Immune reconstitution inflammatory syndrome manifesting as development of multiple autoimmune disorders and skin cancer progression

We report the case of a 56-year-old man with the rare autoimmune pathologies of alternating hypothyroidism and hyperthyroidism due to thyroid-stimulating hormone receptor antibodies, and rheumatoid arthritis as manifestations of a human immunodeficiency virus-related immune reconstitution inflammatory syndrome. The patient also developed overt progression of a pre-existing skin malignancy that may also be related. This case highlights immune reconstitution syndrome as an important differential diagnosis following antiretroviral therapy commencement, and that a high index of suspicion should be maintained for this rare but important cluster of conditions. Furthermore, the patient's genetic predisposition to autoimmunity provides helpful insights into the pathogenesis of these disorders.

Continuous and 4 h infusion of amphotericin B: a comparative study involving high-risk haematology patients

OBJECTIVES

To assess whether a continuous infusion of amphotericin B (CI-AmB) is less nephrotoxic than a 4 h infusion in haematology patients with fever and neutropenia, including bone-marrow transplant recipients. Efficacy was assessed as a secondary end-point.

PATIENTS AND METHODS

We conducted a retrospective cohort study over a 2 year period. A total of 1073 haematology admissions were reviewed (98.3% complete) and 81 admissions were eligible for study entry; 39 received CI-AmB and 42 a 4 h infusion of AmB.

RESULTS

Renal impairment occurred significantly less frequently with CI-AmB compared with a 4 h infusion of AmB [10% versus 45%, respectively, odds ratio (OR) 0.14; 95% confidence interval (CI) 0.04-0.5, P < 0.001]. The difference was maintained among allogeneic transplant recipients (P = 0.007) and patients receiving concurrent nephrotoxic drugs (P < 0.001). An AmB infusion rate of <0.08 mg/kg/h was associated with a significant reduction in renal impairment (P < 0.001). A difference in survival was observed between the continuous and 4 h infusion of AmB (95% versus 79%, respectively, OR 5.1; 95% CI 1.02-25.1, P = 0.03).

CONCLUSIONS

CI-AmB appears to be significantly less nephrotoxic than 4 h infusion AmB in haematology patients with fever and neutropenia--including high-risk bone-marrow transplant recipients--without increasing mortality. An AmB infusion rate of <0.08 mg/kg/h appears to be a safe threshold, associated with reduced renal impairment.

Coupling of the TCR to integrin activation by Slap-130/Fyb

SLAP-130/Fyb (SLP-76-associated phosphoprotein or Fyn-binding protein; also known as Fyb/Slap) is a hematopoietic-specific adapter, which associates with and modulates function of SH2-containing leukocyte phosphoprotein of 76 kilodaltons (SLP-76). T cells from mice lacking SLAP-130/Fyb show markedly impaired proliferation following CD3 engagement. In addition, the T cell receptor (TCR) in SLAP-130/Fyb mutant cells fails to enhance integrin-dependent adhesion. Although TCR-induced actin polymerization is normal, TCR-stimulated clustering of the integrin LFA-1 is defective in SLAP-130/Fyb-deficient cells. These data indicate that SLAP-130/Fyb is important for coupling TCR-mediated actin cytoskeletal rearrangement with activation of integrin function, and for T cells to respond fully to activating signals.

Signaling networks regulating beta1 integrin-mediated adhesion of T lymphocytes to extracellular matrix

T-cell recognition of foreign antigen and migration to specific anatomic sites in vivo involves transient adhesive contacts between beta1 integrins expressed on T cells and cell surface proteins or extracellular-matrix components. Engagement of the CD3-T-cell receptor (CD3-TCR) complex initiates a complex signaling cascade involving coordinated regulation and recruitment of tyrosine and lipid kinases to specific regions or microdomains in the plasma membrane. Although considerable attention has been focused on the signaling events by which the CD3-TCR complex regulates transcriptional events in the nucleus, CD3-TCR signaling also rapidly enhances integrin-mediated adhesion without increasing surface expression of integrins. Recent studies suggest that CD3-TCR signaling to beta1 integrins involves coordinated recruitment and activation of the Tec family tyrosine kinase Itk by src family tyrosine kinases and phosphatidylinositol 3-kinase. These signaling events that regulate integrin-mediated T-cell adhesion share both common and distinct features with the signaling pathways regulating interleukin-2 gene transcription.

Disseminated mycobacterium avium complex infection presenting as osteomyelitis in a normal host

Disseminated Mycobacterium avium complex (MAC) infection presenting as a painful lytic femur lesion with associated fever, night sweats and weight loss occurred in a 45-y-old woman with apparent normal immune function. Surgical drainage and 24 months of medical therapy resulted in a cure.

Activation-dependent changes in soluble fibronectin binding and expression of beta1 integrin activation epitopes in T cells: relationship to T cell adhesion and migration

The relationship between activation-dependent changes in beta1 integrin conformation, T cell adhesion to immobilized fibronectin, and T cell migration in vitro was analyzed in this study. Stimulation of Jurkat T cells and peripheral T cells with Mn(2+), the activating beta1 integrin-specific monoclonal antibody (mAb) TS2 /16, CD2, or CD28 stimulation led to increased adhesion, soluble fibronectin (FN) binding and expression of the activation epitope defined by the beta1 integrin mAb HUTS-21. Phorbol 12-myristate 13-acetate treatment increased adhesion, but not soluble FN binding or HUTS-21 epitope expression. In peripheral T cells, CD3 or CD7 stimulation also led to increased adhesion, soluble FN binding and HUTS-21 epitope expression. Soluble FN blocked peripheral T cell adhesion induced by Mn(2+) or TS2/16, but had no effect on adhesion induced by the other integrin-activating signals. In contrast, migration induced by TS2/16, CD2, CD3, CD7 or CD28 stimulation was blocked by excess soluble FN. Phosphoinositide 3-OH kinase (PI 3-K) inhibitors blocked receptor-mediated increases in cell adhesion, but not soluble FN binding or HUTS-21 expression. Migration was similarly unaffected by PI 3-K inhibitors, with the exception of CD7- and CD28-induced migration, which was specifically blocked by LY294,002. These results suggest that activation-dependent changes in beta1 integrin conformation are PI 3-K-independent and are involved in T cell migration but not adhesion.

Candida tropicalis vertebral osteomyelitis complicating epidural catheterisation with disease paralleled by elevated D-arabinitol/L-arabinitol ratios

Deep-seated Candida infections are challenging to diagnose by noninvasive means, and new modalities are needed to improve the yield of such investigations. Reported here is a case of Candida tropicalis vertebral osteomyelitis complicating epidural catheterisation in a diabetic patient with complicated abdominal sepsis. The diagnosis was supported by detection of increased D-arabinitol/L-arabinitol ratios in urine samples, and failure of medical management was indicated by elevated D-arabinitol/L-arabinitol ratios, which later decreased to baseline with successful surgical debridement and prolonged antifungal therapy.

Protein meals reduce nausea and gastric slow wave dysrhythmic activity in first trimester pregnancy

First trimester nausea is associated with gastric slow wave dysrhythmias (tachygastria, bradygastria). We tested the roles of meal composition and caloric content on nausea and slow wave rhythm in 14 nauseated pregnant women. Electrogastrography quantified dysrhythmic activity and signal power responses to meals. Symptomatic women reported mild to moderate nausea and exhibited increased dysrhythmias during fasting (P < 0.05). Protein-predominant meals reduced nausea and dysrhythmic activity to greater degrees than equicaloric carbohydrate and fat meals and noncaloric meals (P < 0.05). Meal consistency did not affect symptom responses, although liquid meals decreased dysrhythmias more than solids (P < 0.05). Carbohydrates and fats increased electrogastrographic power to similar degrees as proteins, whereas responses to noncaloric meals were less. In conclusion, protein meals selectively reduce nausea and gastric slow wave dysrhythmias in first trimester pregnancy. Meal consistency is a limited factor in the favorable effects of protein. Electrogastrographic power changes do not explain the symptom response to protein. Thus dietary modulation of gastric myoelectric rhythm with protein supplementation may provide symptomatic benefit in nausea of pregnancy.

Investigation of an outbreak of vancomycin-resistant Enterococcus faecium in a low prevalence university hospital

BACKGROUND

Until 1995, there were no cases of vancomycin resistant enterococcus (VRE) identified at our university hospital. From May 1995 to August 1996, we investigated a cluster of 10 cases of phenotypic class Van B Enterococcus faecium.

METHODS

Patients were matched with controls who were on the same unit for at least 7 days prior to the case developing VRE. Control patients were age and sex matched if possible, and had duration of hospitalization at least as long as the number of days it took the patient to become VRE positive. We analyzed 16 independent risk factors using Epi-info version 6. Environmental cultures were obtained in the MICU where 5 of the patients were located. All 10 patient isolates and environmental isolates were analyzed by pulsed field gel electrophoresis (PFGE).

RESULTS

PFGE confirmed the genetic relatedness of all 10 patient isolates and environmental isolates. The VRE-positive group was more likely to be immunosuppressed and to have exposure to 3 physicians. In the MICU, significant, P < 0.05) risk factors for VRE were higher Apache scores, location adjacent to a VRE case, duration of vancomycin and amino-glycoside use, duration of invasive catheter use, and diarrhea. Among the VRE-positive environmental cultures was a blood pressure cuff wash that was used on several patients.

CONCLUSION

We hypothesize that a VRE strain was introduced into our hospital environment and was spread by personnel or contaminated equipment. As a consequence of this study, a hospital-wide VRE policy was implemented.

Differential symptomatic and electrogastrographic effects of distal and proximal human gastric distension

Nausea and gastric dysrhythmias occur in conditions associated with gastric distension. The roles of distal and proximal gastric mechanoreceptors in these responses are unexplored. Because antral distension induces vomiting in animals and antral and fundic vagal afferent discharges differ, we hypothesized that distal gastric distension in humans leads to greater symptomatic and dysrhythmic responses than proximal distension. Symptoms and electrogastrograms were recorded in healthy humans during distal and proximal gastric distension with a barostat. Distal but not proximal distension induced nausea and a 747 +/- 250% increase in dysrhythmic power (P < 0.05), responses not affected by granisetron, indomethacin, or atropine, agents that block dysrhythmias in other settings. In the distal stomach, bloating and pain developed at lower pressures (P < 0.05) not modified by granisetron, and compliance was significantly lower (P < 0.05). In conclusion, gastric mechanoreceptor activation in the less-compliant distal stomach produces nausea and dysrhythmias via non-5-hydroxytryptamine3 (5-HT3), non-prostaglandin-dependent, and noncholinergic pathways. Distal mechanoreceptor activation induces greater bloating and pain than proximal mechanoreceptor activation via 5-HT3-independent pathways.

Differential 5-HT3 mediation of human gastrocolonic response and colonic peristaltic reflex

Colonic motor function is modulated by extended and local neural reflexes involving unknown mediators. To test the role of serotonin (5-HT3) pathways, increases in colonic tone during antral distension and duodenal lipid perfusion (gastrocolonic responses) and changes in orad and caudad colonic tone in response to local colonic distension (peristaltic reflex) were measured after double-blind granisetron (10 microg/kg) or placebo infusion in healthy human volunteers. Antral distension evoked increases in colonic tone, which were blunted by granisetron (P < 0.05) without effects on antral compliance. Intraduodenal lipid perfusion also evoked increased colonic tone, which was reduced by granisetron (P < 0.05). In contrast, orad colonic contractions and caudad relaxations and contractions during colonic distension were unaffected by granisetron. In conclusion, 5-HT3 receptor antagonism blunts both the mechano- and chemoreceptor components of the human gastrocolonic response without altering antral compliance. In contrast, 5-HT3 pathways play no role in the ascending or descending components of the colonic peristaltic reflex. These findings demonstrate different roles for 5-HT3 receptors in the control of colonic motor function by the proximal gastrointestinal tract and by local neural reflexes.

HIV combination therapy: partial immune restitution unmasking latent cryptococcal infection

OBJECTIVE

To describe two cases of cryptococcal meningitis and one re-exacerbation of Cryptococcus-associated meningitis occurring in temporal association with commencement of highly active antiretroviral therapy (HAART) in patients with advanced HIV infection (CD4 cells < 50 x 10(6)/l), which suggests that partial immune restitution can facilitate development of clinically apparent meningitis in response to Cryptococcus or its antigen.

DESIGN

All HIV-infected patients with culture-proven cryptococcal meningitis diagnosed at a tertiary referral centre specialist infectious diseases unit from 1 January 1996 to 31 December 1996 were reviewed to examine the clinical and immunological parameters prior to and after commencing antiretroviral therapy.

RESULTS

Three patients were diagnosed with clinically apparent meningitis within 7-39 days of changing or altering antiretroviral combination therapy consisting of zidovudine or stavudine, in combination with lamivudine and saquinavir. All patients had CD4 cell counts below 50 x 10(6)/l at initiation of therapy. Following institution of HAART, evidence of immune restitution was suggested by the following: (i) significant increases (3.7-14-fold) in numbers of CD4 cells (all three patients), (ii) significantly reduced (> 2-4 log10 reduction) HIV viral loads (two out of three patients), and (iii) prominent inflammatory changes in cerebrospinal fluid (white blood cells > 10 x 10(6)/l) at diagnosis (two out of three patients).

CONCLUSIONS

Our report suggests that in patients with advanced HIV infection, partial immune restitution induced by HAART can precipitate onset of clinically apparent meningitis in those patients with latent cryptococcal central nervous system infection or with residual cryptococcal antigen present in the cerebrospinal fluid.

Chlamydia species infect human vascular endothelial cells and induce procoagulant activity

BACKGROUND

Chlamydia pneumoniae infections have been linked with myocardial infarction, stroke, and the development of atherosclerosis by epidemiologic studies, immunohistochemical studies, and electron microscopic studies. The mechanisms underlying this association are unknown.

METHODS

Using cultured human venous endothelial cells, we investigated whether C pneumoniae, C trachomatis (types H and L2/434/BU) could infect these cells. The ability of infected cells to express procoagulant (tissue factor) activity was also measured using clotting and chromogenic substrate assays. Adhesion of platelets to chlamydia-infected cells was also quantitated.

RESULTS

We found that C pneumoniae, C trachomatis type H, and C trachomatis L2/434/BU could infect cultured human umbilical vein endothelial cells and stimulate a 4-fold increase in expression of tissue factor, which reached a peak 18 hours postinfection. Tissue factor expression was enhanced even in the presence of tetracycline, suggesting that the chlamydial factor responsible for stimulating synthesis of endothelial cell tissue factor was preformed. Platelet adhesion was significantly enhanced when endothelial cells were infected by chlamydia species.

CONCLUSIONS

These in vitro studies suggest possible pathogenic mechanisms that may explain the association of thrombotic events with C pneumoniae infection, including pathologically enhanced production of tissue factor by human endothelial cells and enhanced focal platelet deposition.

Necrotizing group A streptococcal infections associated with streptococcal toxic shock syndrome

BACKGROUND

Group A streptococci (GAS) cause a variety of life-threatening infectious complications, including necrotizing fasciitis (NF), purpura fulminans (PF), and streptococcal toxic shock syndrome (strepTSS), in which bacteremia is associated with shock and organ failure.

METHODS

We reviewed our experience in the management of patients with necrotizing GAS infections from 1991 to 1995.

RESULTS

Eight adult patients (6 NF, 2 PF) were identified. Patients presented with fever, leukocytosis, and severe pain, and rapidly developed shock and organ dysfunction. The diagnosis of strepTSS was confirmed in 6 cases. A total of 54 surgical procedures were required, including widespread debridements and amputations. Two patients died (25%).

CONCLUSIONS

Recognition of the need for aggressive diagnosis and surgical treatment of this most rapidly progressive surgical infection is necessary for successful management.

Increased incidence of Chlamydia species within the coronary arteries of patients with symptomatic atherosclerotic versus other forms of cardiovascular disease

OBJECTIVES

The objectives of this study were to test prospectively for an association between Chlamydia and atherosclerosis by comparing the incidence of the pathogen found within atherosclerotic plaques in patients undergoing directional coronary atherectomy with a variety of control specimens and comparing the clinical features between the groups.

BACKGROUND

Previous work has suggested an association between Chlamydia pneumoniae infection and coronary atherosclerosis, based on the demonstration of increased serologic titers and the detection of bacteria within atherosclerotic tissue, but this association has not yet been regarded as established.

METHODS

Coronary specimens from 90 symptomatic patients undergoing coronary atherectomy were tested for the presence of Chlamydia species using direct immunofluorescence. Control specimens from 24 subjects without atherosclerosis (12 normal coronary specimens and 12 coronary specimens from cardiac transplant recipients with subsequent transplant-induced coronary disease) were also examined.

RESULTS

Coronary atherectomy specimens were definitely positive in 66 (73%) and equivocally positive in 5 (6%), resulting in 79% of specimens showing evidence for the presence of Chlamydia species within the atherosclerotic tissue. In contrast, only 1 (4%) of 24 nonatherosclerotic coronary specimens showed any evidence of Chlamydia. The statistical significance of this difference is a p value < 0.001. Transmission electron microscopy was used to confirm the presence of appropriate organisms in three of five positive specimens. No clinical factors except the presence of a primary nonrestenotic lesion (odds ratio 3.0, p = 0.057) predicted the presence of Chlamydia.

CONCLUSIONS

This high incidence of Chlamydia only in coronary arteries diseased by atherosclerosis suggests an etiologic role for Chlamydia infection in the development of coronary atherosclerosis that should be further studied.

Ochrobactrum anthropi meningitis in pediatric pericardial allograft transplant recipients

An epidemiologic investigation was done after 3 patients contracted Ochrobactrum anthropi meningitis at one hospital in October 1994. Neurosurgical patients with pericardial tissue implants were at greater risk of infection than other neurosurgical patients (3/14 vs. 0/566; P<.001). Cultures of implants removed from 2 case-patients, an implant at implantation, a nonimplanted pericardial tissue, and an unwrapped but unopened bottle of Hank's balanced salt solution (HBSS) grew O. anthropi. Patient and tissue isolates had identical genotypes; the isolate from the HBSS bottle had a unique genotype. Culture samples from an unopened HBSS bottle and from pericardial tissue grew Pseudomonas stutzeri of the same genotype; however, no P. stutzeri infections were detected. The investigation documented intrinsic P. stutzeri contamination of HBSS. O. anthropi contamination of tissues occurred during processing, possibly due to extrinsic contamination of HBSS. Active surveillance is needed to detect infection in patients receiving transplanted tissues, and rigorous infection control practice are necessary during tissue harvesting and processing to ensure sterility.

Detection of individual hypoxic cells in multicellular spheroids by flow cytometry using the 2-nitroimidazole, EF5, and monoclonal antibodies

PURPOSE

The purpose of this work was to evaluate EF5, a 2-nitroimidazole compound, and anti-EF5 antibodies as a method to quantify radiobiologically hypoxic cells.

METHODS AND MATERIALS

Multicellular spheroids of EMT6 mammary sarcoma cells were used as a model to identify hypoxic cells that were resistant to radiation damage. This was accomplished by incubating the spheroids with the 2-nitroimidazole (EF5), which forms hypoxia-dependent adducts with cellular macromolecules that are detected by fluorescent monoclonal antibodies.

RESULTS

Cells from spheroids grown for 2 days in sealed flasks had an increased surviving fraction following radiation as compared to fully reoxygenated spheroids, indicating the presence of radiobiological hypoxia. Treatment of the spheroids with EF5 and subsequent immunohistochemical staining of cryosections with an anti-EF5 fluorochrome conjugated monoclonal antibody allowed for the identification of EF5-adduct containing cells. Spheroids grown under hypoxic conditions in the presence of EF5 showed limited staining of the peripheral cell layers, intense staining of the interior, and an absence of staining within the necrotic center. In contrast, there was minimal staining in reoxygenated spheroids and no staining in control spheroids incubated in the absence of EF5. Flow cytometric analysis of single cells dissociated from spheroids allowed for the calculation of the percentage of stained cells, as well as the intensity of staining. A comparison of the intensity of staining of EF5 treated hypoxic spheroids with the intensity of staining of single cells incubated with EF5 under controlled oxygen concentrations was used to estimate the oxygen concentration range within spheroids. Selective dissociation of spheroids provided a direct demonstration that the cells containing the highest level of EF5 binding were also the cells with increased radiation resistance.

CONCLUSION

This technique provides an excellent means of detecting and quantifying hypoxia, which should be directly applicable in tumors.

DHEAS as an effective vaccine adjuvant in elderly humans. Proof-of-principle studies

We have demonstrated that in aged mice, the titer of serum antibody induced against tetanus toxoid correlates with resistance to local paralysis caused by injection of tetanus toxin. Only mice immunized shortly after oral dosing with DHEAS demonstrated high serum antibody titers and complete protection from paralysis. These results became the basis for initiating proof-of-principle studies in human volunteers above age 65 using a licensed influenza vaccine and tetanus toxoid in two independent studies. The use of an oral delivery form of DHEAS before influenza vaccination was associated with a demonstrable increase in the number of individuals with a fourfold increase in HAI titers following vaccination. The overall mean increase in HAI titers was highest in the DHEAS-treated group. The use of DHEAS in the immunization of elderly subjects against tetanus toxoid, while unable to enhance the responses, was not a detriment to antibody response. We conclude that further studies will justify the use of DHEAS as an adjuvant for antigens that represent primary responses in the elderly.

B7-1 enhances natural killer cell-mediated cytotoxicity and inhibits tumor growth of a poorly immunogenic murine carcinoma

The B7-1 molecule expressed on antigen presenting cells is an important costimulatory molecule for T cell activation. It has been demonstrated that murine B7-1 can enhance host immunity and lead to tumor rejection via its costimulatory function. Here, we investigate how transfection of B7-1 into line 1, a poorly immunogenic murine lung carcinoma, affects the generation and function of different immune effector cells. Line 1 cells expressing B7-1 form tumors that grow at a slower rate than the parental line 1. Our studies have shown that tumor infiltrating lymphocytes present within the B7-1 expressing tumors are primarily composed of nonspecific killer cells with no specific cytotoxic T cells present. To determine if increased nonspecific killer cells could inhibit the tumor growth of line 1 in the presence of B7-1, we examined the cytotoxicity of natural killer (NK) cells and lymphokine-activated killer (LAK) cells on the B7-1-transfected line 1 and the parental line 1. We found that B7-1 augments the NK- but not LAK-mediated killing against line 1 as measured in an in vitro 51Cr-release cytotoxicity assay. This enhancement could be blocked by CTLA-4 Ig. In vivo depletion of NK cells led to growth of the B7-1-transfected line 1 at the same rate as the parental line 1. These results suggest that in addition to its costimulatory role for T cell activation B7-1 could be an accessory molecule that intensifies NK-mediated cytotoxicity. This novel finding may provide a mechanism for the effect of B7-1 on tumors of low immunogenicity.

Comparison of MIDI Sherlock system and pulsed-field gel electrophoresis in characterizing strains of methicillin-resistant Staphylococcus aureus from a recent hospital outbreak

An outbreak of methicillin-resistant Staphylococcus aureus infections at the University of Utah Health Sciences Center occurred over a 7-month period. While the isolates phenotypically appeared to be similar in gross morphology and have similar Vitek antibiotic susceptibility patterns, two additional methods of strain characterization were evaluated to enhance the epidemiological investigation: pulsed-field gel electrophoresis and gas chromatography with the MIDI Sherlock system. Sherlock uses gas chromatography to qualitatively and quantitatively analyze the cellular fatty acid composition of organisms and creates two-dimensional plots based on principal-component analysis to define groups of closely related organisms. All isolates were also evaluated by digesting their chromosomal DNAs with the low-frequency-cutting enzyme SmaI and separating the restriction fragments by contour-clamped homogeneous electric field gel electrophoresis. Sample preparation for this pulsed-field gel electrophoresis included a novel cell lysis procedure involving achromopeptidase, greatly reducing the turnaround time. Isolates tested were recovered from the following: 45 suspected outbreak patients, 6 hospitalized patients believed to be unrelated to the outbreak, 6 patients from outside the hospital, and one health care practitioner implicated in the outbreak. Of 45 phenotypically similar suspect strains, 43 clustered tightly on the Sherlock two-dimensional plot. All outbreak patient isolates were also identical by pulsed-field gel electrophoresis with the exception of the same two outliers identified by Sherlock. In this epidemiologic investigation, we found an excellent correlation between the Sherlock and pulsed-field gel electrophoresis results for strain characterization of methicillin-resistant S. aureus.

Transfection of transforming growth factor-beta producing tumor EMT6 with interleukin-2 elicits tumor rejection and tumor reactive cytotoxic T-lymphocytes

One mechanism by which potentially immunogenic tumors evade the immune response is production of immunosuppressive factors. The murine mammary sarcoma EMT6 has previously been demonstrated to inhibit the proliferation of B-cells, suggesting that this tumor produces immunosuppressive factors. Here, we show that supernatant from EMT6 inhibits the development of cytotoxic T-lymphocytes (CTLs) and that this inhibition can be reversed by addition of recombinant interleukin (IL)-2. Furthermore, we show that EMT6 produces high levels of the immunosuppressant factor transforming growth factor (TGF)-beta. To determine if the T-cell growth factor IL-2 within the tumor microenvironment could reverse the immunosuppressive effect of EMT6, we transfected EMT6 with an expression vector containing the cDNA for murine IL-2 under the control of the beta-actin promoter. These transfectants produce significant levels of IL-2 (26 U/ml). EMT6/IL-2 is rejected by mice at 100-fold higher challenge than are parental cells or control transfectants (neomycin resistance only). Thy-1-expressing cells purified from EMT6/IL-2 tumors show greater cytotoxicity against the parental EMT6 cells than do those from the control transfectant. Thus, IL-2 can reverse the effects of TGF-beta on development and/or proliferation of CTL reactive with EMT6, allowing the establishment of mature effectors in vivo. This has significant implications for the development of CTL and immunotherapy for immunosuppressive tumors.

Reversal of the immunosenescent phenotype by dehydroepiandrosterone: hormone treatment provides an adjuvant effect on the immunization of aged mice with recombinant hepatitis B surface antigen

This study sought to establish whether administration of dehydroepiandrosterone (DHEA) or its sulfate derivative to aged mice could effectively correct the immunosenescent phenotype. Supplemental DHEA sulfate and topical DHEA fully corrected the age-associated dysregulated production of T cell lymphokines by cells from all of the different lymphoid organs tested. Either DHEA or DHEA sulfate supplementation promoted enhanced antibody responses against recombinant hepatitis B surface antigen (rHBsAg) by the aged recipients when incorporated directly into the vaccine. When DHEA was provided either topically or was incorporated directly into vaccine, vigorous primary and secondary antibody responses were detected in the aged mice given a single administration of DHEA, regardless of the mode of administration. It was also established that DHEA treatment could enhance specific antibody responses to rHBsAg in aged animals that had previously not been effectively immunized by conventional vaccination procedures.

Gamma interferon-induced nitric oxide production reduces Chlamydia trachomatis infectivity in McCoy cells

McCoy cells, murine-derived cells commonly used for propagation of chlamydiae, were found to be efficient producers of nitric oxide (NO) when primed with murine gamma interferon (IFN-gamma) and then exposed to the second signals provided by Escherichia coli lipopolysaccharide, human interleukin-1 alpha, murine tumor necrosis factor alpha, or Chlamydia trachomatis type H. Murine recombinant IFN-gamma over a range of 0 to 50 U/ml inhibited infectivity of C. trachomatis type H in a dose-dependent fashion in McCoy cells while simultaneously inducing NO production. Quantitation of infectious chlamydia progeny remaining in McCoy cells 48 or 72 h postinfection revealed that IFN-gamma-primed McCoy cells reduced chlamydial inclusion-forming units (expressed as units per milliliter) by 4 log10 units at higher IFN-gamma concentrations (50 U/ml) compared with control values. The magnitude of this antichlamydial effect was directly related to increased synthesis of NO, the production of which was IFN-gamma dose dependent. The antichlamydial effects of IFN-gamma were blocked in a dose-dependent manner by the addition of N-guanidino-monomethyl L-arginine (MLA), an inhibitor of nitric oxide synthesis. These results suggest that although IFN-gamma priming of McCoy cells is required for antichlamydial activity, nitric oxide is a necessary effector molecule involved in the mechanism(s) of IFN-gamma-induced inhibition of chlamydial proliferation in this murine cell line. The ability to block the potent antichlamydial effects of IFN-gamma by inhibition of a specific enzyme, nitric oxide synthase, may give insights into mechanisms by which IFN-gamma and perhaps other cytokines are able to control proliferation of chlamydiae and other intracellular pathogens.

Induction of arthritis in DA rats by incomplete Freund's adjuvant

OBJECTIVE

To define the arthritogenic effects of incomplete Freund's adjuvant (ICFA) injections in DA rats.

METHODS

ICFA was injected into DA rats and other inbred rat strains. The severity of arthritis was scored and associated changes in weight recorded.

RESULTS

After ICFA injection a mild transient symmetric arthritis developed in 15/22 (68%) of the DA rats observed for greater than 4 weeks. Histologic examination of the observed arthritis showed edema and neutrophil infiltrates with some lymphocytes and plasma cells. No arthritis developed in DA rats given normal saline injections nor in Lewis, DA.1N and WF.1N rats given ICFA.

CONCLUSIONS

Injection of DA rats with ICFA alone can produce arthritis.

Suppression of adjuvant-induced arthritis in DA rats by incomplete Freund's adjuvant

OBJECTIVE

To define the effects of incomplete Freund's adjuvant (ICFA) on subsequent arthritis induced by complete Freund's adjuvant (CFA) and type II collagen (CII) in DA and Lewis rats.

METHODS

ICFA was injected into DA and Lewis rats before CFA or CII injection.

RESULTS

DA rats previously injected with ICFA had significantly less severe arthritis induced by CFA compared with those not receiving ICFA pretreatment (P < 0.01). ICFA had no significant impact on CFA-induced arthritis in Lewis rats or on CII-induced arthritis in DA rats.

CONCLUSION

The injection of ICFA alone specifically suppresses subsequent CFA-induced arthritis in DA rats, but not in Lewis rats.

Neurological melioidosis: seven cases from the Northern Territory of Australia

Pseudomonas pseudomallei, which causes melioidosis, is most commonly associated with pulmonary infection. We describe seven patients who developed a neurological syndrome as the predominant manifestation of melioidosis: this syndrome was characterized by peripheral motor weakness (mimicking Guillain-Barré syndrome), brain-stem encephalitis, aseptic meningitis, and respiratory failure. Neurological melioidosis occurred in the absence of demonstrable foci of infection in the central nervous system (CNS) in five of six patients whose cerebrospinal fluid was available for culture. Computed tomography and magnetic resonance imaging of the brain and spinal cord of these patients were not suggestive of pyogenic infection, although the latter procedure detected brain-stem encephalitis. Autopsy findings in one case confirmed brain-stem encephalitis without evidence of direct bacterial infection. The clinical presentation of neurological melioidosis includes features of an exotoxin-induced neurological syndrome, with profound neurological disease occurring in the absence of apparent direct infection of the CNS. This syndrome appears to be a newly recognized clinical presentation of melioidosis.

Pertussis: an old disease in a new era

Pertussis has a worldwide incidence of 51,000,000 cases per year with a 1% case fatality rate and primarily affects young children. Despite the availability of an effective whole-cell pertussis vaccine, pertussis has reemerged as a significant cause of human morbidity in areas where pertussis vaccine programs have ceased because of vaccine safety concerns. The search for new vaccines without side effects has stimulated an intensive study of virulence determinants of Bordetella pertussis. As a result of this research, virulence genes of B pertussis and factors that regulate these genes have been identified and characterized. The molecular characterization of the virulence determinants of B pertussis has helped to elucidate the basis of some of the clinical observations that characterize disease caused by B pertussis. It appears that host factors may potentially determine whether virulence genes are expressed. It is now possible to construct mutants of B pertussis that are deficient in individual virulence determinants. The era of the molecular Koch's postulates is upon us, and the roles of individual virulence factors in disease pathogenesis can be studied. In this article, issues concerning immunity to pertussis, safety of whole-cell vaccine, and virulence factors of B pertussis are considered. The molecular Koch's postulates as they relate to testing prospective virulence factors in pertussis infection model systems will be presented. The mucosal environment as a potential modulator of virulence factors will be addressed.

Synthesis of a select group of proteins by Neisseria gonorrhoeae in response to thermal stress

We report the thermal conditions that induce the heat shock response in Neisseria gonorrhoeae. Under conditions of thermal stress, Neisseria gonorrhoeae synthesizes heat shock proteins (hsps), which differ quantitatively from conventionally studied gonococcal proteins. Gonococci accelerate the rate of synthesis of the hsps as early as 5 min after the appropriate stimulus is applied, with synthesis continuing for 30 min, as demonstrated by in vivo labeling experiments with L-[35S]methionine. Two of the gonococcal hsps are immunologically cross-reactive with the hsps of Escherichia coli, DnaK and GroEL, as demonstrated by Western blot (immunoblot) analysis. Ten hsps can be identified on two-dimensional autoradiograms of whole gonococci (total protein). Four hsps can be identified on two-dimensional autoradiograms of 1% N-lauroylsarcosine (sodium salt) (Sarkosyl)-insoluble membrane fractions. Two of the hsps from the 1% Sarkosyl-insoluble fraction are found exclusively in this fraction, suggesting that they are membrane proteins. The identification of this group of proteins will facilitate further study of the function of these proteins and provide insight into the possible role of hsps in disease pathogenesis.

Molecular mechanisms of pathogenicity of gonococcal salpingitis

Despite the availability of effective antimicrobial agents and aggressive public health programmes, gonococcal infections, including salpingitis, remain a major worldwide problem resulting in significant rates of morbidity and infertility. Using an experimental model of gonococcal-infected human fallopian tubes in organ culture which are examined by light microscopy and scanning and transmission electron microscopy, basic pathogenic interactions between the gonococcus and the fallopian tube have been elucidated. The major steps in the pathogenic process include attachment, damage and invasion. Attachment appears to result from interaction of gonococcal pili with the tips of microvilli of non-ciliated cells of the fallopian tube mucosa. After gonococcal attachment occurs, fallopian tube damage is evident with loss of ciliary activity and sloughing of ciliated cells. The 2 compounds most likely to be mediators of this damage appear to be gonococcal lipopolysaccharide, which is released from the surface of the organism in the form of outer membrane blebs, as well as monomeric units of peptidoglycan, which are elaborated by the organism. Gonococcal attachment and perhaps elaboration of some molecule appear to initiate phagocytosis by non-ciliated epithelial cells. Gonococci are transported to the base of the non-ciliated cells and are released into the subepithelial space. This may lead to local disease (salpingitis) or disseminated disease (dermatitis-arthritis). Understanding the molecular mechanisms by which gonococci attach to, damage or invade the fallopian tube mucosa may result in identification of ways of preventing gonococcal infections and their sequelae.

Extrinsic factors that put patients at risk of acquiring central nervous system infections

Although many host defenses, including physical barriers, phagocytic cells, and humoral elements, normally protect the central nervous system from microbial pathogens, a variety of extrinsic factors may compromise these defenses and put patients at risk of acquiring central nervous system infection. These risk factors include: (1) communication of the cerebrospinal fluid space with integumentary surfaces; (2) communication of the cerebrospinal fluid space with other body spaces through shunts; (3) suppurative foci contiguous to the central nervous system; (4) hematogenous spread of infectious agents; (5) new acquisition of infectious agents with a propensity for causing central nervous system infection; and (6) administration of certain antimicrobial or immunosuppressive drugs. Recognition that these factors are present and therefore that the patient is at risk allows monitoring for and prompt response to signs and symptoms of central nervous system infection.