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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 123-126

Pulmonary mycoses treated by topical amphotericin B

Department of Microbiology, Al-Shomali General Hospital, Babil, Iraq

Date of Submission10-Feb-2020
Date of Acceptance25-Feb-2020
Date of Web Publication17-Jun-2020

Correspondence Address:
Dr. Falah Hasan Obayes AL-Khikani
Department of Microbiology, Al-Shomali General Hospital, Babil
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bbrj.bbrj_12_20

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Since its discovery, amphotericin B (AmB) became a key management because it is the most common antifungal drug with activity to disrupt the fungal cell wall. Furthermore, it is the first-choice treatment in pulmonary mycoses that may consider lethal infection; the difference in lipid structure between fungal and mammalian cell membranes determines the effect of AmB. However, some fungal pulmonary diseases such as aspergillomas are partially contact with the blood and narrow touch the walls of the lung cavities, thus administration of systemic antifungal agents may be ineffective to eliminate these infections. Tissue penetration of systemic antifungal agents must be evaluated to get a proper appreciation of their antifungal activity, which may differ even within the same antifungal class. So, topical administration considered necessity in these situations. AmB belongs to the polyene group has a wide-spectrum in vitro and in vivo antifungal activity. All of the known available formulas of AmB are administrated through intravenous injection to treat severe systemic fungal infections, while the development of the topical formula of AmB is still under preliminary development, including topical pulmonary AmB. Due to the revealing of antimicrobial-resistant fungi in recent years and ineffective systemic management of pulmonary fungi, this study explains the role of topical AmB in treating refractory lung fungi that not response to other drugs that may help researchers to develop an effective topical formula of AmB regarding pulmonary mycosis.

Keywords: Antifungal agents, fungal treatment, pulmonary mycosis, topical amphotericin B, topical treatment

How to cite this article:
AL-Khikani FH. Pulmonary mycoses treated by topical amphotericin B. Biomed Biotechnol Res J 2020;4:123-6

How to cite this URL:
AL-Khikani FH. Pulmonary mycoses treated by topical amphotericin B. Biomed Biotechnol Res J [serial online] 2020 [cited 2022 Aug 16];4:123-6. Available from: https://www.bmbtrj.org/text.asp?2020/4/2/123/286836

  Introduction Top

Formulations of the amphotericin B (AmB) remain the first-choice agents for the management of pulmonary fungal diseases.[1] AmB is an ancient agent used over many decades in treating various fungal infections clinically in the human.[2] Low fungal resistance and broad-spectrum antifungal activities are the most valuable pharmaceutical characters encourage continuous usage of AmB.[3]

AmB isolated from Streptomyces nodosus in the soil of the Orinoco River region of Venezuela in the 1950s. Deoxycholate AmB (D-AmB) is the first form of AmB developed in 1955 to use against systemic fungal infections.[4] It quickly approved to use clinically by the Food and Drug Administration in 1958 in spite of unknown its structure due to its broad-spectrum antifungal activity.[5] In 1958, an intravenous formula of sodium D-AmB solution was presented in the markets at the name Fungizone Squibb.[6] The ancient formula of AmB that contains D-AmB has more side effects presented by nephrotoxicity than recently developed lipid formula in 1990, which releases low concentrations of AmB in the human serum.[7]

Systemic drugs distribute in tissues at different concentration that may differ from their concentration in bloodstream, hence, the knowledge of systemic antifungal drug tissue penetration is important to understand the efficacy of drug to treat fungi, some pulmonary mycosis are located in balls at lung cavity with few contacts to blood vessels, thus, these systemic antifungal drugs are ineffective. Hence, using a topical antifungal drug is required.[1]

This study highlights the topical efficacy of AmB to treat pulmonary mycosis depending on searches and case report studies.

  Topical Usage of Amphotericin B Top

Topical modern applications of AmB provide a promising way of fungal treatment to reduce the adverse effects of intravenous usage of AmB.[2]

There are many advantages to using AmB as a topical treatment of dermatophytosis. First, discover new drugs or modification old one will participate to increase the available limited number of antifungal drugs.[8] Second, topical preparations are much less costly than systemic administration of antifungal drugs and cause minimal adverse side effects.[9],[10] Third, the application of the topical formula of AmB considers more safety to use and will not produce clinically relevant serum levels of AmB.[10],[11]

AmB is used over many decades in the management of different fungal infections in the human as pulmonary mycosis. Opportunistic systemic fungal infection considered the most common type of fungal infection mainly treated by AmB.[2] At present, many studies focused on the topical preparation of AmB as eye drop[12] or gel[12] or solution[13] or as nanoparticles drug.[14] However, treatment with topical AmB may not always give satisfying results as with ordinary forms of this drug in the treatment of fungal infection, while some topical applications of AmB gave performing outcomes with complete healing, especially in certain cases not responded to conventional therapy that considered life-threatening danger as lung and bronchial mycosis. The topical formula of AmB to treat fungal respiratory tract give good results as mentioned in the previous studies, hence, developing this formula is necessary due to the appearance of drug-resistant fungi.

  Mechanisms of Action of Amphotericin B Top

There is no clear vision about the mechanism of action to explain the antifungal effect of AmB although it has been used for many decades. The most accepted one is the activity of AmB adheres to the ergosterol of the fungal cell membrane causing dysfunction by forming pore ion channels.[4],[15],[16],[17] Pore formation may lead to inhibition of fungal glycolysis and quick efflux of K+ and Mg+ ions inside fungal cells which increase the acidity consequently fungal cell death occurs.[18]

The mechanisms of liposomal AmB (L-AmB) began when the liposomal vesicle become attached to fungal cells in the infection site, then release AmB from holding vesicle to adhere to the ergosterol of fungal cell membrane and damage it.[4]

Another mechanism of action of AmB presented by production of free radicals inside fungal cell,[17],[19] this leads to oxygen depletion and superoxide anion formation that effects on the cellular pathways of fungi.[20] Moreover, AmB has immunomodulatory properties that induce pro-inflammatory response and this gives protection to the immunocompromised persons.[17]

  Topical Amphotericin B in Treatment Lung Fungi Top

Mitomo et al. 2018[21] were studied the endobronchial instillation of AmB as a pulmonary topical formula. Lung chromomycosis due to Scedosporium prolificans that appeared after lung transplantation failed to be treated by systemic itraconazole [Table 1].
Table 1: Topical amphotericin B against pulmonary mycosis

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The patient was a female, after 8 years of the lung transplantation, chest radiography X-ray appeared an abnormal shadow in the right lung, the pulmonary chromomycosis diagnosed in bronchoscopic aspirate, and S. prolificans was detected as the causative agent.

Topical AmB instillation is used. About 5 mg of AmB was topically prepared. After three topical instillations, the bronchial obstruction is highly cleared; endobronchial topical AmB instillation was used one time every 3 months. After six instillations, the abnormal shadow disappeared, and the bronchial obstruction is improved. This study revealed that endobronchial topical AmB instillation is a therapeutic required when systemic antifungal management is ineffective to treat pulmonary mycosis.[21]

Takeda et al., 2014[22] presented a case report study of a 72-year-old male suffering from recurrent hemoptysis and dyspnea, with 28-mm fungus ball in a pulmonary cavity, aspergilloma was diagnosed. A biopsy examination of which detected Aspergillus fumigates, a yellow fungus ball was observed in the cavity.

Systemic voriconazole among 2 months followed by itraconazole for 4 weeks was ineffective, the patient was poor pulmonary functions, and surgical was not possible.

L-AmB clinically administered locally into the bronchial instillation of yellow fungus ball, 2.5 mg/kg of 1% L-AmB administrated every treatment by dissolving L-AmB in distilled water at 10 mg/mL. The procedure was conducted once a week in the outpatient department for 4 weeks, the L-AMB dose was increased to 200 mg/body, by the sixth stage of management, the fungus ball decreased in size, after the seventh treatment stage, the diameter had diminished to 14 mm. In the end, the aspergilloma disappeared at 2 months after the ninth round of topical L-AmB treatment. This treatment strategy is suitable for patients with pulmonary complications.[22]

Boettcher et al., 2000,[23] reported three patients with invasive aspergillosis, who got combined antifungal management with systemic, aerosolized, and topical AmB, administrated bronchoscopically. In the first case, Aspergillus fumigatus was detected and 50 mg of conventional AmB used. In case two, Aspergillus flavus was isolated.

In the third case, a 46-year-old male developed necrosis 2 weeks after bilateral lung transplantation, 5 weeks later, culture showed A. fumigatus from bronchoalveolar lavage The patient received 2–3 mg L-AmB (0.5 mg/ml) aqueous solution administrated bronchoscopically once a week for a total of 4 weeks, resulting in a progressive reduction of secretions at each control bronchoscopy, successfully treatment achieved at 4–8 months after lung transplantation.[23]

Yamada et al.[24] demonstrated that 12 patients with aspergilloma treated with intracavitary antifungal agents from 1988 through 1992 by endobronchial or percutaneous approach. The AmB management performed in seven patients by dissolving AMB in 10–20 ml of 5% dextrose.

Persons with effective topical treatment had a shorter mean period of the disease course (3.6 months) than the less effective group (44.4 months). This study suggested that the old mycetoma was not effective to antifungal agents, so early diagnosis and therapy are demanded to achieve a better treatment effect.[24]

  Conclusion Top

Pulmonary mycosis is one of the most common lethal problems that make patients under serious risks of life-threatening. Topical AmB formulas are a promising way to develop effective management of the refractory fungal lung mycosis. Using AmB in modern branches and new applications is demanded, because AmB is a potential antifungal agent with rare resistance, as well as its broad-spectrum activity toward many fungal infections, more studies about topical AmB pulmonary formulas are recommended.

Topical treatment of pulmonary fungi is urgent when systemic drugs are ineffective, for patients with fungal pulmonary complications, and when the operation is inappropriate for patients.

Some formulas of AmB utilized in the treatment of pulmonary mycosis as D-AmB and L-AmB, the topical application of these formulas are promising as additional therapeutic options in the management of bronchial mycosis as aspergillosis and other fungal infections in the lung. Anyway, this branch of treatment demanded more accurate information as dose frequency and adjustment of bronchoscopic administration need to be evaluated.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Felton T, Troke PF, Hope WW. Tissue penetration of antifungal agents. Clin Microbiol Rev 2014;27:68-88.  Back to cited text no. 1
Al-Khikani FH, Al-Janabi AA. Topical amphotericin B formulas: Promising new application. IntJ Med Sci Curr Res 2019;2:187-96.  Back to cited text no. 2
Lanternier F, Lortholary O. Liposomal amphotericin B: What is its role in 2008? Clin Microbiol Infect 2008;14 Suppl 4:71-83.  Back to cited text no. 3
Stone NR, Bicanic T, Salim R, Hope W. Liposomal Amphotericin B (AmBisome(®): A review of the pharmacokinetics, pharmacodynamics, clinical experience and future directions. Drugs 2016;76:485-500.  Back to cited text no. 4
Volmer AA, Szpilman AM, Carreira EM. Synthesis and biological evaluation of amphotericin B derivatives. Nat Prod Rep 2010;27:1329-49.  Back to cited text no. 5
Mesa-Arango AC, Scorzoni L, Zaragoza O. It only takes one to do many jobs: Amphotericin B as antifungal and immunomodulatory drug. Front Microbiol 2012;3:286.  Back to cited text no. 6
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Scorzoni L, de Paula E Silva AC, Marcos CM, Assato PA, de Melo WC, de Oliveira HC, et al. Antifungal therapy: New advances in the understanding and treatment of mycosis. Front Microbiol 2017;8:36.  Back to cited text no. 8
Crawford F, Hollis S. Topical treatments for fungal infections of the skin and nails of the foot. Cochrane Database of Syst Rev 2007;1:161.  Back to cited text no. 9
Hay R. Therapy of skin, hair and nail fungal infections. J Fungi (Basel) 2018;4:99.  Back to cited text no. 10
Pendleton RA, Holmes JH 4th. Systemic absorption of amphotericin B with topical 5% mafenide acetate/amphotericin B solution for grafted burn wounds: Is it clinically relevant? Burns 2010;36:38-41.  Back to cited text no. 11
Morand K, Bartoletti AC, Bochot A, Barratt G, Brandely ML, Chast F. Liposomal amphotericin B eye drops to treat fungal keratitis: Physico-chemical and formulation stability. Int J Pharm 2007;344:150-3.  Back to cited text no. 12
Trasmonte MV, Jiménez JD, Santiago MÁ, Gálvez E, Jerez V, Pérez D, et al. Association of topical amphotericin B lipid complex treatment to standard therapy for rhinomaxillary mucormycosis after liver transplantation: A case report. Transplant Proc 2012;44:2120-3.  Back to cited text no. 13
Sanchez DA, Schairer D, Tuckman-Vernon C, Chouake J, Kutner A, Makdisi J, et al. Amphotericin B releasing nanoparticle topical treatment of Candida spp. in the setting of a burn wound. Nanomedicine 2014;10:269-77.  Back to cited text no. 14
Hartsel SC, Hatch C, Ayenew W. How does amphotericin B work? Studies on model membrane systems. J Liposome Res 1993;3:377-408.  Back to cited text no. 15
Shimizu K, Osada M, Takemoto K, Yamamoto Y, Asai T, Oku N. Temperature-dependent transfer of amphotericin B from liposomal membrane of AmBisome to fungal cell membrane. J Control Release 2010;141:208-15.  Back to cited text no. 16
Gray KC, Palacios DS, Dailey I, Endo MM, Uno BE, Wilcock BC, et al. Amphotericin primarily kills yeast by simply binding ergosterol. Proc Natl Acad Sci U S A 2012;109:2234-9.  Back to cited text no. 17
Hamill RJ. Amphotericin B formulations: A comparative review of efficacy and toxicity. Drugs 2013;73:919-34.  Back to cited text no. 18
Sangalli-Leite F, Scorzoni L, Mesa-Arango AC, Casas C, Herrero E, Gianinni MJ, et al. Amphotericin B mediates killing in Cryptococcus neoformans through the induction of a strong oxidative burst. Microbes Infect 2011;13:457-67.  Back to cited text no. 19
Haido RM, Barreto-Bergter E. Amphotericin B-induced damage of Trypanosoma cruzi epimastigotes. Chem Biol Interact 1989;71:91-103.  Back to cited text no. 20
Mitomo H, Sakurada A, Matsuda Y, Notsuda H, Watanabe T, Oishi H, et al. Endobronchial topical amphotericin b instillation for pulmonary chromomycosis after lung transplantation: A case report. Transplant Proc 2018;50:939-42.  Back to cited text no. 21
Takeda T, Itano H, Kakehashi R, Fukita S, Saitoh M, Takeda S. Direct transbronchial administration of liposomal amphotericin B into a pulmonary aspergilloma. Respir Med Case Rep 2014;11:7-11.  Back to cited text no. 22
Boettcher H, Bewig B, Hirt SW, Möller F, Cremer J. Topical amphotericin B application in severe bronchial aspergillosis after lung transplantation: Report of experiences in 3 cases. J Heart Lung Transplant 2000;19:1224-7.  Back to cited text no. 23
Yamada H, Kohno S, Koga H, Maesaki S, Kaku M. Topical treatment of pulmonary aspergilloma by antifungals. Relationship between duration of the disease and efficacy of therapy. Chest 1993;103:1421-5.  Back to cited text no. 24


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