The cases were classified following the EORTC/MSG Consensus Group criteria (European Organization for Research and Treatment of Cancer/Mycosis Study Group).27 Proven histoplasmosis or PCM was considered when the fungus was recovered in culture from a specimen or when the microorganism was observed using histopathology or direct microscopy. Cases were classified as probable when a consistent clinical picture was found and we had a positive result in an immunodiffusion test (ID Fungal Antibody System, Immuno-Mycologics Inc, Norman, OK, USA). All cases except one fulfilled the proven

or probable criterion. In Patient 11, there were only clinical suspicion and positive results by RT-PCR (Table 2). This case was classified as possible. Alpelisib cell line Using epidemiological criteria, we also classified the cases as either travelers or immigrants and people who had lived in an endemic region for a long period of time. In case of H capsulatum strains, mycelia were stained with lactophenol cotton blue dye (Difco, Soria-Melguizo, Madrid, Spain). Characteristic macroconidia were observed microscopically.

Extraction of nucleic acids from clinical strains was undertaken in Biosafety Level III facilities and in compliance with Spanish Laws (Royal Decree 664/1997). DNA extraction from strains and clinical samples was performed as described by Buitrago and colleagues.20 DNA extracted from clinical strains was used to amplify the internal transcriber spacer (ITS) region.28 Sequence analysis of amplified fragments was performed by

comparing the DNA sequences with the ITS sequences of H capsulatum http://www.selleckchem.com/products/CAL-101.html var. duboisii (ATCC 24295), H capsulatum var. capsulatum (CBS207.55 and CBS214.53), and P brasiliensis (ATCC32069 and ATCC60855) obtained from the GenBank database (http://www.ncbi.nlm.nih.gov/Genbank/). RT-PCR for the detection of H capsulatum was carried out following the protocol described by Buitrago and colleagues.19 Primers and probes were designed on the basis of the nucleotide sequence of the ITS1 rDNA region. Probes were marked using fluoresce resonance energy transfer (FRET) technology, and the PCR Methisazone reactions were performed in the Lightcycler 480 (Roche Applied Science, Madrid, Spain). An internal control was included in the RT-PCR reaction following the Brugraff method.20,29 RT-PCR for the detection of P brasiliensis DNA was performed as described by Buitrago and colleagues.25 Detection of precipitating antibodies in patient’s sera was performed by an immunodiffusion test following manufacturer’s recommendations (ID Fungal Antibody System). This commercial test uses the antigens M and H against histoplasmosis sera and antigen gp43 against PCM sera. A total of 39 cases of histoplasmosis and 6 cases of PCM have been diagnosed in the Spanish Mycology Reference Laboratory in the last 3 years.