MYCOTIC INFECTIONS IN THE MIDDLE EAST Basidiobolus and ... · Basidiobolusis a ubiquitous fungus...
Transcript of MYCOTIC INFECTIONS IN THE MIDDLE EAST Basidiobolus and ... · Basidiobolusis a ubiquitous fungus...
MYCOTIC INFECTIONS IN THEMIDDLE EAST
(Basidiobolus and Rhinocladiella)Ziauddin Khan, PhD
Professor of Medical MycologyDepartment of Microbiology
Faculty of MedicineKuwait University
Basidiobolus and Basidiobolomycosis
TAXONOMICAL CONSIDERATIONS Zygomycota underwent major taxonomic
changes in 2007. Hibbet and others proposed to eliminate
Zygomycota and the taxa conventionally placedin Zygomycota were distributed among thephylum Glomeromycota.
Mucorales and Entomophthorales, whichcontain zoopathogenic fungi, and 2 other ordersincluding Kickxellales and Zoopagales wereraised to the rank of subphyla:Mucoromycotina, Entomophthoromycotina,Kickxellomycotina and Zoopagomycotina.
Zygomycota underwent major taxonomicchanges in 2007.
Hibbet and others proposed to eliminateZygomycota and the taxa conventionally placedin Zygomycota were distributed among thephylum Glomeromycota.
Mucorales and Entomophthorales, whichcontain zoopathogenic fungi, and 2 other ordersincluding Kickxellales and Zoopagales wereraised to the rank of subphyla:Mucoromycotina, Entomophthoromycotina,Kickxellomycotina and Zoopagomycotina.
TAXONOMIC CLASSIFICATION
OLD
NEW
Kwon-Chung Clin Infect Dis. 2012;54:S8-S15
A proposed new classification schemesof the kingdom Fungi
Basidiobolomycetes Neozygitomycetes EntomophothoromycetesBasidiobolus spp. Neozygitis spp. Conidiobolus spp.
Humber, 2012
Phylum: EntomophthoromycotaClass: Basidiobolomycetes
Order: Basidiobolales
Phylogenetic classification of entomophthoroidfungi
Class: BasidiobolomycetesOrder: Basidiobolales
Family: BasidiobolaceaeGenus: Basidiobolus
Gryganskyi et al. Persoonia 2013; 30;94-105.
Maximum likelihood phylogeny of Basidiobolomycotina
(secondary conidiogenesis)
Basidiobolus and the still formally undescribed genera Schizangiella andDrechslerosporium (LSU, SSU, RPB2, mtSSU, ITS).
Gryganskyi et al. Persoonia 2013; 30;94-105
Life Cycle of
Adapted from Mendoza et al. 2015
Basidiobolus ranarum in intestinal tract of bats,reptiles and amphibians
Intestinal contents of 14 (7%) of 200 bats belonging toRhinopoma hardwickei hardwickei Gray ('the lesser rat-tailed bat'), an insectivorous species captured from Delhiarea.
Intestinal tract of 50% of trapped reptiles and amphibiansfrom Florida were found colonized with a Basidiobolusspecies.
Basidiobolus ranarum in intestinal tract of bats,reptiles and amphibians
Intestinal contents of 14 (7%) of 200 bats belonging toRhinopoma hardwickei hardwickei Gray ('the lesser rat-tailed bat'), an insectivorous species captured from Delhiarea.
Intestinal tract of 50% of trapped reptiles and amphibiansfrom Florida were found colonized with a Basidiobolusspecies.
Chaturvedi et al. Sabouraudia. 1984;22:185-9.
Okafor et al. Sabouraudia. 1984;22:47-51.
Epidemiology• Most cases of basidiobolomycosis have been
reported from tropical and subtropical regions ofAfrica, South America, and Asia
• It usually causes subcutaneous infections• Infections caused by B. ranarum are mainly
diagnosed in children (80% under the age of 20years) with a male/female ratio of 3:1.
• B. ranarum also causes chronic granulomatousinfection of the gastrointestinal tract in apparentlyimmunocompetent patients, mostly from Arizona(USA) and Middle East
• Most cases of basidiobolomycosis have beenreported from tropical and subtropical regions ofAfrica, South America, and Asia
• It usually causes subcutaneous infections• Infections caused by B. ranarum are mainly
diagnosed in children (80% under the age of 20years) with a male/female ratio of 3:1.
• B. ranarum also causes chronic granulomatousinfection of the gastrointestinal tract in apparentlyimmunocompetent patients, mostly from Arizona(USA) and Middle East
Basidiobolus is a ubiquitous fungus
The majority of cases have been reported in South America, Africa and tropicalAsia. However, recently this fungus has been classified as an emerging invasivefungal infection in desert regions of the US Southwest and Middle East causinggastrointestinal basidiobolomycosis.
Subcutaneous“Bathing suitdistribution”
Basidiobolomycosis: Clinical types
GastrointestinalColorectal
involvement
Complications: Small bowel, Liver, Gall bladder,Kidney, Pancreas, other intraabdominal organs
Clinical Manifestations:Basidiobolomycosis
The presenting feature is a single painless,unilateral, well-circumscribed subcutaneousmass that usually affects the buttock or thethigh but can also be seen in the arm, theneck, the face or the trunk.The disease starts as a single nodule that
progressively grows. The swelling is oftendescribed as woody and hard.
The presenting feature is a single painless,unilateral, well-circumscribed subcutaneousmass that usually affects the buttock or thethigh but can also be seen in the arm, theneck, the face or the trunk.The disease starts as a single nodule that
progressively grows. The swelling is oftendescribed as woody and hard.
The swelling over thigh in an 18-month-old female ofthree months duration caused by Basidiobolusranarum (culture and histopathology proven). Treatedwith KI (3 times a day) and lesion resolved within 1month
Naniwadekar et al. 2009A case from Karad, Karnataka
Buttock (toilet leaves?)Induration and multiple nodules in theperineum and labia (biopsy site seen)Radjou & Rajesh Ind J Microbiol. 2011; 29:186-188
A case fro Puducherry
HistopathologyChronic inflammatory process can be seen with
small abscesses surrounded by a granulomatoustissue reaction.A strong eosinophilic perihyphal reaction is often
observed (Splendore-Hoeppli phenomenon) that isvariable in size (2-6 µm).Board irregular hyphae (4-30µm) with thin walls and
rare septation can be seen, singly or in clusters.There is no invasion of blood vessels or infection of
tissue.
Chronic inflammatory process can be seen withsmall abscesses surrounded by a granulomatoustissue reaction.A strong eosinophilic perihyphal reaction is often
observed (Splendore-Hoeppli phenomenon) that isvariable in size (2-6 µm).Board irregular hyphae (4-30µm) with thin walls and
rare septation can be seen, singly or in clusters.There is no invasion of blood vessels or infection of
tissue.
Splendore-Hoeppli phenomenon (H &E) and Broad, aseptate hyphal fragments(GMS)
CULTUREBiopsy specimen should be cultured immediately
as B. ranarum dies quickly in tissues kept in arefrigerator.Tissue biopsy should be minced and not
homogenized. Homogenization in a tissue grindershould be avoided, because it decreases cultureyield by destroying hyphae.SDA with antibiotics can be used. Cycloheximide
should not be used in SDA. Incubation at 25°-30° C for 2-5 days.
Biopsy specimen should be cultured immediatelyas B. ranarum dies quickly in tissues kept in arefrigerator.Tissue biopsy should be minced and not
homogenized. Homogenization in a tissue grindershould be avoided, because it decreases cultureyield by destroying hyphae.SDA with antibiotics can be used. Cycloheximide
should not be used in SDA. Incubation at 25°-30° C for 2-5 days.
Gastrointestinal Basidiobolomycosis
CASE 1: A 30-year-old Bangladeshiwith rectal bleeding
• Rectal mass ~10 cm large polypoid mass onlower third of rectum
• Provisional diagnosis: Piles, rectal carcinoma• First biopsy: epithelioid cell granuloma
infiltrated with eosinophils- Crohn’s diseaseHistopathology: Fungal elements were missed
• Second biopsy: Histopathology: Fungalelements missed, culture yielded a fungus
• Rectal mass ~10 cm large polypoid mass onlower third of rectum
• Provisional diagnosis: Piles, rectal carcinoma• First biopsy: epithelioid cell granuloma
infiltrated with eosinophils- Crohn’s diseaseHistopathology: Fungal elements were missed
• Second biopsy: Histopathology: Fungalelements missed, culture yielded a fungus
Khan et al. Clin Infect Dis. 1998;26:521-3
B. ranarum colonies on SDA
Khan et al. Clin Infect Dis 1998;26:521
Zygospores
Immunodiffusion test
Case 2: A 41-year-old Indian male with historyof repair of a left inguinal hernia
• Examination: palpable, nodular mass near rt.hypochondrium,
• Ultrasound: thickening of ascending colon andcecum and renal involvement
• Provisional diagnosis: Intestinal tuberculosis
• Examination: palpable, nodular mass near rt.hypochondrium,
• Ultrasound: thickening of ascending colon andcecum and renal involvement
• Provisional diagnosis: Intestinal tuberculosis
Khan et al. J Clin Microbiol. 2001 ;39:2360-3
An open segment of large intestineshowing a thick-walled mucosa with acobblestone appearance mimickingCrohn's disease
Hematoxylin-and-eosin-stained sectionof intestinal mucosa showing a crosssection of a B. ranarum hypha (arrow)surrounded by the Splendore-Hoeppliphenomenon and many eosinophils
KOH-calcofluor white mount showing broad, non-septate, branched hyphae in urine sediment
The isolate was resistant to Amphotericin B(4 µg/ml) and itraconazole (8 µg/ml)
Serodiagnosis
Ab-I Ab-II
Ag
Ag-whole cell homoginate; patients’ seraAb-I and Ab-II
A case from Yemen/SA
Saeed et al. JMM CR 2014
A 12-year-old Yemeni boy, living in Saudi Arabia, was referred with a2-month history of diffuse abdominal pain, non-bilious vomiting,poor appetite and weight loss. percutaneous liver biopsy underultrasound guidance and sent for histopathological evaluation, whichrevealed granulomatous lesions rich in eosinophils with broadaseptate fungal hyphae surrounded by eosinophilic material(Splendore–Hoeppli phenomenon).
Abdominal CT showing multiple small, low-attenuation lesionsscattered throughout both lobes of the liver, some showing ringenhancement Saeed et al. JMM CR 2014
Liver CT after treatment with itraconazole treatment.Complete resolution after 12 months.
Saeed et al. JMM CR 2014
Gastrointestinal basidiobolomycosis accompanied by liverInvolvement
A case from Iran
Granuloma, Eosinophilic Infiltration andSplendore-Hoeppli Phenomenon (Arrow)
Ejtehadi et al. Iran Red Crescent Med J. 2014; 16: e14109.
Gross Pathology of theTerminal Ileum and RightColon Shows Ulceration in theCecum (Arrow)
A 41-year-old lady from Shiraz, south of Iran. CT-scan of the abdomen and pelvicshowed increased thickness of the cecum with infiltrative process and hypoattenuatinglesions in the liver, supporting liver abscesses or metastasis with central necrosisDiagnosis was based on histopathologic observation and response to itraconazoletherapy (200 mg twice a day for 4 months)
A 24-year-old woman from SaudiArabia with type I diabetes mellituspresented to the emergencydepartment with a 4-day history ofsevere abdominal pain, nausea,vomiting, abdominal distension, andconstipation. Magnetic resonanceimaging of the abdomen showed 2long segments of circumferentialheterogeneous enhancing soft tissuemasses involving the descendingcolon and descending sigmoid colonand multiple different-size hepaticlesions. Isolate identified by D1/D2sequencing. Treated withvoriconazole.
.
Gastrointestinal basidiobolomycosis with liver InvolvementA case from Saudi Arabia
A 24-year-old woman from SaudiArabia with type I diabetes mellituspresented to the emergencydepartment with a 4-day history ofsevere abdominal pain, nausea,vomiting, abdominal distension, andconstipation. Magnetic resonanceimaging of the abdomen showed 2long segments of circumferentialheterogeneous enhancing soft tissuemasses involving the descendingcolon and descending sigmoid colonand multiple different-size hepaticlesions. Isolate identified by D1/D2sequencing. Treated withvoriconazole.
Lactophenol cotton blue stain ofgrowth from fine needle aspirationmaterial from the liver lesion,X400
Alhuraiji et al. Clin Infect Dis. 2014; 58:990
Eosinophilic granulomatous gastrointestinal andhepatic abscesses attributable to basidiobolomycosis
in Iraqi Kurdistan (2009-2012)
- All males (6 cases)- Age: 17 months -59 years- Sites affected: Cecum and/or colon-5 cases, oropharyngeal and
transverse colon mass-1- Diagnosis- Histopathological (sparsely septate hyphae)- Treatment: oral itraconazole -5, all responded, became
asymptomatic (4-6 months);- One (17 months old) died after 2days of start of amphotericin B
Hassan et al. BMC Infect Dis. 2013; 13: 91.
- All males (6 cases)- Age: 17 months -59 years- Sites affected: Cecum and/or colon-5 cases, oropharyngeal and
transverse colon mass-1- Diagnosis- Histopathological (sparsely septate hyphae)- Treatment: oral itraconazole -5, all responded, became
asymptomatic (4-6 months);- One (17 months old) died after 2days of start of amphotericin B
Characteristics of 72 Patients With GastrointestinalBasidiobolomycosis
Variables ValueAge, years 13 months-81 years, ~85% in pediatric age group
Male sex 59 (82%)
Country of residenceUnited StatesSaudi ArabiaIranKuwaitIraq/KurdistanBrazilOthers
19, 17 from Arizona16, 14 in <12 years18, 11 <12 years
2, Adults (Indian, Bangladeshi)6, 2 in< 12 years47 (Nigeria, Italy, Netherlands, UK, Egypt, Thailand)
United StatesSaudi ArabiaIranKuwaitIraq/KurdistanBrazilOthers
19, 17 from Arizona16, 14 in <12 years18, 11 <12 years
2, Adults (Indian, Bangladeshi)6, 2 in< 12 years47 (Nigeria, Italy, Netherlands, UK, Egypt, Thailand)
Onset of GIB1964–19941995–2008
864 (86%)
n=42
(Geramizadeh et al. 2012; Vikram et al. 2012; Al-Asmi et al. 2013)
Antifungal susceptibilities ofConidiobolus and Basidiobolus
Species Geometric mean MICs (mg/L)(no. ofisolatestested)
Amphotericin B
Fluconazole
Flucytosine
Itraconazole
Ketoconazole
Miconazole
Conidiobolus spp.(9)
Conidiobolus spp.(9) 3.1 107.5 234.6 11.3 20.7 11.3Basidiobolus spp.(8)* 2.7 14.8 165.9 1.8 1.0 3.9
Guarro et al. J. Antimicrob. Chemother. 1999;44557-560
*Voriconazole and Posaconazole also exhibit good activity
Management• Therapeutic recommendations for the treatment of
basidiobolomycosis can be made only based on empiricobservations
• Potassium iodide, azoles, triazoles, terbinafine, and amphotericinB have been all used.
• In general, Basidiobolus spp. display lower MICs for triazoles thanConidiobolus spp.
• Potassium iodide has been used alone or in combinationwith itraconazole.
• In addition, surgical removal of accessible nodules andreconstructive surgery are usually required
• Therapeutic recommendations for the treatment ofbasidiobolomycosis can be made only based on empiricobservations
• Potassium iodide, azoles, triazoles, terbinafine, and amphotericinB have been all used.
• In general, Basidiobolus spp. display lower MICs for triazoles thanConidiobolus spp.
• Potassium iodide has been used alone or in combinationwith itraconazole.
• In addition, surgical removal of accessible nodules andreconstructive surgery are usually required
Conclusions
• Basidiobolomycosis is a disease of tropical andsub-tropical regions, however, GIB ispredominantly seen in arid regions.
• GIB is presumably acquired through ingestion• Surgical intervention combined with prolonged
antifungal therapy (itraconazole) is the preferredtreatment option
• Basidiobolomycosis is a disease of tropical andsub-tropical regions, however, GIB ispredominantly seen in arid regions.
• GIB is presumably acquired through ingestion• Surgical intervention combined with prolonged
antifungal therapy (itraconazole) is the preferredtreatment option
R. mackenziei (cerebral pheohyphomycosis)R. aquaspersa (Chromoblastomycosis)R. basitona (rare agents of skin infections)R. similis (rare agents of skin infections)
Colonies olivaceous to black, velvety; long, erect, brown,unbranched sympodial conidiophores; 1-celled pale ellipsoidalconidia borne on crowded denticles. Conidiophores usually poorlydifferentiated from the vegetative hyphae; conidial apparatus oftenloosely branched; exophiala-like budding cells usually present inculture.
Order - Chaetothyriales:Genus - Rhinocladiella
R. mackenziei (cerebral pheohyphomycosis)R. aquaspersa (Chromoblastomycosis)R. basitona (rare agents of skin infections)R. similis (rare agents of skin infections)
Colonies olivaceous to black, velvety; long, erect, brown,unbranched sympodial conidiophores; 1-celled pale ellipsoidalconidia borne on crowded denticles. Conidiophores usually poorlydifferentiated from the vegetative hyphae; conidial apparatus oftenloosely branched; exophiala-like budding cells usually present inculture.
Arzanlou et al. 2007
Phylogenetic and morphotaxonomic revision of Ramichloridium and alliedgenera (based on partial sequences of the 28S (LSU) rRNA gene and the ITS region (ITS1,5.8S rDNA and TS2).
First fatal cerebral phaeohyphomycosis due to Rhinocladiellamackenziei
A 54-year-old male, construction workerwith a 2-day-history of fever, frontalheadache, dizziness, and facio-brachialtonic-clonic seizures and left-sidedhemiparesis. The patient was treated withintravenous amphotericin B deoxycholate(0.5 mg/kg/day) combined with oralitraconazole (200 mg twice daily),nevertheless, his neurological functiondeteriorated rapidly and ultimately thepatient died due to respiratory failurelater two weeks.
A case from Iran
A. CT scan showed a discrete, large, irregular, peripheral ring-enhancing necrotic masslesion in the right fronto-parietal region with perifocal edema; B. MRI)revealed a large,supratentorial, intracranial, hyper dense, right fronto-temporal, space occupying lesionwith contrast enhancement components Didehdar et al. 2010 J Mycol Medicale 2014
A 54-year-old male, construction workerwith a 2-day-history of fever, frontalheadache, dizziness, and facio-brachialtonic-clonic seizures and left-sidedhemiparesis. The patient was treated withintravenous amphotericin B deoxycholate(0.5 mg/kg/day) combined with oralitraconazole (200 mg twice daily),nevertheless, his neurological functiondeteriorated rapidly and ultimately thepatient died due to respiratory failurelater two weeks.
A. KOH mount: Pigmented,septate, branch fungalhyphae
B. H & E stain: showed necrosiswith dense and diffuse mixedinflammatory infiltrates
Rhinocladiella mackenziei in Iran
A. KOH mount: Pigmented,septate, branch fungalhyphae
B. H & E stain: showed necrosiswith dense and diffuse mixedinflammatory infiltrates
R. mackenziei was identified based on the sequencing ofinternal transcribed spacer (ITS rDNA region) (KJ140287
Didehdar et al. 2010 J Mycol Medicale 2014
R. mackenziei in a Woman Native to AfghanistanAn 80-year-old Afghaniwoman with a history ofischemic heart diseaseand colon cancer, livingin France for 20 years,with no travel to MiddleEast or to her nativecountry. Initially treatedwith voriconazole ,followed by oralposaconazole (400 mgBID). Four months aftersurgery, the patient wasconscious, with a stableneurological status anddisappearance of Rttemporal lesion.Discharged onposaconazole but died 7months later.
(A) Postcontrast axial T1-weighted MR image showingthe rim-enhancing left temporal lesion with a centralhypointensity. (B) The low ADC suggests the diagnosis ofabscesses.
An 80-year-old Afghaniwoman with a history ofischemic heart diseaseand colon cancer, livingin France for 20 years,with no travel to MiddleEast or to her nativecountry. Initially treatedwith voriconazole ,followed by oralposaconazole (400 mgBID). Four months aftersurgery, the patient wasconscious, with a stableneurological status anddisappearance of Rttemporal lesion.Discharged onposaconazole but died 7months later.Cristini et al. J Clin Microbiol. 2010;48:3451
59-year-old Qatarifemale with carcinomaof the left breastshowed a cyst-likeenhancing lesion of theright posterior-parietaland occipital regionswith edema. Treatedwith AMB, VOR and POSbut died.
A case from Qatar
Taj –Aldeen et al Med Mycol. 2010;48:546-56
59-year-old Qatarifemale with carcinomaof the left breastshowed a cyst-likeenhancing lesion of theright posterior-parietaland occipital regionswith edema. Treatedwith AMB, VOR and POSbut died.
A case from Qatar
Invasion of fungal hyphae of R. mackenziei into the brain tissueshowing right angle-branched hyphae and moniliform (bead-like)hyphae.
Taj –Aldeen et al.Med Mycol. 2010;48:546-56
GMS PAS
Reports from Kuwait (Case 1)
Pondos et al. Neurosurgery 1999; 45:372
A 58-year-old Kuwaiti woman, with a history of chronic renal failure requiringhemodialysis, presented with a 3-day history of left frontal headache, blurry vision,dizziness, and right-sided clumsiness. CT demonstrated multiple, ring-enhancing,cerebral lesions in the deep left parieto-occipital region. Biopsy yielded dark caseousfluid, which demonstrated long, branching, septate hyphae. Cultures grew R.obovoideum. Despite treatment with a combination of amphotericin B anditraconazole, the patient died.
56-year-old Egyptianemployed as a masonsince 1994 in Kuwait,presented withheadache (1 monthduration) andprogressive loss ofvision. Abdominalultrasound revealed acirrhotic liver and brainCT scan, revealed alarge circular lesion(arrow)
Reports from Kuwait (Case 2)
Large circular lesions with ring enhancing lesion in left occipital lobe
56-year-old Egyptianemployed as a masonsince 1994 in Kuwait,presented withheadache (1 monthduration) andprogressive loss ofvision. Abdominalultrasound revealed acirrhotic liver and brainCT scan, revealed alarge circular lesion(arrow)
Brain biopsy culture onSDA
KOH preparation of brainbiopsy
Slide culture preparation of R.mackenziei showingsympodially proliferating conidiogenous cells withmostly two conidia
Isolate resistant to Amphotericin B
Cerebral pheohyphomycosis due toR.mackenziei in Pakistan
Six cases: 5 M (30-75 years), 1 F (20 years),Residence: 3 Balochistan, 2 Sindh, I NotknownIdentification confirmed by DNA sequencingSurgical intervention and antifungal therapyComorbidities: Present in 4 patientsOutcome: 3 died, 2 survived, 1 lost for follow-up
Six cases: 5 M (30-75 years), 1 F (20 years),Residence: 3 Balochistan, 2 Sindh, I NotknownIdentification confirmed by DNA sequencingSurgical intervention and antifungal therapyComorbidities: Present in 4 patientsOutcome: 3 died, 2 survived, 1 lost for follow-up
Jabeen et al. CID 2011;52:213
2 cases
2 casesIND, AFG
Cerebral Phaeohyphomycosis due toRhinocladiella mackenziei
Predominantly a disease of the Middle EastKUWAIT
13 cases
6 cases
5 cases 46%
Saudi ArabiaQ, O, UAE,ISR, Moracco
28 cases
Pakistan
8 antifungal drugs against 10 clinicalisolates by CLSI microdilution method
Antifungal drugs against Rhinocladiellamackenziei
Rhinocladiella mackenziei gave MIC90 values (mg/L) forAmB, FLU, ITC, VOR, POS, ISA, CAS and ANI of 16, 64,0.25, 2, 0.063, 1, 8 and 8 mg/L, respectively. In vitroactivities have shown that all strains of Rhinocladiellamackenziei are resistance to AmB and echinocandindrugs. In contrast, POS, ITC, and ISA were the most activedrugs with high in vitro activity against R. mackenziei alsoconfirmed by animal experiments.
Rhinocladiella mackenziei gave MIC90 values (mg/L) forAmB, FLU, ITC, VOR, POS, ISA, CAS and ANI of 16, 64,0.25, 2, 0.063, 1, 8 and 8 mg/L, respectively. In vitroactivities have shown that all strains of Rhinocladiellamackenziei are resistance to AmB and echinocandindrugs. In contrast, POS, ITC, and ISA were the most activedrugs with high in vitro activity against R. mackenziei alsoconfirmed by animal experiments.
Badali et al. J. Atimicrobial Chemother. 2010
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Fungi spare nobody
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An ant infected withascomycetous fungus of the genus
Cordyceps