Pythium insidiosum, classificado no Reino Stramenopila e Classe Oomycetes, é o agente etiológico da pitiose, uma doença diagnosticada principalmente em eqüinos, caninos e humanos. As atividades in vitro do voriconazol, itraconazol e terbinafina, sozinhos ou em combinação, foram estudadas empregando uma metodologia de macrodiluição baseada na técnica M 38-A (CLSI, 2002) contra 30 isolados clínicos de Pythium insidiosum, com o objetivo de avaliar novas medidas para tratar infecções causadas por este agente utilizando quimioterapia. As combinações (terbinafina e voriconazol; terbinafina e itraconazol) tiveram suas interações avaliadas utilizando a técnica de checkerboard seguindo o modelo da macrodiluição em caldo. Terbinafina foi ativa quando testada sozinha, mostrando uma concentração inibitória mínima (CIM) e concentração fungicida mínima ≤ 8,0 mg/L para todos os isolados. Voriconazol e itraconazol foram inativos contra os isolados testados quando usados sozinhos. A combinação de voriconazol com terbinafina foi sinérgica contra 17% das amostras e indiferente em 25 (83%) amostras. O uso concomitante de terbinafina e itraconazol foi sinérgico contra 17% e indiferente contra 83% das amostras. As interpretações de ambas as interações foram equivalentes para 26 isolados (87%): vinte e três foram indiferentes e três mostraram efeito sinérgico. Antagonismo não foi observado. A terapia combinada é uma alternativa à monoterapia, especialmente para pacientes com infecções invasivas que são difíceis de tratar. Estes resultados precisam ser correlacionados com relatos clínicos; e ensaios in vivo, usando modelos animais, podem preencher a lacuna entre avaliações clínicas e avaliações in vitro das drogas. / Pythium insidiosum is classified in the kingdom Stramenopila, class Oomycetes. It causes pythiosis, a disease mainly diagnosed in horses, dogs, and humans. In order to evaluate new approaches to treat infections caused by Pythium insidiosum using chemotherapy, the in vitro activities of voriconazole, itraconazole and terbinafine, alone or in combination, against 30 clinical isolates were studied employing a macrodilution methodology based on the M 38-A technique (CLSI, 2002). The combinations (terbinafine plus voriconazole and terbinafine plus itraconazole) had their interactions evaluated using the checkerboard technique following the broth macrodilution design. Terbinafine was active when used as a single drug, showing minimal inhibitory concentration (MIC) and minimal fungicidal concentration ≤ 8,0 mg/L for all the isolates. Voriconazole and itraconazole were inactive against the isolates tested when used alone. The combination of voriconazole with terbinafine was synergic against 17% of the strains and indifferent on 25 (83%) strains. The concomitant use of terbinafine and itraconazole was synergic against 17% and indifferent against 83% of the strains. The interpretations of both interactions were equivalent for 26 isolates (87%): twenty three were indifferent and three showed synergistic effect. Antagonism was not observed. Combination therapy provides an alternative to monotherapy, especially for patients with invasive infections that are difficult to treat. These results need to be correlated with clinical outcomes, and in vivo assays using experimental animal models could bridge the gap between in vitro and clinical evaluation of drugs.

Pythium insidiosum, classificado no Reino Stramenipila e Classe Oomycetes, é o agente etiológico da pitiose, uma doença diagnosticada principalmente em equinos, caninos e humanos. A secreção de enzimas por micro-organismos é considerada um fator importante na invasão tecidual. O presente estudo teve como objetivo analisar a atividade enzimática de isolados de P. insidiosum obtidos de lesões equinas (n=13), coelhos infectados experimentalmente (n=2) e uma amostra padrão (ATCC). Para isso, utilizou-se o kit comercial API ZYM. Zoósporos foram cultivados em caldo RPMI 1640 por 24h a 37 oC. Após esse período, a presença de hifas foi observada, as quais foram separadas e 65μl do líquido restante foram inoculados em cada um dos 20 poços (um controle e 19 com substratos específicos para cada enzima) do kit. As galerias foram então incubadas por 4 h a 37 oC. Os resultados foram obtidos através da leitura visual das reações. As análises foram feitas em triplicata e submetidas à análise de variância utilizando um nível de significância de 5%. Houve uma variação intraespecífica na atividade enzimática entre os isolados, sendo que enzimas dos grupos fosfohidrolases e éster hidrolases foram as mais prevalentes. Esses dados demonstram a capacidade de P. insidiosum em secretar enzimas que degradam substratos presentes em animais e em plantas, bem como a variabilidade enzimática entre os isolados. / Pythium insidiosum is classified in the kingdom Stramenipila, class Oomycetes. It causes pythiosis, a disease mainly diagnosed in horses, dogs, and humans. This study aimed at analyzing the enzymatic activity of P. insidiosum isolates obtained from equine lesions (n=13), experimentally infected rabbits (n=2) and a standard strain (ATCC 58637). To address this issue, the API ZYM commercial kit was used. Zoospores were cultivated in RPMI 1640 broth for 24 h at 37oC. After this period, the presence of hyphae was observed and they were carefully separated from the liquid phase. Then, 65 μl of this liquid were inoculated in each of the 20 microwells (one control, 19 containing specific substrates for each enzyme) of the API ZYM kit. The strips were incubated for 4h at 37oC. Results were obtained by visual observation of the reactions. The tests were carried out in triplicate and submitted to an analysis of variance using a significance level of 5%. An intraspecific variation among the enzymatic activities was observed among the isolates, where the group of phosphohydrolases and ester hydrolases were conspicuous among most of the isolates. Data here obtained highlighted the capacity of P. insidiosum in secreting enzymes capable of degrading substrates present in animals and plants, besides the enzymatic variability among the isolates.

Fundação de Amparo a Pesquisa no Estado do Rio Grande do Sul / The oomycete Pythium insidiosum, classified in the kingdom Straminipila, is the agent of pythiosis, a chronic disease that can be hard to treat and life-threatening. The predisposing factors in mammals are unknown, but the iron overload is suspected to act directly or indirectly in the development of the infection. This aim of this study was: to evaluate the iron metabolism in rabbits with experimental pythiosis; to verify the antifungal activity and the mechanism of action in vitro of the iron chelator deferasirox against P. insidiosum isolates and to compared the treatment and the mechanism of action of the drug with immunotherapy in vivo; to verify the antifungal activity of micafungin, alone and in combination with deferasirox, in vitro and in vivo; to develop an experimental model of pythiosis using the fruit-fly Drosophila melanogaster with iron overload. The drug susceptibility tests included 17 P. insidiosum clinical isolates, and were performed according to the CLSI M38-A2 guidelines. The mechanism of action of deferasirox was evaluated by the XTT and DiBAC assays. For the in vivo tests, five P. insidiosum infected rabbits were included per group, as follows: infected treated with placebo, treated with immunotherapy, treated with deferasirox, treated with immunotherapy and deferasirox, treated with micafungin and treated with micafungin and deferasirox. Five uninfected rabbits were used as controls. Hematological and biochemical analyses were performed at days 0 25, 50 and 75 post-infection. The quantification of iron in the hepatocytes was performed after 50 days of treatment (day 75). The mechanism of action of deferasirox was evaluated by the quantification of the catabolic enzyme adenosine deaminase and by the histology of the subcutaneous lesions. The results show that P. insidiosum is poorly susceptible to deferasirox in vitro, with minimum inhibition concentrations (MICs) ranging from 12.5 to 50 μg/ml and minimum fungicidal concentrations between 50 and 100 μg/ml. No activity against P. insidiosum was observed for micafungin in vitro (MICs > 128 μg/ml) and in rabbits with pythiosis. Notwithstanding, synergism was observed in 88% of the isolates when micafungin was combined with deferasirox, and the lesions were decreased in comparison to the other groups (P = 0.06). In general, the rabbits showed microcytic hypochromic anemia with depleted iron stores, which was less prominent in the groups treated with immunotherapy or deferasirox. Despite the iron chelator has failed to thwart the infection, deferasirox showed toxicity against P. insidiosum hyphae in vitro and an immunomodulatory action was observed in the lesions, in a similar pattern to that seen in immunotherapy-treated rabbits. However, the use of deferasirox favored the dissemination of the disease to the lung by unrevealed mechanisms. D. melanogaster flies were resistant to P. insidiosum infection, independently of the iron overload. Conversely, toll-deficient D. melanogaster flies were susceptible to the infection, highlighting the importance of these receptors in pythiosis. In conclusion, rabbits with pythiosis showed iron deficiency anemia and, despite the chelating effect of deferasirox, the administration of the drug should be evaluated with care because of the dissemination of the disease observed in some of the treated animals. / O oomiceto Pythium insidiosum, classificado no Reino Straminipila, é o agente etiológico da pitiose, uma doença crônica, de difícil tratamento e que pode levar à morte. Os fatores predisponentes da doença em mamíferos não são conhecidos, mas suspeita-se que a sobrecarga de ferro exerça um papel direto ou indireto no desenvolvimento da infecção. Este estudo teve por objetivos: avaliar o metabolismo do ferro em coelhos com pitiose experimental; verificar a atividade antifúngica e o mecanismo de ação in vitro do quelante de ferro deferasirox frente a isolados de P. insidiosum e comparar o tratamento e o mecanismo de ação do fármaco com a imunoterapia in vivo; verificar a atividade antifúngica da micafungina, sozinha e em combinação com deferasirox, in vitro e in vivo; desenvolver um modelo experimental de pitiose utilizando-se a mosca-das-frutas Drosophila melanogaster com sobrecarga de ferro. Os testes de susceptibilidade aos fármacos foram realizados com 17 isolados clínicos de P. insidiosum, utilizando-se o protocolo de microdiluição M38-A2 do CLSI. O mecanismo de ação in vitro do deferasirox foi avaliado através da técnica de XTT e DiBAC. Para os testes in vivo, foram utilizados cinco coelhos infectados por P. insdiosum por grupo, conforme o delineamento a seguir: infectados tratados com placebo, tratados com imunoterápico, tratados com deferasirox, tratados com imunoterápico e deferasirox, tratados com micafungina e tratados com micafungina e deferasirox. Cinco coelhos não infectados foram utilizados como controle negativo. Realizaram-se avaliações hematológicas e bioquímicas, incluindo os níveis séricos de ferro, transferrina e ferritina nos dias 0, 25, 50 e 75 pós-infecção. A quantificação do ferro depositado nos hepatócitos foi realizada após 50 dias de tratamento (dia 75). O mecanismo de ação do deferasirox in vivo foi avaliado através da mensuração da atividade da enzima catabólica adenosina deaminase e da histologia das lesões subcutâneas. Os resultados mostram que P. insidiosum demonstrou ser pouco susceptível ao deferasirox in vitro, com concentrações inibitórias mínimas (CIMs) que variaram de 12,5 a 50 μg/ml e concentrações fungicidas mínimas entre 50 e 100 μg/ml. A micafungina não apresentou atividade antifúngica contra P. insidiosum in vitro (CIMs > 128 μg/ml) e nos coelhos com pitiose. Contudo, sinergismo foi observado em 88% dos isolados quando a micafungina foi associada ao deferasirox, e as lesões dos coelhos estavam diminuídas em relação aos demais grupos (P = 0,06). No geral, os coelhos infectados apresentaram anemia microcítica hipocrômica com depleção das reservas corporais de ferro, que foi menos acentuada nos grupos tratados com imunoterápico ou quelante de ferro. Apesar do deferasirox não ter sido capaz de conter a infecção, o mesmo teve ação tóxica sobre as hifas de P. insidiosum in vitro e teve ação imunomodulatória sobre as lesões, em um padrão similar ao observado nos coelhos tratados com imunoterapia. Contudo, o uso do deferasirox favoreceu a disseminação pulmonar da doença por mecanismos não compreendidos. Moscas D. melanogaster foram resistentes à infecção por P. insidiosum, independente da sobrecarga de ferro. Entretanto, D. melanogaster deficientes de receptores do tipo Toll foram susceptíveis à infecção, evidenciando a importância desses receptores na pitiose. Em conclusão, coelhos com pitiose apresentaram anemia por deficiência de ferro e, apesar do efeito quelante do deferasirox, a utilização do mesmo deve ser avaliada com cuidado devido à disseminação da doença em alguns animais.

Pythiosis is a granulomatous, life-threatening disease of humans and animals, which is caused by the oomycete Pythium insidiosum. The treatment of the infections caused by this pathogen is complicated because of its cell wall and cytoplasmic membrane characteristics. Therefore, immunotherapy obtained from P. insidiosum culture extracts has emerged as an alternative treatment for equine pythiosis. Notwithstanding, the mechanisms by which immunotherapy work are not yet fully understood. The aims of this study were: a) to evaluate the immunological parameters in immunotherapy by measuring interleukin-2 (IL-2) and interferon-γ (IFN-γ) levels; b) to evaluate the biochemical parameters (hepatic function) in the horses of the experiment. To address this issue, 10 horses were divided in two groups: control (n=5), composed of animals without pythiosis; and infected (n=5), composed of animals with the disease. Animals from both groups received four doses of the immunotherapeutic product PitiumVac®. A significant increase in IL-2 and IFN- γ levels was observed after 42 days of immunotherapy in the infected group, and the animals were considered cured. The immunotherapy also improved the hepatic function of the animals, decreasing alanine aminotransferase and alkaline phosphatase levels. This may be a result of the interaction of different immunotherapeutic antigen present in the immune system, causing an increase in the production of these cytokines and establishing a predominance of TH1. / A pitiose é uma doença infecciosa, com risco de morte, que acomete animais e humanos, caracterizada por lesões granulomatosas, tendo como agente etiológico o oomiceto Pythium insidiosum. O tratamento de infecções causadas por P. insidiosum em animais e humanos é complicado pelas características do agente, sobretudo a composição de sua parede celular e membrana plasmática. A imunoterapia surgiu como uma alternativa para o tratamento da pitiose equina, com a produção de imunoterápico a partir de culturas do próprio agente. Apesar dos estudos sobre a doença e a imunoterapia, ainda não há um completo conhecimento dos mecanismos envolvidos. . Os objetivos deste trabalho foram: a) analisar os parâmetros imunológicos envolvidos na resposta frente à imunoterapia por meio da quantificação da interleucina 2 (IL2) e interferon gama (IFN-γ); b) analisar os parâmetros bioquímicos (função hepática) dos equinos envolvidos no experimento. Para tal foram utilizados 10 equinos, divididos em 2 grupos: controle n=5( animais hígidos sem a doença) e infectado n=5( com pitiose clínica). Todos os 10 animais dos 2 grupos receberam 4 doses do imunoterápico PitiumVac a cada 14 dias. Os parâmetros imunológico dos animais demostraram uma diferença estatística significativa no grupo infectado após o tratamento com o imunoterápico PitiumVac®. Após 42 dias de imunoterapia foi observado um aumentando de forma significativa os níveis séricos de IL-2 e IFN-γ no grupo dos animais infectados, culminando com a cura clínica destes animais. Após a imunoterapia foi constatada uma melhora na função hepática, com a diminuição da alanina aminotransferase (ALT) e fosfatase alcalina (FA). Este resultado pode ser decorrente da interação distinta do antígeno presente no imunoterápico com o sistema imunológico, provocando o aumento na produção destas citocinas e estabelecendo um predomínio de resposta TH1.

Orientador: Sandra de Moraes Gimenes Bosco / Resumo: A pitiose, cujo agente etiológico é o oomiceto Pythium insidiosum, é umadoença que acomete diversas espécies animais, incluindo-se a humana, sendomais prevalente em equinos. A doença é de difícil diagnóstico e tratamento.Estudos sobre a caracterização proteica de P. insidiosum são escassos. Oobjetivo deste estudo foi determinar o perfil proteico de Pythium insidiosum pormeio da estratégia espectrometria de massas e bioinformática, a fim deidentificar fatores de virulência. Para isso, foi padronizada uma técnica deextração de proteínas totais de P. insidiosum, as quais foram quantificadas. Apartir do protocolo de extração de proteínas foi obtido o perfil das proteínasexpressas pelo oomiceto P. insidiosum por meio da análise por eletroforesebidimensional. Os géis analisados apresentaram 186 spots com massamolecular de 12 a 89 KDa, e ponto isoelétrico entre 4-7, destes 103 foramrecortados e sequenciados. Um total de 36 proteínas foram identificadas eagrupadas de acordo com suas funções, seis delas foram classificadas comoproteínas relacionadas à virulência - β 1,3 glucano sintetase, Hsp 70, enolase,peroxirredoxina 2, proteína G e proteassoma unidade β. Os resultados dopresente trabalho contribuirão para o melhor entendimento dos mecanismospatogênicos de P. insidiosum, bem como para novos estudos no campoterapêutico e diagnóstico. / Abstract: Pythiosis, whose etiologic agent is the oomycete Pythium insidiosum, is a disease that affects several animal species, including human, being more prevalent in horses. The disease has difficult diagnosis and treatment. Studies on protein characterization of P. insidiosum are scarce. The objective of this study was to determine the protein profile of Pythium insidiosum by mass spectrometry and bioinformatics strategies aiming to identify virulence factors. To this end, an extraction was standardized technique of total proteins of P. insidiosum, which were quantitated. From the protein extraction protocol it was obtained the profile of proteins expressed by the oomycete P. insidiosum through analysis by two-dimensional electrophoresis. The gels had 186 spots analyzed with molecular weight 12-89 kDa and an isoelectric point of 4-7, 103 of these were cut and sequenced. A total of 36 proteins were identified and grouped according to their functions, six of them were classified as proteins related to virulence - β 1,3 glucan synthase, Hsp 70, enolase, peroxiredoxin 2, G protein and the proteasome β unit. The results of this work will contribute to better understanding of the pathogenic mechanisms of P. insidiosum as well as for further studies in the therapeutic field and diagnosis. / Mestre

Pythium insidiosum é o oomiceto causador da pitiose uma doença de caráter crônico de difícil tratamento que acomete humanos e animais. Este microrganismo aquático semelhante aos fungos possui características distintas de parede celular e ausência de ergosterol na membrana celular, particularidades estas que dificultam o tratamento da doença com antifúngicos tradicionais. O presente estudo teve por objetivos: avaliar as interações sinérgicas das associações de antibacterianos, antifúngicos e compostos fenólicos sobre P. insidiosum; comparar, in vivo e in vitro, a monoterapia e combinação de azitromicina, claritromicina, minociclina e tigeciclina em coelhos com pitiose experimental. Para os testes in vitro de microdiluição em caldo foram utilizados 30 isolados de P. insidiosum, conforme o protocolo de M38-A2 do CLSI. Para os testes in vivo, os animais foram distribuídos nos grupos: Infectados com zoósporos de P. insidiosum, tratados com placebo (Controle positivo, n=6) e não infectados tratados com placebo (controle negativo, n=5), tratados com azitromicina; claritromicina; minociclina; e tigeciclina (n=6); e com as combinações minociclina com azitromicina; minociclina com claritromicina; minociclina com tigeciclina (n=6). Amostras de sangue, medidas da área da lesão, e tecidos foram coletados para análise antes, durante e ao término do tratamento. Índices mais elevados de sinergismo foram obtidos com a associação de claritromicina com micafungina (73,33%); minociclina com claritromicina ou azitromicina (93,33%); itraconazol com os compostos fenólicos timol ou carvacrol (96,60%) e minocilina com claritromicina, azitromicina (93,33%) ou tigeciclina (86,67%). Interações antagônicas das associações de timol ou carvacrol com antibacterianos ou antifúngicos, e antibiótico com antibiótico, não foram observadas. Porém nas associações de antibacterianos com antifúngicos os percentuais mais altos foram vistos em claritromicina ou azitromicina com itraconazol (6,67%) e minociclina com caspofungina (6,67%). A completa regressão da pitiose foi comprovada pela queda nos níveis de anticorpos, regressão das lesões e negatividade nos testes de detecção de hifas em tecido: PCR, histopatologia e isolamento. Nos tratamentos in vivo todos os grupos diferiram do controle positivo. Cura clínica e completa regressão da lesão foram obtidos nos tratamentos com azitromicina (n=5∕6), minociclina (n=1∕6), azitromicina com minociclina (n=4∕6), minociclina com claritromicicna (n=1∕6) e minociclina com tigeciclina (n=1∕6). A comparação in vitro das associações de minociclina com azitromicina ou claritromicina (93,33%), e tigeciclina (86,67) revelou percentuais de sinergismo elevados, no entanto a correlação destes dados com o in vivo demonstra o cuidado na escolha da associação, pois claritromicina (93,33%) e tigeciclina (86,67%) mesmo apresentando altos índices de sinergismo com minociclina nos testes in vivo tiveram um baixo percentual de regressão das lesões (16,66%). Além disso, os tecidos coletados submetidos à análise molecular e histopatológica revelaram que a tigeciclina mesmo em associação com minociclina não foi capaz de conter a metástase da pitiose para os pulmões. A azitromicina em monoterapia demonstrou ser a melhor terapia para a regressão completa das lesões causadas pela pitiose. / Pythium insidiosum is the cause of the oomycete pythiosis one chronic nature of the disease is difficult to treat that affects humans and animals. This water organism similar to fungi has distinct characteristics of cell wall and absence of ergosterol in the cell membrane, these peculiarities that make it difficult to treat the disease with traditional antifungal agents. This study aimed to: assess the synergistic interactions of antibiotics associations, antifungal and phenolic compounds on P. insidiosum; comparison, in vivo and in vitro, monotherapy and combination of azithromycin, clarithromycin, tigecycline with minocycline in rabbits with pythiosis experimental. For testing in vitro broth microdilution were used 30 strains of P. insidiosum as the M38-A2 CLSI protocol. For tests in vivo, the animals were divided into groups: Infected with zoospores of P. insidiosum treated with placebo (positive control, n = 6) and uninfected treated with placebo (negative control, n = 5) treated with azithromycin; clarithromycin; minocycline and tigecycline (n = 6); and minocycline + azithromycin combinations; minocycline and clarithromycin; minocycline and tigecycline (n = 6). Blood samples, the lesion area of measures, and tissues were collected for analysis before, during and after treatment. Higher rates of synergism were obtained with the clarithromycin association with micafungin (73.33%); minocycline with clarithromycin or azithromycin (93.33%); itraconazole with phenolic compounds thymol or carvacrol (96.60%) and minocycline with clarithromycin or azithromycin (93.33%) and tigecycline (86.67%). Antagonistic interactions of thymol or carvacrol associations with antibiotics or antifungal and antibiotic and antibiotic, were observed. However, the associations with antifungal antibiotics the highest percentages were seen in clarithromycin or azithromycin with itraconazole (6.67%) and minocycline with caspofungin (6.67%). The regression of lesions caused by pythiosis was confirmed by the fall in antibodies, regression of lesions and negativity in hyphae detection tests in tissue: PCR, histopathology and isolation. In treatments in vivo all groups differed from positive control. Clinical cure and complete regression of the lesion were obtained in the treatments with azithromycin (n = 5/6), minocycline (n = 1/6), azithromycin or minocycline (n = 4/6), clarithromycin and minocycline (n = 1/6) and tigecycline with minocycline (n = 1/6). In vitro comparisons of minocycline associations with azithromycin or clarithromycin (93.33%), and tigecycline (86.67) showed high percentages of synergism, however the correlation of these data with in vivo demonstrates the care in the association of choice, for clarithromycin (93.33%) and TIG (86.67%) even with high rates of synergism with minocycline in vivo tests had a low percentage of cure (16.66%). In addition, the collected tissues subjected to molecular and histological analysis revealed that even in tigecycline and tigecycline with minocycline association was not able to contain the disease metastasis to the lungs.The azithromycin monotherapy was shown to be the best therapy to the regression of lesions caused by pythiosis.

Pythium insidiosum, classificado no Reino Stramenopila e Classe Oomycetes, é o agente etiológico da pitiose, uma doença diagnosticada principalmente em eqüinos, caninos e humanos. As atividades in vitro do voriconazol, itraconazol e terbinafina, sozinhos ou em combinação, foram estudadas empregando uma metodologia de macrodiluição baseada na técnica M 38-A (CLSI, 2002) contra 30 isolados clínicos de Pythium insidiosum, com o objetivo de avaliar novas medidas para tratar infecções causadas por este agente utilizando quimioterapia. As combinações (terbinafina e voriconazol; terbinafina e itraconazol) tiveram suas interações avaliadas utilizando a técnica de checkerboard seguindo o modelo da macrodiluição em caldo. Terbinafina foi ativa quando testada sozinha, mostrando uma concentração inibitória mínima (CIM) e concentração fungicida mínima ≤ 8,0 mg/L para todos os isolados. Voriconazol e itraconazol foram inativos contra os isolados testados quando usados sozinhos. A combinação de voriconazol com terbinafina foi sinérgica contra 17% das amostras e indiferente em 25 (83%) amostras. O uso concomitante de terbinafina e itraconazol foi sinérgico contra 17% e indiferente contra 83% das amostras. As interpretações de ambas as interações foram equivalentes para 26 isolados (87%): vinte e três foram indiferentes e três mostraram efeito sinérgico. Antagonismo não foi observado. A terapia combinada é uma alternativa à monoterapia, especialmente para pacientes com infecções invasivas que são difíceis de tratar. Estes resultados precisam ser correlacionados com relatos clínicos; e ensaios in vivo, usando modelos animais, podem preencher a lacuna entre avaliações clínicas e avaliações in vitro das drogas. / Pythium insidiosum is classified in the kingdom Stramenopila, class Oomycetes. It causes pythiosis, a disease mainly diagnosed in horses, dogs, and humans. In order to evaluate new approaches to treat infections caused by Pythium insidiosum using chemotherapy, the in vitro activities of voriconazole, itraconazole and terbinafine, alone or in combination, against 30 clinical isolates were studied employing a macrodilution methodology based on the M 38-A technique (CLSI, 2002). The combinations (terbinafine plus voriconazole and terbinafine plus itraconazole) had their interactions evaluated using the checkerboard technique following the broth macrodilution design. Terbinafine was active when used as a single drug, showing minimal inhibitory concentration (MIC) and minimal fungicidal concentration ≤ 8,0 mg/L for all the isolates. Voriconazole and itraconazole were inactive against the isolates tested when used alone. The combination of voriconazole with terbinafine was synergic against 17% of the strains and indifferent on 25 (83%) strains. The concomitant use of terbinafine and itraconazole was synergic against 17% and indifferent against 83% of the strains. The interpretations of both interactions were equivalent for 26 isolates (87%): twenty three were indifferent and three showed synergistic effect. Antagonism was not observed. Combination therapy provides an alternative to monotherapy, especially for patients with invasive infections that are difficult to treat. These results need to be correlated with clinical outcomes, and in vivo assays using experimental animal models could bridge the gap between in vitro and clinical evaluation of drugs.

Pythium insidiosum é o oomiceto causador da pitiose uma doença de caráter crônico de difícil tratamento que acomete humanos e animais. Este microrganismo aquático semelhante aos fungos possui características distintas de parede celular e ausência de ergosterol na membrana celular, particularidades estas que dificultam o tratamento da doença com antifúngicos tradicionais. O presente estudo teve por objetivos: avaliar as interações sinérgicas das associações de antibacterianos, antifúngicos e compostos fenólicos sobre P. insidiosum; comparar, in vivo e in vitro, a monoterapia e combinação de azitromicina, claritromicina, minociclina e tigeciclina em coelhos com pitiose experimental. Para os testes in vitro de microdiluição em caldo foram utilizados 30 isolados de P. insidiosum, conforme o protocolo de M38-A2 do CLSI. Para os testes in vivo, os animais foram distribuídos nos grupos: Infectados com zoósporos de P. insidiosum, tratados com placebo (Controle positivo, n=6) e não infectados tratados com placebo (controle negativo, n=5), tratados com azitromicina; claritromicina; minociclina; e tigeciclina (n=6); e com as combinações minociclina com azitromicina; minociclina com claritromicina; minociclina com tigeciclina (n=6). Amostras de sangue, medidas da área da lesão, e tecidos foram coletados para análise antes, durante e ao término do tratamento. Índices mais elevados de sinergismo foram obtidos com a associação de claritromicina com micafungina (73,33%); minociclina com claritromicina ou azitromicina (93,33%); itraconazol com os compostos fenólicos timol ou carvacrol (96,60%) e minocilina com claritromicina, azitromicina (93,33%) ou tigeciclina (86,67%). Interações antagônicas das associações de timol ou carvacrol com antibacterianos ou antifúngicos, e antibiótico com antibiótico, não foram observadas. Porém nas associações de antibacterianos com antifúngicos os percentuais mais altos foram vistos em claritromicina ou azitromicina com itraconazol (6,67%) e minociclina com caspofungina (6,67%). A completa regressão da pitiose foi comprovada pela queda nos níveis de anticorpos, regressão das lesões e negatividade nos testes de detecção de hifas em tecido: PCR, histopatologia e isolamento. Nos tratamentos in vivo todos os grupos diferiram do controle positivo. Cura clínica e completa regressão da lesão foram obtidos nos tratamentos com azitromicina (n=5∕6), minociclina (n=1∕6), azitromicina com minociclina (n=4∕6), minociclina com claritromicicna (n=1∕6) e minociclina com tigeciclina (n=1∕6). A comparação in vitro das associações de minociclina com azitromicina ou claritromicina (93,33%), e tigeciclina (86,67) revelou percentuais de sinergismo elevados, no entanto a correlação destes dados com o in vivo demonstra o cuidado na escolha da associação, pois claritromicina (93,33%) e tigeciclina (86,67%) mesmo apresentando altos índices de sinergismo com minociclina nos testes in vivo tiveram um baixo percentual de regressão das lesões (16,66%). Além disso, os tecidos coletados submetidos à análise molecular e histopatológica revelaram que a tigeciclina mesmo em associação com minociclina não foi capaz de conter a metástase da pitiose para os pulmões. A azitromicina em monoterapia demonstrou ser a melhor terapia para a regressão completa das lesões causadas pela pitiose. / Pythium insidiosum is the cause of the oomycete pythiosis one chronic nature of the disease is difficult to treat that affects humans and animals. This water organism similar to fungi has distinct characteristics of cell wall and absence of ergosterol in the cell membrane, these peculiarities that make it difficult to treat the disease with traditional antifungal agents. This study aimed to: assess the synergistic interactions of antibiotics associations, antifungal and phenolic compounds on P. insidiosum; comparison, in vivo and in vitro, monotherapy and combination of azithromycin, clarithromycin, tigecycline with minocycline in rabbits with pythiosis experimental. For testing in vitro broth microdilution were used 30 strains of P. insidiosum as the M38-A2 CLSI protocol. For tests in vivo, the animals were divided into groups: Infected with zoospores of P. insidiosum treated with placebo (positive control, n = 6) and uninfected treated with placebo (negative control, n = 5) treated with azithromycin; clarithromycin; minocycline and tigecycline (n = 6); and minocycline + azithromycin combinations; minocycline and clarithromycin; minocycline and tigecycline (n = 6). Blood samples, the lesion area of measures, and tissues were collected for analysis before, during and after treatment. Higher rates of synergism were obtained with the clarithromycin association with micafungin (73.33%); minocycline with clarithromycin or azithromycin (93.33%); itraconazole with phenolic compounds thymol or carvacrol (96.60%) and minocycline with clarithromycin or azithromycin (93.33%) and tigecycline (86.67%). Antagonistic interactions of thymol or carvacrol associations with antibiotics or antifungal and antibiotic and antibiotic, were observed. However, the associations with antifungal antibiotics the highest percentages were seen in clarithromycin or azithromycin with itraconazole (6.67%) and minocycline with caspofungin (6.67%). The regression of lesions caused by pythiosis was confirmed by the fall in antibodies, regression of lesions and negativity in hyphae detection tests in tissue: PCR, histopathology and isolation. In treatments in vivo all groups differed from positive control. Clinical cure and complete regression of the lesion were obtained in the treatments with azithromycin (n = 5/6), minocycline (n = 1/6), azithromycin or minocycline (n = 4/6), clarithromycin and minocycline (n = 1/6) and tigecycline with minocycline (n = 1/6). In vitro comparisons of minocycline associations with azithromycin or clarithromycin (93.33%), and tigecycline (86.67) showed high percentages of synergism, however the correlation of these data with in vivo demonstrates the care in the association of choice, for clarithromycin (93.33%) and TIG (86.67%) even with high rates of synergism with minocycline in vivo tests had a low percentage of cure (16.66%). In addition, the collected tissues subjected to molecular and histological analysis revealed that even in tigecycline and tigecycline with minocycline association was not able to contain the disease metastasis to the lungs.The azithromycin monotherapy was shown to be the best therapy to the regression of lesions caused by pythiosis.

Thesis (MSc)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: Damping-off of rooibos (Aspalathus linearis), which is an important indigenous crop in South Africa, causes serious losses in rooibos nurseries and is caused by a complex of pathogens of which oomycetes, mainly Pythium, are an important component. The management of damping-off in organic rooibos nurseries is problematic, since phenylamide fungicides may not be used. Therefore, alternative management strategies such as rotation crops, compost and biological control agents, must be investigated. The management of damping-off requires knowledge, which currently is lacking, of the Pythium species involved, and their pathogenicity towards rooibos and two nursery rotation crops (lupin and oats). Pythium species identification can be difficult since the genus is complex and consists of more than 120 species. Species identification is, however, greatly facilitated by analyses of the internal transcribed spacer (ITS) regions. These regions, have also been used to divide the genus into 11 phylogenetic clades (A to K), with some clades, such as clade G, still being poorly characterised. The first aim of the study was to characterize 12 Pythium clade G isolates that were obtained from damped-off rooibos seedlings, along with six known clade G species. Subsequently, oligonucleotides were designed for differentiating two rooibos associated groups that may represent new taxons, for future use in DNA macro-array analyses. Phylogenetic analyses of the ITS region and a combined phylogeny of four gene regions (ITS, -tubulin and, COX1 and COX2 [cytochrome c oxidase subunits I and II]) identified five sub-clades within Pythium clade G. The rooibos isolates formed two groups, Rooibos group I (RB I) and II (RB II) that clustered into two groups within sub-clade 1 with good support (64%-89% bootstrap, 1.00 probability). The Pythium RB I isolates had P. iwayamai as its nearest neighbour, and may represent a new species. The Pythium RB II isolates had P. canariense and P. violae as their closest relatives and may, along with other isolates contained in the RB II sub-clade, represent several new species. Morphological analyses of the rooibos isolates were inconclusive, since the isolates all contained similar morphological characteristics that did not correspond to the description of known Pythium species. The Pythium RB I and II isolates were all non-pathogenic toward rooibos, lupin and oats seedlings. For each of the two rooibos groups, one newly developed oligonucleotide was able to differentiate the isolates from clade G reference isolates using DNA macro-array analyses. The second aim of the study was to determine the oomycetes species associated with rooibos in nurseries and in a native rooibos site, and their pathogenicity towards rooibos and two nursery rotation crops (lupin and oats). Since some isolates were shown to be nonpathogenic, another aim was to determine whether these isolates, along with the previously characterised non-pathogenic Pythium RB I and RB II isolates, could suppress pathogenic oomycetes. Characterisation of isolates from 19 nurseries and one native rooibos site revealed the presence of five Pythium species (P. acanthicum, P. irregulare, P. mamillatum, P. myriotylum, and P. pyrilobum) and Phytophthora cinnamomi. In nurseries, P. irregulare was the most common species (81%) followed by P. myriotylum (14%). Similarly, P. irregulare was also the most prevalent species (57%) in native rooibos, but P. pyrilobum (26%) was second most prevalent. Pathogenicity studies on rooibos showed that all species, except P. acanthicum, were highly virulent causing 100% damping-off. On lupin, P. acanthicum was also the only non-pathogenic species, with the other species being less virulent on lupin than on rooibos. Only P. irregulare, P. myriotylum, and P. pyrilobum were pathogenic towards oats, and were also less virulent on oats than on rooibos. On lupin and oats, not all off the isolates from a specific species was pathogenic. Non-pathogenic Pythium species (P. acanthicum, Pythium RB I and II) was only effective at suppressing disease on the less susceptible crops of lupin and oats, but not on rooibos. The third aim of the study was to investigate the management of rooibos damping-off using two composts (A and B), and composts combined with non-pathogenic Pythium species. Evaluation of the suppression by composts of Ph. cinnamomi and 29 Pythium isolates, which represented the four pathogenic Pythium rooibos species, showed that both composts were able to suppress some, but not all of the pathogenic Pythium isolates. Both composts were very effective at, and the highest percentage control was achieved, with suppression of Ph. cinnamomi. Most isolates of P. mamillatum and P. pyrilobum were suppressed by composts, whereas most P. irregulare (> 62%) and P. myriotylum (>50%) isolates were not suppressed. Non-pathogenic Pythium species combined with either of the two composts were able to significantly reduce damping-off caused by P. irregulare or a combination of pathogenic species (P. irregulare, P. mamillatum, P. myriotylum, P. pyrilobum, and Ph. cinnamomi), compared to than when only the pathogens were present. In the absence of non-pathogenic species, neither of the composts was able to suppress the aforementioned pathogenic isolates. This study has improved our knowledge of the oomycete species that are involved in rooibos damping-off, and has identified possible management strategies for use in organic nurseries. Several oomycete species are involved in causing damping-off and their differential virulence, and responses to being suppressed by composts, will require the use of integrated management strategies. Management strategies that showed promise include the combined use of compost and non-pathogenic Pythium taxons. The use of oats, which is susceptible to fewer oomycete isolates than rooibos, could also be valuable as a rotation crop. Altogether, knowledge obtained in this study can be used to (i) optimize integrated management strategies for organic nurseries, (ii) elucidate the mechanisms involved in disease suppression and (ii) develop molecular techniques, such as DNA macro-arrays and quantitative PCR (qPCR) for the rapid assessment of the species involved, and the quantification of inoculum in nursery soils. / AFRIKAANSE OPSOMMING: Omvalsiekte van rooibos (Aspalathus linearis), wat ‘n belangrike inheemse gewas in Suid-Afrika is, veroorsaak ernstige verliese in rooiboskwekerye, en word deur ‘n kompleks van patogene veroorsaak, waarvan oömysete, hoofsaaklik Pythium, ’n belangrike komponent is. Die bestuur van omvalsiekte in organiese rooiboskwekerye is problematies, aangesien fenielamied fungisiedes nie gebruik mag word nie. Alternatiewe bestuurstrategieë, soos rotasie-gewasse, kompos en biologiese beheer-agente, moet dus ondersoek word. Die bestuur van omvalsiekte vereis kennis, wat tans ontbreek, naamlik die Pythium spesies wat betrokke is, hul patogenisiteit teenoor rooibos, en twee kwekery rotasie-gewasse (lupiene en hawer). Pythium spesie-identifikasie kan moeilik wees aangesien die genus kompleks is en uit meer as 120 spesies bestaan. Spesie-identifikasie word egter grootliks vergemaklik deur analise van die interne getranskribeerde spasieerder (ITS) areas. Hierdie areas is ook gebruik om die genus in 11 filogenetiese “clades” (A tot K) te verdeel, met sommige “clades”, soos “clade” G, wat steeds swak gekarakteriseer is. Die eerste doelwit van die studie was om 12 Pythium “clade” G isolate te karakteriseer, wat vanaf omvalsiekte rooibossaailinge verkry is, tesame met ses bekende “clade” G spesies. Gevolglik is oligonukleotiede ontwerp ten einde twee rooibosgeassosieerde groepe, wat nuwe taksons kan verteenwoordig, te onderskei, en vir toekomstige gebruik in DNS makro-“array” analise. Filogenetiese analise van die ITS area en ‘n gekombineerde filogenie van vier geen-areas (ITS, -tubulien en, COX1 en COX2 [sitokroom c oksidase sub-eenhede I en II]) het vyf sub-“clades” binne Pythium “clade” G geïdentifiseer. Die rooibos isolate het twee groepe gevorm, Rooibos groep I (RB I) en II (RB II) wat twee groepe binne sub-“clade” 1 gevorm het, met goeie ondersteuning (64%-89% “bootstrap”, 1.00 waarskynlikheid). Die Pythium RB I isolate het P. iwayamai as sy naaste verwant, en mag ‘n nuwe spesie verteenwoordig. Die Pythium RB II isolate het P. canariense en P. violae as hul naaste verwante en mag, tesame met ander isolate wat in die RB II sub-“clade” ingesluit word, verskeie nuwe spesies verteenwoordig. Morfologiese analise van die rooibos-isolate was onbeslis, aangesien die isolate almal soortgelyke morfologiese kenmerke bevat het, wat nie met die beskrywing van bekende Pythium spesies ooreengestem het nie. Die Pythium RB I en II isolate was almal nie-patogenies teenoor rooibos-, lupien- en hawersaailinge. Vir elk van die twee rooibosgroepe, was een nuut-ontwikkelde oligonukleotied in staat om die isolate van “clade” G verwysingsisolate te differensieer, deur die gebruik van DNS makro-“array” analise. Die tweede doelwit van die studie was om die oömysete spesies wat met rooibos in kwekerye en in ‘n inheemse rooibos-area geassosieer word, te bepaal, en hul patogenisiteit teenoor rooibos en twee kwekery rotasie-gewasse (lupien en hawer). Aangesien van die isolate nie-patogenies was, was ’n ander doelwit om te bepaal of hierdie isolate, tesame met die voorheen gekarakteriseerde nie-patogeniese Pythium RB I en RB II isolate, patogeniese oömysete kan onderdruk. Karakterisering van isolate van 19 kwekerye en een inheemse rooibos-area, het op die teenwoordigheid van vyf Pythium spesies (P. acanthicum, P. irregulare, P. mamillatum, P. myriotylum, en P. pyrilobum) en Phytophthora cinnamomi gedui. P. irregulare was die mees algemene spesie (81%) in kwekerye, gevolg deur P. myriotylum (14%). Soortgelyk was P. irregulare ook die mees algemene spesie (57%) in inheemse rooibos, maar P. pyrilobum (26%) was tweede mees algemeen. Patogenisiteitstudies op rooibos het getoon dat alle spesies, behalwe P. acanthicum, hoogs virulent was en 100% omvalsiekte veroorsaak het. Op lupien was P. acanthicum ook die enigste nie-patogeniese spesie, terwyl die ander spesies minder virulent op lupien as op rooibos was. Slegs P. irregulare, P. myriotylum en P. pyrilobum was patogenies teenoor hawer, en was ook minder virulent op hawer as op rooibos. Op lupien en hawer was nie alle isolate van ‘n spesifieke spesie patogenies nie. Nie-patogeniese Pythium spesies (P. acanthicum, Pythium RB I en II) was slegs effektief om siekte op die minder vatbare gewasse, lupien en hawer, te onderdruk, maar nie op rooibos nie. Die derde doelwit van die studie was om die bestuur van rooibos omvalsiekte te ondersoek, deur die gebruik van twee tipes kompos (A en B), en kompos gekombineer met nie-patogeniese Pythium spesies. Evaluasie van die onderdrukking deur kompos van Ph. cinnamomi en 29 Pythium isolate, wat die vier patogeniese Pythium rooibosspesies verteenwoordig het, het getoon dat beide tipes kompos in staat was om sommige, maar nie al die patogeniese Pythium isolate, te onderdruk nie. Beide tipes kompos was baie effektief, en die hoogste persentasie beheer was met die onderdrukking van Ph. cinnamomi verkry. Meeste isolate van P. mamillatum en P. pyrilobum is deur kompos onderdruk, terwyl meeste P. irregulare (> 62%) en P. myriotylum (>50%) isolate nie onderdruk is nie. Nie-patogeniese Pythium spesies, in kombinasie met enige van die twee tipes kompos, was in staat om betekenisvol omvalsiekte veroorsaak deur P. irregulare, of in ’n kombinasie met patogeniese spesies (P. irregulare, P. mamillatum, P. myriotylum, P. pyrilobum, en Ph. cinnamomi), te verminder, in vergelyking met wanneer slegs die patogene aanwesig was. In die afwesigheid van nie-patogeniese spesies, was nie een van die tipes kompos in staat om die voorafgenoemde patogeniese isolate te onderdruk nie. Hierdie studie het ons kennis rakende die oömysete spesies betrokke in rooibos omvalsiekte verbeter, en het moontlike bestuurstrategieë geïdentifiseer wat in organiese kwekerye gebruik kan word. Verskeie oömysete spesies is betrokke in die oorsaak van omvalsiekte, en hul verskille in virulensie, en reaksies op onderdrukking deur kompos, sal die gebruik van geïntegreerde bestuurstrategieë vereis. Bestuurstrategieë wat belofte toon, sluit die gekombineerde gebruik van kompos en nie-patogeniese Pythium taksons in. Die gebruik van hawer, wat vir minder oömysete isolate as rooibos vatbaar is, kan ook waardevol as ‘n rotasie-gewas wees. Tesame, kan kennis wat in die studie opgedoen is gebruik word om (i) geïntegreerde bestuurstrategieë vir organiese kwekerye te optimaliseer, (ii) die meganismes betrokke in siekte-onderdrukking te bepaal, en (iii) molekulêre tegnieke, soos DNS makro- “arrays” en kwantitatiewe PKR (qPKR) te ontwikkel vir die vinnige bepaling van die spesies betrokke, en die kwantifisering van inokulum in kwekery-gronde.

2 pp. / Originally published: 1998 / Damping off is caused by several different fungi under different environmental conditions. The fungi include Pythium, Rhizoctonia solani, and Thielaviopsis basicola. This article discusses the symptoms, environmental conditions, diseases, prevention and control methods for the damping-off caused by fungi.