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Polish Journal of Pathology
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Original paper

Massively parallel targeted resequencing reveals novel genetic variants associated with aspergillosis in paediatric patients with haematological malignancies

Katarzyna Skonieczna, Jan Styczyński, Anna Krenska, Piotr Stawiński, Rafał Płoski, Katarzyna Derwich, Wanda Badowska, Mariusz Wysocki, Tomasz Grzybowski

Pol J Pathol 2017; 68 (3): 210-217
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Invasive aspergillosis (IA) and other infections caused by the filamentous fungus A. fumigatus as well as several related pathogenic species of Aspergillus essentially concern immunocompromised individuals [1]. Among paediatric patients, primarily affected are those suffering from haematological malignancies and those who were subjected to haemopoietic stem cell transplantation (HSCT) [2]. Approximately 250 children from the Polish population are diagnosed with leukaemia annually. The incidence of IA in these patients is estimated to be 5-24% [3]. However, both diagnosis and treatment of IA are still challenging.
Along with genomic, transcriptomic and proteomic research focused on the infection process and drug resistance of the pathogen alone, studies were also conducted on the pathogen-host interactions [4] and the host response to fungal infections [5].
Additionally, the host’s genetic susceptibility to infections is of particular interest and complexity. Since aspergillosis primarily affects immunocompromised patients, most research into the genetic factors possibly associated with the condition has employed a candidate gene strategy and focused on the immune-modulating genes, including the genes for Toll-like receptors (TLRs), the C-type lectin receptors (CLRs), NOD-like receptors (NLRs), cytokines, chemokines and immune receptors. As a result of those studies, a limited number of genetic polymorphisms were reported whose associations with aspergillosis were replicated and/or proved to have biological significance [reviewed in 6]. However, the majority of the studies concerning candidate genes concentrated on a limited number of single nucleotide polymorphisms (SNPs), employing low- or medium-throughput genotyping strategies [6, 7, 8].
In recent years, novel technologies of massively parallel sequencing (MPS) have certainly sped up the process of discovering new genetic variants of potential clinical significance and thus facilitated association analyses at a genomic level [9]. In particular, the targeted re-sequencing approach has made analysis of entire sequences of candidate genes relatively straightforward and cost-effective. Nevertheless, data including complete sequences of the human innate immunity genes in paediatric patients of significant risk factors for aspergillosis are practically non-existent. Searching for new variants possibly associated with the condition, in this study we analyzed with high coverage the sequences of fifteen human innate immunity genes (~230 kb in total) in two groups of paediatric patients with haematological malignancies – affected and not affected by aspergillosis. For targeted re-sequencing of all samples, we used two different MPS approaches.

Material and methods

Protection of human subjects

The study was approved by the Bioethics Committee of the Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland (statement no. KB 605/2011). Parents of all patients gave informed written consent to participate in the study.

Patient characteristics

Altogether, 40 unrelated paediatric patients from Poland, treated for haematological malignancies at the Department of Paediatrics, Haematology and Oncology of the Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Department of Paediatric Oncology, Haematology and Transplantology, Poznań University of Medical Sciences, and Division of Paediatric Haematology and Oncology, Children Hospital, Olsztyn, Poland, were recruited for the study. The case group consisted of 20 individuals affected by aspergillosis, while the control group included 20 persons unaffected by the condition. None of the patients underwent HSCT prior to the study. Clinical characteristics of the studied individuals are given in Table I.

DNA extraction and quantitation

DNA was extracted from buccal swabs using the GeneMatrix Bio-Trace DNA Purification Kit according to the manufacturer’s protocols (Eurx, Gdansk, Poland). Quality of DNA extracts was assessed by agarose gel electrophoresis. DNA was quantitated both spectrophotometrically and by real-time PCR, using the Quantifiler Duo DNA Quantification Kit and the ViiA 7 Real-Time PCR System (Thermo Fisher Scientific, Waltham, USA).

Targeted re-sequencing

A total of fifteen candidate genes for human innate immunity (CCL2 – C-C motif chemokine ligand 2; CCR2 – C-C motif chemokine receptor 2; CD209; CLEC6A – C-type lectin domain family 6 member A; CLEC7A – C-type lectin domain family 7 member A; and ten TLR [Toll-like receptor] genes) were chosen for targeted resequencing (Supplementary Table I).
All samples were analyzed using two different target enrichment strategies and respective massively parallel sequencing approaches – HaloPlex Target Enrichment System for Illumina sequencing and NimbleGen SeqCap EZ Target Enrichment System for 454 sequencing.
The construction of a custom gene library from 225 ng of DNA was performed using the HaloPlex Target Enrichment System Kit (Agilent Technologies, Santa Clara, USA) according to the manufacturers’ instructions. PCR-amplified target libraries were quantified using the Bioanalyzer High Sensitivity DNA Assay kit and a 2100 Bioanalyzer (Agilent Technologies). After pooling equimolar amounts of differentially indexed samples, the final HaloPlex enrichment pool was sequenced following the protocol for the Illumina MiSeq V3 chemistry 2 × 150-bp paired-end reads (Illumina, San Diego, USA).
NimbleGen SeqCap EZ Choice libraries were prepared according to the manufacturer’s instructions (Roche Diagnostics GmbH, Mannheim, Germany). NimbleGen libraries of samples were subsequently labelled with different RLMID adaptors (Roche Diagnostics GmbH) and subjected to 454 rapid library construction (Roche Diagnostics GmbH). Ten libraries (labelled with different RLMIDs) were mixed in equimolar ratios and sequenced on a PTP plate using a GS FLX Sequencer (Roche Diagnostics GmbH). Rapid Library preparation, emulsion PCR (emPCR), and 454 sequencing were performed according to the manufacturer’s instructions using Titanium reagents (Roche Diagnostics GmbH).

Analysis of sequence data

Bcl2fastq (1.8.4) software (Illumina) was used for generating sample-specific fastq files. After assessing base quality scores, fastq files were subsequently aligned to the reference human genome hg19 (NCBI build 37) using the BWA tool [10]. The GATK programming framework [11] was used for recalibrating base quality scores and performing local realignment around indels. The Haplotype Caller algorithm from the GATK framework was employed for calling nucleotide variants.
The raw data obtained by the 454 platform were analysed with GS Run Processor v.2.5.3 and GS Reporter v.2.5.3 (Roche Diagnostics GmbH). The DNA sequences obtained by the 454 were analysed with GS Reference Mapper v.2.5.3 (Roche Diagnostics GmbH). For the GS Reference Mapper v.2.5.3 results, all three files (454AllDiffs.txt, 454HCDifffs.txt, and 454AlignmentInfo.tsv) were used to determine each sample’s genotype. Several quality control steps were applied to detect DNA polymorphic positions. Heterozygosity was confirmed when the 454 unique reads had a high quality score, when the nucleotide variant that differed from the reference sequence was observed in 20-80% of all reads, and if the ratio of forward to reverse reads for the changed variant was similar to that calculated for the unchanged variant.
Nucleotide variants are presented in subsequent sections of the paper in reference to the original GenBank records for the targeted genes.

Statistical analysis of nucleotide variants

Nucleotide variants were filtered against the dbSNP database [12], 1000 Genomes Project database [13], GWAS central database [14] and ENSEMBL database [15]. Statistical significance of the differences between case and control groups in both allele and genotype frequencies was calculated using two-tailed Fisher’s exact test. The odds ratio (OR) and 95% confidence intervals (95% CI) were calculated. For the purpose of initial screening, p values < 0.05 were considered as statistically significant. The SNPs found to be associated with aspergillosis at a conventional statistical significance level (p < 0.05) were subsequently scrutinized against the Better Associations for Disease and Genes (BADGE) classification system to assess their potential for reproducibility of associations. The BADGE system organizes genetic associations by five classes based on p-values, from p < 0.0000002 (a first-class association) to p < 0.05 (a fifth-class association) [16]. Calculations were performed using STATISTICA v. 12.5 (StatSoft Inc.) software. The ASSP tool [17] was used to determine the implication of the changes in the noncoding regions of the targeted genes on the splicing process. This web application employs backpropagation networks trained for classification of constitutive and alternative isoform/cryptic splice sites, with confidence ranging from 0 (undecided) to 1 (perfect classification) [17].


Two different enrichment strategies enabled the resequencing of a total of 233 589 base pairs (bp) out of 325 771 bp of the fifteen targeted genes (~72% of the total gene sequence, Supplementary Table II). The uncaptured regions mainly constituted highly repetitive DNA. A total of 1961 genetic variants were identified (Supplementary Table III), out of which 60 polymorphisms showed differences at the conventional level of p < 0.05 between the case and control groups for allele and/or genotype frequencies (Table II). Out of the 60 SNPs showing potential association (p < 0.05), 55% of the SNPs were not reported previously in the dbSNP database. Thirty-five nucleotide variants were located in intronic regions, eight were found in exons (four of which were non-synonymous), seven were located in upstream or downstream regions of genes and two were identified in 3-untranslated regions (UTRs). Two SNPs were intergenic, whereas six other polymorphisms were found in well-characterized regulatory sequences (promoter flanking sites, a transcription factor binding site and near the end of an enhancer) (Table II).
Only one SNP, identified in this study as showing a significant differences for allele frequencies between cases and controls at p < 0.05 (rs7959451 at 3UTR of CLEC7A), was recently found to be associated with aspergillosis in a population of European ancestry [18]. However, 16 other SNPs previously identified as possibly determining susceptibility to the condition did not reach a level of significance in our research (Supplementary Table IV). Conversely, two common SNPs in the TLR9 gene (promoter flanking rs187084 and rs352140 in the second exon) which showed significance for both allele and genotype frequencies (p < 0.05) in our analysis (Table II) did not reach the level of significance in an earlier association study on the risk of invasive aspergillosis among recipients of allogeneic haematopoietic cell transplants [19]. Nevertheless, many other studies have proved associations of rs187084 and rs352140 with numerous immune-related diseases, response to therapies, as well as bacterial and viral infections in populations of both Western and Eastern Eurasian ancestry [20, 21, 22, 23, 24, 25]. It is also worth noting that the common rs4586 SNP, flanking the promoter of CCL2 gene, which appeared significant for genotype frequencies between our cases and controls (p = 0.0079, OR = 8.5, Table II), was recently found to be significantly correlated with anti-tumour immune reaction in Korean patients with colorectal cancer [26] and associated with the clinical outcome in Japanese individuals with locoregional gastric cancer [27]. Moreover, the TLR2 intergenic polymorphism rs4585282 (previous rs numbers: rs6535939, rs61329579), which was found in our study as significant for genotype frequencies (at p = 0.0000033 or p = 0.0083, depending on the model of association, Table II), was recently indicated as displaying modest associations with some vitiligo subgroups [28], while the T allele of this SNP was previously reported to be associated with pulmonary tuberculosis in a West African but not a European population sample [29].
The ASSP analysis did not point to the vast majority of the huge intronic variation found in this study to alter the splicing mechanism. However, rs12099687 in CLEC6A, which was found to be significant for allele frequencies between the two groups of patients (p = 0.00000023, Table II), constitutes notable exception. The ASSP application predicted the rs12099687 position as an alternative isoform/cryptic splicing donor site with very high confidence (0.927).
After filtering the associations against the very conservative BADGE system, the vast majority of associations were classified as fifth class (p < 0.05, Table II). However, eight fourth-class (p< 0.002) and two second-class associations (p < 0.00005) were also identified in our study (in TLR2 and CLEC6A genes, Table II). The strongest second-class association (p = 0.00000023) concerns intronic SNP rs12099687 in CLEC6A (Table II). According to the BADGE recommendations, the p-value for this association is very close to that of a first-class association (p < 0.0000002).


According to our knowledge, this is the first study employing massively parallel targeted resequencing in quest of potential susceptibility variants to aspergillosis in complete sequences of the candidate genes. We attempted to capture both exonic and intronic variation of fifteen genes of human innate immunity in two groups of paediatric haematooncological patients of the same ethnic origin. Since considerable homogeneity within the Polish population was previously reported for different genetic markers, a hidden population substructure is unlikely to affect the results of this study. Among the targeted genes, we included all ten genes for Toll-like receptors (TLRs), some of which were recently reported to have alleles critical to the innate immune response, introgressed from archaic humans [30]. The five remaining genes included in our research (CCL2, CCR2, CD209, CLEC6A, CLEC6A) were previously subjected to case-control studies concerning aspergillosis. However, even the most comprehensive of those studies included only a limited number of the known SNPs [7].
As a result of targeted enrichment and resequencing of all samples using two different MPS strategies, we captured ~70% of the studied genes, excluding highly repetitive DNA sequences located mostly in non-coding regions. In our analysis of resulting sequence data, we concentrated on both known and unknown variation, subsequently filtering differences in allele and genotype frequencies between the two groups of patients against five thresholds of significance, according to the BADGE recommendations [16].
Most studies in medical genomics still address coding parts of the human genome [9]. However, intronic variation has continually been attracting more attention, since introns are currently acknowledged to possess regulatory elements that can influence both gene expression and splicing [reviewed in 31]. Expectedly, we identified huge variations in the introns of the targeted genes, a limited proportion of which were previously characterized and presented in genomic databases. In particular, we found five novel intronic variants in the TLR2 gene apparently showing differences for allele frequencies between cases and controls at p < 0.002. However, their functional significance is difficult to assess at this point in time without other comparable genomic data. Meanwhile, out of all intronic SNPs described in this study, rs12099687 in CLEC6A, which showed the strongest association with aspergillosis for allele frequencies (at p = 0.00000023), was predicted to constitute an alternative isoform or cryptic splice site. It is worth noting that the predictive power of alternatively or cryptically spliced sites using ASSP application is generally lower than that of constitutively spliced sites [17]. Nevertheless, the confidence of prediction for rs12099687 was very high (0.927). This strongly supports a potential role of non-canonical splicing of CLEC6A gene coding for Dectin-2 protein in susceptibility to aspergillosis. Interestingly, it was recently proved that Dectin-2 (but not Dectin-1) present on plasmacytoid dendritic cells (pDCs) directly recognizes hyphae of A. fumigatus, which triggers cytokine release and subsequent antifungal activity [32]. Considering this, non-canonical splicing of the CLEC6A gene may result in changing activity of Dectin-2, ultimately affecting a host’s response to fungal infection.
Among the other SNPs implicated in potential association with aspergillosis in our study, of particular interest is a common promoter flanking polymorphism rs187084 in the TLR9 gene. While it was not previously reported to be associated with the condition, many studies have revealed its involvement in the immune response in a variety of diseases, including auto-immune disorders, infectious diseases and cancers, as well as pharmacotherapies. These observations suggest the common mechanism that underlies the acting of this functional variant, presumably by down-regulating TLR9 expression and thus affecting the immune cascade initiated by TLR9 activation [33]. Similar regulatory functions at the level of transcription may be attributed to TLR9 synonymous variants rs352140 and rs4586 flanking the promoter of the CCL2 gene, of which the latter was reported to affect the immune response to some tumours. Overall, given the location of non-coding variants identified in our study as potentially associated with aspergillosis (Table II, excluding intronic variation), at least 28% of SNPs may be considered as potentially or actually affecting gene regulation. Interestingly, variation in TLR genes in modern humans that was recently reported as introgressed from Neanderthals and pivotal for human innate immunity also emphasizes the importance of differences in gene expression. Importantly, all TLR SNPs introgressed from Neanderthals are located in non-coding parts of the human genome (of which 47% lie in introns) and many of them overlap known regulatory sites [30]. It is also worth noting that gene regulation is often influenced by epistatic interactions. Possibility of SNP-SNP epistasis in invasive aspergillosis was actually suggested for selected variants of CLEC7A, CCL2 and CCR2 [34]. Overall, the findings of this and other studies contribute to our understanding of the complicated nature of potential susceptibility to aspergillosis, underlining the importance of non-canonical splicing, gene regulation and gene-gene interactions.
We acknowledge that association studies employing small population samples are usually underpowered in terms of detecting weak associations [17]. However, we also consider recruiting large groups of paediatric patients affected by aspergillosis as essentially unrealistic at the first, discovery stage of analysis. Therefore, for assessing the replication potential and actual strength of the reported associations, we applied very conservative BADGE recommendations based on p-values of associations. Two of the reported associations, classified as second class (TLR2 rs4585282 and CLEC6A rs12099687), are most promising in terms of replication. In fact, the p-value for CLEC6A rs12099687 is very close to that of a first-class association (p < 0.0000002), suggesting replication, under conservative assumptions, without any prior evidence [17]. Seven fourth-class associations (p < 0.002) reported for the novel intronic SNPs in TLR2 may be strong enough to justify additional replication efforts, although their actual potential is difficult to assess without other comparable data. The remaining associations reported in this study are classified as fifth class (p < 0.05). While a fifth-class association itself does not provide assurance of reproducibility, it may be considered as much more reliable when replicated in another population sample [17]. For example, SNPs rs187084, rs352140 (TLR9) and rs4586 (CCL2), which are formally implicated in fifth-class associations in our study, were previously proved to be involved in the immune response in a variety of conditions. Similarly, rs7959451 at the 3UTR of CLEC7A, showing differences for allele frequencies between our groups of patients (at p < 0.05), was recently found to be associated with bronchopulmonary aspergillosis in asthma. These independent findings constitute additional evidence justifying further replication studies.


In summary, our research should be considered as initial discovery and screening of complete genes in the search for genetic variants which deserve to be further replicated in larger cohorts. We attempted to cover for the first time the complete sequences of fifteen genes of innate immunity in two groups of paediatric patients affected by haematological disorders. Using two different MPS approaches, we identified a number of variants of potential importance in host susceptibility to aspergillosis, the vast majority of which are located in intronic and other non-coding parts of the targeted genes. Most of the variants indicated in this study were not previously reported in relation to aspergillosis, although several common SNPs were previously implicated in associations with other immune-related conditions. Some of these common variants may have functional significance, influencing splicing and gene expression.

This work was supported by the National Science Centre (Poland) [grant number 2011/03/B/NZ6/01728].
The authors declare no conflicts of interest.


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Address for correspondence

Katarzyna Skonieczna
Department of Forensic Medicine
Division of Molecular and Forensic Genetics
Collegium Medicum in Bydgoszcz
9 Curie-Sklodowskiej St.
85-094 Bydgoszcz, Poland
tel. +48 12 585 35 52
fax +48 12 585 35 53
e-mail: k.skonieczna@gmail.com
Copyright: © 2017 Polish Association of Pathologists and the Polish Branch of the International Academy of Pathology This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
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