Alteration of ß-glucan in the emerging fungal pathogen Candida auris leads to immune evasion and increased virulence.

Candida auris is an emerging pathogenic yeast that has been categorized as a global public health threat and a critical priority among fungal pathogens. Despite this, the immune response against C. auris infection is still not well understood. Hosts fight Candida infections through the immune system that recognizes pathogen-associated molecular patterns such as ß-glucan, mannan, and chitin on the fungal cell wall. In this study, levels of ß-glucan and mannan exposures in C. auris grown under different physiologically relevant stimuli were quantified by flow cytometry-based analysis. Lactate, hypoxia, and sublethal concentration of fluconazole trigger a decrease in surface ß-glucan while low pH triggers an increase in ß-glucan. There is no inverse pattern between exposure levels of ß-glucan and mannan in the cell wall architecture among the three clades. To determine the effect of cell wall remodeling on the immune response, a phagocytosis assay was performed, followed by quantification of released cytokines by ELISA. Lactate-induced decrease in ß-glucan leads to reduced uptake of C. auris by PMA-differentiated THP-1 and RAW 264.7 macrophages. Furthermore, reduced production of CCL3/MIP-1⍺ but not TNF-⍺ and IL-10 were observed. An in vivo infection analysis using silkworms reveals that a reduction in ß-glucan triggers an increase in the virulence of C. auris. This study demonstrates that ß-glucan alteration occurs in C. auris and serves as an escape mechanism from immune cells leading to increased virulence.

Histoplasma antigen detection in unconfirmed pulmonary tuberculosis and cross-reactivity with Aspergillus antigen in patients and in food in Jakarta, Indonesia.

PURPOSE: H. capsulatum is endemic in Indonesia, but the value of Histoplasma antigen detection has not been studied. PATIENTS AND METHODS: Histoplasma galactomannan (GM) ELISA was applied to sera of patients with unproven pulmonary tuberculosis (TB) and patients with a positive Aspergillus GM. Both Histoplasma and Aspergillus GM tests were performed to determine any possible cross-reaction with certain foods. RESULTS: Fourteen of 122 (11.5%) sera of patients with newly diagnosed clinical TB were positive for Histoplasma GM. The positivity rate in the serum of patients 5-6 and 12 months after TB diagnosis was 3.8% and 3.5%, respectively. Of 88 positive Aspergillus GM sera, 63 (71.6%) were also positive for Histoplasma GM. All tested foods were positive for Aspergillus GM, while 65% of foods were positive for Histoplasma GM. CONCLUSION: Galactomannan is widespread in sera and food in Jakarta, possibly related to food consumption. Histoplasma and Aspergillus antigen detection for the diagnosis will require additional means of confirming the diagnosis; negative tests may be more helpful for ruling out invasive histoplasmosis and aspergillosis.

Expert Panel Recommendations on the Clinical Practice Guidelines for the Diagnosis and Management of Invasive Candidiasis in Indonesia.

Invasive candidiasis (IC) ranks among the primary causes of deadly fungal infections. The frequency of IC rises alongside increasing number of patients with altered immune systems, critically ill, chronic diseases, and various medical procedures. The disease causes high morbidity and mortality, as well as prolonged stay and increases hospital costs. The diagnosis and management of IC in Indonesia is still a challenge. Laboratory facilities in identifying pathogenic fungi and susceptibility tests to antifungals are still limited. Clinical awareness and financial support from health policymakers are also insufficient. Early diagnosis is essential for proper treatment to reduce morbidity and mortality rates. Initiated by the Indonesian Pulmonary Mycoses Centre (IPMC), several expert representatives from six medical professional organizations in Indonesia have agreed to set up a meeting series to prepare a joint draft on the diagnosis and management of IC. The expert panel aimed to achieve a consensus on the clinical practice guidelines for diagnosing and treating IC in Indonesia.

A prospective longitudinal study of chronic pulmonary aspergillosis in pulmonary tuberculosis in Indonesia (APICAL).

OBJECTIVES: Chronic pulmonary aspergillosis (CPA) can complicate recovery from pulmonary TB. CPA may also be misdiagnosed as bacteriologically negative TB. This study aimed to determine the incidence of CPA in patients treated for TB in Indonesia, a country with a high incidence of TB. METHODS: In this prospective, longitudinal cohort study in patients treated for pulmonary TB, clinical, radiological and laboratory findings were analysed. Sputum was collected for fungal culture and TB PCR. Patients were assessed at baseline (0-8 weeks) and at the end (5-6 months) of TB therapy. CPA diagnosis was based on symptoms (≥3 months), characteristic radiological features and positive Aspergillus serology, and categorised as proven, probable and possible. RESULTS: Of the 216 patients recruited, 128 (59%) were followed up until end of TB therapy. At baseline, 91 (42%) had microbiological evidence for TB. Aspergillus-specific IgG was positive in 64 (30%) patients and went from negative to positive in 16 (13%) patients during TB therapy. The incidence rates of proven and probable CPA at baseline were 6% (n=12) and 2% (n=5) and end of TB therapy 8% (n=10) and 5% (n=7), respectively. Six patients (two with confirmed TB) developed an aspergilloma. Diabetes mellitus was a significant risk factor for CPA (p=0.040). Persistent cough (n=5, 50%; p=0.005) and fatigue (n=6, 60%; p=0.001) were the most common symptoms in CPA. CONCLUSION: CPA should be considered a relatively frequent differential diagnosis in patients with possible or proven TB in Indonesia. Lack of awareness and limited access to Aspergillus-specific IgG tests and CT imaging are obstacles in establishing a CPA diagnosis.

A New Filter Based Cultivation Approach for Improving Aspergillus Identification using Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS).

Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) is widely used in clinical laboratories for routine identification of bacteria and yeasts. However, methodological difficulties are still apparent when applied to filamentous fungi. The liquid cultivation method recommended by Bruker Daltonics GmbH for identification of filamentous fungi by MALDI-TOF MS is labour intensive and time-consuming. In this study, growth of Aspergillus species on different (porous) surfaces was investigated with the aim to develop a more reliable, quicker and less laborious identification method using MALDI-TOF MS. Mycelial growth without sporulation mimicking liquid cultivation and reliable MALDI-TOF MS spectra were obtained when A. fumigatus strains were grown on and in between a polycarbonate membrane filter on Sabouraud dextrose agar. A database of in-house reference spectra was created by growing Aspergillus reference strains (mainly focusing on sections Fumigati and Flavi) under these selected conditions. A test set of 50 molecularly identified strains grown under different conditions was used to select the best growth condition for identification and to perform an initial validation of the in-house database. Based on these results, the cultivation method on top of a polycarbonate filter proved to be most successful for species identification. This method was therefore selected for the identification of two sets of clinical isolates that mainly consisted of Aspergilli (100 strains originating from Indonesia, 70 isolates from Qatar). The results showed that this cultivation method is reliable for identification of clinically relevant Aspergillus species, with 67% and 76% correct identification of strains from Indonesia and Qatar, respectively. In conclusion, cultivation of Aspergilli on top of a polycarbonate filter showed improved results compared to the liquid cultivation protocol recommended by Bruker in terms of percentage of correct identification, ease of MSP creation, time consumption, cost and labour intensity. This method can be reliably applied for identification of clinically important Aspergilli and has potential for identification of other filamentous fungi.

Serious fungal disease incidence and prevalence in Indonesia.

BACKGROUND: Indonesia is a tropical country, warm and humid, with numerous environmental fungi. Data on fungal disease burden help policymakers and clinicians. OBJECTIVES: We have estimated the incidence and prevalence of serious fungal diseases. METHODS: We found all published and unpublished data and estimated the incidence and prevalence of fungal diseases based on populations at risk. HIV data were derived from UNAIDS (2017), pulmonary tuberculosis (PTB) data from 2013-2019, data on chronic pulmonary aspergillosis (CPA) were used to estimate CPA prevalence and likely deaths, COPD data from Hammond (2020), lung cancer incidence was from Globocan 2018, and fungal rhinosinusitis was estimated using community data from India. RESULTS: Overall ~7.7 million Indonesians (2.89%) have a serious fungal infection each year. The annual incidence of cryptococcosis in AIDS was 7,540. Pneumocystis pneumonia incidence was estimated at 15,400 in HIV and an equal number in non-HIV patients. An estimated 1% and 0.2% of new AIDS patients have disseminated histoplasmosis or Talaromyces marneffei infection. The incidence of candidaemia is 26,710. The annual incidence of invasive aspergillosis was estimated at 49,500 and the prevalence of CPA is at 378,700 cases. Allergic bronchopulmonary aspergillosis prevalence in adults is estimated at 336,200, severe asthma with fungal sensitisation at 443,800, and fungal rhinosinusitis at 294,000. Recurrent vulvovaginal candidiasis is estimated at 5 million/year (15-50 years old). The incidence of fungal keratitis around 40,050. Tinea capitis prevalence in schoolchildren about 729,000. CONCLUSIONS: Indonesia has a high burden of fungal infections.

Talaromyces atroroseus in HIV and non-HIV patient: A first report from Indonesia.

We performed morphology, molecular study and antifungal susceptibility test on 10 Talaromyces sp. isolates: eight clinical isolates (human immunodeficiency virus (HIV) and non-HIV-patient) and two isolates from rats. All strains produced red soluble pigment and microscopically showed Penicillium-like structure in room temperature and yeast-like structure in 37°C. Based on molecular analysis, nine isolates were identified as Talaromyces atroroseus (including the isolates from rats) and one as T. marneffei. Our susceptibility result of T. marneffei supports the use of amphotericin B, itraconazole for talaromycosis marneffei management. Talaromyces atroroseus showed variable MIC to echinocandin, azole derivatives, 5-flucytosine and amphotericin B.

Therapeutic response time of topical voriconazole 1% and intrastromal voriconazole 0.05% versus topical natamycin 5% monotherapy in Fusarium keratitis in rabbit.

BACKGROUND: Fungal keratitis can be more difficult to treat than bacterial keratitis with worse outcomes. OBJECTIVE: To evaluate the therapeutic response time of topical voriconazole combined with intrastromal voriconazole, and topical natamycin on Fusarium keratitis. METHODS: The stroma of corneas of twelve New Zealand White rabbits was inoculated with Fusarium sp spores. Seven days after inoculation, they were divided into 2 groups randomly. Group A was treated with topical natamycin 5% for 21 days. Group B was treated with intrastromal voriconazole 0.05% single injection at the beginning of treatment, continued with topical voriconazole 1% for 21 days. Clinical evaluations for epithelial defect size and clinical scores in each group were performed on 1st, 3rd, 7th, 10th, 14th and 21st days after treatment. Mycological examinations were performed before and after the treatment. RESULTS: After treatment, there was no statistically significant difference between natamycin and voriconazole in reducing epithelial defect size at first, second or third week after treatment (P = .15; P = .39; and P = .90). The clinical scores on both groups also showed no statistically significant differences at first, second and third weeks after treatment (P = .24; P = .09; and P = .32). Qualitative mycological evaluation before and after the treatment showed no statistically significant difference in KOH examination (P = 1; P = 1) and culture in Sabouraud dextrose agar (P = 1; P = 1). CONCLUSION: Intrastromal voriconazole injection combined with topical voriconazole seems to give similar response time but not earlier in improving clinical presentation of Fusarium keratitis as topical natamycin.

Factors Associated with Death in COVID-19 Patients in Jakarta, Indonesia: An Epidemiological Study.

BACKGROUND: Coronavirus Disease 2019 is an emerging respiratory disease that is now a pandemic. Indonesia is experiencing a rapid surge of cases but the local data are scarce. METHODS: this is an analysis using data from the ongoing recapitulation of Epidemiological Surveillance (ES) by the Provincial Health Office of Jakarta from March 2nd to April 27th 2020. We evaluated demographic and clinical characteristics of all confirmed cases in association with death. RESULTS: of the 4,052 patients, 381 (9.4%) patients were deceased. Multivariable analysis showed that death was associated with older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.02, 1.05, per year increase; p<0.001), dyspnea (OR 4.83; 95% CI 3.20, 7.29; p<0.001), pneumonia (OR 2.46; 95%CI 1.56, 3.88; p<0.001), and pre-existing hypertension (OR 1.86; 95% CI 1.24, 2.78; p=0.003). Death was highest in the week of April 6th 2020 and declined in the subsequent weeks, after a large-scale social restriction commenced. CONCLUSION: older age, dyspnea, pneumonia, and pre-existing hypertension were associated with death. Mortality was high, but may be reduced by lockdown.

Case Definition of Chronic Pulmonary Aspergillosis in Resource-Constrained Settings.

Chronic pulmonary aspergillosis (CPA) is a recognized complication of pulmonary tuberculosis (TB). In 2015, the World Health Organization reported 2.2 million new cases of nonbacteriologically confirmed pulmonary TB; some of these patients probably had undiagnosed CPA. In October 2016, the Global Action Fund for Fungal Infections convened an international expert panel to develop a case definition of CPA for resource-constrained settings. This panel defined CPA as illness for >3 months and all of the following: 1) weight loss, persistent cough, and/or hemoptysis; 2) chest images showing progressive cavitary infiltrates and/or a fungal ball and/or pericavitary fibrosis or infiltrates or pleural thickening; and 3) a positive Aspergillus IgG assay result or other evidence of Aspergillus infection. The proposed definition will facilitate advancements in research, practice, and policy in lower- and middle-income countries as well as in resource-constrained settings.

The Association of Chronic Pulmonary Aspergillosis and Chronic Pulmonary Histoplasmosis with MDR-TB Patients in Indonesia.

In Indonesia, 2.4% of all new tuberculosis patients had multi-drug resistant disease (MDR-TB); an estimated 24,000 incidences. Historical case series of MDR-TB described a high frequency of cavitation and poor prognosis. The diagnosis of chronic pulmonary aspergillosis (CPA) relies on raised levels of Aspergillus IgG antibodies, and detectable Histoplasma IgG antibodies are suspicious for chronic pulmonary histoplasmosis (CPH). We investigated whether MDR-TB patients might have concurrent CPH or CPA. This was a cross-sectional study with 50 MDR-TB patients. ELISA was used to detect Histoplasma IgG antibodies and lateral flow assay was used to detect Aspergillus IgG/IgM antibodies. Several other possible disease determinants were assessed by multivariate analysis. Of the 50 MDR-TB patients, 14 (28%) and 16 (32%) had positive Histoplasma or Aspergillus serology; six patients (12%) had dual antibody reactivity. Radiological abnormalities in positive patients included diffuse or local infiltrates, nodules, consolidation, and apical cavities, consistent with CPH and CPA. Patients with detectable fungal antibodies tended to have worse disease, and 4 of 26 (15.3%) died in the first 5 months of dual infection (p = 0.11 compared with no deaths in those with only MDR-TB). The criteria for the diagnosis of CPH and CPA were fulfilled in those with moderately and far advanced disease (13 of 14 or 93%) and 12 of 16 (75%), respectively. Damp housing was the only determinant associated with Histoplasma antibodies (PR 2.01; 95%CI 0.56-7.19), while pets were associated with the Aspergillus antibody (PR 18.024; 95%CI 1.594-203.744). CPA or CPH are probably frequent in MDR-TB patients in Indonesia and may carry a worse prognosis.

The Antifungal Activities of Syzygium aromaticum and Alpinia purpurata Extracts Against Candida krusei: Bioactivity Tests, Molecular Modeling, and Toxicity Tests.

BACKGROUND: Candida krusei is the cause of the fungal infection candidiasis, which has a high mortality rate. Intrinsic resistance to fluconazole can cause the failure of Krusei candidiasis treatment. Therefore, it is necessary to find alternative drugs to eliminate the fungus. Extracts of Syzygium aromaticum and Alpinia purpurata have been proven to be alternative solutions for treating Candida krusei resistance. OBJECTIVE: This study aims to explore the active compounds Syzygium aromaticum and Alpinia purpurata as treatments against Candida krusei through bioactivity tests, molecular modeling, and toxicity tests. METHODS: Determination of antifungal activity with the agar well diffusion and microbroth dilution method. Molecular modeling was conducted using the following software: Marvin Sketch, LigandScout  4.4.5, AutoDock ver 4.2.6, PyMOL, LigPlus, MOE ver 2008. RESULT: Bioactivity test results of the two natural extracts against C. krusei ATCC 6258, it was found that the S. aromaticum and A. purpurata extracts have MIC50 values of 0.031 µg/mL and 1.435x105 µg/mL. The molecular modeling found that the compounds Benzotriazole, 1-(4-methyl-3-nitrobenzoyl)-, 1,3,4-Eugenol Acetate, Stigmasta-5,22-dien-3-ol, acetate (3 beta)- and Farnesyl acetate from the two natural extracts, interacts with the active site of the enzyme lanosterol-14-α-demethylase with a binding energy of -8.91, -6.04, -13.53, and -7.15 kcal/mol. The oral acute toxicity test of S. aromaticum and A. purpurata extracts proved that the LD50 was >6000 mg/kg BW and >8000 mg/kg BW. The acute dermal toxicity test of the two extracts showed that the LD50 was >6000 mg/kg BW. CONCLUSION: S. aromaticum and A. purpurata extracts have been proven to be alternative solutions for treating Candida krusei resistance.

The Fungal and Bacterial Interface in the Respiratory Mycobiome with a Focus on Aspergillus spp.

The heterogeneity of the lung microbiome and its alteration are prevalently seen among chronic lung diseases patients. However, studies to date have primarily focused on the bacterial microbiome in the lung rather than fungal composition, which might play an essential role in the mechanisms of several chronic lung diseases. It is now well established that Aspergillus spp. colonies may induce various unfavorable inflammatory responses. Furthermore, bacterial microbiomes such as Pseudomonas aeruginosa provide several mechanisms that inhibit or stimulate Aspergillus spp. life cycles. In this review, we highlighted fungal and bacterial microbiome interactions in the respiratory tract, with a focus on Aspergillus spp.

Low-cost SYBR Green-based RT-qPCR assay for detecting SARS-CoV-2 in an Indonesian setting using WHO-recommended primers.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent for the ongoing coronavirus disease 2019 (COVID-19) pandemic. For laboratory diagnosis, low-cost detection of SARS-CoV-2 is urgently needed, particularly in developing countries with limited resources. Probe- or TaqMan-based real-time reverse transcription polymerase chain reaction (RT-qPCR) is currently the gold standard for diagnosing infected individuals, as recommended by the World Health Organization (WHO). However, this assay is expensive, making it difficult to use for diagnosis on a large scale. Therefore, in this study, we develop and validate an alternative approach for RT-qPCR diagnosis by employing the DNA intercalating dye SYBR Green. We evaluate and use two WHO-recommended primers, namely CCDC-N and HKU-ORF1b-nsp14. The compatibility of the two primers was tested in silico with Indonesian SARS-CoV-2 genome sequences retrieved from the GISAID database and using bioinformatic tools. Using in vitro-transcribed RNA, optimization, sensitivity, and linearity of the two assays targeting the N and Nsp-14 genes were carried out. For further evaluation, we used clinical samples from patients and performed the SYBR Green-based RT-qPCR assay protocol in parallel with TaqMan-based commercial assay. Our results show that our methodology performs similarly to the broadly used TaqMan-based detection method in terms of specificity and sensitivity and thus offers an alternative assay for the detection of SARS-CoV-2 RNA for diagnostic purposes.

Whole genome sequencing data of Candida krusei, the pathogen causing Candidaemia, from Department of Parasitology Culture Collection, Faculty of Medicine Universitas Indonesia.

Candida krusei is a Candida non-albicans species with a high prevalence, which causes candidaemia. Current treatment guidelines include fluconazole as a primary therapeutic option for the treatment of these infections; however, it is only a fungistatic against Candida spp., and both inherent and acquired resistance to fluconazole have been reported. C. krusei species is also reported as the only Candida sp. which has an intrinsic resistance factor to fluconazole. Therefore, in dealing with antifungal resistance, it is necessary to develop new antifungal agents that are efficient in the treatment of fungal infections, especially those caused by C. krusei. The purpose of this study was to investigate the genome of clinical C. krusei isolates and correlate the resistant phenotypes with mutations in resistance genes. A total of 16 samples of C. krusei from clinical samples from hospitals in Jakarta were used in the experiment. All colonies were extracted using the QIAamp DNA Mini Kit. The library was prepared using the Illumina DNA Prep Kit. The sequencing process was carried out on the Illumina MiSeq Platform using a 2x301 paired-end configuration. FASTQ raw files are available under the BioProject Accession Number PRJNA819536 and Sequence Read Archive Accession Numbers SRR18739949 and SRR18739964.

Pneumocystis jirovecii colonization in bronchoalveolar lavage among naïve non-small cell lung cancer from tertiary respiratory hospital in Jakarta, Indonesia.

INTRODUCTION: Pneumocystis jirovecii pneumonia (PJP) is a lung mycosis commonly found in immunocompromised patients (e.g., HIV patients); however, its role in solid cancer remains unclear. This study aims to identify Pneumocystis jirovecii colonization among naïve non-small-cell lung cancer (NSCLC) through bronchoalveolar lavage (BAL) and explore its correlation with clinical parameters. METHODOLOGY: This cross-sectional study recruited newly diagnosed naïve NSCLC patients who had not been given systemic treatments. We tested BAL from patients for P. jirovecii colonization with nested PCR targeting the mtLSU rRNA gene. Demographic and clinical characteristics were obtained from medical records, and the correlation between P. jirovecii colonization and clinicopathological data were analyzed. Kaplan-Meier analyses were done to evaluate survival. RESULTS: Among 56 newly diagnosed, naïve NSCLC patients enrolled, the prevalence of P. jirovecii colonization was 17.9% (10 subjects). There was no statistically significant difference in demographic and clinical characteristics between the P. jirovecii colonization group versus no colonization (p value > 0.05). The overall survival duration for both groups demonstrated no significant difference. CONCLUSIONS: This study demonstrated a relatively high prevalence of P. jirovecii colonization among BAL samples of naïve Indonesian NSCLC patients. Further study is needed to delineate its implications for the potential transmission source, lung cancer pathogenesis, and prognosis.

Bronchoscopy Findings of Severe and Critical COVID-19 Patients Treated in ICU: A Year of Experience in a Developing Country.

Background: Bronchoscopy procedure in patients with COVID-19 poses significant challenges, especially in a developing country with limited resources. Objectives: We aim to describe the clinical characteristics of severe and critical COVID-19 patients treated in an intensive care unit (ICU) and their bronchoscopy findings. Methods: We performed a retrospective analysis of clinical data of ICU patients with COVID-19 treated and received bronchoscopy procedures. This study retrospectively included all consecutive patients who underwent bronchoscopy at a teaching hospital in Depok, Indonesia, from May, 2020, until May, 2021. Results: A total of 57 bronchoscopy procedures in 54 patients were performed in this study. Primary procedure indications were retained mucus (68.4%) and ventilatory support weaning failure (15.8%). Bronchoscopic findings were mostly hyperaemic mucosa (95.00%) and purulent secretion (50.90%). Microbiological findings from bronchoalveolar samples were Acinetobacter baumanii, Klebsiella pneumoniae, and Candida albicans (33.3%, 26.6%, and 10.5%, respectively). The most common fungal isolated were Candida albicans (28%), followed by Candida tropicalis (16%) and Aspergillus sp. (8%). The overall length of hospital stay was 24 days, and the in-ICU stay was 22.06 ± 10.99 days. The patients' survival of 28-days postprocedural outcome was 25.9% (14 subjects). Follow-up found that 20.4% of patients survived after sixty days of hospitalization. Conclusion: Diagnostic and therapeutic bronchoscopy in ICU patients with COVID-19 was safe and feasible to perform in developing countries with limited resources. It could help bronchial mucous clearance and confirm microbiological infection. The procedures should be strictly performed for patients with indications and comply with safety standards.

Unravelling the Molecular Identification and Antifungal Susceptibility Profiles of Aspergillus spp. Isolated from Chronic Pulmonary Aspergillosis Patients in Jakarta, Indonesia: The Emergence of Cryptic Species.

Cryptic species of Aspergillus have rapidly increased in the last few decades. Chronic pulmonary aspergillosis (CPA) is a debilitating fungal infection frequently affecting patients with previous TB. The identification and antifungal susceptibility profiles of different species of Aspergillus are important to support the management of CPA. The aim of this study was to describe the molecular and susceptibility profiles of Aspergillus isolated from CPA patients. The species identity of isolates was determined by combined DNA analyses of internal transcribed space (ITS), partial ß-tubulin genes, and part of the calmodulin gene. We revealed a high (27%) prevalence of cryptic species among previous tuberculosis patients with persistent symptoms. Twenty-nine (49%) patients met the criteria for diagnosis of CPA with 24% containing Aspergillus cryptic species. This is the first report of five cryptic Aspergillus species from clinical isolates in Indonesia: A. aculea tus, A. neoniger, A. brunneoviolacues, A. welwitschiae, and A. tubingensis. Significantly, there was decreased sensitivity against itraconazole in the CPA group (66% susceptible to itraconazole) compared to the non-CPA group (90% susceptible to itraconazole) (p = 0.003). The species-level characterisation of Aspergillus and its antifungal susceptibility tests demands greater attention to better the management of CPA patients.

The effect of repeated education using live demonstrations and videos of how to use inhalation drugs on quality of life for COPD patients.

Repeated education regarding the proper use of inhalers can reduce the error rate in inhaler-using patients and improve COPD patients' quality of life. This study investigates the effect of repeated education on the quality of life of COPD patients during the pandemic of COVID-19 from February to June 2020. Repeated education is provided using direct demonstrations to patients through educational media in the form of short videos made by the researchers for each inhaler type. This is a pre-experimental study design which was carried out prospectively at Grha Permata Ibu Hospital, Depok. The quality of life of 22 subjects was examined using the COPD assessment test (CAT) questionnaire. Each patient was given a direct verbal demonstration of the appropriate use of the inhaler. One month later, each patient was provided further education using less than 2 min of video sent to them online via the WhatsApp application. Final quality-of-life examination and assessment of inhaler technique were carried out three months after the initial examination. Assessment of proper inhaler technique was carried out using a specific checklist regarding the use of inhaler translated by the researcher. Before and after delivery of repeated education, the mean CAT score showed a decrease of two points, i.e., 12.8 ± 1.3 and 10.8 ± 2.0, respectively. This indicated that quality of life of the patients had significant improvement. However, as many as 63.6% of patients still made mistakes in using inhaler even though they had been educated. For DPI-type inhalers, mistake mostly happened at step "breath out gently, away from inhaler". For pMDI-type inhalers, mistake mostly happened at step "while holding breath, remove inhaler from mouth". It can be concluded that repeated education regarding proper inhaler technique with direct demonstrations and further maintained by videos can improve the quality of life in COPD patients.

Glutathione (GSH) and superoxide dismutase (SOD) levels among junior high school students induced by indoor particulate matter 2.5 (PM2.5) and nitrogen dioxide (NO2) exposure.

BACKGROUND: Indoor air pollution has globally known as the risk factor of acute respiratory infection in young children.  The exposure to indoor particulate matter 2.5 (PM2.5) and nitrogen dioxide (NO2) at house or school can be a potential risk to children's health. This study aimed to examine the association between indoor PM2.5 and NO2 with oxidative stress markers in junior high school students. DESIGN AND METHOD: This study was conducted using a cross sectional study with 75 students collected randomly from four junior high schools in Jakarta.  PM2.5 and NO2 were measured in classrooms and school yards. The schools were categorized based on the exposure level of PM2.5 and NO2 in classrooms. Superoxide dismutase (SOD) and reduced glutathione (GSH) were examined from the blood sample. All students were interviewed with questionnaires to determine upper respiratory tract infection, smoking family members, mosquito repellent usage, and dietary supplement consumption. RESULTS: Mean concentration of indoor PM2.5 and NO2 were 0.125±0.036 mg m-3 and 36.37±22.33 µg m-3, respectively. The schools which located near to highway showed lower PM2.5 and higher NO2 level indicated the emission of traffic activity. Mean activity of SOD was 96.36±50.94 U mL-1 and mean concentration of GSH was of 0.62±0.09 µg mL-1. Most of the students reported upper respiratory tract infection history, smoking family member, use mosquito repellent at home, and do not consume dietary supplement. CONCLUSION: The level of oxidative stress markers and the exposure categories of classroom PM2.5 and NO2 was not significantly different, however there were significant correlation with cigarette smoke and mosquito repellent at home. Nevertheless, the exposure of indoor PM2.5 and NO2 increased the risk of the exposure to cigarette smoke and mosquito repellent at home. Further study on the air pollution at school and home is needed to affirm association towards student's health and to design strategic control efforts.