An Engineered Pseudo-Macrophage for Rapid Treatment of Bacteria-Infected Osteomyelitis via Microwave-Excited Anti-Infection and Immunoregulation

Preventing deep bacterial infection and simultaneously enhancing osteogenic differentiation are in great demand for osteomyelitis. Microwave (MW) dynamic therapy is attracting attention due to its excellent penetration ability, but the mechanism of MW-induced reactive oxygen species (ROS) is still unknown. Herein, MW-responsive engineered pseudo-macrophages (M-Fe₃ O₄ /Au nanoparticles (NPs)) are fabricated to clear Staphylococcus aureus infections and induce M2 polarization of macrophages to improve osteogenic differentiation of bone marrow mesenchymal stem cells (MSCs) under MW irradiation. Fe₃ O₄ /Au NPs can generate ·O₂ ^- and heat under MW irradiation in a saline solution, and the mechanism is put forward via finite element modeling and density functional theory calculations. Due to the gap plasmon, electromagnetic hotspots are produced at Fe₃ O₄ -Au interface at 2.45 GHz. Because of these induced electromagnetic hotspots, the sodium species is field-ionized and subsequently reacts with oxygen to produce ·O₂ ^- . Meanwhile, the Fe₃ O₄ /Au NPs have a stronger ability than Fe₃ O₄ NPs to fix oxygen, favoring the production of ROS. Additionally, MW-treated macrophages diminish to secrete inflammatory cytokines, resulting in the decrease of ROS production in MSCs and thus enhancing their osteogenic differentiation. These engineered pseudo-macrophages will be promising for effectively treating bacterial infections and promoting osteoblast differentiation simultaneously in deep tissues under MW irradiation.

Ureaplasma septic polyarthritis in a young woman with neuromyelitis optica receiving rituximab

We report a case of septic polyarthritis caused by Ureaplasma urealyticum in a woman with neuromyelitis optica who was receiving rituximab. Her case exemplifies some of the unique characteristics of invasive Ureaplasma infections that can lead to delayed diagnosis as well as treatment challenges including recurrence following antibiotic discontinuation.

An electroporation strategy to synthesize the membrane-coated nanoparticles for enhanced anti-inflammation therapy in bone infection

The cell membrane-coated nanoparticles (MNPs) showed great potential in treating infectious disease due to their superior biofunctions in improving biocompatibility of nanoparticles and neutralization of pathogen or toxins. However, bone infection is accompanied with severe inflammation and bone loss, which also requires anti-inflammatory and osteoconductive treatment. The conventional membrane coating method has to undergo ultrasonication and extrusion procedures, which reduces the functionality of cell membrane and limits the choice of nanoparticles. In this study, we proposed an electroporation-based membrane coating strategy to facilitate the synthesis of MNPs to tackle those problems. Methods: Magnetic composite nanoparticles with osteoconductive Ca3(PO4)2 and bactericidal TiO2 were assembled into macrophages through phagocytosis and then collected to expose in electric field for obtaining macrophage membrane-coating nanoparticles. By using molecular dynamics simulation and materials characterizations, the cell membrane coating efficiency was confirmed. The in vitro anti-bacterial and anti-inflammatory abilities were tested by bacteria culturing and immune cells activation. Then drug-resistant bacteria induced bone infection model was established to verify its in vivo therapeutic effects. Results: The coated membrane prepared through electroporation reserved the integrality of membrane structure and right-sidedness, with more functional proteins. Those led to the superior properties of recognition and adsorption with bacteria, toxins and inflammatory cytokines. Owing to the benefits of electroporation, the MNPs exhibited significant better antibacterial and anti-inflammatory abilities for enhancing the tissue repair process. Conclusion: This study provides a novel self-assembly cell membrane coating strategy by electroporation to construct multifunctional membrane-coating nanoparticles for bone infection treatment. This strategy not only improves the functions of coated membrane, but is also proved to be universal for varies nanoparticles or cells, indicating a great potential for future applications in the bioengineering field.

Dysregulated NADPH Oxidase Promotes Bone Damage in Murine Model of Autoinflammatory Osteomyelitis

Autoinflammatory diseases are characterized by dysregulation of the innate immune system, leading to spontaneous inflammation. Pstpip2cmo mouse strain is a well-characterized model of this class of disorders. Because of the mutation leading to the lack of adaptor protein PSTPIP2, these animals suffer from autoinflammatory chronic multifocal osteomyelitis similar to several human syndromes. Current evidence suggests that it is driven by hyperproduction of IL-1β by neutrophil granulocytes. In this study, we show that in addition to IL-1β, PSTPIP2 also negatively regulates pathways governing reactive oxygen species generation by neutrophil NOX2 NADPH oxidase. Pstpip2cmo neutrophils display highly elevated superoxide production in response to a range of stimuli. Inactivation of NOX2 NADPH oxidase in Pstpip2cmo mice did not affect IL-1β levels, and the autoinflammatory process was initiated with similar kinetics. However, the bone destruction was almost completely alleviated, suggesting that dysregulated NADPH oxidase activity is a key factor promoting autoinflammatory bone damage in Pstpip2cmo mice.

Mechanisms of Immune Evasion and Bone Tissue Colonization That Make Staphylococcus aureus the Primary Pathogen in Osteomyelitis

PURPOSE OF REVIEW

Staphylococcus aureus is the primary pathogen responsible for osteomyelitis, which remains a major healthcare burden. To understand its dominance, here we review the unique pathogenic mechanisms utilized by S. aureus that enable it to cause incurable osteomyelitis.

RECENT FINDINGS

Using an arsenal of toxins and virulence proteins, S. aureus kills and usurps immune cells during infection, to produce non-neutralizing pathogenic antibodies that thwart adaptive immunity. S. aureus also has specific mechanisms for distinct biofilm formation on implants, necrotic bone tissue, bone marrow, and within the osteocyte lacuno-canicular networks (OLCN) of live bone. In vitro studies have also demonstrated potential for intracellular colonization of osteocytes, osteoblasts, and osteoclasts. S. aureus has evolved a multitude of virulence mechanisms to achieve life-long infection of the bone, most notably colonization of OLCN. Targeting S. aureus proteins involved in these pathways could provide new targets for antibiotics and immunotherapies.

MyD88 and IL-1R signaling drive antibacterial immunity and osteoclast-driven bone loss during Staphylococcus aureus osteomyelitis

Staphylococcus aureus is able to infect virtually all organ systems and is a frequently isolated etiologic agent of osteomyelitis, a common and debilitating invasive infection of bone. Treatment of osteomyelitis requires invasive surgical procedures and prolonged antibiotic therapy, yet is frequently unsuccessful due to extensive pathogen-induced bone damage that can limit antibiotic penetration and immune cell influx to the infectious focus. We previously established that S. aureus triggers profound alterations in bone remodeling in a murine model of osteomyelitis, in part through the production of osteolytic toxins. However, staphylococcal strains lacking osteolytic toxins still incite significant bone destruction, suggesting that host immune responses are also major drivers of pathologic bone remodeling during osteomyelitis. The objective of this study was to identify host immune pathways that contribute to antibacterial immunity during S. aureus osteomyelitis, and to define how these immune responses alter bone homeostasis and contribute to bone destruction. We specifically focused on the interleukin-1 receptor (IL-1R) and downstream adapter protein MyD88 given the prominent role of this signaling pathway in both antibacterial immunity and osteo-immunologic crosstalk. We discovered that while IL-1R signaling is necessary for local control of bacterial replication during osteomyelitis, it also contributes to bone loss during infection. Mechanistically, we demonstrate that S. aureus enhances osteoclastogenesis of myeloid precursors in vitro, and increases the abundance of osteoclasts residing on bone surfaces in vivo. This enhanced osteoclast abundance translates to trabecular bone loss, and is dependent on intact IL-1R signaling. Collectively, these data define IL-1R signaling as a critical component of the host response to S. aureus osteomyelitis, but also demonstrate that IL-1R-dependent immune responses trigger collateral bone damage through activation of osteoclast-mediated bone resorption.

Implant-Associated Posttraumatic Osteomyelitis: Collateral Damage by Local Host Defense?

Infections following osteosynthesis or total joint replacement, also known as “implant-associated posttraumatic osteomyelitis”, represent a major complication in orthopedic and trauma surgery. While the formation of bacterial biofilms on the implanted osteosynthesis materials is generally accepted as cause of the persistent infection, the molecular mechanisms leading to the progressive and destructive local inflammatory process and eventually to bone degradation, the osteolysis, have not been delineated. Here we provide evidence supporting the hypothesis that it is not the infection per se that causes tissue degradation and osteolysis, but rather the cytotoxic, proteolytic, and proinflammatory effector functions of cells of the host defense, particularly of the infiltrating polymorphonuclear neutrophils.

Chronic Recurrent Multifocal Osteomyelitis (CRMO): Presentation, Pathogenesis, and Treatment

PURPOSE OF REVIEW

Chronic non-bacterial osteomyelitis (CNO) with its most severe form chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disorder. We summarize the clinical presentation, diagnostic approaches, most recent advances in understanding the pathophysiology, and available treatment options and outcomes in CNO/CRMO.

RECENT FINDINGS

Though the exact molecular pathophysiology of CNO/CRMO remains somewhat elusive, it appears likely that variable defects in the TLR4/MAPK/inflammasome signaling cascade result in an imbalance between pro- and anti-inflammatory cytokine expressions in monocytes from CNO/CRMO patients. In this context, we present previously unpublished data on cytokine and chemokine expression in monocytes and tissues. CNO/CRMO is an autoinflammatory bone disorder resulting from imbalanced cytokine expression from innate immune cells. Though the exact molecular pathophysiology remains unclear, variable molecular defects appear to result in inflammasome activation and pro-inflammatory cytokine expression in monocytes from CNO/CRMO patients. Recent advances suggest signaling pathways and single molecules as biomarkers for CNO/CRMO as well as future treatment targets.

Dermatologic Manifestations of Monogenic Autoinflammatory Diseases

Autoinflammatory disorders are sterile inflammatory conditions characterized by episodes of early-onset fever, rash, and disease-specific patterns of organ inflammation. Gain-of-function mutations in innate danger-sensing pathways, including the inflammasomes and the nucleic acid sensing pathways, play critical roles in the pathogenesis of IL-1 and Type-I IFN-mediated disorders and point to an important role of excessive proinflammatory cytokine signaling, including interleukin (IL)-1b , Type-I interferons, IL-18, TNF and others in causing the organ specific immune dysregulation. The article discusses the concept of targeting proinflammatory cytokines and their signaling pathways with cytokine blocking treatments that have been life changing for some patients.

Primary fusobacterium osteomyelitis and pyomyositis of the thigh in an immunocompetent young adult

An unusual case of an immunocompetent young adult with osteomyelitis and pyomyositis of his right thigh is presented. Despite the absence of typical clinical signs, a high index of suspicion and 16S RNA PCR led to an early diagnosis of Fusobacterium infection and subsequent successful multidisciplinary treatment.

Monitoring immune responses in a mouse model of fracture fixation with and without Staphylococcus aureus osteomyelitis

Post-traumatic bone fractures are commonly fixed with implanted devices to restore the anatomical position of bone fragments and aid in the healing process. Bacterial infection in this situation is a challenge for clinicians due to the need for aggressive antibiotic therapy, debridement of infected tissues, and the need to maintain fracture stability. The aim of this study was to monitor immune responses that occur during healing and during Staphylococcus aureus infection, in a clinically relevant murine model of fracture fixation. Skeletally mature C57bl/6 mice received a transverse osteotomy of the femur, which was treated with commercially available titanium fracture fixation plates and screws. In the absence of infection, healing of the fracture was complete within 35days and was characterized by elevated Interleukin (IL)-4 and Interferon-gamma secretion from bone-derived cells and expression of these same genes. In contrast, mice inoculated with S. aureus could not heal the fracture within the observation period and were found to develop typical signs of implant-associated bone infection, including biofilm formation on the implant and osteolysis of surrounding bone. The immune response to infection was characterized by a TH17-led bone response, and a pro-inflammatory cytokine-led Tumor necrosis factor (TNF)-α, Interleukin (IL)-1β) soft tissue response, both of which were ineffectual in clearing implant related bone and soft tissue infections respectively. In this murine model, we characterize the kinetics of pro-inflammatory responses to infection, secondary to bone trauma and surgery. A divergent local immune polarization is evident in the infected versus non-infected animals, with the immune response ultimately unable to clear the S. aureus infection.

[Chronic nonbacterial osteomyelitis]

Chronic nonbacterial osteomyelitis is an autoinflammatory disease occurring mainly in children and adolescents, typically involving recurrent or persistent osteitic foci. The symptom is bone pain, possibly accompanied by soft tissue tenderness. Some patients exhibit symptoms of systemic inflammation. The. precise etiology of the disease is not known, but an imbalance of inflammatory and anti-inflammatory cytokines is presumed to play a role in the development of the disease. While an anti-inflammatory analgesic is in most cases sufficient to calm down the osteitis, the use of corticosteroids, anti- TNF-a inhibitors or bisphosphonates is required in some cases.

[INFLUENCE OF SAUSSUREA CONTROVERSA AND FILLIPENDULA ULMARIA EXTRACTS ON IMMUNOLOGICAL REACTIVITY OF RATS WITH EXPERIMENTAL OSTEOMYELITIS.]

The influence of Saussurea controversa DC and Fillipendula ulmaria (L.) Maxim extracts on the immunological reactivity of rats with experimental osteomyelitis has been studied. The application of these extracts on the background of antibiotic therapy normalized the immunological reactivity indices: (i) reduced the levels of total immunoglobulins, IgM and IgG and (ii) increased the percentage of active neutrophils and their absorption capacity, as well as the percentage of completion of phagocytosis. The treatment with plant extracts reduced the acute inflammatory reaction and increased the total number of megakaryocites as compared to those upon antibiotic therapy.

Disseminated Mycobacterium avium complex infection in a child with partial dominant interferon gamma receptor 1 deficiency in India

Mendelian susceptibility to mycobacterial disease (MSMD) is a rare condition characterized by clinical disease caused by weakly virulent mycobacteria. All genes mutated in MSMD patients are involved in IFN-γ immunity. Autosomal partial dominant (PD) interferon-γ receptor 1 (IFN-γR1) deficiency is the most frequent abnormality affecting the group of MSMD patients leading to impaired response of IFN-γ. We describe here a patient from India with disseminated infection due to Mycobacterium avium intracellulare (MAC) including multifocal osteomyelitis and BCG disease. A heterozygous mutation in exon 6 of IFNGR1 gene was identified, conferring an autosomal PD IFN-γR1 deficiency. Patient had recurrence of mycobacterial disease during antibiotic therapy for which subcutaneous IFN-γ was added as a modality of treatment for resistant MAC infection.

Th17 cytokine deficiency in patients with Aspergillus skull base osteomyelitis

BACKGROUND

Fungal skull base osteomyelitis (SBO) is a severe complication of otitis externa or sinonasal infection, and is mainly caused by Aspergillus species. Here we investigate innate and adaptive immune responses in patients with Aspergillus SBO to identify defects in the immune response that could explain the susceptibility to this devastating disease.

METHODS

Peripheral blood mononuclear cells isolated from six patients with Aspergillus SBO and healthy volunteers were stimulated with various microbial stimuli, among which also the fungal pathogens Candida albicans and Aspergillus fumigatus. The proinflammatory cytokines IL-6, TNFα and IL-1β, and the T-helper cell-derived cytokines IFNγ, IL-17 and IL-22 were measured in cell culture supernatants by ELISA.

RESULTS

Proinflammatory cytokine responses did not differ between SBO patients and healthy volunteers. The Candida- and Aspergillus-specific Th17 response (production of IL-17 and IL-22) was significantly decreased in the SBO patients compared to healthy individuals, while Th1 cytokine response (IFNγ production) did not differ between the two groups.

CONCLUSIONS

We show that patients with Aspergillus skull base osteomyelitis infection have specific defects in Th17 responses. Since IL-17 and IL-22 are important for stimulating antifungal host defense, we hypothesize that strategies that have the ability to improve IL-17 and IL-22 production may be useful as adjuvant immunotherapy in patients with Aspergillus SBO.

Assessing diabetic foot osteomyelitis remission with white blood cell SPECT/CT imaging

AIMS

Diabetic foot osteomyelitis is an important risk factor of lower limb amputation. Antibiotic therapy is often effective in preventing surgery. However, the duration of antibiotic therapy is difficult to define in the absence of a marker to diagnose osteomyelitis remission at the end of the treatment. In this study, we assessed the diagnostic performance of white blood cell SPECT/CT imaging for evaluating osteomyelitis remission.

PATIENTS AND METHODS

Twenty-nine out of 42 episodes of diabetic foot osteomyelitis seen between December 2009 and April 2012 had radiographs, a three-phase bone scintigraphy and a white blood cell SPECT/CT at the end of antibiotic therapy. They were treated with antibiotics alone and considered in clinical remission. White blood cell SPECT/CT results were considered positive when abnormal uptake in the osteomyelitis location was identified. Osteomyelitis remission was defined by the absence of an osteomyelitis relapse after 12 months' follow-up.

RESULTS

A negative white blood cell SPECT/CT was seen for 22 episodes of osteomyelitis. All of them were in remission. A positive white blood cell SPECT/CT was observed for seven episodes. A relapse occurred in five episodes (71.5%) after a median duration of 4 months (2-7 months). Sensitivity, specificity, positive predictive value and predictive negative value in predicting osteomyelitis relapse after the discontinuation of antibiotic treatment were, respectively, for radiographs 80%, 33%, 20% and 89%; for three-phase bone scintigraphy 100%, 12.5%, 15.5% and 100%; and for the white blood cell SPECT/CT 100%, 91.5%, 71.5% and 100%.

CONCLUSION

Negative uptake on white blood cell SPECT/CT is a good marker for diagnosis of diabetic foot osteomyelitis remission and might be very useful in guiding antibiotic therapy.

Gene expression analysis of children with acute hematogenous osteomyelitis caused by Methicillin-resistant Staphylococcus aureus: correlation with clinical severity of illness

Children with acute hematogenous osteomyelitis (AHO) demonstrate a broad spectrum of clinical manifestations, ranging from mild to severe. Several advances have been achieved in the study of host immune response to acute invasive Staphylococcus aureus infections through gene expression analysis. However, previous research has neither attempted to evaluate the response of children with AHO specific to Methicillin-resistant Staphylococcus aureus (MRSA) nor to correlate gene expression with clinical phenotype. Study objective was to correlate gene expression of children with AHO due to MRSA with clinical severity of illness. Whole blood samples were obtained in Tempus tubes from 12 children with osteomyelitis once cultures obtained directly from the site of infection confirmed to be positive for MRSA. Using an Illumina platform and a systems-wide modular analysis, microarray findings from ten of these children were compared to that of nine healthy (age, ethnicity and gender) matched controls and correlated with clinical severity of illness. Children with AHO from MRSA demonstrated over-expression of innate immunity with respect to neutrophil activity, coagulation, inflammatory response, and erythrocyte development. Concurrently, these children demonstrated under-expression of adaptive immunity with respect to lymphocyte activation and activity of T-cell, cytotoxic or NK cell, and B-cell lines. Three over-expressed genes, P2RX1, SORT1, and RETN, and two under-expressed genes, LOC641788 and STAT 4, were significantly correlated with severity of illness. STAT 4 showed the strongest correlation (R2 = –0.83). STAT4 downregulation could potentially explain under-expression of genes related to adaptive immunity in this cohort of patients with AHO. This study identified specific genes which correspond to disease severity during the early hospitalization of children with AHO from MRSA. Pattern recognition of this combination of genes could help to identify in the future severe clinical phenotypes before the disease is fully manifest and direct appropriate attention and resources to those children.

Exome sequencing reveals RAG1 mutations in a child with autoimmunity and sterile chronic multifocal osteomyelitis evolving into disseminated granulomatous disease

We describe a boy who developed autoinflammatory (chronic sterile multifocal osteomyelitis) and autoimmune (autoimmune cytopenias; vitiligo) phenotypes who subsequently developed disseminated granulomatous disease. Whole exome sequencing revealed homozygous RAG1 mutations thus expanding the spectrum of combined immunodeficiency with autoimmunity and granuloma that can occur with RAG deficiency.

[The factorial analysis in evaluation of cell immunity of patients with pyo-inflammatory diseases of long bones and large joints]

The factorial analysis was applied to calculate the values of main components determining condition of cell immunity in patients with pyo-inflammatory diseases of long bones and large joints. It is demonstrated that in conditions of chronic purulent infection the main are the factors related with regulative T-lymphocytes involved in suppression of T-cell immunity. In case of development of fistula form of osteomyelitis the main role is attached to mechanisms related to markers of activation of T-lymphocytes and to derangement of expression of HLA-DR on monocytes in case of infection of prosthesis.

Autoinflammatory bone disorders

Autoinflammatory bone disorders are characterized by chronic non-infectious osteomyelitis and inflammation-induced bone resorption and result from aberrant activation of the innate immune system. Sporadic chronic non-bacterial osteomyelitis (CNO) is the most common disease subtype. The clinical picture is highly variable and the exact underlying pathophysiology remains to be determined. Recently, novel insights in the pathophysiology of sterile bone inflammation have been gathered by analyzing patients with rare, monogenic inflammatory diseases. In this overview CNO and Majeed syndrome, cherubism, hypophosphatasia and primary hypertrophic osteoarthropathy will be discussed. For the latter four disorders, a genetic cause affecting bone metabolism and leading to chronic bone inflammation has been described. The exact pathophysiology of CNO remains to be determined. Insights from monogenic autoinflammatory bone diseases and the identification of distinct inflammatory pathways may help to understand the pathogenesis of bone inflammation and inflammation-induced bone resorption in more common diseases.

Microbiological and immunological diagnosis of tuberculous spondylodiscitis

BACKGROUND

Tuberculous spondylodiscitis is one the many manifestations of active tuberculosis (TB) and can result following primary infection or, more frequently, from reactivation of active TB in subjects with latent TB. Definitive diagnosis of tuberculous spondylodiscitis requires the identification of Mycobacterium tuberculosis in the biological sample following microbiological analysis.

AIM

To summarize the recent advancement in the diagnosis of TB, focusing on classical and molecular microbiological procedures, providing an overview on the recent advancements in the understanding of TB pathogenesis and their implications for the immunological diagnosis

MATERIALS AND METHODS

Isolation in culture of the bacilli and detection using molecular tools are the gold standards, though sensitivity of these assays is significantly lower compared to what observed for pulmonary TB, making diagnosis of spinal TB challenging.

RESULTS

The use of the interferon-gamma release assays (IGRAs) for the immunological diagnosis of TB infection could be of help and shall precede the invasive techniques, such as biopsy or surgery, required to obtain the biological sample. IGRAs measure the presence of effector T cells in the blood that can readily respond to an antigenic stimuli by secreting cytokines, and that are an indication of the presence of the bacilli in vivo. IGRAs are more sensitive and specific than the intradermic reaction of Mantoux, though both these immunological tests cannot distinguish between latent TB infection and active TB.

CONCLUSIONS

A modern diagnosis of TB spondylodiscitis should rely on the use of microbiological and immunological assays and the latter could potentially be of great help in monitoring therapy effectiveness.

Osteomyelitis following Bacille Calmette-Guerin vaccination

Secondary complications after Bacille Calmette-Guerin (BCG) vaccination are unusual. We describe 3 immunocompetent children who developed osteomyelitis after BCG vaccination. The course of the disease is not dramatic, but marked changes are frequently visible in plain radiograph and MRI. The real-time polymerase chain reaction has an essential role to confirm the diagnosis of BCG osteomyelitis. With proper surgical intervention and chemotherapy, the prognosis is usually good.

Attachment of Staphylococcus aureus is required for activation of nuclear factor kappa B in human osteoblasts

Nuclear factor kappa B (NF-κB) plays a prominent role in the pathogenesis of infectious diseases. Staphylococcus aureus (S. aureus), which can attach to and invade human osteoblasts, is the most common causative agent of osteomyelitis. To determine whether S. aureus can activate NF-κB in human osteoblasts and explore the possible factors of activation in response to infection, we used flow cytometry, enzyme-linked immunosorbent assay, immunoblots, and electrophoretic mobility shift assays to quantify the invasion of bacteria, to measure the interleukin-6 (IL-6) of culture supernatants, and to investigate the IκBα degradation and NF-κB activation in human osteoblasts. Moreover, we explored the possible factors responsible for the activation of NF-κB by preventing S. aureus from physically touching human osteoblasts or inhibiting the invasion of S. aureus into human osteoblasts under co-culture conditions, by incubating proteinase K-treated or ultraviolet-killed S. aureus with human osteoblasts and by treating human osteoblasts with peptidoglycan (PGN) or lipoteichoic acid (LTA). We found that S. aureus induced the IκBα degradation and NF-κB activation, which could regulate IL-6 secretion in the culture supernatants of human osteoblasts in response to infection. In addition, the maximal IκBα degradation and NF-κB activation in human osteoblasts occurred prior to the maximal invasion of S. aureus. It was the attachment not invasion or the secreted soluble factor(s), PGN, LTA of S. aureus, that could induce the IκBα degradation and NF-κB activation in human osteoblasts. These results indicated that S. aureus can activate NF-κB in human osteoblasts and that the attachment of S. aureus is required for this activation in response to infection.

[Various aspects of the pathogenesis of hematogenic osteomyelitis in children]

Characteristic features of the pathogenesis of hematogenous osteomyelitis in children against the background of complex treatment are described. The data characterizing the development of an osteomyelitic focus are presented. Some of the causes of the prolonged course of the disease and its transition into the chronic stage, as well as the aspects of immunobiological protection of the organism in the course of treatment have been studied.

[Interleukin 2 (Ronkoleukin) and its effect on immune state in children with acute hematogenous osteomyelitis]

The object of the present research was to study the effect of recombinant interleukin-2 (Ronkoleikin) on immune system in children with acute hematogenous osteomyelitis of long cortical bones. The investigation was conducted on 13-15 year old 30 patients with acute hematogenous osteomyelitis of long cortical bones. It was found that Ronkoleukin in sick children with acute hematogenous osteomyelitis of long cortical bones leads to improvement in humoral immune system. The pro- and anti inflammatory cytokine content is normalized.

[Mechanisms of disturbance in regenerative processes in chronic traumatic osteomyelitis]

Analysis of long-term observation and treatment of patients with long bone fractions complicated by chronic traumatic osteomyelitis and relevant literature data made it possible to elucidate general and local mechanisms of disturbance of regenerative processes. Key pathogenetic factors in chronic traumatic osteomyelitis proved to be stress reaction, impaired functional thyroid activity, suppressed immune responsiveness, disturbed bone metabolism, dysbalance of micro- and macroelements, secondary disturbances of peripheral blood flow in the affected limb segment (chronic venous insufficiency), formation of Staphylococcus-dominated microflora in wound discharge, enhanced pathological bone resorption followed by regional osteoporotic changes. It is concluded that the development of pathogenetically-sound treatment modalities based on the above findings will help to avoid undesirable outcomes of chronic traumatic osteomyelitis.

[Assessment of the level of immunoglobulin E in patients with pyo-inflammatory diseases and its influence on the course of the infectious process]

The level of immunoglobulin E (IgE) in patients with different pyo-inflammatory diseases was assessed and it was found to elevate in patients with acute appendicitis in 49% of cases, in patients with chronic relapsing furunculosis (CRF) in 41%, with chronic osteomyelitis--in 66.6%. In 8 out of 16 examined patients with the elevated level of IgE there were antibodies to toxocars in titers 1:800, 1:400. No correlation with the IgE level was found in assessing the level of IL-4 and gamma-IFN in blood serum of patients with CRF. In patients with acute appendicitis, CRF and chronic osteomyelitis the elevated level of IgE can be considered as a marker of unfavorable course of pyo-inflammatory diseases. The elevated level of IgE does not influence the oxygen-dependent mechanisms of bactericidal action of neutrophils.

Quantitative mouse model of implant-associated osteomyelitis and the kinetics of microbial growth, osteolysis, and humoral immunity

Although osteomyelitis (OM) remains a serious problem in orthopedics, progress has been limited by the absence of an in vivo model that can quantify the bacterial load, metabolic activity of the bacteria over time, immunity, and osteolysis. To overcome these obstacles, we developed a murine model of implant-associated OM in which a stainless steel pin is coated with Staphylococcus aureus and implanted transcortically through the tibial metaphysis. X-ray and micro-CT demonstrated concomitant osteolysis and reactive bone formation, which was evident by day 7. Histology confirmed all the hallmarks of implant-associated OM, namely: osteolysis, sequestrum formation, and involucrum of Gram-positive bacteria inside a biofilm within necrotic bone. Serology revealed that mice mount a protective humoral response that commences with an IgM response after 1 week, and converts to a specific IgG2b response against specific S. aureus proteins by day 11 postinfection. Real-time quantitative PCR (RTQ-PCR) for the S. aureus specific nuc gene determined that the peak bacterial load occurs 11 days postinfection. This coincidence of decreasing bacterial load with the generation of specific antibodies is suggestive of protective humoral immunity. Longitudinal in vivo bioluminescent imaging (BLI) of luxA-E transformed S. aureus (Xen29) combined with nuc RTQ-PCR demonstrated the exponential growth phase of the bacteria immediately following infection that peaks on day 4, and is followed by the biofilm growth phase at a significantly lower metabolic rate (p < 0.05). Collectively, these studies demonstrate the first quantitative model of implant-associated OM that defines the kinetics of microbial growth, osteolysis, and humoral immunity following infection.

Therapeutic strategies against inflammation and bone loss associated with osteomyelitis

Despite current treatment strategies, osteomyelitis is often refractory and recurrent. The bacteria responsible for osteomyelitis can invade bone-forming osteoblasts, which are active participants in the generation of damaging inflammation and bone loss at sites of infection. Therefore, strategies promoting cell-mediated immune responses while limiting inflammation are required for the treatment of chronic bone infections. This review describes the mechanisms utilized by resident bone cells to perceive bacteria, recruit leukocytes to sites of infection and promote osteoclast-mediated bone destruction, as well as novel targets for the therapeutic intervention of these processes.

Clinical and laboratory features of Nigerian patients with osteomyelitis

INTRODUCTION

The aim of this study was to investigate the clinicopathological characteristics of Nigerian patients with osteomyelitis.

METHODS

30 patients with osteomyelitis and 30 apparently-healthy age- and sex-matched controls were investigated. The packed cell volume (PCV), white blood cells (WBC) and differentials, and platelet counts were measured using an automated counter, while the erythrocyte sedimentation rate (ESR) was determined by Westergren's technique. C3 activator, C1 esterase inhibitor (C1-INH), IgA, IgG and IgM were estimated by the single radial immunodiffusion method. Wound swabs, blood cultures and biopsies were taken and sent for microscopic, culture and sensitivity analysis.

RESULTS

Patients with osteomyelitis had elevated total leucocytes, neutrophils, and platelet counts compared to the controls. There was also significant anaemia (t equals 3.17, p-value equals 0.002) and a significantly elevated ESR (t equals 3.75, p-value equals 0.000). Serum levels of C3 activator were significantly higher in patients with osteomyelitis (t equals 6.29, p-value equals 0.000). Although serum levels of C1-INH, IgG and IgM were higher in osteomyelitis, they were not significantly so. Serum levels of IgA were reduced in patients with osteomyelitis. Significant correlations between PCV and ESR (r equals -0.486, p-value equals 0.006), ESR and total WBC count (r equals +0.542, p-value equals 0.002), ESR and platelet count (r equals 0.445, p-value equals 0.013) and total WBC count and IgG (r equals 0.507, p-value equals 0.019) were noted .

CONCLUSION

Nigerian patients with osteomyelitis have similar clinical and laboratory features already described in literature, with some noted immune dysfunctions.

Autoinflammatory bone disorders

PURPOSE OF REVIEW

This review provides an update on clinical, genetic, and immunologic aspects of the autoinflammatory bone disorders.

RECENT FINDINGS

Chronic noninfectious inflammation of the bone is a clinical feature of both chronic recurrent multifocal osteomyelitis and (to a lesser degree) cherubism. The genes responsible for Majeed syndrome (LPIN2), murine chronic multifocal osteomyelitis (pstpip2), and cherubism (SH3BP2 and possibly PTPN11) have been identified. Murine models of both chronic recurrent multifocal osteomyelitis and cherubism have demonstrated that the bone inflammation is mediated by hematopoietically derived cells and can occur in the absence of a functioning adaptive immune system. As the immunologic defects become better defined, the cells of the myeloid lineage are emerging as the primary players.

SUMMARY

Chronic multifocal osteomyelitis and cherubism are hereditary chronic inflammatory disorders in which bone is the primary inflammatory target. Recent genetic and immunologic discoveries demonstrate involvement of the innate immune system, which places these entities in the category of autoinflammatory disorders.

Refractory osteomyelitis caused by bacille Calmette-Guérin vaccination: a case report

A male infant, 1 and a half years old, was affected with bacille Calmette-Guérin osteomyelitis of the left tibia. The gyrB DNA direct sequencing, followed by restriction fragment length polymorphism of genomic DNA from a biopsy sample of the lesion, made diagnosis rapid.

Bax gene G(-248)A promoter polymorphism is associated with increased lifespan of the neutrophils of patients with osteomyelitis

BACKGROUND

Patients with osteomyelitis have a decreased rate of spontaneous apoptosis of their peripheral blood neutrophils. The G(-248)A polymorphism in the promoter region of the bax gene is associated with prolonged peripheral blood neutrophil survival in leukemic patients and may play some role in osteomyelitis.

METHODS

Bax G(-248)A promoter polymorphism was detected by DNA amplification using polymerase chain reaction, followed by restriction fragment length polymorphism analysis. Spontaneous apoptosis of peripheral blood neutrophils was measured by propidium iodide, annexin V, and flow cytometry, and Bax was quantified by Western blotting.

RESULTS

The bax promoter polymorphism A allele was significantly more frequent in 80 patients with osteomyelitis than in 220 healthy donors (18.1% vs. 10.6%, chi=4.84, odds ratio=1.81, 95% confidence interval=1.06-3.07, P=.028). Carriers of the A allele had a lower apoptotic rate of their peripheral blood neutrophils compared with noncarriers (33.3+/-16.7 vs. 43.1+/-3.1, P=.036). Patients with the AA genotype showed a lower expression of the Bax protein compared with carriers of other genotypes (P=.038).

CONCLUSIONS

Substitution of a nucleotide G-->A at position -248 in the bax gene was more frequent in patients with osteomyelitis and was associated with a longer lifespan of their peripheral blood neutrophils and lower Bax protein expression. These findings may play a role in the pathogenesis of osteomyelitis.

[Implant-associated post-traumatic osteomyelitis. Bacterial biofilms and the immune defence as protagonists of the local inflammatory process]

BACKGROUND

Formation of bacterial biofilms on implants is a severe complication following orthopaedic surgery. In the present study we addressed the role of the immune response, particularly with regard to the pathogenesis of the disease.

METHODS

In a prospective study comprising 74 patients with implant-associated post-traumatic osteomyelitis, peripheral blood cells as well as cells recovered from the infected site during surgery were characterised phenotypically and functionally.

RESULTS

We found massive infiltration of polymorphonuclear neutrophils (PMN), which were highly activated, particularly regarding their bactericidal potential, such as increased production of superoxides and upregulation of activation-associated surface receptors.

CONCLUSION

PMN are activated in response to the implant-associated osteomyelitis; they also infiltrate the infected tissue, but cannot control the infection. By release of their cytotoxic entities they could contribute to tissue destruction and eventually to osteolysis.

The anti-nuclease humoral immune response of broiler chickens exposed to Staphylococcus aureus, infectious bursal disease virus and chicken anaemia virus in an experimental model for bacterial chondronecrosis and osteomyelitis

This study aimed to develop an enzyme-linked immunosorbent assay to detect antibody associated with Staphylococcus aureus that is produced during the chicken immune response to this organism. The protein nuclease was tested for suitability as an antigen to detect antibody in sera from broiler chickens that had been exposed to aerosolized S. aureus on day 1 post hatch during experiments to reproduce bacterial chondronecrosis and osteomyelitis. An enzyme-linked immunosorbent assay was developed to measure the levels of nuclease antibody in 509 chicken sera from various experiments, which also enabled the examination of the influence of factors such as the S. aureus infection status and co-infection with chicken anaemia virus (CAV) and infectious bursal disease virus (IBDV) on nuclease antibody levels. Positive levels of nuclease antibody were detected in 71% of serum samples from chickens inoculated with S. aureus, CAV and IBDV, while positive levels were detected in 35% of chickens inoculated with S. aureus only. The influence of CAV and IBDV on the number of chickens with positive levels was most prominent in chickens aged up to 42 days. The study showed that nuclease-specific antibodies form part of the humoral immune response in broiler chickens that have been exposed to S. aureus. Co-infection with CAV and IBDV appeared to promote development of antibody in birds younger than 42 days; however, the presence of antibody did not necessarily prevent systemic infection.

Novel mutation in the interferon-gamma-receptor gene and susceptibility to mycobacterial infections

In 1981 we presented a patient with Mycobacterium intracellulare osteomyelitis and depressed monocyte cytotoxicity. It is now demonstrated that the molecular defect was a never-before-described nucleotide deletion at position 794 (794delT) in the interferon-gamma-receptor alpha-1 gene. The genetic defect was passed on to his daughter who was diagnosed with non-tuberculous mycobacterial osteomyelitis at the age of 7 years.

Identification of Staphylococcus aureus proteins recognized by the antibody-mediated immune response to a biofilm infection

Staphylococcus aureus causes persistent, recurrent infections (e.g., osteomyelitis) by forming biofilms. To survey the antibody-mediated immune response and identify those proteins that are immunogenic in an S. aureus biofilm infection, the tibias of rabbits were infected with methicillin-resistant S. aureus to produce chronic osteomyelitis. Sera were collected prior to infection and at 14, 28, and 42 days postinfection. The sera were used to perform Western blot assays on total protein from biofilm grown in vitro and separated by two-dimensional gel electrophoresis. Those proteins recognized by host antibodies in the harvested sera were identified via matrix-assisted laser desorption ionization-time of flight analysis. Using protein from mechanically disrupted total and fractionated biofilm protein samples, we identified 26 and 22 immunogens, respectively. These included a cell surface-associated beta-lactamase, lipoprotein, lipase, autolysin, and an ABC transporter lipoprotein. Studies were also performed using microarray analyses and confirmed the biofilm-specific up-regulation of most of these genes. Therefore, although the biofilm antigens are recognized by the immune system, the biofilm infection can persist. However, these proteins, when delivered as vaccines, may be important in directing the immune system toward an early and effective antibody-mediated response to prevent chronic S. aureus infections. Previous works have identified S. aureus proteins that are immunogenic during acute infections, such as sepsis. However, this is the first work to identify these immunogens during chronic S. aureus biofilm infections and to simultaneously show the global relationship between the antigens expressed during an in vivo infection and the corresponding in vitro transcriptomic and proteomic gene expression levels.

The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning

AIMS

Foot infections and their sequelae are among the most common and severe complications of diabetes mellitus. As diabetic patients with foot infections develop osteomyelitis and may progress to amputation, early diagnosis of osteomyelitis is critical.

METHODS

We compared the diagnostic values of labelled leucocyte scanning with Tc(99)m, magnetic resonance imaging (MRI) and microbiological examination of bone tissue specimens with histopathology, the definitive diagnostic procedure. Thirty-one diabetic patients with foot lesions were enrolled in the study and histopathological examination was performed in all. Patients had clinically suspected foot lesions of > or = grade 3 according to the classification of Wagner.

RESULTS

Bone specimens were obtained for histopathological examination. Microbiology had a sensitivity of 92% and specificity of 60%. Labelled leucocyte scanning had a sensitivity of 91%, specificity of 67%, and MRI a sensitivity of 78%, specificity of 60%.

CONCLUSIONS

Microbiological examination may be as useful as and less costly than other diagnostic procedures and is the only method which can guide the choice of antibiotic therapy.

T lymphocytes in implant-associated posttraumatic osteomyelitis: Identification of cytotoxic T effector cells at the site of infection

In implant-associated posttraumatic osteomyelitis, a massive infiltration of leukocytes into the infected site is seen. As described previously, the most infiltrated cells were highly activated polymorphonuclear neutrophils. In addition, a considerable T-cell infiltrate was noted. Whereas our previous work was mainly concerned with the phenotypical and functional characterization of the polymorphonuclear neutrophils, we now analyzed T lymphocytes of 32 patients with implant-associated posttraumatic osteomyelitis. We found evidence for an expansion of CD8 T cells in the peripheral blood of the patients and for an infiltration of these cells into the infected site. Further analysis of the surface-receptor pattern by three-color cytofluorometry revealed that the majority of these cells belonged to the cytotoxic-effector phenotype. Of note is that cytotoxic T cells are generally associated with virus infection. Thus, the detection of those cells in patients with bacterial infection was rather unexpected and points to a novel, not yet appreciated, role of CD8 T cells also in the defense of bacterial infections.

Experimental model of chronic osteomyelitis caused by Leishmania (L) amazonensis

Experimental animal models have been used for the study of the physiopathogenesis of leishmaniasis, on some occasions with success, while in other situations such as bone alterations that accompany tegumentary leishmaniasis, especially in diffuse cutaneous form (DCL), the mechanisms are still unknown. In the present study, we determined these alterations in an animal model susceptible to Leishmania (L) amazonensis. Amastigotes of L. (L) amazonensis isolated from patients with diffuse cutaneous leishmaniasis (DCL) were inoculated into the hind paws of eight BALB/c mice, macroscopic and histopathological aspects were analyzed. After 90 and 120 days of evolution, histopathological analysis demonstrated a mononuclear cell infiltrate rich in plasma cells and intense parasitism of intra- and extra-medullary macrophages, with areas of bone necrosis and discrete involvement of cartilaginous tissue. The results show that the inflammatory process developed during L. (L) amazonensis infection might cause bone tissue destruction and secondarily affect the joints.

The Toll-like receptor 4 (Asp299Gly) polymorphism is a risk factor for Gram-negative and haematogenous osteomyelitis

Osteomyelitis is a bone infection caused mostly by Staphylococcus aureus but also by Gram-negative bacteria. Toll-like receptors (TLRs), after recognizing microbial products, induce a signal in neutrophils, leading to NF-kappaB activation and transcription of pro-inflammatory genes. Polymorphisms in TLR2 (Arg753Gln) and TLR4 (Asp299Gly, Thr399Ile) genes are associated with bacterial infections, we therefore studied these polymorphisms in osteomyelitis patients. Homozygotes for the TLR4 (Asp299Gly) polymorphism were significantly more frequent among the 80 osteomyelitis patients than in the 155 healthy controls (3/80, 3.8%versus 0/155, 0%; P = 0.038). Carriers of one or two G alleles of this tlr4 polymorphism were more likely to have Gram-negative, haematogenous and/or chronic osteomyelitis than those without this mutation (P < 0.031). Patients with the TLR4 (Thr399Ile) mutant, which cosegregates with the TLR4 (Asp299Gly), were also carriers of this second polymorphism. No differences for the TLR2 (Arg753Gln) genotypes were found between patients and controls. Neutrophils of patients homozygous for the TLR4 (Asp299Gly) polymorphism showed lower LPS-induced apoptosis reduction, phosphorylation of the inhibitor of NF-kappaB, and lower IL-6 and TNF-alpha levels (P < 0.05). We report here for the first time an association between this TLR4 polymorphism and susceptibility to Gram-negative bacteria and haematogenous osteomyelitis.

[Clinical, x-ray, and laboratory features of tuberculosis and osteomyelitis of the spine]

In 20% of cases, tuberculous spondylitis running with a prevalence of the exudative-necrotic type of a local tissue reaction has an acute onset with febrile fever, severe pains, and progressive neurological disorders and clinically resembles acute hematogenous osteomyelitis of the spine. With a predominance of the productive type of a tissue reaction, tuberculous spondylitis resembles subacute hematogenous osteomyelitis of the spine. History data, laboratory parameters, and an X-ray follow-up are of great importance in its differential diagnosis.

[Decision on the immunomodulating therapy in unspecific osteomyelitis of the spine]

Immunomodulating therapy was used in treatment of 54 patients with unspecific osteomyelitis of the spine (UOS). The age of the patients was from 15 through 76 years. The authors consider that immunocorrection should be included in the complex of obligatory measures of treatment of patients with purulent infections of the spine and is dependent on the type of immunological impairments. For its success it is necessary to determine the type and degree of immunity impairment. Since in most cases of UOS there is a disorder in the T-cell link of immunity, it is preferable to use cytomedins (T-activin, thymalin, thymogen etc) or cytokines (e.g. roncoleukin). In cases of an insufficient B-cell link the medicines of choice are licopid and myelopid.

Osteoblast responses to bacterial pathogens: a previously unappreciated role for bone-forming cells in host defense and disease progression

Although the primary roles of osteoblasts are to synthesize the components of bone matrix and to regulate the activity of bone resorbing osteoclasts, there is growing realization that osteoblasts have an additional function during bone diseases, such as osteomyelitis. Based on our recent studies, we propose a novel role for osteoblasts during bacterial infections of bone, namely, the initiation and maintenance of inflammatory immune responses. In this article, we describe how these nonleukocytic cells can perceive bacterial pathogens of bone to initiate the production of an array of immune regulatory molecules. This pattern of expression is one that could promote the recruitment of leukocytes to sites of bacterial challenge, initiate antigen-specific activation of infiltrating cells, and facilitate the development of cell-mediated host responses to intracellular pathogens of bone tissue, thereby identifying this cell type as a previously unappreciated component in host responses.