevent exposure in the well-controlled hospital environment during admission, but patients are increasingly being treated in the setting of the out-patient clinic, thereby significantly reducing the ability to control exposure to moulds. Preventing disease by antifungal prophylaxis or immunomodulating agents seems to be a logical alternative approach in the setting of out-patient management. However, no regimen has been reported to be clearly effective or superior in preventing disease. Amphotericin B, in various dosages and formulations, has been evaluated for preventing invasive aspergillosis but safety and efficacy data are lacking in high-risk patient groups. Itraconazole prophylaxis is not recommended due to the poor and variable absorption of the capsules and the potential of drug interactions. Although two studies suggested that itraconazole oral suspension can offer protection against deep fungal infections [10 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0010> ,11 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0011> ], two meta-analyses found no beneficial effect on survival with either the use of mould-active azoles or amphotericin B for chemoprophylaxis against invasive aspergillosis in hematology patients with severe neutropenia [12 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0012> ,13 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0013> ]. In some patients on prophylaxis, infection due to primary or secondary resistant moulds was described [14 <http://www.metapress.com/content/m2781t8133n435x2/bib.htm#CIT0014> ]. Even less data exist on the benefits of the use of immunomodulating agents and we are still far from any recommendations for clinical practice. Therefore, efforts should be made to develop rational control measures to prevent exposure of the immunocompromised host to Aspergillus spp. In order to implement effective prevention strategies we need to understand the routes of transmission by identifying environmental sources of Aspergillus spp. and activities that lead to high exposure of patients and, furthermore, to gain insight into the pathogenesis of invasive Aspergillus infections once patients have been exposed. _____ From: [email protected] [mailto:[EMAIL PROTECTED] On Behalf Of Con.Traas Sent: Sunday, December 17, 2006 10:19 AM To: Apple-Crop Subject: Apple-Crop: Medical question Hello all, I have the unfortunate task of asking you what might turn out to be a life and death question. An apple growing friend of mine contracted cancer some time ago, and was getting chemotherapy and other treatments. As a result of his suppressed immune system, he subsequently contracted what appears to be an unusual fungal infection of his lungs. All efforts to diagnose this in Ireland, and now in Sweden, have failed. The doctors are considering the possibility that the fungal infection may be something that was carried on the apples, as the grower in question continued with his normal apple harvesting, packing, sorting of rotten apples etc. despite his condition. I would appreciate that if any one out there on the list could shed any light on this, or would have any suggestions, or might have heard of something like this before, to let me know as soon as possible. Or perhaps, if you know someone off-list, who might know, and would not mind to ask them the question, that would also be much appreciated. The condition of this person is perilous, and without an answer, the prognosis is not good. So any help at all would be better than nothing. Best wishes, Con Traas The Apple Farm Ireland ++353-52-41459 _____
