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Pastoor R, Hatta M, Abdoel TH, Smits HL. Simple, rapid, and affordable point-of-care test for the serodiagnosis of typhoid fever. Diagn Microbiol Infect Dis 2008; 61:129-34. [PMID: 18276100 DOI: 10.1016/j.diagmicrobio.2007.12.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Revised: 12/06/2007] [Accepted: 12/18/2007] [Indexed: 10/22/2022]
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102
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Gordon MA. Salmonella infections in immunocompromised adults. J Infect 2008; 56:413-22. [PMID: 18474400 DOI: 10.1016/j.jinf.2008.03.012] [Citation(s) in RCA: 297] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 03/25/2008] [Accepted: 03/31/2008] [Indexed: 12/11/2022]
Abstract
Clinical syndromes caused by Salmonella infection in humans are divided into typhoid fever, caused by Salmonella typhi and Salmonella paratyphi, and a range of clinical syndromes, including diarrhoeal disease, caused by a large number of non-typhoidal salmonella serovars (NTS). Typhoid is a human-restricted and highly adapted invasive disease, but shows little association with immunocompromise. In contrast, NTS have a broad vertebrate host range, epidemiology that often involves food animals, and have a dramatically more severe and invasive presentation in immunocompromised adults, in particular in the context of HIV. Immunocompromise among adults, including underlying severe or progressive disease, chronic granulomatous disease, defects or blockade of specific cytokines (particularly IL-12/IL-23/IL-17 and TNF), and HIV, is associated with suppurative foci and with primary bacteraemic disease, which may be recurrent. These patients have markedly increased mortality. Worldwide, invasive recurrent NTS bacteraemia associated with advanced HIV disease is a huge problem, and the epidemiology in this context may be more human-restricted than in other settings. This review will describe the presentation and pathogenesis of NTS in different categories of immunocompromised adults, contrasted to typhoid fever.
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Affiliation(s)
- Melita A Gordon
- Division of Gastroenterology, Henry Wellcome Laboratories, Nuffield Building, Crown Street, Liverpool University L69 3GE, UK.
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103
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Crump JA, Ram PK, Gupta SK, Miller MA, Mintz ED. Part I. Analysis of data gaps pertaining to Salmonella enterica serotype Typhi infections in low and medium human development index countries, 1984-2005. Epidemiol Infect 2008; 136:436-48. [PMID: 17686194 PMCID: PMC2870843 DOI: 10.1017/s0950268807009338] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2007] [Indexed: 11/05/2022] Open
Abstract
There are only 10 contemporary, population-based studies of typhoid fever that evaluate disease incidence using blood culture for confirmation of cases. Reported incidence ranged from 13 to 976/100 000 persons per year. These studies are likely to have been done preferentially in high- incidence sites which makes generalization of data difficult. Only five of these studies reported mortality. Of these the median (range) mortality was 0% (0-1.8%). Since study conditions usually involved enhanced clinical management of patients and the studies were not designed to evaluate mortality as an outcome, their usefulness for generalizing case-fatality rates is uncertain. No contemporary population-based studies reported rates of complications. Hospital-based typhoid fever studies reported median (range) complication rates of 2.8% (0.6-4.9%) for intestinal perforation and case-fatality rates of 2.0% (0-14.8%). Rates of complications other than intestinal perforation were not reported in contemporary hospital-based studies. Hospital-based studies capture information on the most severe illnesses among persons who have access to health-care services limiting their generalizability. Only two studies have informed the current understanding of typhoid fever age distribution curves. Extrapolation from population-based studies suggests that most typhoid fever occurs among young children in Asia. To reduce gaps in the current understanding of typhoid fever incidence, complications, and case-fatality rate, large population-based studies using blood culture confirmation of cases are needed in representative sites, especially in low and medium human development index countries outside Asia.
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Affiliation(s)
- J A Crump
- Enteric Diseases Epidemiology Branch, National Center for Zoonotic, Vectorborne, and Enteric Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Speil C, Mushtaq A, Adamski A, Khardori N. Fever of unknown origin in the returning traveler. Infect Dis Clin North Am 2008; 21:1091-113, x. [PMID: 18061090 DOI: 10.1016/j.idc.2007.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The returning traveler with fever presents a diagnostic challenge for the health care provider. When evaluating such a patient, the highest priority should be given to diseases that are potentially fatal or may represent public health threats. A good history is paramount and needs to include destination, time and duration of travel, type of activity, onset of fever in relation to travel, associated comorbidities, and any associated symptoms. Pretravel immunizations and chemoprophylaxis may alter the natural course of disease and should be inquired about specifically. The fever pattern, presence of a rash or eschar, organomegaly, or neurologic findings are helpful physical findings. Laboratory abnormalities are nonspecific but when corroborated with clinical and epidemiologic data may offer a clue to diagnosis.
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Affiliation(s)
- Cristian Speil
- Division of Infectious Diseases, Department of Internal Medicine and Medical Microbiology/Immunology, Southern Illinois School of Medicine, Springfield, IL 62794-9636, USA
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105
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Munford RS. Sensing gram-negative bacterial lipopolysaccharides: a human disease determinant? Infect Immun 2008; 76:454-65. [PMID: 18086818 PMCID: PMC2223455 DOI: 10.1128/iai.00939-07] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Robert S Munford
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas 75390-9113, USA.
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106
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ROLE OF ENTERIC FEVER IN ILEAL PERFORATIONS: AN OVERSTATED PROBLEM IN TROPICS? Indian J Med Microbiol 2008. [DOI: 10.1016/s0255-0857(21)01993-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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107
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Munford RS. Severe sepsis and septic shock: the role of gram-negative bacteremia. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2007; 1:467-96. [PMID: 18039123 DOI: 10.1146/annurev.pathol.1.110304.100200] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract Although Gram-negative bacteria have often been implicated in the pathogenesis of severe sepsis and septic shock, how they trigger these often lethal syndromes is uncertain. In particular, the role played by blood-borne bacteria is controversial. This review considers two alternatives. In the first, circulating Gram-negative bacteria induce toxic reactions directly within the vasculature; in the second, the major inflammatory stimulus occurs in local extravascular sites of infection and circulating bacteria contribute little to inducing toxic responses. Evidence for each alternative is found in the literature. Bacteremia and severe sepsis are not so closely linked that the most striking cases can be a model for the rest. Intravascular and extravascular triggers may warrant different approaches to prevention and therapy.
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Affiliation(s)
- Robert S Munford
- Departments of Internal Medicine and Microbiology, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9113, USA.
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108
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Chen X, Stanton B, Pach A, Nyamete A, Ochiai RL, Kaljee L, Dong B, Sur D, Bhattacharya SK, Santoso SS, Agtini M, Memon Z, Bhutta Z, Do CG, von Seidlein L, Clemens J. Adults' perceived prevalence of enteric fever predicts laboratory-validated incidence of typhoid fever in children. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2007; 25:469-478. [PMID: 18402191 PMCID: PMC2754016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This study was undertaken to develop a model to predict the incidence of typhoid in children based on adults' perception of prevalence of enteric fever in the wider community. Typhoid cases among children, aged 5-15 years, from epidemic regions in five Asian countries were confirmed with a positive Salmonella Typhi culture of the blood sample. Estimates of the prevalence of enteric fever were obtained from random samples of adults in the same study sites. Regression models were used for establishing the prediction equation. The percentages of enteric fever reported by adults and cases of typhoid incidence per 100,000, detected through blood culture were 4.7 and 24.18 for Viet Nam, 3.8 and 29.20 for China, 26.3 and 180.33 for Indonesia, 66.0 and 454.15 for India, and 52.7 and 407.18 for Pakistan respectively. An established prediction equation was: incidence of typhoid (1/100,000= -2.6946 + 7.2296 x reported prevalence of enteric fever (%) (F=31.7, p<0.01; R2=0.992). Using adults' perception of prevalence of disease as the basis for estimating its incidence in children provides a cost-effective behavioural epidemiologic method to facilitate prevention and control of the disease.
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Affiliation(s)
- Xinguang Chen
- Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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109
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Characterization of plasmacytoid dendritic cells in bone marrow of pig-tailed macaques. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2007; 15:35-41. [PMID: 17989338 DOI: 10.1128/cvi.00309-07] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Plasmacytoid dendritic cells (pDCs), one of two types of bone marrow (BM)-derived blood DCs, play an important role in linking innate and adaptive immune responses. However, little is known about the nature of pDCs that reside in the BM. Because the simian immunodeficiency virus-macaque model closely mimics human immunodeficiency virus disease in humans, with both infections inducing a decrease in pDCs, we characterized and compared pDCs in the BM with those in peripheral blood (PB) of healthy pig-tailed macaques. The results revealed that pDCs from both compartments had the same CD123++ HLA-DR+ Lin- phenotype and were similar in size. Although BM-derived pDCs (BM-pDCs) were 3-fold greater in frequency and 10-fold greater in number, they had lower cell surface expression of both HLA-DR and the costimulatory molecule CD86 than did PB-pDCs. Both BM- and PB-pDCs responded ex vivo to synthetic CpG oligodeoxynucleotides and inactivated influenza virus by upregulating HLA-DR and CD86 and secreting cytokines; however, stimulated BM-pDCs secreted less alpha interferon and tumor necrosis factor alpha per cell than did PB-pDCs. These results suggest that while BM-pDCs appear to be phenotypically less mature than PB-pDCs, they do respond to pathogens. Thus, during acute infections, these cells could initiate immune responses either in the BM or after rapidly migrating from the BM into the periphery. A better characterization of pDCs in blood and tissues will be beneficial for future studies of macaques that focus on either pathogenesis or vaccine development.
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110
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Ochiai RL, Acosta CJ, Agtini M, Bhattacharya SK, Bhutta ZA, Do CG, Dong B, Chen X, Stanton B, Kaljee L, Nyamete A, Galindo CM, von Seidlein L, DeRoeck D, Jodar L, Clemens JD. The Use of Typhoid Vaccines in Asia: The DOMI Experience. Clin Infect Dis 2007; 45 Suppl 1:S34-8. [PMID: 17582567 DOI: 10.1086/518144] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Two currently licensed typhoid vaccines have been evaluated in Asia, yet few Asian countries have considered including typhoid vaccines in their vaccination programs. The Diseases of the Most Impoverished (DOMI) Program was initiated to provide evidence to decide on the introduction of typhoid vaccines in Asian countries. METHODS The centerpiece of the program is a multidisciplinary demonstration project with Vi vaccine in 5 Asian countries. The project includes epidemiologic, economic, sociobehavioral, and policy studies. RESULTS Policy makers want evidence on which to base their vaccine-related decisions. The DOMI Program has provided updated information on the typhoid fever burden at several Asian sites. Cost-of-illness studies found high costs to governments and individuals. Sociobehavioral studies indicated a positive attitude toward typhoid vaccines. The results of the demonstration projects indicate that mass-immunization campaigns are feasible and acceptable. CONCLUSIONS The DOMI Program has begun to provide momentum for the evidence-based, rational introduction of typhoid vaccines into the public health programs of several Asian countries.
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Affiliation(s)
- R Leon Ochiai
- International Vaccine Institute, Kwanak-gu, Seoul, Korea.
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111
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Smith-Vaughan H, Byun R, Nadkarni M, Jacques NA, Hunter N, Halpin S, Morris PS, Leach AJ. Measuring nasal bacterial load and its association with otitis media. BMC EAR, NOSE, AND THROAT DISORDERS 2006; 6:10. [PMID: 16686940 PMCID: PMC1479363 DOI: 10.1186/1472-6815-6-10] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 05/10/2006] [Indexed: 11/10/2022]
Abstract
Background Nasal colonisation with otitis media (OM) pathogens, particularly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, is a precursor to the onset of OM. Many children experience asymptomatic nasal carriage of these pathogens whereas others will progress to otitis media with effusion (OME) or suppurative OM. We observed a disparity in the prevalence of suppurative OM between Aboriginal children living in remote communities and non-Aboriginal children attending child-care centres; up to 60% and <1%, respectively. This could not be explained by the less dramatic difference in rates of carriage of respiratory bacterial pathogens (80% vs 50%, respectively). In this study, we measured nasal bacterial load to help explain the different propensity for suppurative OM in these two populations. Methods Quantitative measures (colony counts and real-time quantitative PCR) of the respiratory pathogens S. pneumoniae, H. influenzae and M. catarrhalis, and total bacterial load were analysed in nasal swabs from Aboriginal children from remote communities, and non-Aboriginal children attending urban child-care centres. Results In both populations nearly all swabs were positive for at least one of these respiratory pathogens. Using either quantification method, positive correlations between bacterial load and ear state (no OM, OME, or suppurative OM) were observed. This relationship held for single and combined bacterial respiratory pathogens, total bacterial load, and the proportion of respiratory pathogens to total bacterial load. Comparison of Aboriginal and non-Aboriginal children, all with a diagnosis of OME, demonstrated significantly higher loads of S. pneumoniae and M. catarrhalis in the Aboriginal group. The increased bacterial load despite similar clinical condition may predict persistence of middle ear effusions and progression to suppurative OM in the Aboriginal population. Our data also demonstrated the presence of PCR-detectable non-cultivable respiratory pathogens in 36% of nasal swabs. This may have implications for the pathogenesis of OM including persistence of infection despite aggressive therapies. Conclusion Nasal bacterial load was significantly higher among Aboriginal children and may explain their increased risk of suppurative OM. It was also positively correlated with ear state. We believe that a reduction in bacterial load in high-risk populations may be required before dramatic reductions in OM can be achieved.
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Affiliation(s)
- Heidi Smith-Vaughan
- Menzies School of Health Research, Darwin, Australia
- Institute for Advanced Studies, Charles Darwin University, Darwin, Australia
| | - Roy Byun
- Institute of Dental Research, Westmead Millennium Institute and Westmead Centre for Oral Health, Sydney, Australia
| | - Mangala Nadkarni
- Institute of Dental Research, Westmead Millennium Institute and Westmead Centre for Oral Health, Sydney, Australia
| | - Nicholas A Jacques
- Institute of Dental Research, Westmead Millennium Institute and Westmead Centre for Oral Health, Sydney, Australia
| | - Neil Hunter
- Institute of Dental Research, Westmead Millennium Institute and Westmead Centre for Oral Health, Sydney, Australia
| | - Stephen Halpin
- Menzies School of Health Research, Darwin, Australia
- Institute for Advanced Studies, Charles Darwin University, Darwin, Australia
| | - Peter S Morris
- Menzies School of Health Research, Darwin, Australia
- Institute for Advanced Studies, Charles Darwin University, Darwin, Australia
- Northern Territory Clinical School, Flinders University, Adelaide, Australia
| | - Amanda J Leach
- Menzies School of Health Research, Darwin, Australia
- Institute for Advanced Studies, Charles Darwin University, Darwin, Australia
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112
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Monack DM, Mueller A, Falkow S. Persistent bacterial infections: the interface of the pathogen and the host immune system. Nat Rev Microbiol 2004; 2:747-65. [PMID: 15372085 DOI: 10.1038/nrmicro955] [Citation(s) in RCA: 369] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Persistent bacterial infections involving Mycobacterium tuberculosis, Salmonella enterica serovar Typhi (S. typhi) and Helicobacter pylori pose significant public-health problems. Multidrug-resistant strains of M. tuberculosis and S. typhi are on the increase, and M. tuberculosis and S. typhi infections are often associated with HIV infection. This review discusses the strategies used by these bacteria during persistent infections that allow them to colonize specific sites in the host and evade immune surveillance. The nature of the host immune response to this type of infection and the balance between clearance of the pathogen and avoidance of damage to host tissues are also discussed.
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Affiliation(s)
- Denise M Monack
- Department of Microbiology and Immunology, Stanford School of Medicine, Stanford University, Stanford, California 94305, USA.
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113
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Abstract
Interactions between microbes and human hosts can range from a benign, even symbiotic collaboration to a competition that may turn fatal--resulting in death of the host, the microbe or both. Despite advances that have been made over the past decades in understanding microbial pathogens, more people worldwide still die every year from infectious disease than from any other cause. This highlights the relevance of continuing to probe the mechanisms used by microorganisms to cause disease, and emphasizes the need for new model systems to advance our understanding of host-pathogen interactions.
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Affiliation(s)
- D Scott Merrell
- Uniformed Services University of the Health Sciences, Department of Microbiology and Immunology, 4301 Jones Bridge Road, Bethesda, Maryland 20814, USA.
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114
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Endimiani A, Luzzaro F, Perilli M, Lombardi G, Colì A, Tamborini A, Amicosante G, Toniolo A. Bacteremia Due toKlebsiella pneumoniaeIsolates Producing the TEM‐52 Extended‐Spectrum β‐Lactamase: Treatment Outcome of Patients Receiving Imipenem or Ciprofloxacin. Clin Infect Dis 2004; 38:243-51. [PMID: 14699457 DOI: 10.1086/380645] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2003] [Accepted: 09/09/2003] [Indexed: 11/03/2022] Open
Abstract
The treatment outcome of 35 cases of bacteremia due to Klebsiella pneumoniae isolates producing TEM-52 extended-spectrum beta-lactamase was studied. Twenty-eight cases, classified as "nonfatal disease" using the McCabe and Jackson classification, were investigated with regard to ciprofloxacin and imipenem response. Because ciprofloxacin was active in vitro against 21 of 28 isolates, only the treatment outcome of the ciprofloxacin-susceptible subgroup was evaluated. Eight of 10 cases occurred in patients who experienced a complete response to imipenem; 2 of 10 failed to respond. In contrast, only 2 of 7 cases had a partial response to ciprofloxacin, and, in 5 of 7 cases, the treatment failed. Statistical analysis revealed a significant difference in the treatment outcome of the 2 groups (P=.03). Because the isolates had minimum inhibitory concentrations of ciprofloxacin close to the susceptibility breakpoint, treatment failure could be ascribed to the inability of the drug to reach therapeutic concentrations at infected sites.
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Affiliation(s)
- Andrea Endimiani
- Laboratorio di Microbiologia, Ospedale di Circolo and Università dell'Insubria, Varese, Italy
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115
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Affiliation(s)
- Christopher M Parry
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
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116
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Abstract
Some bacterial pathogens can establish life-long chronic infections in their hosts. Persistence is normally established after an acute infection period involving activation of both the innate and acquired immune systems. Bacteria have evolved specific pathogenic mechanisms and harbor sets of genes that contribute to the establishment of a persistent lifestyle that leads to chronic infection. Persistent bacterial infection may involve occupation of a particular tissue type or organ or modification of the intracellular environment within eukaryotic cells. Bacteria appear to adapt their immediate environment to favor survival and may hijack essential immunoregulatory mechanisms designed to minimize immune pathology or the inappropriate activation of immune effectors.
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Affiliation(s)
- Douglas Young
- Centre for Molecular Microbiology and Infection, Imperial College of Science, Technology and Medicine, London SW7 2AZ, UK.
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117
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Mehta G, Arya SC. Capsular Vi polysaccharide antigen in Salmonella enterica serovar typhi isolates. J Clin Microbiol 2002; 40:1127-8. [PMID: 11880463 PMCID: PMC120298 DOI: 10.1128/jcm.40.2.1127-1128.2002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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118
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Wain J, House D, Parkhill J, Parry C, Dougan G. Unlocking the genome of the human typhoid bacillus. THE LANCET. INFECTIOUS DISEASES 2002; 2:163-70. [PMID: 11944186 DOI: 10.1016/s1473-3099(02)00225-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Molecular studies are shedding new light on the pathogenesis of human typhoid fever, which is still a very common disease in developing countries. For example, the total genome DNA sequence has recently been determined for a multiple-drug-resistant Salmonella typhi, the serotype that is the cause of typhoid fever. The genome sequence showed many distinguishing features, including clusters of S typhi specific genes and a large number--over 200--of pseudogenes. This information, together with other molecular studies, has provided vital clues in several important areas of typhoid biology. We have new insights into the mechanisms underpinning the human host specificity of S typhi, and have exploitable new routes to improved diagnostics and a better understanding of the epidemiology of the disease.
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Affiliation(s)
- John Wain
- Centre for Molecular Microbiology and Infection, Department of Biological Sciences, Imperial College of Science, Technology, and Medicine, London SW7 2AZ, UK
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119
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Abstract
Typhoid fever is an infectious disease of global distribution. Although there is a wealth of data on Salmonella typhimurium infection in the mouse and the interaction of this serovar with human cell lines in vitro, there is a relatively small amount of data on S. typhi and the pathogenesis of typhoid fever. In this review we focus on three areas: adherence to and invasion of gut epithelial cells, dissemination to systemic sites, and survival and replication within host cells. In addition, we attempt to put current salmonella research into the context of typhoid fever.
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Affiliation(s)
- D House
- Centre for Molecular Microbiology and Infection, Imperial College of Science Technology and Medicine, London, UK
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