Kumaresan recently described genetic modification of T cells to express a chimeric antigen receptor encoding the fungal PRR Dectin-1 in association with T-cell receptor signalling components.59 Cells expressing Dectin-1 could be enriched through stimulation with antigen-presenting cells coated with Dectin-1 agonist and expanded with the support of IL-2 and IL-21. invasive zygomycoses and over 90% in patients with invasive fusariosis.1 Various risk factors contribute to the high incidence of IFDs in allogeneic HSCT recipients. These include severe neutropenia, lymphopenia, HLA disparity between the donor and recipient, graft-versus-host disease, the use of corticosteroid and immunosuppressive therapy, and diabetes.2, 3, 5, 6 Following allogeneic HSCT, full immune recovery can take up to a year. Innate immunity, including neutrophils and phagocytes, typically recovers within weeks after grafting.7 However, recovery of adaptive immune components take longer, for example, B cells and CD8 T cells can take months to recover.7 CD4 T-cell counts may be low for months to years and recovery is prolonged in older patients with poor thymic function and in patients receiving prophylaxis or treatment for graft-versus-host disease.7 The reason for the lower incidence of IFDs in autologous HSCT is not entirely clear but is likely attributable to lower intensity conditioning, a shorter period of neutropenia and the absence of HLA disparity and graft-versus-host disease, and the consequent absence of mandatory immunosuppressive medication.8 Acute leukaemia A large-scale retrospective study of >11?000 patients with haematological malignancy in Italy between 1999C2003 reported an overall IFD rate of 4.6%, with incidence rates of 12% in acute myeloid leukaemia and 6.5% in acute lymphoblastic leukaemia.9 Invasive aspergillosis is the most common form, accounting for over 50% of all IFDs in acute leukaemia patients.9 The percentage of patients with invasive aspergillosis who die from fungal disease has RAD140 fallen over the last two decades, largely as a result of better diagnosis and the early initiation and use of improved fungal pharmacotherapy. In patients with acute leukaemia, neutropenia, quantitative and qualitative alterations in monocytes and tissue macrophages, the use of broad-spectrum antibiotics, renal insufficiency, RAD140 prior fungal contamination and anti-fungal therapy, and active haematological disease leading to suppression of immune function are important risk factors for the development of IFDs.10 RAD140 In addition, colonisation of fungi in the gastrointestinal mucosa following acute mucosal damage caused by cytotoxic drugs is a risk factor in the pathogenesis of yeast-related IFDs. Common fungal pathogens, treatment and changing patterns of IFDs in haematology patients A number of studies have looked at the distribution of fungal isolates observed in clinical specimens obtained from recipients of HSCT.1, 3, 11 was RAD140 the most common fungal pathogen in both autologous and allogeneic transplantation settings. Other positively identified species included and infections, and were most common, followed by and and species were common agents of zygomycoses. The less common fungal pathogens included and the species. Notably, co-infection by multiple fungal species is common in recipients of HSCT,11 making treatment and management of IFDs challenging. Amphotericin B was the mainstay of the treatment of invasive fungal infections until the mid-1990s. It has been replaced in the past two decades by more effective and less toxic drugs such as the less nephrotoxic lipid formulations of Amphotericin B, the broad spectrum triazoles (voriconazole, itraconazole, fluconazole and posaconazole), the echinocandins (caspofungin and micafungin) and the pyrimidine analogues (flucytosine). Voriconazole, posaconazole, caspofungin and lipid formulations of Amphotericin B are the common choices for treatment and prophylaxis of IFDs in haematology patients, also being administered empirically to patients with febrile neutropenia persisting 3C7 days after treatment with broad-spectrum antibacterials. Advances in molecular diagnostic testing and detection of the serum biomarkers -glucan and galactomannan have facilitated prompt, targeted treatment and early initiation of pre-emptive therapy.12 The selection of antifungal drug depends on the type, site and severity of Rabbit Polyclonal to MDC1 (phospho-Ser513) fungal infection, potential for organ toxicity and possible interaction with other drugs. Caspofungin is the drug of choice for treatment of invasive candidiasis, voriconazole for invasive aspergillosis and lipid formulation of amphotericin B for zygomycosis; however, combination therapy.