ARFI-based tissue elasticity quantification and kidney graft dysfunction: first clinical experiences

BACKGROUND AND PURPOSE

Beyond the medical history, the clinical exam and lab findings, non-invasive ultrasound parameters such as kidney size and Doppler values (e.g. the resistive index) are important tools assisting clinical decision making in the monitoring of renal allografts. The gold standard for the diagnosis of renal allograft dysfunction remains the renal biopsy; while an invasive procedure, the justifiable necessity for this derives from its definitive nature a requirement beyond the synopses of all non-invasive tools. "Acoustic Radiation Force Impulse Imaging"(ARFI)-quantification is a novel ultrasound-based technology measuring tissue elasticity properties. So far experience related to this new method has not been reported in renal transplant follow-up. The purpose of this study was to evaluate changes in ARFI-measurements between clinically stable renal allografts and biopsy-proven transplant dysfunction.

METHODS

We employed "Virtual Touch™ tissue quantification" (Siemens Acuson, S2000) for the quantitative measurement of tissue stiffness in the cortex of transplant kidneys. We performed initial baseline and later disease-evaluative ultrasound examinations in 8 renal transplant patients in a prospective study design. Patients were first examined during stable allograft function with a routine post-transplant renal ultrasound protocol. A second follow-up examination was carried out on subsequent presentation with transplant dysfunction prior to allograft biopsy and histological evaluation. All patiens were examined using ARFI-quantification (15 measurements/kidney). Resistive indices (RI) were calculated using pulsed-wave Doppler ultrasound, and transplant kidney size was measured on B-mode ultrasound images. All biopsies were evaluated histologically by a reference nephropathologist unaware of the results of the ultrasound studies. Histopathological diagnoses were based on biopsy results, taking clinical and laboratory findings into account. Finally we calculated the relative changes in ARFI-quantification, resistive indices and the absolute change of kidney size on a percentage basis at these defined assessment times and compared the results with the final pathologic diagnosis.

RESULTS

Histological results enumerated five cases of acute T-cell-mediated rejection, one case of calcineurin inhibitor toxicity and two cases of acute tubular necrosis. Calcineurin inhibitor toxicity and acute tubular necrosis were subsumed as "other pathologies". Mean ARFI-values showed an average increase of more than 15% percent in transplants with histologically proven acute rejection whereas no increase was seen in transplants with other pathologies. Mean RI-values showed no increase either in the diagnostic group of acute rejection, nor in the group with other pathologies. Kidney size showed a mean absolute increase of 0.5 centimetres in allografts with acute rejection, whereas a mean decrease of 0.17 centimetres was seen in the group with other pathologies.

CONCLUSION

As shown before in other studies, RI values and kidney size are of doubtful utility in the evaluation of kidney allograft dysfunction. ARFI-based elasticity measurement shows promise as a complementary non-invasive parameter in follow-on diagnosis of renal allograft rejection.

ARFI-based tissue elasticity quantification in comparison to histology for the diagnosis of renal transplant fibrosis

BACKGROUND AND PURPOSE

Until recently clinical diagnosis of chronic renal allograft dysfunction could only be established invasively by renal biopsy. Given the risks of that procedure, a non-invasive, diagnostic test would be very advantageous. Novel ultrasound-based elasticity tools, using "Acoustic Radiation Force Impulse (ARFI)" technology are now available. Previously this technique has been utilised to quantify liver fibrosis. First results of these studies are promising. The purpose of our study was to investigate correlation between stiffness values obtained by ARFI-quantification and histological fibrosis score in renal transplants.

METHODS

We employed "Virtual Touch™ tissue quantification" (Siemens Acuson, S2000) to quantitatively measure tissue stiffness in the cortex of transplant kidneys. Eighteen patients were included in this prospective study, recording close temporal ARFI-quantification and fibrosis measurements. All patients undergoing renal transplant biopsy were examined with ARFI-quantification (15 measurements per transplant kidney). Resistive indices were also calculated from pulsed-wave Doppler ultrasound. Transplant biopsies were histologically evaluated by a reference nephropathologist and graded according to the percentage of fibrosis and to the BANFF-score. Due to the non-normal distribution of the data the Spearman-correlation-coefficient (rho) was used to assess the bivariate relationship of ARFI and fibrosis in the transplant kidney.

RESULTS

There was a significant positive moderate correlation between mean ARFI-values and the grade of fibrosis (rho = +0.465; p = 0.026). This correlation was also valid for the mean ARFI-values and the BANFF-category (rho = +0.468; p = 0.025). There was no significant correlation between the mean ARFI-values and the resistive indices in the transplant kidney (rho = +0.034; p = 0.904). Nevertheless, a positive correlation between the mean RI-values of the kidney and the grade of fibrosis was established (rho = +0.563; p = 0.015).

CONCLUSION

The mean values of ARFI measurements and the resistive indices are potentially independent explanation variables for evaluating the grade of fibrosis in transplant kidneys.

Development and application of a green fluorescent protein sentinel system for identification of RNA interference in Blastomyces dermatitidis illuminates the role of septin in morphogenesis and sporulation

A high-throughput strategy for testing gene function would accelerate progress in our understanding of disease pathogenesis for the dimorphic fungus Blastomyces dermatitidis, whose genome is being completed. We developed a green fluorescent protein (GFP) sentinel system of gene silencing to rapidly study genes of unknown function. Using Gateway technology to efficiently generate RNA interference plasmids, we cloned a target gene, "X," next to GFP to create one hairpin to knock down the expression of both genes so that diminished GFP reports target gene expression. To test this approach in B. dermatitidis, we first used LACZ and the virulence gene BAD1 as targets. The level of GFP reliably reported interference of their expression, leading to rapid detection of gene-silenced transformants. We next investigated a previously unstudied gene encoding septin and explored its possible role in morphogenesis and sporulation. A CDC11 septin homolog in B. dermatitidis localized to the neck of budding yeast cells. CDC11-silenced transformants identified with the sentinel system grew slowly as flat or rough colonies on agar. Microscopically, they formed ballooned, distorted yeast cells that failed to bud, and they sporulated poorly as mold. Hence, this GFP sentinel system enables rapid detection of gene silencing and has revealed a pronounced role for septin in morphogenesis, budding, and sporulation of B. dermatitidis.

Blastomycosis in solid organ transplant recipients

BACKGROUND

Blastomyces dermatitidis, the etiologic agent of blastomycosis, causes severe disease and substantial mortality in those immunocompromised by acquired immunodeficiency syndrome or malignancy. In solid organ transplant recipients, the epidemiology, clinical features, and outcomes have not been fully described.

METHODS

We conducted a retrospective case-series at the University of Wisconsin Hospital and Clinics. Case patients were solid organ transplant recipients with blastomycosis.

RESULTS

From 1986 to 2004, we identified 11 cases of post-transplant blastomycosis with 64% occurring between 2000 and 2004. Onset of infection occurred a median of 26 months post transplantation with near equal distribution before and after the first year of transplantation. Rejection did not precede any case of post-transplant blastomycosis. Opportunistic co-infections were common, occurring in 36% of patients. Pneumonia was the most common clinical presentation and was frequently complicated by acute respiratory distress syndrome (ARDS). Extrapulmonary disease predominantly involved the skin and spared the central nervous system. The overall mortality rate was 36%; however, this increased to 67% in those with ARDS. None of the surviving patients relapsed or received routine secondary antifungal prophylaxis.

CONCLUSION

Blastomycosis is an uncommon infection following solid organ transplantation that is frequently complicated by ARDS, dissemination, and opportunistic co-infection. After cure, post-transplant blastomycosis may not require lifelong antifungal suppression.

Role of glucan and surface protein BAD1 in complement activation by Blastomyces dermatitidis yeast

Our previous studies showed that Blastomyces dermatitidis yeast activates the human complement system, leading to deposition of opsonic complement fragments onto the yeast surface. This report examines the influence of altered surface expression of glucan or BAD1 protein (formerly WI-1) on the yeast's ability to activate and bind C3. Compared to the wild type, a glucan-deficient mutant yeast delayed initiation of C3 deposition and reduced C3-binding capacity by 50%. Linkage of baker's-yeast beta-glucan to the glucan-deficient yeast restored initial C3 deposition kinetics to the wild-type level and partially restored C3-binding capacity, suggesting that beta-glucan is an initiator of complement activation and a C3 acceptor. The role of BAD1 in B. dermatitidis yeast-complement interaction was also assessed. BAD1 knockout yeast initiated faster C3 deposition and increased C3-binding capacity compared to the wild-type yeast or a BAD1-reconstituted yeast, suggesting either a lack of an intrinsic ability in BAD1 or an inhibitory role of BAD1 in complement activation and binding. However, both complement activation and the capacity for C3 binding by the wild-type yeast were enhanced in normal human serum supplemented with an anti-BAD1 monoclonal antibody (MAb) or in immune sera from blastomycosis patients. Microscopic analysis revealed that more initial C3-binding sites were formed on yeast in the presence of both naturally occurring complement initiators and exogenous anti-BAD1 MAb, suggesting that anti-BAD1 antibody enhanced the ability of B. dermatitidis yeast to interact with the host complement system. Thus, glucan and BAD1 have distinctly different regulatory effects on complement activation by B. dermatitidis.

The WI-1 adhesin blocks phagocyte TNF-alpha production, imparting pathogenicity on Blastomyces dermatitidis

The WI-1 adhesin is indispensable for pathogenicity of Blastomyces dermatitidis and is thought to promote pulmonary infection by fixing yeast to lung tissue and cells. Recent findings suggest that WI-1 confers pathogenicity by mechanisms in addition to adherence. Here, we investigated whether WI-1 modulates host immunity by altering production of pro-inflammatory cytokines. Production of TNF-alpha in lung alveolar fluids of mice infected with B. dermatitidis was severalfold higher for WI-1 knockout yeast compared with wild-type yeast, and in vitro coculture of unseparated lung cells with these isogenic yeast disclosed similar differences. Upon coculture with purified macrophages and neutrophils, wild-type yeast blocked TNF-alpha production, yet WI-1 knockout yeast stimulated production. Coating knockout yeast with purified WI-1 converted them from stimulating TNF-alpha production to inhibiting production. Addition of purified WI-1 into stimulated phagocyte cultures led to concentration-dependent inhibition of TNF-alpha production. Neutralization of TNF-alpha in vivo exacerbated experimental pulmonary infection, particularly for the nonpathogenic WI-1 knockout yeast. Inducing increased TNF-alpha levels in the lung by adenovirus-vectored gene therapy controlled infection with wild-type yeast. Thus, the WI-1 adhesin on yeast modulates host immunity through blocking TNF-alpha production by phagocytes, which fosters progression of pulmonary infection.

Selective expression of the virulence factor BAD1 upon morphogenesis to the pathogenic yeast form of Blastomyces dermatitidis: evidence for transcriptional regulation by a conserved mechanism

Most dimorphic fungal pathogens grow as non-pathogenic moulds in soil and convert to pathogenic yeast in the host, suggesting that virulence factors are upregulated during phase transition. Such factors have been difficult to identify. We analysed BAD1 (formerly WI-1), a virulence factor in the dimorphic fungus Blastomyces dermatitidis, for expression in yeast and mycelial morphotypes. BAD1 was expressed in yeast but not in mycelia of North American strains of B. dermatitidis, and this expression pattern was confirmed for BAD1 transcript. BAD1 under the control of its promoter was transferred into African B. dermatitidis lacking a native BAD1 locus, and phase-specific expression was conserved. Sequence similarity was identified between the BAD1 promoter and the promoters of two yeast phase-specific genes in Histoplasma capsulatum. In H. capsulatum BAD1 transformants, yeast phase-specific expression of BAD1 was conserved, and no transcript was detected in mycelia. BAD1 beta-galactosidase reporter fusions analysed in B. dermatitidis and H. capsulatum confirmed that BAD1 is transcriptionally regulated in both fungi. BAD1 promoter activity and surface BAD1 expression were detected 6 h after shifting mycelia to 37 degrees C. Thus, BAD1 is expressed after transition to the pathogenic yeast morphotype and is regulated by a mechanism for phase-specific gene expression that appears to be conserved.

Mutation of the WI-1 gene yields an attenuated blastomyces dermatitidis strain that induces host resistance

Systemic fungal infections are becoming more common and difficult to treat, and vaccine prevention is not available. Pulmonary infection with the dimorphic fungus Blastomyces dermatitidis often progresses and requires treatment to prevent fatality. We recently created a recombinant strain of the fungus lacking the WI-1 adhesin and pathogenicity. We show here that administration of viable yeast of this attenuated strain vaccinates against lethal pulmonary experimental infection due to isogenic and nonisogenic strains from diverse geographic regions. To our knowledge, this is the first example of a recombinant attenuated vaccine against fungi. The vaccine induces delayed-type hypersensitivity and polarized type 1 cytokine responses, which are linked with resistance. A cell-wall/membrane (CW/M) antigen from the vaccine strain also induces polarized and protective immune responses. Lymph node cells and CD4(+) T-cell lines raised with CW/M antigen transfer protective immunity when they release type 1 cytokine IFN-gamma, but not when they release IL-4, and neutralization of IFN-gamma confirmed its role in vivo. Thus, by mutating a pathogenetic locus in a dimorphic fungus, we have created an attenuated vaccine strain and have begun to elucidate fungal and host elements requisite for vaccine immunity.

Interleukin 12 as an adjuvant to WI-1 adhesin immunization augments delayed-type hypersensitivity, shifts the subclass distribution of immunoglobulin G antibodies, and enhances protective immunity to Blastomyces dermatitidis infection

Cell-mediated immunity is pivotal in host resistance to Blastomyces dermatitidis infection. Immunization of mice with the WI-1 adhesin enhances resistance against experimental pulmonary infection but elicits features of a mixed T-helper-cell immune response. Immune mice acquire delayed-type hypersensitivity (DTH) but also high titers of WI-1-specific immunoglobulin G1 (IgG1) and IgG2b, a result indicative of T-helper-2 cellular immunity. We report that interleukin-12, used as an adjuvant for WI-1 immunization, augments DTH, shifts the balance of the T-helper phenotype toward Th1, and enhances resistance to B. dermatitidis infection.

Microbiology. Turning up the heat on Histoplasma capsulatum

Many fungal pathogens are opportunistic, that is, they infect individuals who have a compromised immune system. Histoplasma capsulatum is a common pathogenic fungus that lives happily inside the phagosomes of macrophages. As Klein explains in his Perspective, an important H. capsulatum virulence factor, CBP1, has been found, which mops up free calcium ions within the phagosome, enabling the yeast to live under calcium-poor conditions (Sebhgati et al.). Chelating calcium ions may also have the added benefit that when the phagosome fuses with the lysosome, destructive lysosomal enzymes that require calcium ions for activity remain inactive.

Molecular basis of pathogenicity in Blastomyces dermatitidis: the importance of adhesion

An understanding of the molecular bases of pathogenicity in Blastomyces dermatitidis and related systemic dimorphic fungi has been limited until recent years. Yeast cells of B. dermatitidis display an adhesion promoting protein termed WI-1. Recent studies entailing homologous gene targeting and mutation of WI-1 have provided null mutants at this locus and demonstrated the crucial role of the WI-1 adhesin in pathogenesis of blastomycosis. Ongoing studies are pointing to a link between phase-specific expression of WI-1 and the observation that transition to yeast cells is essential for the acquisition of pathogenicity by B. dermatitidis. Recombinant attenuated yeast that lack WI-1 are serving as invaluable tools for induction of vaccine resistance and are pointing to new insights about adaptive immunity to B. dermatitidis.

Investigation of anti-WI-1 adhesin antibody-mediated protection in experimental pulmonary blastomycosis

Infection with Blastomyces dermatitidis elicits strong antibody responses to the surface adhesin WI-1. The antibodies are directed chiefly against the adhesive domain, a 25-amino-acid repeat. Tandem-repeat-specific monoclonal antibodies (mAbs) were studied for their opsonic activity in vitro and their capacity to adoptively transfer protection in murine experimental blastomycosis. mAbs to WI-1 enhanced binding and entry of B. dermatitidis yeasts into J774. 16 cells but did not enhance killing or growth inhibition of the yeast. Passive transfer of 8 mAbs to WI-1 into 3 different inbred strains of mice also did not improve the course of experimental infection and sometimes worsened it. mu-deficient mice were more resistant to experimental blastomycosis than were intact littermates, and passive transfer of the mAbs into these mice did not protect them against experimental infection. Thus, antibody to WI-1 does not appear to improve the outcome of murine blastomycosis and may enhance the infection.

Canine antibody response to Blastomyces dermatitidis WI-1 antigen

OBJECTIVE

To assess whether dogs with blastomycosis produce antibodies against the WI-1 and A-antigens of Blastomyces dermatitidis and whether the antibodies are useful in serodiagnosis.

SAMPLE POPULATION

359 serum samples obtained from 245 dogs.

PROCEDURE

233 samples from 122 dogs with blastomycosis, and 1 sample each from 24 dogs with suspected blastomycosis, 51 control dogs without infection, and 48 healthy dogs from an enzootic region were obtained. Antibodies against WI-1 antigen were detected by radioimmunoassay (RIA). Serum samples were tested in parallel for antibodies against the A-antigen of B dermatitidis by commercial agar-gel immunodiffusion (AGID) in a reference laboratory.

RESULTS

Antibodies were detected in 92% of infected dogs by RIA and in 41 % by AGID. For 29 serum samples that were obtained 11 to 1,545 days after diagnosis, antibodies were detected in 92% of samples by RIA and 7% by AGID. For 93 serial serum samples from 29 dogs with blastomycosis, the mean anti-WI-1 titer was 1:18,761 at the time of diagnosis, and decreased to a mean of 1:1,338 by 210 days after treatment was initiated. Of 24 dogs with suspected infection, antibodies were detected in 67% by RIA and 33% by AGID. Control dogs without blastomycosis had no detectable antibodies in either assay. Thus, sensitivity was 92% for RIA and 41 % for AGID, and specificity was 100% for both tests.

CONCLUSIONS AND CLINICAL RELEVANCE

Anti-WI-1 antibodies are readily detected by RIA in dogs with blastomycosis. Titers become high, decline during treatment, and persist for months. Anti-A antibodies are sometimes detected with AGID, but these decrease quickly.

T-Cell epitopes and human leukocyte antigen restriction elements of an immunodominant antigen of Blastomyces dermatitidis

Humans infected with the dimorphic fungus Blastomyces dermatitidis develop strong T-lymphocyte responses to WI-1, an immunodominant antigen that has been shown to elicit protective immunity in mice. In the present study, the T-cell epitopes of WI-1 and human leukocyte antigen (HLA) restricting elements that display them were investigated. Peripheral blood mononuclear cells (PBMC) from 37 patients with a confirmed history of blastomycosis were tested for a response to WI-1 in primary proliferation assays; PBMC from 35 (95%) responded. Six patients whose PBMC proliferated strongly in response to WI-1 (defined as a stimulation index greater than 50) were tested further for responses to subcloned, recombinant fragments of the antigen. These patients responded chiefly to sequences within the N terminus and the 25-amino-acid tandem repeat. Cloned CD4(+) T cells from an infected individual were used to delineate more precisely the peptide epitopes in the fragments and HLA restricting elements that present them. A majority of the T-cell clones recognized an epitope spanning amino acids 149 to 172 within the N terminus, displayed by HLA-DR 15. A minority of the clones, which have been shown to perform a cytolytic function in vitro, recognized an epitope in the tandem repeat displayed by HLA-DPw4, an uncommon restricting element. Tandem repeat epitopes required display by the beta chain of DPw4 heterodimers. Thus, human T cells with different functions in vitro also recognize distinct regions of WI-1, raising the possibility that HLA restricting elements that present them could modulate immunity during blastomycosis by selection and display of WI-1 peptides.

Immunogenicity and protective efficacy of the WI-1 adhesin of Blastomyces dermatitidis

People infected with Blastomyces dermatitidis develop strong immunity to the yeast surface adhesin WI-1, including antibody responses to the adhesive domain, a 25-amino-acid repeat, and cellular responses to the N terminus. We studied the immunogenicity of WI-1 and the ability of anti-WI-1 immune responses to protect against lethal pulmonary infection in mice. WI-1 immunization, given in Freund's adjuvant subcutaneously in two doses 2 weeks apart, evoked delayed hypersensitivity responses in a concentration-dependent manner. Immunized mice also had anti-WI-1 antibody responses, with titers reaching an endpoint dilution of approximately 1:800,000. Anti-WI-1 immunoglobulin G (IgG) antibody subclasses were IgG1 > IgG2b > IgG2a > IgG3, indicating a mixed T helper 1 and T helper 2 immune response. In protection experiments, WI-1 immunization significantly prolonged the survival of C57BL/6 and BALB/c mice compared to controls following intranasal administration of a lethal dose of B. dermatitidis yeasts (Kaplan-Meier survival curve P values of 0.027 to 0.0002) and also protected a proportion of the animals from death due to progressive pulmonary blastomycosis. Taken together, our results suggest that administration of WI-1 raises antibody and cell-mediated immune responses, which enhance resistance against pulmonary infection with B. dermatitidis. Mechanisms of vaccine-induced resistance require further investigation.

Flow cytometric quantitation of yeast a novel technique for use in animal model work and in vitro immunologic assays

Animal models of fungal and other infectious diseases often require that the number of organisms in tissue be quantified, traditionally by grinding organs, plating them on agar and counting colony forming units (CFU). This method is labor intensive, slow as some fungi require two weeks of culture and limited in reliability by poor plating efficiency. To circumvent these problems, we developed a flow cytometric method to quantify yeast. In vitro cultured Blastomyces dermatitidis, Cryptococcus neoformans, Candida albicans and Histoplasma capsulatum yeast were labelled with specific monoclonal or polyclonal antibodies to stain surface determinants or with Calcofluor to stain cell-wall chitin. A defined number of fluorescently labelled beads were added prior to acquisition by flow cytometry as a reference standard for quantitation. Beads were readily distinguished from yeast by forward scatter, side scatter and intensity of fluorescence. Cultured yeast were enumerated by both standard CFU determination and flow cytometry in a range of 10(2) to 10(7) cells. Only flow cytometry enabled discrimination of live and dead yeast by using appropriate fluorescent dyes. The flow cytometric method was applied to murine models of histoplasmosis and blastomycosis to quantify the burden of fungi in the lungs of infected mice. Labelling yeast with Calcofluor alone resulted in unacceptably high levels of nonspecific binding to mouse cell debris. In contrast, labelling H. capsulatum with a rabbit polyclonal antiserum and B. dermatitidis with a monoclonal antibody to the surface protein WI-1 permitted accurate quantitation. We conclude that this flow cytometry technique is rapid, efficient and reliable for quantifying the burden of infection in animal models of fungal disease. The technique also should lend itself to performing cytotoxicity assays that require discrimination of live and dead fungi, or phagocytosis assays that require discrimination of intracellular and extracellular organisms.

Role of cell surface molecules of Blastomyces dermatitidis in the pathogenesis and immunobiology of blastomycosis

The cell surface of pathogenic microbes is critical in directing their interactions with the host. The discovery of a 120 kd antigen/adhesin WI-1 on the yeast or parasitic form of Blastomyces dermatitidis has elucidated the molecular basis of host/pathogen interactions in blastomycosis. WI-1 has three structural domains: (1) an N-terminal hydrophobic domain that spans the cell membrane, (2) a C-terminal epidermal growth factor-like domain that may bind extracellular matrix, and (3) a central domain of many 24- or 25 amino-acid repeats arrayed in tandem. The repeat is homologous to invasin, a Yersinia adhesin, and binds CD11b/CD18 (CR3) and CD14 receptors on host cells. WI-1 expression is altered on genetically related strains of B dermatitidis differing in virulence and modulates how hypovirulent mutants interact with macrophages. WI-1 also evokes humoral and cell-mediated immune responses in acquired resistance to B dermatitidis that may help clear the fungus in the host. These observations on WI-1 provide new insight into a key pathogenic factor and antigen of the fungus and may ultimately help in designing new ways to diagnose, treat, and prevent blastomycosis.

African strains of Blastomyces dermatitidis that do not express surface adhesin WI-1

African strains of Blastomyces dermatitidis differ from North American strains in their growth, morphology, and clinical disease phenotype. In addition, two serotypes, designated 1 and 2, have been described. We investigated African strains of B. dermatitidis for expression of the surface protein adhesin WI-1 and found that serotype 2 strains do not express it because they lack the coding sequence in their genome. The defect will make the strains useful for gene complementation and for testing the pathogenetic role of the WI-1 adhesin.

Transforming DNA integrates at multiple sites in the dimorphic fungal pathogen Blastomyces dermatitidis

Blastomyces dermatitidis is a primary fungal pathogen of man and other mammals, but like many other human fungal pathogens, relatively little is known about the factors that account for its virulence and pathogenicity. We developed a transformation system to facilitate molecular genetic studies of putative virulence factors from B. dermatitidis. Transformation of the multinucleate yeasts was achieved by electroporation of DNAs containing a dominant selectable marker, hygromycin B (HygB) resistance. Southern analysis showed that transforming DNA invariably integrated ectopically into the chromosome. No evidence was found for extrachromosomal DNA. The HygB resistance could be expressed by either a 375-bp promoter fragment of the B. dermatitidis WI-1 gene encoding adhesin or an Aspergillus gpdA promoter placed 5' of the E. coli hph gene. Primer extension analysis showed that for plasmids containing the WI-1 promoter, transcription of the hph gene initiated within the 375-bp WI-1 promoter fragment. The combination of gene transfer and two promoters capable of independent transcription will allow us to restore or augment gene expression in appropriate strains and test an influence on virulence. Molecular genetic manipulation of B. dermatitidis represents a major advance in our ability to investigate the pathogenesis of blastomycosis and other similar fungal diseases.

Virulence factors of medically important fungi

Human fungal pathogens have become an increasingly important medical problem with the explosion in the number of immunocompromised patients as a result of cancer, steroid therapy, chemotherapy, and AIDS. Additionally, the globalization of travel and expansion of humankind into previously undisturbed habitats have led to the reemergence of old fungi and new exposure to previously undescribed fungi. Until recently, relatively little was known about virulence factors for the medically important fungi. With the advent of molecular genetics, rapid progress has now been made in understanding the basis of pathogenicity for organisms such as Aspergillus species and Cryptococcus neoformans. The twin technologies of genetic transformation and "knockout" deletion construction allowed for genetic tests of virulence factors in these organisms. Such knowledge will prove invaluable for the rational design of antifungal therapies. Putative virulence factors and attributes are reviewed for Aspergillus species, C. neoformans, the dimorphic fungal pathogens, and others, with a focus upon a molecular genetic approach. Candida species are excluded from coverage, having been the subject of numerous recent reviews. This growing body of knowledge about fungal pathogens and their virulence factors will significantly aid efforts to treat the serious diseases they cause.

Role of cell-surface molecules of Blastomyces dermatitidis in host-pathogen interactions

The fungal pathogen Blastomyces dermatitidis produces an adhesin (WI-1) in yeast stages, which contains repetitive regions that bind host-cell receptors. Adhesin and glucan may modulate fungal interactions with macrophages; their level of expression is altered in hypovirulent mutants. Adhesin is also involved in immune responses, and may be important in eliciting the clearance of the fungus.

Genomic cloning, characterization, and functional analysis of the major surface adhesin WI-1 on Blastomyces dermatitidis yeasts

WI-1 is a 120-kDa surface protein adhesin on Blastomyces dermatitidis yeasts that binds CD18 and CD14 receptors on human macrophages. We isolated and analyzed a clone of genomic WI-1 to characterize this key adherence mechanism of the yeast. The 9.3-kilobase insert contains an open reading frame of 3438 nucleotides and no introns. The amino acid sequence of native WI-1 matches the deduced sequence of genomic WI-1 at positions 757-769, 901-913, and 1119-1138, demonstrating the cloned gene is authentic WI-1. The complete coding sequence has 30 highly conserved repeats of 24 amino acids arrayed in tandem in two noncontiguous regions of the protein. The repeat sequence is homologous to the Yersiniae adhesin invasin, the C terminus displays an epidermal growth factor-like domain, and the N terminus has a short hydrophobic sequence that may be a membrane-spanning domain. The tandem repeats are predicted to be at the exposed surface of the protein, thereby explaining the adhesive properties of WI-1. The WI-1 promoter contains a CAAT box (nucleotide positions 2287-2290), TATA box (2380-2385), and CT motif (2399-2508). Transcription is initiated within the CT motif at nucleotide 2431. A 5.5-kilobase subclone containing the full coding sequence of WI-1 was expressed as a histidine-tagged fusion protein in Escherichia coli. Recombinant WI-1 has the expected molecular mass of 120 kDa, is strongly recognized in Western blots by rabbit anti-WI-1 antiserum, and binds human macrophage receptors in the same manner as native WI-1. This work clarifies a key adherence mechanism of B. dermatitidis and will permit further analysis of WI-1-mediated attachment to host cells, receptors, and extracellular matrix.

The WI-1 antigen of Blastomyces dermatitidis yeasts mediates binding to human macrophage CD11b/CD18 (CR3) and CD14

Three genetically related strains of Blastomyces dermatitidis (Bd) yeasts that differ in their expression of WI-1, an immunodominant cell wall Ag, were tested for their capacity to bind to human macrophages (M phi) in the absence of serum. These strains included American Type Culture Collection (ATCC, Rockville, MD) ATCC 26199, which is virulent for mice; an attenuated mutant strain ATCC 60915, which expresses 2.5-fold more WI-1 than strain 26199; and an avirulent mutant strain, ATCC 60916, which has sixfold more WI-1 than strain 26199. Attachment of both mutant strains to M phi was rapid and was maximum after 10 min at 37 degrees C. Attachment of strain 26199 to M phi was approximately 40% of that obtained with the mutants. Binding of Bd to M phi was temperature- and Mg(2+)-dependent, and heat-killed yeasts bound to M phi as well as viable yeasts. Experiments with receptor-specific mAbs demonstrated that 26199 yeasts bound predominantly to the LPS binding site on CD11b/CD18 (CR3). However, the mutants bound to M phi CD14 as well as CR3. Fab anti-WI-1 inhibited the binding of all strains to M phi by 69 to 78%. Latex microspheres coated with purified WI-1 or a 25-amino acid tandem repeat located within WI-1 also bound to M phi CR3 and CD14. These data demonstrate that: 1) WI-1 is a major ligand on Bd that mediates attachment of yeasts to human M phi; 2) the binding activity of WI-1 is located within the 25-amino acid tandem repeat; and 3) binding of Bd yeasts to M phi is mediated through the LPS binding site on CR3 and CD14.

The WI-1 antigen of Blastomyces dermatitidis yeasts mediates binding to human macrophage CD11b/CD18 (CR3) and CD14

Three genetically related strains of Blastomyces dermatitidis (Bd) yeasts that differ in their expression of WI-1, an immunodominant cell wall Ag, were tested for their capacity to bind to human macrophages (M phi) in the absence of serum. These strains included American Type Culture Collection (ATCC, Rockville, MD) ATCC 26199, which is virulent for mice; an attenuated mutant strain ATCC 60915, which expresses 2.5-fold more WI-1 than strain 26199; and an avirulent mutant strain, ATCC 60916, which has sixfold more WI-1 than strain 26199. Attachment of both mutant strains to M phi was rapid and was maximum after 10 min at 37 degrees C. Attachment of strain 26199 to M phi was approximately 40% of that obtained with the mutants. Binding of Bd to M phi was temperature- and Mg(2+)-dependent, and heat-killed yeasts bound to M phi as well as viable yeasts. Experiments with receptor-specific mAbs demonstrated that 26199 yeasts bound predominantly to the LPS binding site on CD11b/CD18 (CR3). However, the mutants bound to M phi CD14 as well as CR3. Fab anti-WI-1 inhibited the binding of all strains to M phi by 69 to 78%. Latex microspheres coated with purified WI-1 or a 25-amino acid tandem repeat located within WI-1 also bound to M phi CR3 and CD14. These data demonstrate that: 1) WI-1 is a major ligand on Bd that mediates attachment of yeasts to human M phi; 2) the binding activity of WI-1 is located within the 25-amino acid tandem repeat; and 3) binding of Bd yeasts to M phi is mediated through the LPS binding site on CR3 and CD14.

Purification and characterization of the major antigen WI-1 from Blastomyces dermatitidis yeasts and immunological comparison with A antigen

The lack of well-defined antigens from Blastomyces dermatitidis has hampered the ability to reliably diagnose human infection and study the immunobiology of blastomycosis. We recently discovered a novel surface protein on B. dermatitidis yeasts, designated WI-1, and demonstrated it to be a key antigenic target of humoral and cellular responses during infection. In the present article, we purified and characterized WI-1 and compared it immunologically with the only Blastomyces antigen commercially available, A antigen. WI-1 was purified by high-performance liquid chromatography over a DEAE-cellulose column. It eluted from the column at a point on the salt gradient corresponding to 460 to 490 mM NaCl, reflecting its acidic pI of approximately equal to 5.2. Purified WI-1 had a molecular mass of 120 kDa and contained a large amount of cysteine (85 residues) and aromatic amino acids but undetectable carbohydrate. In contrast, A antigen had a molecular mass of 135 kDa and contained 37% carbohydrate. Immunological comparison of the two antigens showed that, when radiolabeled, WI-1 was more reactive with anti-Blastomyces antisera than A antigen but did not cross-react with anti-Histoplasma antisera. Proteinase digestion of WI-1 eliminated its recognition by anti-WI-1 and anti-Blastomyces antisera. Proteinase treatment of A antigen had no effect on its recognition by anti-Blastomyces or anti-Histoplasma antisera, but periodate treatment abolished recognition by anti-Histoplasma antisera, indicating that the cross-reactive determinant(s) of A antigen is displayed on the accompanying carbohydrate. In further studies, anti-WI-1 antiserum reacted with A antigen and, conversely, anti-A antiserum and monoclonal antibodies (MAbs) reacted with WI-1, indicating a shared determinant on the two antigens. A recombinant 25-amino-acid repeat, recently cloned from WI-1 and found to be the major target of antibody recognition of WI-1, reacted strongly with anti-A antiserum and MAbs. In MAb competition tests, MAbs specific for the 25-residue repeat abolished binding of anti-A antiserum to A antigen. In antigen inhibition tests, the recombinant repeat abolished binding of anti-A antiserum to A antigen. These results demonstrate that the repeat is the major site of antibody recognition of both WI-1 and A antigen and that the recombinant, nonglycosylated peptide could replace either native antigen in formatting better diagnostic tests for blastomycosis. Moreover, they suggest that producing fungal protein antigens as nonglycosylated peptides in a procaryotic expression system may circumvent problems of antigen cross-reactivity that are due to posttranslational modification.

Altered expression of surface protein WI-1 in genetically related strains of Blastomyces dermatitidis that differ in virulence regulates recognition of yeasts by human macrophages

The molecular basis for pathogenicity and virulence of the dimorphic fungus Blastomyces dermatitidis remains unknown. WI-1 is a major cell wall protein of B. dermatitidis yeasts and is a recognition target of both humoral and cell-mediated immunity. As an initial study to determine if WI-1 might be linked to virulence of B. dermatitidis, we quantified WI-1 expression on three genetically related strains that differ in their virulence for mice: wild-type virulent ATCC strain 26199, mutant ATCC strain 60915 (which is 10,000-fold reduced in virulence), and mutant ATCC strain 60916 (which is avirulent). Two principal alterations in WI-1 expression were observed in the mutants. First, the mutants express more WI-1 on their surface, as quantified by flow cytometry with monoclonal antibody to WI-1 and by radioimmunoassay, but the WI-1 on their cell wall is less extractable than that on the wild-type strain. Second, the mutants shed less WI-1 during culture and demonstrate impaired processing of shed WI-1. Surface alterations in WI-1 were accompanied by significant differences in the binding of the virulent and mutant strains to human monocyte-derived macrophages. Attachment of yeasts to macrophages paralleled and was proportional to the expression of WI-1. Compared with wild-type yeasts, both mutants bound to macrophages more rapidly and in two- to threefold-greater magnitude. Furthermore, about 75% of yeast binding to macrophages was inhibited by a Fab anti-WI-1 monoclonal antibody. These results suggest that altered WI-1 expression on attenuated and avirulent mutant B. dermatitidis yeasts greatly facilitates macrophage recognition and binding of yeasts and, in turn, may contribute to more rapid ingestion and killing in the host.

Altered expression of surface alpha-1,3-glucan in genetically related strains of Blastomyces dermatitidis that differ in virulence

Recent studies of the dimorphic fungal pathogens Histoplasma capsulatum and Paracoccidioides brasiliensis have suggested a role in virulence for the cell surface carbohydrate alpha-(1,3)-glucan. To investigate a possible basis for alpha-(1,3)-glucan in the pathogenicity and virulence of the dimorphic fungus Blastomyces dermatitidis, we examined three genetically related strains of B. dermatitidis that differ in their virulence for mice: wild-type virulent strain ATCC 26199; mutant strain ATCC 60915, which is 10,000-fold reduced in virulence; and mutant strain ATCC 60916, which is avirulent. Immunologic quantitation of cell wall alpha-(1,3)-glucan revealed that the mutant yeasts were almost devoid of this sugar moiety, in contrast to the high concentration of alpha-(1,3)-glucan on the cell wall of the wild-type yeasts. These differences are discussed in relation to previous studies of yeast surface expression of the WI-1 antigen and recognition and binding of the related strains by human monocyte-derived macrophages.

Utility of anti-WI-1 serological testing in the diagnosis of blastomycosis in Wisconsin residents

WI-1, a 120-kD protein found in the outer cell wall of Blastomyces dermatitidis, has been purified, labeled with 125I, and used as a target in a radioimmunoassay (RIA). In an assessment of the usefulness of anti-WI-1 serology in the diagnosis of blastomycosis, the RIA was used to test four panels of sera from residents of Wisconsin, a state in which blastomycosis is endemic. Twenty-four (75%) of 32 patients whose blastomycosis had been reported to the Wisconsin Division of Health had at least one serum sample positive for antibody to WI-1; 25 (93%) of 27 serum samples obtained from these patients within 60 days of diagnosis were positive. In an effort to simulate clinical practice, 132 serum samples were assayed from another 107 patients in whom blastomycosis was being considered as a cause of illness. The result was positive for at least one sample from 83% of the 23 patients with confirmed blastomycosis and from 5% of the 84 patients from whom the fungus was not documented. Serum samples from another five patients with blastomycosis identified during investigation of a 1990 outbreak in Oconto Falls, Wisconsin, also gave a positive result, whereas none of the serum specimens from 57 healthy family members or neighbors did so. Only three (0.56%) of 535 serum samples from random blood donors residing in two counties with a high annual incidence of blastomycosis were positive for antibody to WI-1. Modification of the RIA so that IgM rather than IgG antibody was detected did not enhance diagnostic sensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunologic recognition of a 25-amino acid repeat arrayed in tandem on a major antigen of Blastomyces dermatitidis

A 120-kD glycoprotein antigen abundantly expressed on Blastomyces dermatitidis yeasts is a target of cellular and humoral immune responses in human infection. To investigate the antigen and immune response more carefully at the molecular level, we screened an expression library from B. dermatitidis to identify clones that encode this antigen, designated WI-1. A 942-bp cDNA was isolated by immunologic screening with polyclonal, rabbit anti-WI-1 antiserum. Northern hybridization analysis showed that the cDNA hybridized to yeast message approximately equal to 3.9 kb. DNA and deduced protein sequence analysis of the clone demonstrated a 25-amino acid repeat arrayed in tandem, present in 4.5 copies near the 5' end, and rich in predicted antigenic epitopes. Further analysis showed strong homology in these tandem repeats with invasin, an adhesin of Yersiniae. Cloned cDNA was used to express a 30-kD fusion protein strongly recognized in western blots by rabbit anti-WI-1 antiserum, and by sera from all 35 blastomycosis patients studied. The fusion protein product of subcloned cDNA encoding only the tandem repeat also was strongly recognized in western blots by sera from the 35 blastomycosis patients, but not by sera from 10 histoplasmosis and 5 coccidioidomycosis patients. An antigen-inhibition radioimmunoassay showed that the tandem repeat alone completely eliminated rabbit and human anti-WI-1 antibody binding to radiolabeled native WI-1. From these results, we conclude that the 25-amino acid repeat of WI-1 displays an immunodominant B cell epitope, and that the carboxyl-terminus of the molecule exhibits an architecture that may promote adhesion of Blastomyces yeasts to host cells or extracellular matrix proteins and ultimately provide a clearer picture of the molecular pathogenesis of blastomycosis.

WI-1, a novel 120-kilodalton surface protein on Blastomyces dermatitidis yeast cells, is a target antigen of cell-mediated immunity in human blastomycosis

A large body of experimental data has demonstrated the central role of T cells in acquired resistance to the dimorphic fungus Blastomyces dermatitidis. We examined the human T-cell response to WI-1, a 120-kDa B. dermatitidis yeast cell surface protein recently shown to be an immunodominant antigen of the B-cell response in infected humans. Peripheral blood lymphocytes from 10 blastomycosis patients studied proliferated in response to WI-1 (mean, 19,431 cpm) and to the standard, crude cell wall antigen, Blastomyces alkali- and water-soluble antigen (B-ASWS) (mean, 19,131 cpm); lymphocytes from 10 histoplasmosis patients and 10 normal control subjects did not respond to WI-1. WI-1 stimulation of patient lymphocytes and rechallenge with WI-1 or B-ASWS showed that the antigens share immunodominant epitopes. Of 100 WI-1-responsive T-cell clones derived from peripheral blood, 10 were studied in detail to assess the phenotype, function, and ligands recognized. The clones exhibit the CD3+ CD4+ phenotype of helper T cells; 2 of 10 clones (and 21% of antigen-stimulated peripheral blood lymphocytes) use the V beta 8 T-cell receptor gene element to respond to WI-1. All the clones proliferate in response to both WI-1 and B-ASWS but not other fungal antigens, and some mediate potent cytolytic effects on WI-1- and B-ASWS-labeled targets. WI-1 recognition requires antigen processing and presentation of epitopes in association with HLA-DR (to noncytolytic clones) and HLA-DP (to cytolytic clones). From these findings, we conclude that CD4+ T cells with regulatory and cytolytic properties are involved in the development of acquired resistance of B. dermatitidis, that the cells are directed against WI-1, and that the manner of display of WI-1 peptide epitopes in conjunction with major histocompatibility complex class II may influence the profile of the immune response.

Nosocomial Pseudomonas pickettii bacteremias traced to narcotic tampering. A case for selective drug screening of health care personnel

Three patients in a university hospital developed nosocomial infusion-related Pseudomonas pickettii bacteremia. Investigation identified six additional patients who had received intravenous fluid contaminated by P pickettii but did not become ill. All nine patients had had surgery, and each of these patients but only nine of 19 operated-on control patients had received intravenous fentanyl citrate in the operating room; the mean dose given to the nine case patients was far greater than that given to control patients. Fentanyl in 20 (40%) of 50 predrawn 30-mL syringes was shown to be contaminated by P pickettii. Contamination was caused by theft of fentanyl from predrawn synringes and replacement by distilled water contaminated by P pickettii. Narcotic theft by health care personnel may cause patients to suffer pain needlessly and can also result in dire unanticipated consequences, such as nosocomial bacteremia. Whereas drug testing in the workplace is highly controversial, we believe that testing of health care personnel is indicated when drug abuse or theft is suspected.

Recognition by human V gamma 9/V delta 2 T cells of a GroEL homolog on Daudi Burkitt's lymphoma cells

All human gamma delta T cells coexpressing the products of the variable (V) region T cell receptor (TCR) gene segments V gamma 9 and V delta 2 recognize antigens from mycobacterial extracts and Daudi cells. Exogenous and endogenous ligands on the cell surface, homologous to the groEL heat shock family, induced reactivities that resembled superantigen responses in this major subset of human peripheral blood gamma delta T cells. Stimulation of human V gamma 9/V delta 2 T cells is not restricted by human leukocyte antigens (HLA), including nonpolymorphic beta 2-microglobulin (beta 2M)-associated class Ib molecules. These data may be important for understanding the role of gamma delta T cells in autoimmunity and in responses to microorganisms and tumors.

Isolation, purification, and radiolabeling of a novel 120-kD surface protein on Blastomyces dermatitidis yeasts to detect antibody in infected patients

No well-defined Blastomyces-specific antigens are currently available. We used sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting to identify immunologically active molecules in the cell wall of B. dermatitidis. A major immunoreactive 120-kD protein (WI-1) was present in all five strains studied and comprised 5% of the protein in the cell wall extract obtained after freezing and thawing yeast cells. WI-1 was recognized by serum from all 10 patients with blastomycosis but by none of those from 5 patients with histoplasmosis. It was purified by electroelution, radiolabeled with 125I, and incorporated into a radioimmunoassay (RIA) for serodiagnosis of blastomycosis. Antibody to WI-1 was detected in 58 (85%) of 68 patients with blastomycosis (geometric mean titer, 1:2,981), in two (3%) of 73 patients with histoplasmosis, coccidioidomycosis, sporotrichosis, or candidiasis (titers, 1:86 and 1:91) and in none of 44 healthy persons. WI-1 was shown to be a surface molecule abundant on B. dermatitidis yeasts that were indirectly stained with serum from a rabbit immunized with WI-1. Approximately 0.93 pg of WI-1 or 4.7 x 10(6) WI-1 molecules were found on the surface of an individual yeast using an antigen-inhibition RIA; none was found on Histoplasma capsulatum or Candida albicans yeasts. We conclude that WI-1 is a novel, immunologically active surface molecule on the invasive form of B. dermatitidis and that WI-1 can be used to reliably detect antibody and study the immunopathogenesis of blastomycosis.

Development of long-term specific cellular immunity after acute Blastomyces dermatitidis infection: assessments following a large point-source outbreak in Wisconsin

Ninety-five persons exposed to a point-source of Blastomyces dermatitidis in Wisconsin in 1984 were evaluated 3 months after exposure for the development of specific cellular immunity, and the 48 infected persons were again evaluated 7 and 21 months after exposure. The immune response was assessed by an assay of [3H]thymidine uptake by lymphocytes proliferating in response to stimulation with Blastomyces alkali- and water-soluble antigen (B-ASWS) or blastomycin and by skin testing with blastomycin. At 3 months, 36 (84%) of 43 patients demonstrated a proliferative response to B-ASWS (mean value of experimental [E]-control [C] counts, 16,852 +/- 2664, and of E/C, 42.2 +/- 5.3). None of the patients demonstrated a proliferative response to blastomycin, and only 19 (41%) of 45 patients tested had a positive blastomycin skin test. By 21 months, 47 (98%) of the 48 patients demonstrated a proliferative response to B-ASWS on at least one testing date. Of those initially positive, 82% had a persistently positive proliferative response at 21 months; mean E-C and E/C values were comparable to those seen at 3 months. None of the 47 uninfected persons demonstrated a proliferative response to B-ASWS: 7 with positive histoplasmin skin tests had a mean E-C value of 1094 +/- 432, and the 40 others, a mean value of 1139 +/- 212. A proliferative response to B-ASWS in exposed individuals is a reliable marker of specific cellular immunity in blastomycosis and the response persists in most patients for up to at least 2 years.

Reduction of nosocomial infection during pediatric intensive care by protective isolation

To determine whether simple protective isolation reduces the incidence of nosocomial bacterial and fungal infection during pediatric intensive care, we randomly assigned 70 children who were not immuno-suppressed and who required mechanical ventilatory support and three or more days of intensive care to receive standard care (n = 38) or protective isolation (n = 32) with use of disposable, non-waven, polypropylene gowns and nonsterile latex gloves. Risk factors predisposing patients to infection were comparable in the two groups. Nosocomial colonization occurred later among isolated patients (median, vs. 7 days; P less than 0.01) and was associated with subsequent infection in 12 patients, as compared with 12 patients given standard care (P = 0.01). Among patients who were isolated, the interval before the first infection was significantly longer than (median, 20 vs. 8 days; P = 0.04), the daily infection rate was 2.2 times lower than (95 percent confidence interval, 1.2 to 4.0; P = 0.007), and there were fewer days with fewer (13 percent vs. 21 percent; P = 0.001). The benefit of isolation was most notable after seven days of intensive care. Isolation was well tolerated by patients and their families. Regular monitoring showed that the children in each group were touched and handled comparably often by hospital personnel and family members. We conclude that the use of disposable, high-barrier gowns and gloves for the care of selected, high-risk children who require prolonged intensive care significantly reduces the incidence of nosocomial infection, is well tolerated, and does not compromise the delivery of care.

Two outbreaks of blastomycosis along rivers in Wisconsin. Isolation of Blastomyces dermatitidis from riverbank soil and evidence of its transmission along waterways

Blastomycosis cannot yet be prevented or controlled, in part because the natural habitat of the causative fungus, Blastomyces dermatitidis, remains ill defined. In investigating 2 outbreaks of blastomycosis that occurred in the summer of 1985 among persons engaged in activities along rivers in contiguous central Wisconsin counties, we isolated B. dermatitidis from soil at one of the riverbanks. Blastomycosis developed in 7 (58%) of 12 residents and guests who had gathered at a pheasant farm on the Tomorrow River in early May, and in 7 (88%) of 8 boys and 1 adult who had visited a site on the Crystal River in early June. Of the 14 patients, 13 (93%) were symptomatic. Two patients visiting the sites only once became ill 23 and 78 days after exposure, respectively. We traced one outbreak to fishing from the bank of the Tomorrow River, and the other to climbing into an underground timber fort along the Crystal River. A culture of soil and organic debris from the fishing site yielded B. dermatitidis. From these and other outbreaks, and studies of endemic disease, we conclude that riverbanks can be a natural habitat of B. dermatitidis, and that the environment around waterways represents the most important site yet identified for transmission of B. dermatitidis.

Serological tests for blastomycosis: assessments during a large point-source outbreak in Wisconsin

Enzyme immunoassay (EIA), immunodiffusion (ID), and complement fixation (CF) tests for antibody to the A antigen of Blastomyces dermatitidis were assessed in 47 patients in an epidemic of blastomycosis and in 89 control subjects with lower respiratory tract illness. Antibody was detected by EIA, ID, and CF in 77%, 28%, and 9% of the patients, respectively. EIA titers ranged from 1:8-1:512 (median titer, 1:128). Antibody detected by ID or CF was always detectable by EIA. Antibody was detected by EIA 13 days after illness onset, and the peak seroprevalence rate and geometric mean titer occurred 50-70 days after onset. Antifungal therapy produced a significant decline in antibody titer by approximately six months after onset. Seven (8%) control subjects had detectable antibody, six had EIA titers of 1:8, and one had a titer of 1:16. The specificities for EIA, ID, and CF were 92%, 100%, and 100%, respectively. The EIA provides a significant advance in serodiagnostic testing for blastomycosis and can be used in an outbreak setting as an epidemiological tool to identify acute B. dermatitidis infection; titers greater than or equal to 1:32 strongly support the diagnosis, whereas titers of 1:8 or 1:16 are suggestive.

Kawasaki syndrome: a controlled study of an outbreak in Wisconsin

The etiology of Kawasaki syndrome remains unestablished, although a possible role has been suggested for exposure to the application of carpet shampoo, house dust mites, and rickettsial infection. During an outbreak of 20 cases of Kawasaki syndrome that occurred in southeastern Wisconsin from November 1982 through March 1983, a case-control study was done of 15 cases and 30 matched controls. The study included questionnaire administration, dust collection from homes, and serum specimen collection. Only one patient had been exposed to a shampooed carpet within 30 days before onset of illness. No differences were noted between cases and controls in the degree of exposure to house dust mite-associated factors in the home, nor in the occurrence, density and species-specific prevalence of house dust mites in the home. Meadow voles exposed to house dust mites from the homes of patients did not develop serologic or pathologic evidence of infection due to rickettsiae in the spotted fever and typhus groups or Coxiella burnetii. Anti-mite-specific immunoglobulin E was not detected in serum specimens from cases or controls. Results from this study do not support hypotheses suggesting that the development of Kawasaki syndrome is associated with exposure to application of carpet shampoo, house dust mites, or rickettsial infection.

Epidemiologic aspects of blastomycosis, the enigmatic systemic mycosis

A growing body of epidemiologic information derives from the study of sporadic cases and seven epidemics of blastomycosis, although a complete epidemiologic description of the disease is impeded by the absence of a skin test and difficulty isolating the causative fungus, Blastomyces dermatitidis, from nature. Most cases occur sporadically in humans and dogs in a worldwide distribution. Endemic areas in the United States include southeastern, southcentral, and midwestern states, particularly Arkansas, Kentucky, Mississippi, and Wisconsin. Blastomycosis is acquired by inhalation of spores from nature and acute disease occurs 21 to 106 days (median 43 days) after exposure; cutaneous inoculation and sexual and intrauterine transmission are rare. Most human cases are in middle aged men with occupation-, or leisure-related activities involving the soil or wooded areas. Identification of a point source in nature at a beaver pond and lodge was first accomplished during a 1984 Wisconsin epidemic, advancing knowledge of the natural habitat and ecology of the fungus. Blastomcyces alkali- and water-soluble antigen, utilized for in vitro lymphocyte transformation studies during the epidemic, may hold considerable promise for incorporation into a skin test.

Isolation of Blastomyces dermatitidis in soil associated with a large outbreak of blastomycosis in Wisconsin

In investigating six cases of blastomycosis in two school groups that had separately visited an environmental camp in northern Wisconsin in June 1984, we identified a large outbreak of the disease and isolated Blastomyces dermatitidis from soil at a beaver pond near the camp. Of 89 elementary-school children and 10 adults from the two groups, 48 (51 percent) of the 95 evaluated in September had blastomycosis. Of the cases, 26 (54 percent) were symptomatic (the median incubation period was 45 days; range, 21 to 106 days). No cases were identified in 10 groups that visited the camp two weeks before or after these two groups. A review of camp itineraries, a questionnaire survey, and environmental investigation showed that blastomycosis occurred in two of four groups that visited a beaver pond and in none of eight groups that did not. Walking on the beaver lodge (P = 0.008) and picking up items from its soil (P = 0.05) were associated with illness. Cultures of soil from the beaver lodge and decomposed wood near the beaver dam yielded B. dermatitidis. We conclude that B. dermatitidis in the soil can be a reservoir for human infection.

Campylobacter infection associated with raw milk. An outbreak of gastroenteritis due to Campylobacter jejuni and thermotolerant Campylobacter fetus subsp fetus

Raw milk is identified with increasing numbers of outbreaks of gastroenteritis and is an important vehicle for transmission of Campylobacter infection. Unlike Campylobacter jejuni, Campylobacter fetus subsp fetus has not been associated with common-source outbreaks of gastroenteritis. This report describes an outbreak of gastroenteritis involving C jejuni and a thermotolerant strain of C fetus subsp fetus associated with raw milk. Fifteen (39%) of 38 persons who attended a banquet in Wisconsin in June 1982 developed acute gastroenteritis. Stool specimens were obtained from nine ill guests; four yielded C jejuni and three yielded C fetus subsp fetus. The C fetus subsp fetus isolates were identified fortuitously, in part because of unusual thermotolerance (growth at 42 degrees C), permitting isolation at temperature appropriate for C jejuni. Survey results implicated raw milk as the source of the outbreak. Findings provide evidence of a potentially emergent milkborne pathogen contributing to the risk of raw milk consumption and suggest that current diagnostic laboratory techniques may fail to identify significant foodborne agents.

Comparison of the enzyme immunoassay, immunodiffusion, and complement fixation tests in detecting antibody in human serum to the A antigen of Blastomyces dermatitidis

Using a new enzyme immunoassay (EIA) and standard immunodiffusion (ID) and complement fixation techniques for antibody to the A antigen of Blastomyces dermatitidis, we tested serum from 27 patients with blastomycosis diagnosed histopathologically or by culture; 20 with diagnoses made during 1981 through 1983 (Group A) and 7 during 1974 through 1976 (Group B). We also studied 30 control subjects with Mycoplasma pneumoniae infection (17 subjects), histoplasmosis (6 subjects), coccidioidomycosis (1 subject) and no known disease (6 subjects). Detectable antibody by all 3 tests was present more often for Group A than for Group B, possibly because of delay in testing. Enzyme immunoassay was the most sensitive test; a 1:8 or greater titer was present in acute-phase serum of all Group A patients tested, and a 1:64 or greater titer was associated with disseminated disease (p = 0.003). A positive ID was also more common in disseminated (88%) than in localized (33%) disease. Enzyme immunoassay titers of 1:16 were present in 4 control subjects, 3 with histoplasmosis. The 100% predictive values of a negative EIA and positive ID suggest that these tests are useful for serologic screening (EIA) and serologic confirmation (ID) of suspected blastomycosis, particularly in disseminated disease. Enzyme immunoassay titers of 1:32 or greater strongly support the diagnosis and titers of 1:16 or less may indicate localized disease or be nonspecific. None of the serologic tests predicted disease progression or reactivation.

A laboratory-based surveillance of human blastomycosis in Wisconsin between 1973 and 1982

Blastomycosis appears to be prevalent in states around the Great Lakes. However, its incidence in these states has not been reported. The Wisconsin Division of Health established a laboratory-based surveillance for human blastomycosis in Wisconsin to estimate disease incidence and identify endemic areas in the state for the interval 1973 to 1982. Certified mycology and pathology laboratories in Wisconsin and at two major medical centers in Minnesota were surveyed for all laboratory isolates and identifications in tissue of Blastomyces dermatitidis obtained in Wisconsin residents during 1973-1982. A total of 235 isolates and identifications of B. dermatitidis were obtained; 214 (88%) Wisconsin laboratories participated. It was estimated that the annual incidence of blastomycosis in Wisconsin for 1973-1982 ranged between 0.32 and 0.72 cases per 100,000 total population (mean, 0.48 cases/100,000 population). Cases were reported in residents from 40 (56%) of the 72 Wisconsin counties. Residents of seven counties in northern and central Wisconsin had significantly higher incidences of blastomycosis than residents of other counties in which cases were documented. The incidence of blastomycosis in Wisconsin for 1973-1982 is similar to that noted in Mississippi, Kentucky, and Arkansas where this disease is thought to be endemic and where similar surveys have been performed.

Nosocomial hepatitis A. A multinursery outbreak in Wisconsin

Seven premature infants contracted asymptomatic hepatitis A while hospitalized in an intensive care nursery (nursery A) from May through August 1981. Fifteen secondary cases occurred between Aug 13 and Oct 14 and included six family members of nursery A infants, five nursery A nurses, and three nurses and a physician at two other nurseries--B and C. Nurseries B and C had each received an infected infant transferred from nursery A in July. An epidemiologic investigation was conducted to determine the mode of transmission of hepatitis A in infants. A common vehicle was not identified. Review of dates of onset of illness in adults suggested that hepatitis A was transmitted in at least two generations of illness in infants at nursery A. Evaluation of infant handling in nursery A, using a case-control study, suggested that hepatitis A was transmitted among infants by nurses. Asymptomatic infected premature infants can be a source of hepatitis A in nursery infants and personnel and in the community.

Diet education for the parents of a young child with diabetes

A retrospective survey of a dietary education program was mailed to 23 families with IDDM children diagnosed under the age of five years. Of the 18 questionnaires returned, results showed that, once educated, the par ents of young diabetic children identi fied the majority of diet-related prob lems as: 1) managing the deviations of meal routines, 2) behavioral issues, 3) illness, and 4) special occasions.

The role of respiratory syncytial virus and other viral pathogens in acute otitis media

We utilized recently developed enzyme immunoassay techniques to examine the role of selected viruses in the etiology of acute otitis media. Viral pathogens were found in middle ear fluids obtained from 13 (24%) of 53 children with acute otitis media; respiratory syncytial virus accounted for ten of the 13 viral agents identified. In addition, respiratory syncytial viral antigen was found in nasopharyngeal washings obtained from 15 of the 53 children. Seven of these children had RSV identified as the sole middle ear pathogen, whereas six children had otitis caused by Streptococcus pneumoniae as either the sole middle ear pathogen or in combination with RSV. Similarly, all three children with respiratory infections caused by influenza virus had ear infections caused by bacterial pathogens, either alone or in combination with influenza virus. These findings suggest that, in patients with viral respiratory infection, coexisting acute otitis media may be associated with the recovery of either viruses or bacteria from the middle ear exudates.