1. Introduction
The genus
Fusarium spp., mainly known as a plant pathogen, is cosmopolite and present in soil, water, and air.
Fusarium is classified in different species complexes, and some of them have been described as human pathogens, such as
Fusarium solani species complex (FSSC),
Fusarium oxysporum species complex (FOSC), or
Fusarium fujikuroi species complex (FFSC). Among them, the
Fusarium solani species complex is the most represented [
1,
2]. Actually, the nomenclature of this complex is under revisions. Indeed, taxonomy experts propose to reclassify FSSC in a new genus,
Neocosmospora. In contrast, the opposite view reasserts that FSSC has to be included in the genus
Fusarium, being the most practical scientific option [
3,
4].
Fusarium can cause skin and ocular infections [
5], but can also lead to severe invasive fungal infections, fusariosis, in immunodeficient patients, in particular those who have received stem cells transplants or suffer from acute leukemia [
1,
6,
7]. The number of fusariosis cases has been steadily increasing over the last two decades [
8,
9].
Therapeutic drugs for fusariosis treatment are limited. Indeed,
Fusarium spp. presents a low susceptibility to most antifungals. Due to the lack of clinical trials, the optimal treatment strategy for patients with fusariosis remains unclear. However, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the European Confederation of Medical Mycology (ECMM) published joint guidelines for the management of fusariosis and recommended the use of voriconazole, associated or not with amphotericin B [
10,
11]. Despite these recommendations, many studies have demonstrated a high variability of voriconazole MIC between
Fusarium strains. In their article, Debourgogne et al. determined voriconazole MICs for 48 FSSCs from clinical and environmental samples by the CLSI M38-A2 method. They found a mean MIC of 4.6 µg/mL and a MIC
90 of 8 µg/mL [
12].
Voriconazole belongs to the class of azole antifungals, whose mechanism of action is based on the inhibition of ergosterol synthesis. Ergosterol is a major component of the fungal membrane. Its production is managed by the 14α-demethylase enzyme, the target of azole antifungals [
13,
14]. The binding of azole to the ferric iron moiety of the heme-binding site blocks the enzyme’s natural substrate lanosterol, disrupting the biosynthetic pathway [
15]. In the
Fusarium genus, this enzyme is encoded by the
CYP51 gene and is present in three isoforms: A, B, and C [
16].
In fungi, azole resistance involves multiple mechanisms, such as (i) target alteration or overexpression, (ii) upregulation of multidrug transporters (efflux and impermeability), or (iii) cellular stress responses [
17,
18,
19].
Qualitative modifications such as amino acid substitutions within the target inhibiting drug binding are a widespread azole-resistance mechanism in fungi. Protein overexpression is also a frequent mechanism among azole-resistant clinical isolates of yeasts, such as
C. albicans with
ERG11 [
19]. In filamentous fungi, the mechanism or the contribution of overexpression to azole resistance remains unclear [
20]. Two cases of
CYP51A overexpression in
A. fumigatus have been described [
21]. Another ubiquitous resistance mechanism involves membrane-associated efflux pumps. Two systems have been highlighted, the ATP-binding cassette (ABC) superfamily which use ATP hydrolysis, and the major facilitator superfamily (MFS) using the electrochemical proton-motive force to power drug efflux.
In
A. fumigatus, target alteration inducing azole resistance can emerge in response to azole therapy [
22]. The most commonly reported resistance mechanisms with CYP51A are substitutions at codons 54 and 220 [
23]. However, resistance could also be of environmental origin and driven by the agricultural use of azoles. The first resistance mechanism described from environmental origin consists of a combination of a substitution at codon 98 in the
CYP51A gene and a 34 base-pair tandem repeat (TR) in the gene promoter (TR
34/L98H) [
24].
The objective of this study was to identify a potential relationship between azole susceptibility and modification by target mutations in Fusarium solani species complex to better understand resistance mechanisms and help adapt treatment of this multi-resistant pathogen.
4. Discussion
MIC determination in our panel of FSSC strains showed a low susceptibility for azoles used in clinical practice and a high variability of susceptibility for voriconazole and isavuconazole (MIC values ranged from 2 to 16 and 4 to 64 µg/mL, respectively). Our MIC values were close to the range of 1–16 µg/mL formerly defined for
Fusarium solani complex species [
1,
35,
36]. Our results also revealed that all FSSC strains exhibited itraconazole and posaconazole MICs superior to 16 µg/mL, except for the FSSC20 strain which had a MIC
PSZ of 8 µg/mL. This observation has also been reported in other publications [
10,
35]. Tortorano et al. showed comparable results for posaconazole as the majority of their FSSC strains presented MICs of 16 µg/mL, except for one strain for which it was 1 µg/mL [
11]. Concerning isavuconazole, the results showed a larger range of MIC values, from 4 to 64 µg/mL. Most of its activities against
Fusarium spp. have shown MIC values often greater than 16 or even 32 µg/mL [
10,
37,
38,
39]. Our findings support the high MIC values previously reported and revealed that 64% of FSSC strains exhibited MICs superior or equal to 16 µg/mL.
The variability of susceptibility to voriconazole observed for FSSC strains in our study raises the question of the mechanism responsible for this low susceptibility. Alignments of CYP51A, CYP51B, and CYP51C protein sequences highlighted similarities between strains, but also allowed their classification into different profiles: 9, 4, and 5 profiles for CYP51A, CYP51B, and CYP51C, respectively. To the best of our knowledge, this approach has not been carried out before. Furthermore, sequence profiling allowed to link voriconazole MICs with the CYP51 protein sequence.
Up to now, no mutations involved in azole resistance within the 14α-demethylase gene of the
Fusarium solani species complex had been described. By comparing with CYP51A of
Aspergillus fumigatus, we showed that 5 of the 23 mutations described in the literature as being associated with a change in azole sensitivity in this pathogen were found in all tested FSSC strains. Most of these mutations have been described as responsible for voriconazole resistance in
A. fumigatus [
23]. In this fungus, a substitution of methionine 220 to lysine, isoleucine, valine, or threonine impacts voriconazole susceptibility. Indeed, it has been shown that clinical strains exhibiting the M220I mutation present increased voriconazole MICs [
40]. This fact has also been proven using yeast clones expressing the CYP51 M220I mutant of
A. fumigatus [
41]. Isoleucine found in
A. fumigatus is very structurally close to leucine found at position 218 in our panel of FSSCs. They are both apolar amino acids and share the same physicochemical properties. It has been shown that changes in amino acids due to their physicochemical properties (polarity, hydrophobicity, etc.) are responsible for modifying protein conformation and consequently, its affinity with targets such as azoles [
42]. Interestingly, L218, corresponding to M220 for
A. fumigatus, is common to all strains. By structure modeling of CYP51A, with
Fusarium vanettenii mpVI 77-13-4 as a query sequence, we observed that L218 is located at the channel entry of the substrate. This conserved leucine at position 218 and its role in protein channel conformation were also described by James et al. [
27]. Thus, we propose that the L218 residue is directly involved in the discrimination of azole by modifying the shape of the channel entry of the substrate for the
Fusarium solani species complex or associated with the genus
Fusarium. Concerning the influence of the mutation at the position 22 on azole discrimination, one possibility could involve its influence on the orientation of the αA′ helix that constitutes an integral part of the channel entry, while the second possibility could be the locking of CYP51A against the membrane, that could infer with the accessibility of the long azole chain to the active site. Mutations at positions 170, 253, and 422 also led to a low susceptibility for azole in our study, whereas they are located far from the azole binding site. Albeit their precise role in azole discrimination is difficult to assess at the molecular level, one can hypothesize that amino acids at these positions could be key residues that affect the plasticity of CYP51A within
Fusarium solani species complex, which is required for ligand binding.
The literature reports that some strains of
A. fumigatus show resistance or reduced sensitivity to one or more azoles without any mutations detected in the
CYP51A gene. These phenotypes have been explained by the presence of mutations in the
CYP51B gene [
43,
44]. These point mutations were not found in our panel. The same observation was made for
CYP51C in comparison with
Aspergillus flavus.Few studies have focused on
Fusarium species complexes other than FSSC and their resistance to clinically used azoles. Indeed, the genus
Fusarium is also a plant pathogen. Studies about
Fusarium graminearum (FSAMSC) and FOSC have shown that the
CYP51A gene encodes an inducible 14α-demethylase, determining sensitivity to azoles. On the contrary, CYP51B is a 14α-demethylase involved in the formation of ascospores, but is barely impacted by antifungals. Indeed, an increase in sensitivity to azole antifungals has been described in strains deleted in
CYP51A (Δ
CYP51A), but no difference was observed for Δ
CYP51B mutants.
CYP51C is genus-specific and is found in the genus
Fusarium. However, its role is not clearly established. Studies show that
CYP51C is not involved in sterol 14-demethylation, but gene deletion increases in sensitivity for some sterol demethylase inhibitors [
45,
46]. Recently, novel
CYP51 paralogues have been described. Similar to
CYP51B, a new paralogue named
CYP51D is involved in azole resistance and occurs in genomes of fungi belonging to Eurotiomycetes. A novel partial
CYP51A gene encodes a truncated form of CYP51A responsible for azole resistance [
47]. Therefore, we focused on CYP51A, the protein most responsible of azole resistance in the genus
Fusarium [
20,
45,
48,
49,
50]. To further characterize our findings about amino acid changes, we compared the CYP51A protein sequence of our FSSC strains with other strains from the same complex and with strains from different complexes. All strains from the different complexes presented the same amino acid at position 218 (L218) as that in our panel. Our hypothesis is that this observation could be a first clue to explain the low susceptibility of clinically used azole drugs in the genus
Fusarium. More studies should be performed to confirm and generalize our findings in fusarioid fungi.