Intraocular inflammation as the main manifestation of Rickettsia conorii infection

Objective

To report the clinical features and management of seven cases of intraocular inflammation caused by Rickettsia infection and review published literature.

Methods

Rickettsia conorii or Rickettsia spp. infection was diagnosed based on the following criteria: (1) positive serology according to the European Guidelines, (2) titer normalization after specific treatment, and (3) complete resolution of ophthalmic disease and accompanying symptoms after antibiotic therapy.

Results

Seven patients were referred for uveitis of unknown etiology. All came from regions where Mediterranean spotted fever is prevalent. One patient met the European guidelines criteria for Rickettsia spp. infection, while the other six cases met the criteria for R. conorii infection. The main symptoms were visual loss, floaters, eye redness, photophobia, and ocular pain. Predominant ophthalmic signs included vasculitis, choroiditis, vitritis, and macular edema. All patients required antibiotic treatment that resulted in the remission of the infection. Doxycycline was the first choice and the only antibiotic used to treat four patients. One patient needed ciprofloxacin as a second antibiotic after not responding to doxycycline. Two patients had doxycycline as a second antibiotic after not responding primarily to sulfonamides (which had been given after 2–3 days of doxycycline gastric intolerance); one of these patients needed ciprofloxacin as a third antibiotic.

Conclusion

Intraocular inflammation can occur as the main manifestation of Rickettsia conorii or Rickettsia spp. infection. It should be considered as a differential diagnosis for uveitis especially for patients living in countries where this infection is endemic in the world. Antibiotic treatment remains effective in the management of Rickettsia infection.

Fas-activated serine/threonine phosphoprotein promotes immune-mediated pulmonary inflammation

We generated Fas-activated serine threonine phosphoprotein (FAST)-deficient mice (FAST(-/-)) to study the in vivo role of FAST in immune system function. In a model of house dust mite-induced allergic pulmonary inflammation, wild type mice develop a mixed cellular infiltrate composed of eosinophils, lymphocytes, and neutrophils. FAST(-/-) mice develop airway inflammation that is distinguished by the near absence of neutrophils. Similarly, LPS-induced alveolar neutrophil recruitment is markedly reduced in FAST(-/-) mice compared with wild type controls. This is accompanied by reduced concentrations of cytokines (TNF-alpha and IL-6 and -23) and chemoattractants (MIP-2 and keratinocyte chemoattractant) in bronchoalveolar lavage fluids. Because FAST(-/-) neutrophils exhibit normal chemotaxis and survival, impaired neutrophil recruitment is likely to be due to reduced production of chemoattractants within the pulmonary parenchyma. Studies using bone marrow chimeras implicate lung resident hematopoietic cells (e.g., pulmonary dendritic cells and/or alveolar macrophages) in this process. In conclusion, our results introduce FAST as a proinflammatory factor that modulates the function of lung resident hematopoietic cells to promote neutrophil recruitment and pulmonary inflammation.

Influence of brucellosis history on serological diagnosis and evolution of patients with acute brucellosis

Serological diagnosis of human brucellosis is problematic in endemic brucellosis regions and with patients having a history of brucellosis. The aim of this study is to ascertain the serologic and evolutionary behavior of the tests of serum agglutination, Coombs anti-Brucella, immunocapture-agglutination, enzyme-linked immunosorbent assay (ELISA) IgG, IgA, IgM and ELISA-IgG avidity against Brucella lipopolysaccharide (S-LPS), in patients with acute brucellosis based on whether or not a history of brucellosis exists. Titers and seropositivity in all the tests assayed were higher in the patients having brucellosis history (from 90.9% in ELISA-IgM to 100% in ELISA-IgG) than in the patients lacking such history (from 79.3% in ELISA-IgM to 86.2% in Coombs, immunocapture-agglutination, and ELISA-IgG). IgG S-LPS avidity results in patients with brucellosis history were significantly higher (always over 84%) than in patients without brucellosis history (from 48.0% in the initial sera to 81% ten months later) (p<0.001). The titers of antibodies against Brucella in the initial sera and ELISA-IgG avidity against S-LPS may allow distinguishing patients with brucellosis caused by primary infection in the initial stages of the disease from patients seropositive due to prior infections from Brucella.

Selective attenuation of Toll-like receptor 2 signalling may explain the atheroprotective effect of sphingosine 1-phosphate

AIMS

Vascular inflammation is a major atherogenic factor and Toll-like receptor (TLR) 2 ligands, including bacterial and serum lipoproteins, seem to be involved in atherogenesis. On this basis, we analysed the effect of lipoproteins and different lipid components on TLR2-dependent signalling.

METHODS AND RESULTS

In TLR2-transfected human embryonic kidney 293 cells and human monocytes, oxidized low-density lipoproteins inhibited nuclear factor (NF)-kappaB-driven transcriptional activity and chemokine gene expression in response to TLR2 ligands. Sphingosine 1-phosphate (S1P) and oxidized palmitoyl-arachidonoyl-phosphatidylcholine, but not lipoprotein-carried lysophospholipids, inhibited TLR2 activation. Silencing experiments in TLR2-transfected 293 cells showed that the S1P-mediated attenuation effect is mediated by S1P receptors type 1 and type 2. To address the physiological significance of these findings, additional experiments were performed in human peripheral blood monocytes and monocyte-derived macrophages. In both cell types, S1P selectively attenuated TLR2 signalling, as NF-kappaB and extracellular signal-regulated kinase activation, but not c-Jun amino terminal kinase phosphorylation, were inhibited by physiologically relevant concentrations of S1P. Moreover, the attenuation of TLR2 signalling was partially reverted by pharmacological inhibition of phosphoinositide 3-kinase (PI3K) and Ras pathways. In addition, S1P inhibited the chemokine gene expression elicited by TLR2, but not by TLR4 ligands.

CONCLUSION

These findings disclose a cross-talk mechanism between lipoprotein components and TLR in which engagement of S1P receptors exert selective attenuation of TLR2-dependent activation via PI3K and Ras signalling. A corollary to these data is that the negative cross-talk of S1P receptors and TLR2 signalling might be involved in the atheroprotective effects of S1P.

Importance of the Omp25/Omp31 family in the internalization and intracellular replication of virulent B. ovis in murine macrophages and HeLa cells

The role of the outer membrane proteins of the Omp25/Omp31 family in invasiveness and intracellular survival of virulent B. ovis in phagocytes was analyzed. The absence of Omp25d or Omp22 in B. ovis abolished its invasive capacity in HeLa cells and reduced it in J774.A1 cells. Additionally, in J774.A1 cells, the Deltaomp25d mutant was unable to multiply, whereas the Deltaomp22 mutant was cleared at 24h post-infection. These findings demonstrate that Omp25d and Omp22 are essential for the invasion and survival of B. ovis inside host cells, and justify the strong attenuation in virulence of the Deltaomp25d and Deltaomp22 mutants.

Seroprevalencia de las hepatitis virales en población general representativa de una zona básica de salud urbana en Castilla y León

INTRODUCTION

Viral hepatitis is a major social, health and economic problem worldwide, requiring strict epidemiological control.

METHODS

This study presents the viral hepatitis seroprevalence in a representative sample from an urban health care area in Valladolid (Spain).

RESULTS

Antibody prevalence was as follows: anti-HAV 52%; anti-HBc, 8.2%; anti-HCV, 1.1%; anti-HEV, 0.8%; and anti-HGV 5.8%. Prevalence of anti-HAV, anti-HBc and anti-HGV increased significantly with age (P < 0.005 in all cases). In individuals younger than 20, prevalence of anti-HAV was 3.8%, anti-HBc < 0.28% and anti-HGV 1.3%. In the 20-39 year-old group, seroprevalence against HAV was associated with low educational levels (P = 0.009) and with birth in other provinces (P = 0.016). Anti-HBc seroprevalence was mainly associated with three factors: prior hospitalization before 1990 (P = 0.002; OR 3.32 [1.48-7.42]); compulsory military service before 1990 (P < 0.0001; OR 37.33 [3.68-378.03]); and acupuncture treatments (P = 0.018; OR 57.75 [26.17-127.42]). Seroprevalence against HGV was associated with hospitalizations before 1990 (P = 0.019; OR = 2.969 [1.154-7.639]). Seropositive status to HCV revealed a transfusion history (2 cases), hospitalization (1 case) or drug addiction (1 case). Only one case among those seropositive to HEV had a history of a prior trip to a HEV-endemic area.

CONCLUSIONS

Our study shows that the seroprevalences of viral hepatitis in a representative sample of urban population of Castille and Leon are similar to the seroprevalences observed in the rest of Spain and other developed countries, lower than the ones observed in the studies performed in Spain in the last 20 years due to the measures of prophylaxis that were taken.

Francisella tularensis LPS induces the production of cytokines in human monocytes and signals via Toll-like receptor 4 with much lower potency than E. coli LPS

Francisella tularensis is a virulent Gram-negative intracellular pathogen. To address the signaling routes involved in the response of host cells to LPS from F. tularensis live vaccine strain (LVS), experiments were performed in transiently transfected 293 cells. Induction of kappaB-driven transcriptional activity by 2.5 mug ml(-1) F. tularensis LPS isolated by phenol-water and ether-water extraction, was observed in cells transfected with Toll-like receptor (TLR) 4 and MD-2, although CD14 was required for optimal induction. Conversely, TLR2, TLR2/TLR1 or TLR2/TLR6 transfected cells did not show kappaB-driven transcriptional activity in the presence of F. tularensis LPS. In human monocytic cells, F. tularensis LPS activated extracellular signal-regulated kinases and the production of pro-inflammatory proteins. Concentrations of 5-10 mug ml(-1) F. tularensis LPS elicited a similar pattern of mRNA and protein induction than 0.1 mug ml(-1) E. coli LPS, including the expression of CXC chemokines (IL-8, Gro and IFN-gamma-inducible protein-10); CC chemokines (monocyte chemoattractant protein-1 and -2, macrophage-derived chemoattractant, macrophage inflammatory protein-1alpha and -1beta and RANTES (regulated upon activation, normal T cell expressed and secreted) and pro-inflammatory cytokines (IL-6 and tumor necrosis factor alpha). Altogether, these data indicate that LPS from F. tularensis LVS signals via TLR4 at higher concentrations than those required for E. coli LPS, which may explain the inflammatory reaction and the low endotoxic response associated to vaccination with LVS in humans.

Reduced interleukin-18 secretion in Brucella abortus 2308-infected murine peritoneal macrophages and in spleen cells obtained from B. abortus 2308-infected mice

Th1 immune responses in which gamma interferon (IFN-gamma) production predominates are associated with protective immunity against intracellular bacteria. Following infection, interleukin-18 (IL-18) may contribute, in association with IL-12, to optimal IFN-gamma production. In this study, the secretion of IL-18 following intracellular infection with virulent Brucella abortus 2308 in CD-1 cultured peritoneal macrophages and splenocyte cultures was investigated. The production of IL-18 was reduced in both CD-1 mouse peritoneal macrophages infected with B. abortus 2308 and splenocyte cultures obtained from B. abortus 2308-infected mice at 3, 6 and 10 days post-infection (p.i.). In contrast, splenocyte cultures obtained from B. abortus 2308-infected mice at 3 days p.i. secreted significant amounts of IFN-gamma. Stimulation of these cells with recombinant IL-18 (rIL-18) and/or rIL-12 did not significantly increase IFN-gamma secretion at the splenocyte level. These data suggest that once the infection has been established, B. abortus 2308 selectively limits IL-18 secretion without affecting endogenous IFN-gamma production.

Interaction of endotoxins with Toll-like receptor 4 correlates with their endotoxic potential and may explain the proinflammatory effect of Brucella spp. LPS

Endotoxins displaying differences in the chemical structure of their lipid A were used to induce the expression of chemokines in the human monocytic THP-1 cell line. LPS from two enterobacterial species such as Escherichia coli and Yersinia enterocolitica induced mRNA expression of IFN-gamma-inducible protein (IP)-10, macrophage-inflammatory protein (MIP)-1alpha, MIP-1beta, monocyte chemoattractant protein (MCP)-1 and IL-8. LPS from the non-enterobacterial genera Brucella and Ochrobactrum induced the expression of these chemokines to a lower extent. Attempts to address the signaling routes involved in these responses were carried out in transiently transfected HEK293 cells. Induction of kappaB-driven transcriptional activity by enterobacterial LPS was observed in cells transfected with TLR-4 alone, although co-transfection of TLR-4, MD-2 and CD14 provided optimal induction. The response to Brucella spp. and Ochrobactrum anthropi LPS was only significant at the concentration of 10 microg/ml. These data indicate that LPS from Brucella spp. and O. anthropi, which contain lipid A moieties with structural features different from those of Enterobacteriaceae elicit biochemical signaling via TLR-4 only at high concentrations. Neither TLR-1, TLR-2 and TLR-6 nor heterodimeric combinations of these receptor molecules are involved. Conversely, the ability of LPS to activate the TLR-4 route is a reliable molecular biomarker for endotoxicity.

Development of a dipstick dye immunoassay for diagnosing hydatidosis

We have developed a kit to diagnose hydatidosis, based on the detection of specific antibodies. This disease, caused by larvae of the cestode Echinococcus granulosus, is a zoonosis commonly found throughout the world. The diagnostic kit discriminates between positive and negative cases in a way that is easily interpreted, i.e., positive cases form a colored band on an inert substrate. The results show test sensitivity to be some 94.87% and specificity 85.71%, which is comparable to those of the ELISA technique. The high sensitivity and specificity of this test affords the great advantage of speed in diagnosing this parasitosis. No other equipment or procedure is required.

[Seroprevalence of infection due to Echinococcus granulosus in the population of Castilla and León (Spain)]

INTRODUCTION

Human hydatidosis is a prevalent zoonotic disease in the Castilla y León region of Spain. The aim of this study is to investigate the seroprevalence of Echinococcus granulosus infection in this region.

METHODS

We studied 4824 serum samples from a random, representative population of healthy individuals from each province of Castilla y León, obtained over one year. An indirect enzyme-immunoassay developed in our laboratory was used to determine the presence of IgG antibodies against Echinococcus granulosus in these samples.

RESULTS

IgG antibodies against Echinococcus granulosus were detected in 3.4% (164/4824) of samples studied, with a range of 1.26% to 7.10%, depending on the province. Antibody seroprevalence increased significantly with age, but there was no significant sex-related difference (3.66% men vs. 3.14% women).

CONCLUSION

The seroprevalence of Echinococcus granulosus infection in Castilla y León is still high. These data contribute to hydatidosis surveillance within the control program for this disease.

Utility of a commercial immunoblot kit (BAG-Borrelia blot) in the diagnosis of the preliminary stages of Lyme disease

The aim of this study was to evaluate the usefulness of a commercial immunoblot (IgG and IgM BAG-Borrelia blot) in the serologic diagnosis of the early stages of Lyme disease. A total of 42 sera from patients with Lyme disease (24 patients with localized early stage (LES) and 18 patients with disseminated early stage (DES)) and 129 sera from patients with non-Lyme diseases (specificity control sera) were studied. IgG anti-p41 from Borrelia burgdorferi s.l. was present in 95.2% of patients followed by anti-p41/I PBi (16.7%), anti-p100 (9.5%) and anti-OspA (9.5%). IgM anti-p41 was present in 66.7% of patients, p41/iPBi (54.8%) and OspC (33.3%). IgM against p100, OspA and OspC were more frequent in DES patients (16.7%, 27.8% and 44.4%) than in LES patients (0.0%, 4.2% and 25.0%). In 4.8% of the cases no IgG bands were present and in 26.2% no IgM bands were present. With the exception of isolated p41 bands (59.5%), no band pattern exceeded 17%. Using manufacturer's instructions, test sensitivity in diagnosis of the early stage of Lyme disease is 61.9%, specificity 98.4% and positive and negative predictive values 92.8% and 88.8% respectively. Applying the EUCALB 5, 6 or 7 rules sensitivity increased to 73.8% although specificity decreased to 89.9%. Of the 129 specific control sera, 41.8% presented IgG anti-p41 and 10.8% IgM anti-p41. Patients with non-Lyme diseases that presented more IgG and IgM bands were those patients with syphilis (88.2%), patients with anti-HIV antibodies (57.8%) and patients with anti-nuclear antibodies (ANA) (52.3%).

Serologic evidence of human infection by Francisella tularensis in the population of Castilla y León (Spain) prior to 1997

Prior to an outbreak in Castilla y León in December 1997, tularaemia was practically non-existent in Spain. In this paper we studied the prevalence of antibodies against Francisella tularensis in a representative sample of the population (4825 people) from Castilla y León (Spain) in samples collected before this outbreak. Antibodies against F. tularensis were detected in nine (0.19%) of the 4825 sera, with antibody titres ranging from 1/20 to 1/160. Of these nine sera, one was positive in seroagglutination against Brucella. Seroagglutination against other bacteria (Yersinia enterocolitica O:9 and O:3 and Proteus OX19) was negative in all sera. Seroprevalence of antibodies in females was 0.20% and 0.17% in males; no statistically significant differences were found in prevalence in terms of sex, age or province.

[Prevalence of antibodies against Francisella tularensis in Castilla y León (Spain) before 1997]

BACKGROUND AND OBJECTIVES

The aim of this paper was determine the prevalence of antibodies against Francisella tularensis in the representative sample of people from Castilla-León (Spain) before epidemic outbreak of end 1997.

SUBJECTS AND METHOD

We obtain 4,825 sera (between april-1996 and april-1997) of people from Castilla-León. All sera were tested by a microagglutination technique to detect antibodies against Francisella tularensis. The positive sera were tested to determine cross-reaction with Brucella, Yersinia enterocolitica and Proteus in the tube agglutination tests.

RESULTS

We detected antibodies against Francisella tularensis in 9 (0,19%) of the 4,825 sera. Only one serum from the 9 seropositive was positive in the tube agglutination against Brucella. None of the 9 sera were positive against the remaining bacterial antigen tested.

CONCLUSIONS

In the people of Castilla-León before 1997 the prevalence of antibodies against Francisella tularensis was 0,19%.

Brucella lipopolysaccharides induce cyclooxygenase-2 expression in monocytic cells

Human brucellosis is characterized by the presence of both acute inflammatory episodes and chronic inflammation with granuloma formation. On this basis, the proinflammatory effects of smooth lipopolysaccharide of Brucella (S-LPS) were addressed and compared to those of LPS from Escherichia coli. For this purpose, the induction of cyclooxygenase-2 (COX-2), the production of the chemokine monocyte chemoattractant protein-1 (MCP-1), and the activation of the nuclear factor kappa B (NF-kappa B) were studied. S-LPS was found to induce both COX-2 expression and MCP-1 production; however, the potency of E. coli LPS exceeded that of Brucella S-LPS by some orders of magnitude. However, at concentrations above 1 microg/ml, all of the LPS produced comparable effects, including their ability to activate the NF-kappa B system. These observations help explain the inflammatory events associated with Brucella infection and the ability of Brucella to produce monocyte recruitment and granuloma formation.

Promotion of platelet aggregation by sera from brucellosis patients with antiphosphatidylcholine antibodies

Results obtained in this study suggest that in human brucellosis there is an antibody response against platelet-activating factor (PAF) and phosphatidylcholine (PC). The specificity of the antiphospholipid response was determined by inhibition assays. The PAF molecule was able to inhibit the anti-PC activity of the brucellosis-control serum. This inhibition capacity of PAF was similar to that of the phosphorylcholine (PYC) group. These results suggest that the inhibition activity could be attributed to the PYC group present in both PAF and PC molecules. Consequently, these findings support an immunodominant role of PYC in the antiphospholipid response of brucellosis. Furthermore, sera from patients infected with Brucella organisms were able to cause platelet aggregation, as were brucella phospholipids, suggesting a possible role of the antiphospholipid antibodies and phospholipids in the inflammatory response in brucellosis.

Comparative sensitivity of six serological tests and diagnostic value of ELISA using purified antigen in hydatidosis

Most serodiagnostic techniques have been evaluated for diagnosis of cystic hydatid disease caused by Echinococcus granulosus. Each, to varying degrees, has been shown to give false results, with considerable variation between laboratories. The comparative study was made concerning the sensitivity of the immunodiagnostic methods based on 58 sera from hydatid disease with different cyst locations. Latex agglutination, immunoelectrophoresis (IEP), and specific IgE, IgG enzyme-linked immunosorbent assay (ELISA) tests were studied. Specific IgG ELISA AgB (antigen B-rich fraction) was the most sensitive test (96.5%) and the least sensitive tests were specific IgE ELISA (24.1%) and IEP (25.8%). The low sensitivity of these two tests was due partly to the low reactivity detected in the sera of patients with lung hydatidosis. Initial laboratory studies showed purified antigens to be preferable to crude cyst fluid, regardless of the type of test used. For this reason, we evaluated the sensitivity and specificity of ELISA by using the purified antigen-B-rich fraction. In all, 117 sera were examined: 78 sera from patients with hydatidosis surgically confirmed, 15 sera from healthy control subjects, and 24 sera from patients with diseases other than hydatidosis. The method gave good results: 93.5% sensitivity, 89.7% specificity, and 92.3% diagnostic efficacy.

Specificity of a polymerase chain reaction assay of a target sequence on the 31-kilodalton Brucella antigen DNA used to diagnose human brucellosis

The aim of this study was to evaluate the specificity of a polymerase chain reaction assay for detecting Brucella DNA using primers specific for the amplification of a 223 bp region of the sequence encoding a 31 kDa immunogenic Brucella abortus protein (BCSP31). DNA from all Brucella strains, including type, reference, vaccine and field strains, were correctly amplified. With the exception of Ochrobactrum spp., no other amplification was detected with a broad panel of microorganisms serologically or phylogenetically related to Brucella spp. This very good degree of specificity, together with its high yield demonstrated in previous clinical studies, confirms that this polymerase chain reaction assay could be a useful tool for the diagnosis of human brucellosis.

Comparative sensitivity of six serological tests and diagnostic value of ELISA using purified antigen in hydatidosis

Most serodiagnostic techniques have been evaluated for diagnosis of cystic hydatid disease caused by Echinococcus granulosus. Each, to varying degrees, has been shown to give false results, with considerable variation between laboratories. The comparative study was made concerning the sensitivity of the immunodiagnostic methods based on 58 sera from hydatid disease with different cyst locations. Latex agglutination, immunoelectrophoresis (IEP), and specific IgE, IgG enzyme-linked immunosorbent assay (ELISA) tests were studied. Specific IgG ELISA AgB (antigen B-rich fraction) was the most sensitive test (96.5%) and the least sensitive tests were specific IgE ELISA (24.1%) and IEP (25.8%). The low sensitivity of these two tests was due partly to the low reactivity detected in the sera of patients with lung hydatidosis. Initial laboratory studies showed purified antigens to be preferable to crude cyst fluid, regardless of the type of test used. For this reason, we evaluated the sensitivity and specificity of ELISA by using the purified antigen-B-rich fraction. In all, 117 sera were examined: 78 sera from patients with hydatidosis surgically confirmed, 15 sera from healthy control subjects, and 24 sera from patients with diseases other than hydatidosis. The method gave good results: 93.5% sensitivity, 89.7% specificity, and 92.3% diagnostic efficacy.

Hydatid cyst of the lung: diagnosis and treatment

Hydatid infestation of the lung can be primary or secondary. In three of four cases the cyst is a single one. Hydatidosis of a different location, particularly the liver, may be associated. The period of initial growth of primary hydatidosis is frequently asymptomatic. Bronchial fistulization is an important event in the evolution of the cyst. Intrapleural rupture constitutes a rare eventuality, but it is often as characteristic as it is severe. Secondary, metastatic hydatidosis, due to breaking of a primary visceral cyst in a vein or heart, is rare. A special form is so-called multiple malignant pulmonary hydatidosis, which causes progressive respiratory deficiency and right ventricular failure. There are a variety of radiographic images. Ultrasonography, computed tomography, and magnetic resonance imaging can recognize certain details of the lesions and discover others that are not visible by conventional radiography. For a specific serologic diagnosis, our experience favors the immunoglobulin G enzyme-linked immunosorbent assay and immunoelectrophoresis. Treatment is essentially surgical. In general, chemotherapy is used as a complement to operative treatment to avoid recurrence. Surgery has two objectives: to remove the parasite and to treat the bronchipericyst pathology and other associated lesions. The prognosis has changed during the last few years, and results are now commonly satisfactory. The most frequent complications are pleural infection and prolonged air leakage. Operative mortality does not exceed 1% to 2%. Despite the low mortality and the limited recurrence rate, it is necessary to remember the invading character of pulmonary hydatid disease, which sometimes makes therapy difficult and questionable. Prophylaxis is essential to eradicate the disease completely.

Evaluation of an immunocapture-agglutination test (Brucellacapt) for serodiagnosis of human brucellosis

We evaluated the validity and the usefulness of a new test for the diagnosis of human brucellosis based on an immunocapture-agglutination technique. A total of 315 sera from 82 patients with a diagnosis of brucellosis, 157 sera from patients in whom brucellosis was suspected but not confirmed, and 412 sera from people living in rural areas with endemic brucellosis were studied. The seroagglutination test (SAT), Coombs anti-Brucella test, and Brucellacapt test were evaluated. All the initial sera from the 82 patients proved to be positive in Brucellacapt and Coombs tests, while only 75 (91.4%) were positive in the SAT. If a >/=1/160 diagnostic threshold titer was defined for the Brucellacapt test, Coombs test, and SAT, the sensitivities were 95.1, 91.5, and 65.8%, respectively. Taking the same diagnostic threshold titer for the 157 sera from the unconfirmed but suspected patients, the specificities of the Brucellacapt, Coombs, and SAT were 81.5, 96.2, and 100%, respectively; for the 412 control sera, the specificities were 99.0, 99.8, and 100%. The diagnostic efficiency (area below the receiver operating characteristic curve) of Brucellacapt was 0.987852 (95% confidence interval [CI], 0.95109 to 0.99286), very similar to the diagnostic efficiency of the Coombs test (0.97611; 95% CI, 0.94781 to 0.99146) and higher than that of SAT (0.91013; 95% CI, 0.86649 to 0.94317). The results of the Brucellacapt test were compared with those of the Coombs test (correlation coefficient, 0.956; P = 0.000) and SAT (correlation coefficient, 0.866; P = 0.000). The study shows very good correlation between the Brucellacapt and Coombs tests, with a high concordance between titers obtained in the two tests. Nevertheless, lower correlation and concordance were found between the Brucellacapt and Coombs tests when the results for titers of >/=1/160 were compared (0.692; P = 0.000). In acute brucellosis, the Brucellacapt and Coombs tests render positive titers of >/=1/160. When the titers are lower, they increase significantly in the following 30 days, despite the evolution of SAT titers. In contrast, Brucellacapt and Coombs titers are always high (>/=1/640) in brucellosis with long evolution, whether SAT titers are higher or lower than 1/160.

[Laboratory diagnosis and serologic course in patients with tularemia]

BACKGROUND

Tularemia was practically unknown in Spain until the end of 1997, when an epidemic outbreak was declared. This paper presents the data on microbiological diagnosis of 55 patients who suffered from tularemia.

PATIENTS AND METHODS

Thirty-two samples from 19 patients and 151 serum samples from 55 patients were obtained for culture. Serologic diagnosis was performed by tube sero-agglutination and microagglutination. Three types of tests were performed on all sera: Wright sero-agglutination (WSA), Coombs test against Brucella spp. and sero-agglutination against Yersinia enterocolitica O:3, Yersinia enterocolitica O:3, and Proteus OX 19.

RESULTS

F. tularensis was found in two samples (6.25%) of the 32 received. Titers > or = 1/160 were obtained in 78.2% and 74.5% of the initial sera by tube sero-agglutination and microagglutination, respectively. Correlation between the two tests was 0.80 (p < 0.001). Prozone phenomenon was observed in 59.9% of the sera, while crossed reactivity to Brucella spp. and Proteus spp. was found in 9.3% and 22.8%, respectively. No crossed reactivity was observed with Yersinia spp.

CONCLUSIONS

Culture of F. tularensis has low sensitivity. The correlation obtained between tube sero-agglutination and microagglutination is good. Both techniques are useful in routine diagnosis of tularemia, although microagglutination has some advantages over tube agglutination.