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			<titleStmt><title level='a'>Case report: contamination of a drinking water distribution system by Exophiala-dominated biofilm in the Midwestern United States</title></titleStmt>
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				<publisher>IWA Publishing</publisher>
				<date>02/07/2025</date>
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				<bibl> 
					<idno type="par_id">10611892</idno>
					<idno type="doi">10.2166/wh.2025.173</idno>
					<title level='j'>Journal of Water and Health</title>
<idno>1477-8920</idno>
<biblScope unit="volume">23</biblScope>
<biblScope unit="issue">3</biblScope>					

					<author>Jon C King</author><author>Emma Lancaster</author><author>Alicia Myers</author><author>Jiyoung Lee</author><author>Karen C Dannemiller</author>
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			<abstract><ab><![CDATA[Fungal contamination of drinking water distribution systems can impact water quality with implications for public health. We document an instance of Exophiala spp. biofilm contamination of customer taps in the Midwest United States following consumer complaints. Three samples of black biofilm were collected from customer taps in Ohio and then processed using next-generation DNA sequencing of the bacterial 16S and fungal ITS regions. Two samples with successful ITS sequencing were dominated by Exophiala spp., putatively identified as E. cancerae and E. lecanii-corni. Dominant bacterial phyla in samples included Proteobacteria, Bacteroidetes, Actinobacteria, and Acidobacteria. Bacterial composition varied substantially at the family and genus levels, and potentially pathogenic bacteria (i.e., Acinetobacter spp., Legionella spp., Mycobacterium spp., and Pseudomonas spp.) were detected. The potential for fungal contamination of drinking water distribution systems should be evaluated when biofilms are observed.]]></ab></abstract>
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<div xmlns="http://www.tei-c.org/ns/1.0"><head>Introduction</head><p>Contamination of drinking water distribution systems by microorganisms has been recognized since the mid-1800s, and contamination events may result from introduction and/or regrowth of bacteria, viruses, protozoa, and fungi <ref type="bibr">(Rochelle and Clancey 2006)</ref>. For example, contamination with opportunistic pathogen bacteria such as Acinetobacter baumannii, Legionella pneumophila, and Mycobacterium avium is well-known <ref type="bibr">(Falkinham 2011;</ref><ref type="bibr">Carvalheira et al. 2021;</ref><ref type="bibr">CDC 2021)</ref> with healthcare costs from these three species estimated at $600 million annually for the elderly in the United States <ref type="bibr">(Naumova et al. 2016)</ref>.</p><p>Fungal contamination of drinking water distribution systems is less frequently studied but is increasingly recognized <ref type="bibr">(Mhlongo et al. 2019)</ref> with impacts upon water quality (e.g., color, odor, and taste), degradation of materials, and concerns about mycotoxin exposure and opportunistic infections <ref type="bibr">(Nucci et al. 2002;</ref><ref type="bibr">Hageskal et al. 2009;</ref><ref type="bibr">Mesquita-Rocha et al. 2013;</ref><ref type="bibr">Mhlongo et al. 2020;</ref><ref type="bibr">Afonso et al. 2021)</ref>. Available reports of fungal growth within distribution systems primarily implicate common, terrestrial, and filamentous genera, including Aspergillus, Cladosporium, and Penicillium <ref type="bibr">(Afonso et al. 2021</ref>). These may co-occur with bacteria and protozoa in biofilm communities, and interkingdom interactions within such biofilms are poorly understood <ref type="bibr">(Afonso et al. 2021)</ref>.</p><p>Aside from common terrestrial fungi, members of the black yeast genus Exophiala are occasionally reported as distribution system contaminants in tap water and especially around outlets in bathrooms, kitchens, dishwashers, and laundry machines <ref type="bibr">(Matos et al. 2002;</ref><ref type="bibr">Lian and De Hoog 2010;</ref><ref type="bibr">Adams et al. 2013;</ref><ref type="bibr">Isola et al. 2013;</ref><ref type="bibr">Biedunkiewicz and Schulz 2012;</ref><ref type="bibr">Babi&#269; et al. 2016;</ref><ref type="bibr">Moat et al. 2016;</ref><ref type="bibr">Zupan&#269;i&#269; et al. 2016;</ref><ref type="bibr">Babi&#269; et al. 2017;</ref><ref type="bibr">Wang et al. 2018;</ref><ref type="bibr">Kulesza et al. 2021</ref>). Within such environments, oligotrophy and tolerance of extreme conditions by certain Exophiala species enables their growth (Hamada and Abe 2010; <ref type="bibr">Lian and De Hoog, 2010;</ref><ref type="bibr">Heinrichs et al. 2013b;</ref><ref type="bibr">Zupan&#269;i&#269; et al., 2016;</ref><ref type="bibr">Wang et al. 2018;</ref><ref type="bibr">Kulesza et al. 2021;</ref><ref type="bibr">Romsdahl et al. 2021)</ref>. Moreover, many Exophiala spp. are opportunistic pathogens affecting both immunecompetent and immune-compromised persons <ref type="bibr">(Zeng et al. 2007;</ref><ref type="bibr">Sav et al. 2016;</ref><ref type="bibr">Singh et al. 2021;</ref><ref type="bibr">Usuda et al. 2021)</ref>. Infections with Exophiala spp. are most often superficial but do include deep-tissue and systemic mycoses which most commonly affect the lungs <ref type="bibr">(Zeng et al. 2007;</ref><ref type="bibr">Woo et al. 2013;</ref><ref type="bibr">Usuda et al. 2021)</ref>. Dermal contact, ingestion, and inhalation may be relevant routes of exposure.</p><p>Recently, <ref type="bibr">Heinrichs et al. (2013a, b)</ref> investigated black biofilms growing on aerators, shower heads, and toilet tanks in Germany. These biofilms were dominated by Exophiala lecaniicorni and smaller amounts of other Exophiala spp and black yeast-like fungi. E. lecanii-corni may cause superficial mycoses effecting skin, nails, eyes, and sinuses in addition to deeper mycoses of the lungs, digestive system, and central nervous system <ref type="bibr">(Futatsuya et al., 2023;</ref><ref type="bibr">Hatta et al., 2021;</ref><ref type="bibr">Lee et al., 2016;</ref><ref type="bibr">Miyakubo et al., 2020;</ref><ref type="bibr">Woo et al., 2013;</ref><ref type="bibr">Zeng et al., 2007)</ref> . After further sampling of that distribution system, retrograde contamination with E. lecanii-corni was suggested <ref type="bibr">(Heinrichs et al. 2013b</ref>). However, it is unknown how frequently similar, extensive E. lecanii-corni biofilms contaminate other distribution systems.</p><p>In this study, we report a series of Exophiala spp. biofilm contamination events at taps within a central Ohio (USA) distribution system similar to that reported by <ref type="bibr">Heinrichs et al. (2013a)</ref>. Our objective was to characterize these biofilms through DNA sequencing of the bacterial 16S and fungal ITS regions and to identify potentially pathogenic taxa of concern to water resource managers and for public health. This work highlights the potential importance of fungal biofilms in drinking water systems.</p></div>
<div xmlns="http://www.tei-c.org/ns/1.0"><head>Methods</head><p>Three biofilm samples were collected during November 2022 from homes that belong to a central Ohio, USA distribution system (Figure <ref type="figure">1</ref>). Samples were collected from an area within the distribution system where multiple homeowners had complained to operators about excessive biofilm growth on taps. Biofilms growing on kitchen sinks (i.e., samples S1 and S2) and a shower head (i.e., sample S3) were collected without prior flushing, using sterile cotton swabs and 4 oz Whirl-Pak&#174; bags (Pleasant Prairie, WI, USA). Samples were promptly transported to The Ohio State University and stored at -20 &#176;C. Microscopic observation, DNA extraction procedure, Illumina sequencing, and bioinformatics are detailed in supplemental materials.</p></div>
<div xmlns="http://www.tei-c.org/ns/1.0"><head>Results and Discussion</head><p>Fungal sequences were identified for samples S1 and S2, which yielded 36,342 and 26,873 sequences per sample respectively, before denoising. Sample S3 failed to amplify during ITS sequencing. Both samples were dominated Order Chaetothryiales, and specifically by Exophiala spp. (Table <ref type="table">1</ref>). In sample S1, the putative species E. cancerae (85% of the reads) and Knufia epidermidis (11% of the reads) were dominant, whereas in S2, the putative species E. lecanii-corni was dominant (98% of the reads). E. lecanii-corni dominated the biofilm samples characterized by <ref type="bibr">Heinrichs et al. (2013a)</ref>. We view the identification of E. cancerae with caution because species-level identifications from next-generation DNA sequencing are tentative owing in part to sequencing and database shortcomings <ref type="bibr">(Nilsson et al. 2006;</ref><ref type="bibr">Yamamoto et al. 2014)</ref>.</p><p>Moreover, E. cancerae is primarily reported from tropical locations. In South America, it is a causative agent of Lethargic Crab Disease (Or&#233;lis-Ribeiro et al. 2011) and we are aware of one report of gastrointestinal infection by E. cancerae from Hong Kong <ref type="bibr">(Woo et al. 2013)</ref>.</p><p>Several additional melanistic, black yeast-like fungi from orders Chaetothryiales and Venturiales that are commonly found in bathrooms <ref type="bibr">(Lian and de Hoog 2010;</ref><ref type="bibr">Wang et al. 2018)</ref>, and that are capable of human opportunism were detected. First, E. oligosperma (0.6% of reads in S2) opportunistically infects cutaneous, subcutaneous, and various deep tissues including the lungs, heart, gastrointestinal tract, spleen, lymphatic system, blood, and brain <ref type="bibr">(Tintelnot et al. 1991;</ref><ref type="bibr">de Hoog et al. 2003;</ref><ref type="bibr">al-Obaid et al. 2006;</ref><ref type="bibr">Zeng et al. 2007;</ref><ref type="bibr">Woo et al. 2013)</ref>. Several additional species that opportunistically primarily infect human skin and nails were also detected, including Knufia epidermidis (11% of reads in S1; <ref type="bibr">Li et al. 2008</ref>; Saunte et al. 2012; Martin-Gomez et al. 2019), Cyphellophora europaea (4% of reads in S2; de Hoog et al. 2000; Lian and de Hoog 2010; Saunte et al. 2012; Feng et al. 2014), Rhinocladiella similis (&lt;0.001% of reads in S2; Lian an de Hoog 2010; Richarz et al. 2018; de Hoog et al. 2003), and Ochroconis mirabilis (0.1% of reads in S1; <ref type="bibr">Giraldo et al. 2014;</ref><ref type="bibr">Shi et al. 2016;</ref><ref type="bibr">Yew et al. 2016)</ref>.</p><p>Bacterial sequencing was successful for all samples with 25,019 to 44,339 sequences per sample before denoising. Across all samples, 114 amplicon sequence variants (ASVs) were identified. Only 19 ASVs (17%) were detected in all three samples and 31 additional ASVs (27%) were present in two samples. Measures of alpha diversity after rarefaction were computed, including Shannon Entropy <ref type="bibr">(Shannon 1948)</ref> and Chao 1 Index <ref type="bibr">(Chao 1984</ref>) (Figure <ref type="figure">2</ref>). Shannon diversity values were comparable to previous analyses of biofilms within water distribution systems <ref type="bibr">(Gomez-Smith et al. 2015;</ref><ref type="bibr">Ren et al. 2024)</ref>, whereas Chao I values were lower <ref type="bibr">(Cruz et al. 2020)</ref>.</p><p>Four phyla -Proteobacteria, Bacteroidetes, Acidobacteria, and Actinobacteria -were present in all samples, accounting for 70-97% of reads (Figure <ref type="figure">3</ref>). Bacterial composition of samples was similar at the phylum and class levels, with more differentiation at the family and genus levels (Figure <ref type="figure">3</ref>) as reported previously <ref type="bibr">(Li et al. 2016)</ref>. Across different geographic regions and distribution system designs, predominant phyla in distribution system biofilms are Proteobacteria, Actinobacteria, Acidobacteria, Cyanobacteria, Bacteroidota, Nitrospira, Firmicutes, and Planctomycetota <ref type="bibr">(Proctor and Hammes 2015;</ref><ref type="bibr">Li et al. 2016;</ref><ref type="bibr">Stanish et al. 2016;</ref><ref type="bibr">Cruz et al. 2020;</ref><ref type="bibr">Ren et al. 2024)</ref>. The most abundant classes identified in our samples, Alphaproteobacteria, Betaproteobacteria, Cytophagia and Gammaproteobacteria, were also detected in a German distribution system, where biofilm samples also displayed high community variance <ref type="bibr">(Henne et al. 2012</ref>). The possible opportunistic pathogens Legionella spp., Pseudomonas spp., Mycobacterium spp., and Acinetobacter spp. were all detected in at least one sample, as in previous studies <ref type="bibr">(Douterelo et al. 2014;</ref><ref type="bibr">Li et al. 2016;</ref><ref type="bibr">Waak et al. 2018)</ref>. Certain members of these genera are capable of growth within distribution system biofilms, resulting in illness <ref type="bibr">(Falkinham 2011;</ref><ref type="bibr">Waak et al. 2018;</ref><ref type="bibr">Carvalheira et al. 2021)</ref>. Moreover, emerging evidence suggests microbial communities in drinking water influence human health through the microbiome <ref type="bibr">(Bowyer et al. 2020;</ref><ref type="bibr">Lugli et al. 2022;</ref><ref type="bibr">Vanhaecke et al. 2022)</ref>. Microbiome impacts from ingesting the bacterial and fungal communities we describe are unknown.</p><p>Beyond health implications, identification of ecological processes promoting growth of biofilms dominated by Exophiala and other black yeast-like fungi may assist control efforts. E. lecanii-corni is resistant to temperature, osmotic, and oxidative stresses <ref type="bibr">(Romsdahl et al. 2021)</ref>, is oligotrophic and exhibits extreme shear strength <ref type="bibr">(Heinrichs et al. 2013b)</ref>, and thrives in environments laden with toxic hydrocarbons <ref type="bibr">(Woertz et al. 2001;</ref><ref type="bibr">Pirnie-Fisker and Woertz 2007)</ref>. For these reasons, <ref type="bibr">Heinrichs et al. (2013b)</ref> proposed that VOCs from cosmetics or cleaning may contribute to biofilm contamination. Other considerations for future studies include depletion of chlorine residual, microbial regrowth and its promoting conditions, and water age.</p><p>In the distribution system sampled, contamination events were somewhat clustered, especially in areas where construction activity necessitated reduction of flow for extended periods. Future studies of these biofilms could sample distribution systems more extensively and seek to understand the source and conditions that encourage growth.</p></div>
<div xmlns="http://www.tei-c.org/ns/1.0"><head>Conclusions</head><p>We document occurrence of Exophiala-dominant biofilm on distribution system taps following <ref type="bibr">Heinrichs et al. (2013a, b)</ref>, this time in the Midwestern USA. Additionally, we report on the bacterial composition of these biofilms. Biofilms samples contained potentially pathogenic bacteria and fungi including Acinetobacter spp., Legionella spp., Mycobacterium spp., Pseudomonas spp., Exophiala spp., and Knufia spp. Health implications of these biofilms are uncertain. Future studies might include more extensive sampling of drinking water distribution systems for fungal contamination and identifying the environmental conditions that support growth to inform future control efforts. 424 425 Figure 1. Biofilms on customer taps (left) and light microscope image of biofilm stained with 426 crystal violet solution at 1000&#215; magnification (right).   Chao 1 index, C) the top five most abundant taxa at phylum, class, family, and genus ranks, and D) relative abundance of bacterial families.</p></div></body>
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