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Wang J, An H, Ding M, Liu Y, Wang S, Jin Q, Wu Q, Dong H, Guo Q, Tian X, Liu J, Zhang J, Zhu T, Li J, Shao Z, Briles DE, Veening JW, Zheng H, Zhang L, Zhang JR. Liver macrophages and sinusoidal endothelial cells execute vaccine-elicited capture of invasive bacteria. Sci Transl Med 2023; 15:eade0054. [PMID: 38117903 DOI: 10.1126/scitranslmed.ade0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/29/2023] [Indexed: 12/22/2023]
Abstract
Vaccination has substantially reduced the morbidity and mortality of bacterial diseases, but mechanisms of vaccine-elicited pathogen clearance remain largely undefined. We report that vaccine-elicited immunity against invasive bacteria mainly operates in the liver. In contrast to the current paradigm that migrating phagocytes execute vaccine-elicited immunity against blood-borne pathogens, we found that invasive bacteria are captured and killed in the liver of vaccinated host via various immune mechanisms that depend on the protective potency of the vaccine. Vaccines with relatively lower degrees of protection only activated liver-resident macrophage Kupffer cells (KCs) by inducing pathogen-binding immunoglobulin M (IgM) or low amounts of IgG. IgG-coated pathogens were directly captured by KCs via multiple IgG receptors FcγRs, whereas IgM-opsonized bacteria were indirectly bound to KCs via complement receptors of immunoglobulin superfamily (CRIg) and complement receptor 3 (CR3) after complement C3 activation at the bacterial surface. Conversely, the more potent vaccines engaged both KCs and liver sinusoidal endothelial cells by inducing higher titers of functional IgG antibodies. Endothelial cells (ECs) captured densely IgG-opsonized pathogens by the low-affinity IgG receptor FcγRIIB in a "zipper-like" manner and achieved bacterial killing predominantly in the extracellular milieu via an undefined mechanism. KC- and endothelial cell-based capture of antibody-opsonized bacteria also occurred in FcγR-humanized mice. These vaccine protection mechanisms in the liver not only provide a comprehensive explanation for vaccine-/antibody-boosted immunity against invasive bacteria but also may serve as in vivo functional readouts of vaccine efficacy.
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Affiliation(s)
- Juanjuan Wang
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing 100084, China
| | - Haoran An
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing 100084, China
| | - Ming Ding
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Yanhong Liu
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Shaomeng Wang
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Qian Jin
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Qi Wu
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Haodi Dong
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing 100084, China
| | - Qile Guo
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Xianbin Tian
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | | | | | - Tao Zhu
- Cansino Biologics, Tianjin 300301, China
| | | | - Zhujun Shao
- National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102299, China
| | - David E Briles
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Jan-Willem Veening
- Department of Fundamental Microbiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne 1015, Switzerland
| | | | - Linqi Zhang
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
| | - Jing-Ren Zhang
- Center for Infectious Disease Research, Department of Basic Medical Science, School of Medicine, Tsinghua University, Beijing 100084, China
- Tsinghua-Peking Center for Life Sciences, Tsinghua University, Beijing 100084, China
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2
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Haggenburg S, Garcia Garrido HM, Kant IMJ, Van der Straaten HM, De Boer F, Kersting S, Issa D, Te Raa D, Visser HPJ, Kater AP, Goorhuis A, De Heer K. Immunogenicity of the 13-Valent Pneumococcal Conjugated Vaccine Followed by the 23-Valent Polysaccharide Vaccine in Chronic Lymphocytic Leukemia. Vaccines (Basel) 2023; 11:1201. [PMID: 37515017 PMCID: PMC10385862 DOI: 10.3390/vaccines11071201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with Chronic Lymphocytic Leukemia (CLL) have a 29- to 36-fold increased risk of invasive pneumococcal disease (IPD) compared to healthy adults. Therefore, most guidelines recommend vaccination with the 13-valent pneumococcal conjugated vaccine (PCV13) followed 2 months later by the 23-valent polysaccharide vaccine (PPSV23). Because both CLL as well as immunosuppressive treatment have been identified as major determinants of immunogenicity, we aimed to assess the vaccination schedule in untreated and treated CLL patients. We quantified pneumococcal IgG concentrations against five serotypes shared across both vaccines, and against four serotypes unique to PPSV23, before and eight weeks after vaccination. In this retrospective cohort study, we included 143 CLL patients, either treated (n = 38) or naive to treatment (n = 105). While antibody concentrations increased significantly after vaccination, the overall serologic response was low (10.5%), defined as a ≥4-fold antibody increase against ≥70% of the measured serotypes, and significantly influenced by treatment status and prior lymphocyte number. The serologic protection rate, defined as an antibody concentration of ≥1.3 µg/mL for ≥70% of serotypes, was 13% in untreated and 3% in treated CLL patients. Future research should focus on vaccine regimens with a higher immunogenic potential, such as multi-dose schedules with higher-valent T cell dependent conjugated vaccines.
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Affiliation(s)
- Sabine Haggenburg
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Hannah M Garcia Garrido
- Department of Infectious Diseases, Center for Tropical Medicine and Travel Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Iris M J Kant
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Fransien De Boer
- Department of Internal Medicine, Ikazia Ziekenhuis, 3083 AN Rotterdam, The Netherlands
| | - Sabina Kersting
- Department of Hematology, HagaZiekenhuis, 2545 AA The Hague, The Netherlands
| | - Djamila Issa
- Department of Internal Medicine, Jeroen Bosch Ziekenhuis, 5223 GZ 's-Hertogenbosch, The Netherlands
| | - Doreen Te Raa
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, 6716 RP Ede, The Netherlands
| | - Hein P J Visser
- Department of Internal Medicine, Noordwest Ziekenhuisgroep, 1815 JD Alkmaar, The Netherlands
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Abraham Goorhuis
- Department of Infectious Diseases, Center for Tropical Medicine and Travel Medicine, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Koen De Heer
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Internal Medicine, Flevoziekenhuis, 1315 RA Almere, The Netherlands
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3
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Garcia Garrido HM, Haggenburg S, Schoordijk MCE, Meijer E, Tanck MWT, Hazenberg MD, Rutten CE, Bree GJ, Nur E, Meek B, Grobusch MP, Goorhuis A. Immunogenicity of a 5-dose pneumococcal vaccination schedule following allogeneic hematopoietic stem cell transplantation. Am J Hematol 2022; 97:592-602. [PMID: 35147238 PMCID: PMC9303771 DOI: 10.1002/ajh.26493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/13/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022]
Abstract
The optimal schedule of pneumococcal vaccination after allogeneic hematopoietic stem cell transplantation (allo‐HSCT) remains controversial. The objective of this study was to investigate the immunogenicity of a 5‐dose pneumococcal vaccination schedule in adult allo‐HSCT recipients with and without immunosuppressive therapy. In this prospective cohort study, allo‐HSCT recipients received four doses of the 13‐valent pneumococcal conjugate vaccine (PCV13) and one dose of the 23‐valent pneumococcal polysaccharide vaccine (PPSV23) starting 4–6 months after allo‐HSCT. PCV13 was administered at T0, T1, T2, and T8 (T = months from enrollment) and PPSV23 at T10. Serum was collected at T0, T4, T8, T10, and T12, and IgG levels were measured for all 24 vaccine serotypes by immunoassay. The primary outcome was overall seroprotection at T12 defined as an IgG concentration ≥1.3 μg/ml for 17/24 vaccine serotypes in allo‐HCST recipients with and without immunosuppressive therapy at baseline. Secondary outcomes were serotype‐specific seroprotection and dynamics of IgG levels. We included 89 allo‐HSCT recipients in the final analysis. Overall seroprotection was 47% (15/32) for patients without immunosuppressive therapy at baseline versus 24% (11/46) for patients with immunosuppressive therapy (p = .03). Seroprotection was higher for PCV13 serotypes (78% and 54% respectively; p = .03) and lower for PPSV23‐unique serotypes (28% and 13% respectively; p = .1). IgG concentrations increased significantly over time for all 24 serotypes. Concluding, although immunogenicity of PCV13 serotypes was reasonable, the poor response to PPSV23 serotypes resulted in an insufficient overall response to pneumococcal vaccination for allo‐HSCT recipients. Research into vaccination strategies with higher‐valent T‐cell‐dependent pneumococcal vaccines is needed.
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Affiliation(s)
- Hannah M. Garcia Garrido
- Amsterdam UMC, Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases University of Amsterdam, Amsterdam institute for Infection and Immunity Amsterdam The Netherlands
| | - Sabine Haggenburg
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
| | - Marieke C. E. Schoordijk
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
| | - Ellen Meijer
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
| | - Michael W. T. Tanck
- Amsterdam UMC, Department of Epidemiology and Data Science University of Amsterdam Amsterdam The Netherlands
| | - Mette D. Hazenberg
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
- Department of Hematopoiesis Sanquin Research Amsterdam The Netherlands
| | - Caroline E. Rutten
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
| | - Godelieve J. Bree
- Amsterdam UMC, Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases University of Amsterdam, Amsterdam institute for Infection and Immunity Amsterdam The Netherlands
| | - Erfan Nur
- Amsterdam UMC, Department of Hematology, Amsterdam Institute for Infection and Immunity Cancer Center Amsterdam Amsterdam The Netherlands
- Department of Hematopoiesis Sanquin Research Amsterdam The Netherlands
| | - Bob Meek
- Department of Medical Microbiology and Immunology St. Antonius Hospital Nieuwegein the Netherlands
| | - Martin P. Grobusch
- Amsterdam UMC, Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases University of Amsterdam, Amsterdam institute for Infection and Immunity Amsterdam The Netherlands
| | - Abraham Goorhuis
- Amsterdam UMC, Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases University of Amsterdam, Amsterdam institute for Infection and Immunity Amsterdam The Netherlands
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4
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van Aalst M, Garcia Garrido HM, van der Leun J, Meek B, van Leeuwen EMM, Löwenberg M, D'Haens GR, Ponsioen CYI, Grobusch MP, Goorhuis A. Immunogenicity of the Currently Recommended Pneumococcal Vaccination Schedule in Patients With Inflammatory Bowel Disease. Clin Infect Dis 2021; 70:595-604. [PMID: 30899961 DOI: 10.1093/cid/ciz226] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/23/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patients with inflammatory bowel disease (IBD) are at increased risk of invasive pneumococcal infections. Therefore, vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) 2 months later is recommended. However, the level of immunogenicity induced by this vaccination schedule in IBD patients with and without immunosuppressive medication remains unclear. METHODS We prospectively assessed the immunogenicity of PCV13 followed by PPSV23 in IBD patients by measuring serotype-specific pneumococcal immunoglobulin G antibody concentrations at baseline and 4-8 weeks postvaccination. Response to vaccination was defined as a postvaccination antibody concentration ≥1.3 μg/mL for 70% of the measured serotypes. We analyzed the immunogenic effect of 4 different medication regimens: (1) conventional immunomodulators (ie, oral prednisolone >10 mg/day, thiopurines, methotrexate); (2) anti-tumor necrosis factor agents; (3) combination therapy; and (4) no treatment with immunosuppressive agents (control group). RESULTS One hundred forty-one IBD patients were included, of whom 37 were controls. Adequate response to vaccination was 59% (61/104) in patients using immunosuppressive agents (groups 1-3) vs 81% (30/37) in controls (odds ratio, 0.33 [95% confidence interval, .13-.82]). A combination of different immunosuppressive drugs most severely impaired the immune response to pneumococcal vaccination (response, 52% [15/29]). CONCLUSIONS Although the sequential vaccination schedule of PCV13 followed by PPSV23 is safe, immunogenic, and thus beneficial in the majority of IBD patients, those receiving immunosuppressive agents, and especially those receiving combination therapy, have an impaired immune response compared to controls. Therefore, preferably, vaccinations should be administered before the initiation of immunosuppressive therapy. CLINICAL TRIALS REGISTRATION Dutch trial register #6315.
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Affiliation(s)
- Mariëlle van Aalst
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centres, Nieuwegein
| | - Hannah M Garcia Garrido
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centres, Nieuwegein
| | - Josephine van der Leun
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centres, Nieuwegein
| | - Bob Meek
- Department of Medical Microbiology and Immunology, St Antonius Hospital, Nieuwegein
| | - Ester M M van Leeuwen
- Department of Experimental Immunology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Mark Löwenberg
- Department of Gastroenterology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Geert R D'Haens
- Department of Gastroenterology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Cyriel Y I Ponsioen
- Department of Gastroenterology, Amsterdam University Medical Centres, University of Amsterdam, The Netherlands
| | - Martin P Grobusch
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centres, Nieuwegein.,Institute of Tropical Medicine, University of Tübingen, Germany
| | - Abraham Goorhuis
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centres, Nieuwegein
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5
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Langedijk AC, van Aalst M, Meek B, van Leeuwen EMM, Zeerleder S, Meijer E, Hazenberg MD, Grobusch MP, Goorhuis A. Long-term pneumococcal vaccine immunogenicity following allogeneic hematopoietic stem cell transplantation. Vaccine 2018; 37:510-515. [PMID: 30502071 DOI: 10.1016/j.vaccine.2018.11.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/24/2022]
Abstract
Infection with Streptococcus pneumoniae is a life-threatening, but vaccine preventable complication in patients with allogeneic hematopoietic stem cell transplantation (allo-HSCT). The international consensus on post allo-HSCT immunization schedules, starting 3-6 months after HSCT, focuses on short-term immunogenicity while long-term immunogenicity is not well characterized. The current Dutch immunization schedule, which starts at 12 months post allo-HSCT, was developed as a result of concerns on the coverage of long-term immunogenicity in international guidelines. We recently encountered two cases of allo-HSCT recipients who developed invasive pneumococcal disease (IPD) despite adequate revaccinations, which led us to question the immunogenicity of pneumococcal vaccinations in this patient group, and whether the currently existing vaccination schedules are appropriate. We included allo-HSCT recipients, vaccinated from one year after transplantation, and tested antibody responses to pneumococcal vaccination. We also performed a systematic review. Antibody concentrations were measured in 42 of 103 (41%) patients, with a response rate of 85% to PCV13 and 62% to PPSV23-unique serotypes. In six relevant studies, protection rates varied between 64 and 98%. Antibody responses in early and late vaccination schedules were similar, but adequate antibody responses were maintained better after late vaccination. Therefore, we propose a vaccination schedule that combines the advantages of early and late vaccination. This new schedule has been introduced since March 2018 in the two academic hospitals in Amsterdam, The Netherlands.
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Affiliation(s)
- Annefleur C Langedijk
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Mariëlle van Aalst
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Bob Meek
- Department of Medical Microbiology and Immunology, St. Antonius Hospital, 3435CM Nieuwegein, the Netherlands
| | - Ester M M van Leeuwen
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Sacha Zeerleder
- Department of Hematology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Ellen Meijer
- Department of Hematology, VU University Medical Center, 1081HV Amsterdam, the Netherlands
| | - Mette D Hazenberg
- Department of Hematology, Academic Medical Center, University of Amsterdam, 1100AZ Amsterdam, the Netherlands
| | - Martin P Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands
| | - Abraham Goorhuis
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Academic Medical Center, University of Amsterdam, 1105AZ Amsterdam, the Netherlands.
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6
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van Kessel D, Hoffman T, van Velzen-Blad H, Meek B, van Mens S, Grutters J, Rijkers G. Case report on a defective antibody response against pneumococcal serotype 9V in a patient with a single episode of pneumonia. Pneumonia (Nathan) 2017; 9:16. [PMID: 29119074 PMCID: PMC5671648 DOI: 10.1186/s41479-017-0040-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/13/2017] [Indexed: 12/25/2022] Open
Abstract
Background Patients with recurrent respiratory tract infections and an impaired response to pneumococcal polysaccharide vaccination are diagnosed with a specific antibody deficiency. In adult patients with pneumococcal pneumonia an impaired antibody response to the infecting pneumococcal serotype can sometimes be found. It is unknown whether these patients are unable to produce an adequate anti-polysaccharide antibody response to pneumococcal vaccination after recovery. Case presentation The authors describe a case of invasive pneumonia caused by Streptococcus pneumoniae serotype 9V in a previously healthy 35-year-old female. This patient did not produce serotype-specific antibodies against the infecting serotype during disease. After pneumococcal polysaccharide vaccination 3 months after recovery, she responded adequately to most other pneumococcal serotypes, but still had no response to the infecting serotype 9V. However, after 9 years (and prior to pneumococcal-conjugate vaccination) normal antibody levels against 9V were found. These antibody levels further increased after pneumococcal-conjugate vaccination. Conclusion The authors believe that this case is the first description of a temporary deficient response to the infecting pneumococcal serotype in adults, while other reports with similar observations all involved children.
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Affiliation(s)
- Diana van Kessel
- Department of Pulmonology and Respiratory Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Thijs Hoffman
- Department of Pulmonology and Respiratory Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Heleen van Velzen-Blad
- Laboratory of Medical Microbiology and Immunology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Bob Meek
- Laboratory of Medical Microbiology and Immunology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Suzan van Mens
- Laboratory of Medical Microbiology and Immunology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Jan Grutters
- Department of Pulmonology and Respiratory Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.,Division of Heart and Lungs, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Ger Rijkers
- Laboratory of Medical Microbiology and Immunology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.,Department of Science, University College Roosevelt, Lange Noordstraat 1, 4330 AB Middelburg, The Netherlands.,Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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