SARS-CoV-2 shedding, infectivity, and evolution in an immunocompromised adult patient

This study aimed to provide further insight into the evolutionary dynamics of SARS-CoV-2 by analyzing the case of a 40-year-old man who had previously undergone autologous hematopoietic stem cell transplantation due to a diffuse large B-cell lymphoma. He developed a persistent SARS-CoV-2 infection lasting at least 218 days and did not manifest a humoral immune response to the virus during this follow-up period. Whole-genome sequencing and viral cultures confirmed a persistent infection with a replication-positive virus that had undergone genetic variation for at least 196 days after symptom onset.

Prevalence and clinical consequences of Hepatitis C virus infection in patients undergoing hematopoietic stem cell transplantation

Hepatitis C virus (HCV) infection is a significant cause of morbidity and mortality among hematopoietic stem cell transplant (HCT) recipients. In Brazil, its occurrence in HCT recipients remains undetermined. We now report on HCV prevalence in HCT recipients and its clinical consequences. The medical records of all HCT recipients seen at Hospital das Clinicas, Sao Paulo University Medical School, from January 2010 to January 2020 were reviewed to determine HCV serostatus. A retrospective analysis of medical charts was undertaken on all seropositive cases to determine HCV genotype, presence of liver fibrosis, co-infections with other viruses, previous treatments, and clinical evolution of liver pathology after HCT. Of the 1,293 HCT recipients included in the study, seven (0.54%) were HCV antibody-positive and five (0.39%) were also viremic for HCV-RNA. Four of these individuals had moderate to severe liver fibrosis (METAVIR F2/F3) and one was cirrhotic. Two of the viremic patients developed acute liver dysfunction following transplantation. All patients had their acute episode of liver dysfunction resolved with no further complications. Four of the viremic patients were treated for HCV infection with direct acting agents (DAA). Information regarding HCV treatment was lacking for one of the viremic HCV patients due to loss of follow up. Sustained anti-virologic responses were observed in three cases after the use of DAA. The detection of HCV in hematological adults undergoing HCT and its successful treatment with DAA highlight the necessity of testing for HCV both prior to and following transplantation.

The Changing Epidemiology of Hepatitis C Virus Acquisition Among HIV-Infected Individuals in Brazil

Identification of mechanisms of hepatitis C virus (HCV) acquisition among HIV-infected people is critical for prevention guidance. The aim of this study was to investigate risk factors for HCV infection and variations in HCV genotype distribution in a cohort of HIV-HCV coinfected patients in Brazil. This was a cross-sectional observational epidemiological study of a cohort of HIV-HCV coinfected individuals seen at a referral center for HIV-infected patients in the city of São Paulo between January and December 2017. The time of HCV acquisition, as determined by chart review, was categorized as before 2000, between 2000 and 2009, and from 2010 onward. HCV genotypes were determined by gene amplification and analysis. Among 3,143 HIV-infected individuals analyzed, 362 (11.5%) were HCV-HIV coinfected. Overall, the reported modes of HCV acquisition were sexual exposure in 172 (47.5%), injection drug use (IDU) in 86 (23.8%), use of inhaled drugs in 67 (18.5%) and blood transfusion in 10 (2.8%) individuals. All individuals who acquired HCV after IDU became infected before 2010. HCV acquisition by sexual contact was reported by 26.4%, 65.9%, and 63.8% of patients before 2000, between 2000 and 2009, and from 2010, respectively. There was an increase (p < .001) in the proportion of cases due to sexual transmission from the period before 2000 (26.4%) to between 2000 and 2009 (65.9%). There was no corresponding increase from 2000 and 2009 to after 2010 (p = .751). HCV genotype 1 was most prevalent at all time periods. The genotype 3 frequency decreased over time (test for trend p < .001), whereas genotype 4, extremely uncommon before 2010, became the second most prevalent genotype from 2010 onward. In HIV-infected individuals in Sao Paulo, Brazil, sexual transmission has replaced IDU as the most frequent mode of HCV acquisition.

Absence of neutralizing antibodies against the Omicron SARS-CoV-2 variant in convalescent sera from individuals infected with the ancestral SARS-CoV-2 virus or its Gamma variant

OBJECTIVES

The aim of the present study was to evaluate if neutralizing antibody responses induced by infection with the SARS-CoV-2 strain that was dominant at the beginning of the pandemic or by the Gamma variant was effective against the Omicron variant.

METHODS

Convalescent sera from 109 individuals, never exposed to a SARS-CoV-2 vaccine, who had mild or moderate symptoms not requiring hospitalization following either a documented SARS-CoV-2 ancestral strain infection or a Gamma variant infection, were assayed for in vitro neutralizing antibody activity against their original strains and the Omicron variant.

RESULTS

Following an infection with the ancestral strain, 56 (93.3%), 45 (77.6%) and 1 (1.7%) serum sample were positive for neutralizing antibodies against the ancestral, Gamma variant, and Omicron variant, respectively. After infection with the Gamma variant, 43 (87.8%) and 2 (4.1%) sera were positive for neutralizing antibodies against the Gamma and Omicron variants, respectively.

CONCLUSIONS

Neutralizing antibodies generated following mild or moderate infection with the SARS-CoV-2 ancestral strain or the Gamma variant are not protective against the Omicron variant.

Identification of bacteriophages in the vagina of pregnant women: a descriptive study

OBJECTIVE

To determine the presence and identity of extracellular bacteriophage (phage) families, genera and species in the vagina of pregnant women.

DESIGN

Descriptive, observational cohort study.

SETTING

São Paulo, Brazil.

POPULATION

Pregnant women at 21-24 weeks' gestation.

METHODS

Vaginal samples from 107 women whose vaginal microbiome and pregnancy outcomes were previously determined were analysed for phages by metagenomic sequencing.

MAIN OUTCOME MEASURES

Identification of phage families, genera and species.

RESULTS

Phages were detected in 96 (89.7%) of the samples. Six different phage families were identified: Siphoviridae in 69.2%, Myoviridae in 49.5%, Microviridae in 37.4%, Podoviridae in 20.6%, Herelleviridae in 10.3% and Inviridae in 1.9% of the women. Four different phage families were present in 14 women (13.1%), three families in 20 women (18.7%), two families in 31 women (29.1%) and one family in 31 women (29.1%). The most common phage species detected were Bacillus phages in 48 (43.6%), Escherichia phages in 45 (40.9%), Staphylococcus phages in 40 (36.4%), Gokushovirus in 33 (30.0%) and Lactobacillus phages in 29 (26.4%) women. In a preliminary exploratory analysis, there were no associations between a particular phage family, the number of phage families present in the vagina or any particular phage species and either gestational age at delivery or the bacterial community state type present in the vagina.

CONCLUSIONS

Multiple phages are present in the vagina of most mid-trimester pregnant women.

TWEETABLE ABSTRACT

Bacteriophages are present in the vagina of most pregnant women.

Impact on mortality of being seropositive for hepatitis C virus antibodies among blood donors in Brazil: A twenty-year study

Introduction

Hepatitis C virus (HCV) infection is a major health problem associated with considerable risk of mortality in different regions of the world. The purpose of this study was to investigate the contribution of HCV infection on all-cause and liver-related mortality, in a large cohort of blood donors in Brazil.

Methods

This is a retrospective cohort study of blood donors from 1994 to 2013, at Fundação Pró-Sangue—Hemocentro de São Paulo (FPS). This cohort included 2,892 and 5,784 HCV antibody seropositive and seronegative donors, respectively. Records from the FPS database and the Mortality Information System (SIM: a national database in Brazil) were linked through a probabilistic record linkage (RL). Mortality outcomes were defined based on ICD-10 (10th International Statistical Classification of Diseases and Related Health Problems) codes listed as the cause of death on the death certificate. Hazard ratios (HRs) were estimated for outcomes using Cox multiple regression models.

Results

When all causes of death were considered, RL identified 209 deaths (7.2%) among seropositive blood donors and 190 (3.3%) among seronegative blood donors. Donors seropositive for HCV infection had a 2.5 times higher risk of death due to all causes (95% CI: 1.76–2.62; p<0.001). When only liver-related causes of death were considered, RL identified 73 deaths among seropositive blood donors and only 6 among seronegative blood donors. Donors seropositive for HCV infection had a 23.4 times higher risk of death due to liver related causes (95% CI: 10.2–53.9; p<0.001). Donors seropositive for HCV had a 29.5 (95%CI: 3.9–221.7), 2.8 (95% CI: 1.4–5.5) and a 1.9 (95% CI: 1.2–3.0) times higher risk of death due to hepatocellular carcinoma, infection or trauma, respectively, compared to seronegative donors.

Conclusions

All-cause and liver-related mortality rate was increased among blood donors seropositive for HCV compared with the mortality rate among seronegative blood donors. Our data confirms HCV as a relevant cause of death in Brazil and also suggest that interventions directed at following patients even after access to specific drug treatment are urgent and necessary.

Amniotic fluid lactic acid and matrix metalloproteinase-8 levels at the time of fetal surgery for a spine defect: association with subsequent preterm prelabour rupture of membranes

OBJECTIVE

In utero fetal surgery to correct incomplete closure of the spinal cord lessens the extent of permanent damage but is associated with preterm prelabour rupture of membranes (PPROM). We determined whether compounds in amniotic fluid collected at the time of surgery predicted subsequent development of PPROM.

DESIGN

Prospective study.

SETTING

Hospitals in Sao Paulo, Brazil.

POPULATION

Twenty-four consecutive pregnant women at 24-26 weeks of gestation seen between February and October 2017 with a singleton pregnancy underwent in utero surgery to correct an open spinal defect in their fetus.

METHODS

Amniotic fluid was tested for lactic acid, matrix metalloproteinase 2 (MMP-2), MMP-8, MMP-9 and interleukin-6 (IL-6) by enzyme-linked immunosorbent assay. Clinical data were collected after completion of all laboratory studies.

MAIN OUTCOME MEASURE

Amniotic fluid concentration of compounds in women with or without PPROM.

RESULTS

Preterm prelabour rupture of membranes occurred in seven (29.2%) women. There were no differences in maternal age, gravidity, parity, race, history of caesarean sections or fetal gender between women with or without PPROM. Length of surgery, days of wound healing and length of hospital stay were also indistinguishable. The median concentrations of MMP-8 (1.7 versus 0.6 ng/ml; P = 0.0041) and lactic acid (7.1 versus 5.9 mm; P = 0.0181) were higher in women with PPROM. The amniotic fluid MMP-8 level was also negatively correlated with gestational age at delivery (Spearman r = -0.4217, P = 0.0319).

CONCLUSION

Differences in susceptibility to develop PPROM are present before fetal surgery. An increase in anaerobic glycolysis, evidenced by the intra-amniotic lactic acid level, may enhance MMP-8 production and weaken maternal and fetal membranes.

TWEETABLE ABSTRACT

Matrix metalloproteinase-8 and lactic acid in amniotic fluid predict preterm prelabour rupture of membranes.

Bacterial vaginosis: a critical analysis of current knowledge

Bacterial vaginosis (BV), the change from a Lactobacillus-dominant vaginal microbiota to an anaerobic and facultative bacterial dominance, is associated with pathological sequelae. In many BV-positive women their microbiota is in fact normal and unrelated to pathology. Whether or not the dominance of BV-associated bacteria persists depends upon interactions between host and bacterial factors. Inconsistencies in diagnosis and erroneous associations with pathology may be due to a failure to differentiate between sub-populations of women. It is only in those women with a BV diagnosis in which the identified bacteria are atypical and persist that BV may be a clinical problem requiring intervention.

TWEETABLE ABSTRACT

Improved diagnosis of bacterial vaginosis is needed to accurately determine its role in pathology.

The vaginal microbiome, vaginal anti-microbial defence mechanisms and the clinical challenge of reducing infection-related preterm birth

Ascending bacterial infection is implicated in about 40-50% of preterm births. The human vaginal microbiota in most women is dominated by lactobacilli. In women whose vaginal microbiota is not lactobacilli-dominated anti-bacterial defence mechanisms are reduced. The enhanced proliferation of pathogenic bacteria plus degradation of the cervical barrier increase bacterial passage into the endometrium and amniotic cavity and trigger preterm myometrial contractions. Evaluation of protocols to detect the absence of lactobaciili dominance in pregnant women by self-measuring vaginal pH, coupled with measures to promote growth of lactobacilli are novel prevention strategies that may reduce the occurrence of preterm birth in low-resource areas.

Differential expression of lactic acid isomers, extracellular matrix metalloproteinase inducer, and matrix metalloproteinase-8 in vaginal fluid from women with vaginal disorders

OBJECTIVE

Do metabolites in vaginal samples vary between women with different vaginal disorders.

DESIGN

Cross-sectional study.

SETTING

Campinas, Brazil.

SAMPLE

Seventy-seven women (39.9%) with no vaginal disorder, 52 women (26.9%) with vulvovaginal candidiasis (VVC), 43 women (22.3%) with bacterial vaginosis (BV), and 21 women (10.9%) with cytolytic vaginosis (CTV).

METHOD

Concentrations of D- and L-lactic acid, extracellular matrix metalloproteinase inducer (EMMPRIN), and matrix metalloproteinase-8 (MMP-8), and the influence of Candida albicans on EMMPRIN production by cultured vaginal epithelial cells, were determined by enzyme-linked immunosorbent assay (ELISA). Associations were determined by the Mann-Whitney U-test and by Spearman's rank correlation test.

MAIN OUTCOME MEASURES

Metabolite levels and their correlation with diagnoses.

RESULTS

Vaginal concentrations of D- and L-lactic acid were reduced from control levels in BV (P < 0.0001); L-lactic acid levels were elevated in CTV (P = 0.0116). EMMPRIN and MMP-8 concentrations were elevated in VVC (P < 0.0001). EMMPRIN and L-lactic acid concentrations (P ≤ 0.008), but not EMMPRIN and D-lactic acid, were correlated in all groups. EMMPRIN also increased in proportion with the ratio of L- to D-lactic acid in controls and in women with BV (P ≤ 0.009). Concentrations of EMMPRIN and MMP-8 were correlated in controls and women with VVC (P ≤ 0.0002). Candida albicans induced EMMPRIN release from vaginal epithelial cells.

CONCLUSIONS

Vaginal secretions from women with BV are deficient in D- and L-lactic acid, women with VVC have elevated EMMPRIN and MMP-8 levels, and women with CTV have elevated L-lactic acid levels. These deviations may contribute to the clinical signs, symptoms, and sequelae that are characteristic of these disorders.

Mannose-binding lectin gene polymorphism and risk factors for cardiovascular disease in postmenopausal women

BACKGROUND

Inflammatory responses may be altered in postmenopausal women and predispose to cardiovascular disease (CVD). Genetic factors can also influence susceptibility to CVD. Mannose-binding lectin (MBL) is a component of the innate immune system and an activator of the complement cascade. We evaluated the association of genetic polymorphism of MBL (MBL2) on risk factors for CVD in postmenopausal women.

METHODS

In this cross-sectional study, 311 Brazilian women (age ≥45 years and amenorrhea ≥12 months) were included.

EXCLUSION CRITERIA

presence of previous or current CVD, insulin dependent diabetes, chronic kidney disease, autoimmune diseases and cancer. Clinical, anthropometric and biochemical assessments were performed to evaluate the cardiovascular risk factors. DNA was extracted from buccal cell and polymorphisms at codons 54 and 57 in the MBL2 were determined by polymerase chain reaction (PCR). For statistical analysis, the chi-square and logistic regression (odds ratio, OR) were used.

RESULTS

The presence of the polymorphic allele for codon 54 was found in 25.8% of women (A/B=22.6%, B/B=3.2%) and for codon 57 in 12.2% (A/C=10.8%, C/C=1.4%). The polymorphism at codon 54 was significantly associated with the presence of hypertension (OR 0.55, 95% CI 0.31-0.99, p=0.044) and insulin resistance assessed by HOMA-IR (OR 0.46, 95% CI 0.24-0.91, p=0.025). No significant associations were observed between the polymorphism at codon 57 with risk factors for CVD.

CONCLUSION

In postmenopausal women, the polymorphism at codon 54 of the MBL2 was associated with lower risk for hypertension and insulin resistance that are important risk factors for CVD.

Altered autophagy induction by sera from pregnant women with pre-eclampsia: a case-control study

OBJECTIVE

Mechanisms leading to pre-eclampsia remain incompletely defined. Autophagy is a conserved process necessary for cell survival under adverse conditions. We hypothesised that sera from women with healthy pregnancies and women with pre-eclampsia differed in autophagy induction.

DESIGN

A case-control study.

SETTING

Weill Cornell Medical College.

POPULATION

Twenty-four normotensive pregnant women and 20 women with pre-eclampsia.

METHODS

Sera were incubated with peripheral blood mononuclear cells (PBMCs) from female donors. After 48 hours the PBMCs were lysed and the intracellular concentration of p62 was determined by enzyme-linked immunosorbent assay (ELISA). Its concentration is inversely proportional to the extent of autophagy induction. Serum endoglin, interleukin 13 (IL-13), insulin-like growth factor 1 (IGF-1), and transforming growth factor β1 (TGF-β1) levels were quantitated by ELISA.

MAIN OUTCOME MEASURES

Differences in autophagy induction and serum mediator levels in the two groups.

RESULTS

Autophagy induction increased with gestational age in sera from normotensive women (P = 0.0045), but not in women with pre-eclampsia. In the presence of an autophagy inducer, the capacity for autophagy induction decreased with gestational age in sera from women with pre-eclampsia (P = 0.0235), but not from controls. Endoglin concentrations were positively associated with the extent of autophagy induction in controls only (P = 0.0141). There was no association between autophagy and serum IL-13, IGF-1, or TGF-β1 levels.

CONCLUSIONS

Sera from women with pre-eclampsia differ from normotensive women by their inability to induce autophagy as a function of gestational age.

Autophagy and female genital tract infections: new insights and research directions

Autophagy is a highly conserved process by which defective organelles, non-functional proteins, and intracellular microorganisms become sequestered within structures called autophagosomes, which fuse with lysosomes and the engulfed components are degraded by lysosomal enzymes. In microbial autophagy degraded peptides are used to induce antigen-specific acquired immunity. Viruses, bacteria, fungi, and protozoa have developed strategies to subvert autophagy and/or to use this process to promote their replication and persistence. This review details the mechanisms by which microorganisms that infect the female genital tract and/or are detrimental to pregnancy interact with this host defence mechanism. Based on an understanding of autophagy-related pathological mechanisms, we propose new avenues for research to more effectively prevent and/or treat these infectious diseases.

Silibinin attenuates oxidative metabolism and cytokine production by monocytes from preeclamptic women

Silibinin is a polyphenolic plant flavonoid with anti-inflammatory properties. The present study investigated the effect of silibinin on oxidative metabolism and cytokine production - tumor necrosis factor-alpha (TNF-α), interleukin (IL)12, granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-6, IL-10, and transforming growth factor beta (TGF-β1) - by peripheral blood monocytes (PBM) from preeclamptic pregnant women. It is a case-controlled study involving women with preeclampsia (PE, n = 30) compared with normotensive pregnant (NT, n = 30) and with non-pregnant (NP, n = 30) women. Monocytes were obtained and cultured with or without silibinin (5 μM or 50 μM) for 18 h. Superoxide anion (O2-) and hydrogen peroxide (H2O2) release were determined by specific assays, and cytokine levels were determined by immunoenzymatic assays (ELISA). Monocytes from preeclamptic women cultured without stimulus released higher levels of O22, H2O2 and TNF-α, and lower levels of IL-10 and TGF-β1 than did monocytes from NT and NP women. Treatment in vitro with silibinin significantly inhibited spontaneous O2- and H2O2 release and TNF-α production by monocytes from preeclamptic women. The main effect of silibinin was obtained at 50 μM concentration. Thus, silibinin exerts anti-oxidative and anti-inflammatory effects on monocytes from preeclamptic pregnant women by inhibiting the in vitro endogenous release of reactive oxygen species and TNF-α production.

LIF and sIL-2R plasma concentrations in IVF patients on the day of embryo transfer: predictive markers of IVF outcome

Successful implantation is still the limiting step in IVF. We hypothesized that maternal plasma concentrations of certain cytokines at the time of embryo transfer could predict the likelihood of successful implantation and pregnancy. sIL-2R, IL-6, LIF, and MMP2 concentrations were measured in plasma from 160 IVF patients (natural and stimulated IVF cycles) on the morning of the embryo transfer (ET0) and 14 days later (ET+14). Patients were ultimately subdivided into four groups depending on the IVF treatment outcome (pregnancy failure, biochemical pregnancy, first-trimester miscarriage and normal term delivery). In natural and stimulated IVF cycles at ET0, sIL-2R concentrations were threefold higher in biochemical pregnancies than in pregnancy failures (P=0.020), and in natural cycles only, 2.5-fold higher in normal term deliveries than in pregnancy failures (P=0.023). Conversely, in natural and stimulated IVF cycles at ET0, LIF concentrations were one third lower in biochemical pregnancies/first-trimester miscarriages compared with pregnancy failures (P=0.042). We suggest that high sIL-2R and low LIF concentrations in maternal plasma on the morning of the embryo transfer might be associated with increased risks of early pregnancy loss, while a basal level of sIL-2R is necessary for normal term delivery outcome. Both cytokine measurements might therefore be useful in the management of IVF patients, and modulation of their concentrations could be investigated as a therapeutic alternative for women with abnormal concentrations at the time of embryo transfer.

Endocervical hyaluronan and ultrasound-indicated cerclage

OBJECTIVE

To investigate whether, at the time of ultrasound-indicated cerclage, the endocervical concentration of hyaluronan (HA), 27-kDa heat shock protein (HSP-27) and/or interleukin-8 (IL-8) would predict pregnancy outcome.

METHODS

Endocervical samples, obtained from 40 women undergoing ultrasound-indicated cerclage at 15 + 3 to 25 + 0 weeks' gestation, were assayed by enzyme-linked immunosorbent assay for HA, HSP-27 and IL-8. All subjects had a cervical length of < 1.5 cm or dramatic cervical length change on serial endovaginal ultrasound, no uterine contractions or tenderness, no fever and intact membranes and underwent a modified Shirodkar cerclage.

RESULTS

The median HA level was 10.0 ng/mL in the 12 women who delivered at < 37 weeks' gestation as opposed to 39.7 ng/mL in the 28 women delivering at 37-41 weeks (P = 0.017). Median HSP-27 and IL-8 concentrations were not significantly different in these groups.

CONCLUSION

A higher endocervical HA level at the time of ultrasound-indicated cerclage is associated with a longer interval before birth.

Unique alterations in infection-induced immune activation during pregnancy

BACKGROUND

Immune responses to infection are uniquely regulated during gestation to allow for antimicrobial defence and tissue repair, whilst preventing damage to developing fetal organs or the triggering of preterm labour.

OBJECTIVE

A review and analysis of studies delineating gestation-specific immune modulation and intra-amniotic regulation of pro-inflammatory immunity.

SEARCH STRATEGY

Identification of the alterations between the fetus/neonate and adult with regard to the endogenous and infection-induced expression of molecules with immune regulatory properties, and the characterisation of intra-amniotic immune mediators that inhibit bacterial-induced pro-inflammatory cytokine production.

SELECTION CRITERIA

English and non-English publications from 1985 to the present.

DATA COLLECTION AND ANALYSIS

An electronic literature search using MEDLINE, PubMed, articles cited in the primary sources, as well as pregnancy-related immunology research from our laboratory at Weill Medical College of Cornell University.

MAIN RESULTS

During fetal development, interleukin (IL)-23, IL-10 and IL-6, as well as T-helper-17 (Th17)-mediated immune responses, are upregulated, whereas tumour necrosis factor-α (TNF-α) and IL-1β- and Th1-mediated immune responses are downregulated in the intrauterine environment (both the fetal compartment and the amniotic compartment). Infection-related immunity during gestation is preferentially directed towards combating extracellular microbial pathogens. Amniotic fluid and the neonatal circulation contain multiple components that improve the ability of the developing neonate to tolerate microbial-induced immune activation.

CONCLUSIONS

The repertoire of immune mechanisms to control infection and inflammation differ between fetal and adult life. The dual mechanisms of resistance to infection and tolerance to infection-induced immune activation prevent damage to the developing fetus and the triggering of premature labour.

Anti-60-kDa heat shock protein antibodies in fetal serum: a biomarker for unexplained small for gestational age fetuses

INTRODUCTION

Small for gestational age (SGA) is an important problem affecting 10% of pregnancies and is associated with significant perinatal morbidity. In about 80% of cases, a probable etiology or a major risk factor can be identified. But almost 20% of SGA cases are considered unexplained. The 60-kDa heat shock protein (HSP60) is a highly immunogenic protein whose synthesis is greatly upregulated under nonphysiological conditions. Bacterial and human HSP60 share a high degree of sequence homology, and immunity to conserved epitopes may result in development of autoimmunity following a bacterial infection. We hypothesized that unexplained SGA could be the consequence of immune sensitization to human HSP60.

METHODS

Unexplained SGA fetuses were identified by ultrasound biometry with normal Doppler velocimetry and with no detectable maternal or fetal abnormalities. Fetal sera were obtained by cordocentesis performed for a karyotype analysis in cases of unexplained SGA (study group) or for screening of Rhesus incompatibility (control group). Fetal sera were tested for HSP60 antigen and for IgG and IgM anti-HSP60 by ELISA as well as for other immune and hematological parameters.

RESULTS

Maternal parameters were similar between the 12 study cases and the 23 control cases. The mean gestational age at cordocentesis was 29 weeks. IgM anti-HSP60 was detected in 12 cases (100%) and in no controls (p < 0.00017), while IgG anti-HSP60 was detected in 7 cases (58%) and only 1 control (p < 0.001). Three of the 4 cases with the highest IgM antibody levels died. There were no differences in fetal serum levels of HSP60 antigen or other immune and hematological markers between the two groups.

CONCLUSION

Fetuses with unexplained SGA are positive for IgM and IgG antibody to human HSP60 and the specific IgM antibody level is predictive of fetal mortality. Detection of these antibodies indicates that a placental perturbation and a fetal autoimmune reaction to HSP60 are associated with this developmental delay.

Chlamydia trachomatis infection, Fallopian tube damage and a mannose-binding lectin codon 54 gene polymorphism

BACKGROUND

Mannose-binding lectin (MBL), a component of the innate immune system, provides a first-line defense against invading microorganisms. Polymorphisms in the MBL gene have been associated with increased risk of infection. Chlamydia trachomatis genital tract infections are a major cause of Fallopian tube occlusion. Our objective was to test whether an MBL codon 54 polymorphism might contribute to development of C. trachomatis-associated tubal damage.

METHODS

In a case-control study, 97 women with occluded and 104 women with patent Fallopian tubes were tested for a history of chlamydial infection by serology and for their MBL codon 54 genotype by PCR and restriction fragment length polymorphism analysis. Clinical data were blinded to those performing all laboratory analyses.

RESULTS

Women with tubal occlusion who also had a positive chlamydial serology had the highest rate of variant MBL B allele carriage (P<0.001). Among women who were chlamydial antibody negative, allele B carriage was also more frequent in those with blocked, as opposed to patent, Fallopian tubes (P<0.01).

CONCLUSIONS

Wild-type allele A homozygosity is protective against, while carriage of the variant allele B is a risk factor for, Fallopian tube occlusion in women who are seropositive or seronegative for C. trachomatis.

Mannose-binding lectin (MBL) codon 54 gene polymorphism protects against development of pre-eclampsia, HELLP syndrome and pre-eclampsia-associated intrauterine growth restriction

Insufficient invasion of the spiral arteries by trophoblast cells is associated with the etiology of pre-eclampsia, the syndrome of hemolysis, elevated liver enzymes and low platelet counts (HELLP) and pre-eclampsia-associated intrauterine growth restriction (IUGR). Mannose-binding lectin (MBL) is a component of the innate immune system. MBL-mediated activation of the complement cascade is an important event in the destruction of invading trophoblasts. The gene coding for MBL is polymorphic, and variant alleles result in greatly reduced circulating MBL levels. The aim of this study was to test the association between an MBL polymorphism and pre-eclampsia, HELLP syndrome and IUGR. DNA was extracted from buccal swabs of 51 women with pre-eclampsia, 81 women with HELLP syndrome and 184 healthy pregnant controls. Aliquots were tested for a single nucleotide MBL gene polymorphism at codon 54 by PCR and endonuclease digestion. Homozygosity for the wild-type allele was more frequent in patients with pre-eclampsia (P = 0.04) and HELLP syndrome (P = 0.02) when compared with controls. The presence of the variant allele was more prevalent among controls than in women with pre-eclampsia (P = 0.02) or HELLP syndrome (P = 0.028). Twenty-two (55%) patients with pre-eclampsia and 43 (53%) women with HELLP syndrome delivered an IUGR neonate. MBL-54 heterozygosity was more frequent in controls (27.2%) than in pre-eclamptic women (4.5%, P = 0.025) and those with HELLP syndrome (11.7%, P = 0.05) who delivered an IUGR neonate. Genotype frequencies of neonates born to mothers in all study groups were similar. Carriage of the MBL codon 54 polymorphism protects against pre-eclampsia, HELLP syndrome and IUGR and implies that an MBL-mediated event might be involved in the pathogenesis of these disorders.

Involvement of interleukin-1 and the interleukin-1 receptor antagonist in in vitro embryo development among women undergoing in vitro fertilization-embryo transfer

PURPOSE

To examine the roles of Interleukin-1 (IL-1) and IL-1 receptor antagonist (IL-1ra), in in vitro embryo development and subsequent pregnancy outcome.

METHODS

Maternal serum utilized to supplement embryo growth in IVF cycles was analyzed for the presence of IL-1 cytokines.

RESULTS

The maternal serum that was utilized to supplement the embryo media was found to have measurable amounts of IL-1beta and IL-1ra.

CONCLUSIONS

Relative antagonism of the IL-1 system was positively associated with embryo development and pregnancy outcome.

Maternal serum levels of interferon- and interleukin-2 soluble receptor- predict the outcome of early IVF pregnancies

BACKGROUND

Elevated maternal serum levels of interleukin-2 soluble receptor-alpha (IL-2 sRalpha), tumour necrosis factor-alpha (TNF-alpha) and interferon-gamma (IFN-gamma) have been associated with pregnancy loss. The aim of our study was to evaluate the predictive value of these cytokines in the outcome of early IVF pregnancies.

METHODS

One hundred and fifty-nine consecutive IVF patients who were subsequently diagnosed to have a biochemical pregnancy (n = 23), a first-trimester miscarriage (n = 19) or a normal term delivery (n = 117) were included in this study. Serum was collected from the initial pregnancy test, 11 days after a day 3 embryo transfer, and all samples were analysed for IL-2 sRalpha, TNF-alpha and IFN-gamma by commercially available enzyme-linked immunosorbent assay (ELISA) kits.

RESULTS

IL-2 sRalpha levels were significantly higher in patients with an early pregnancy loss compared with patients with a normal term delivery (849.5 +/- 69.6 versus 693.5 +/- 31.2 pg/ml, P = 0.02), and a cut-off point of IL-2 sRalpha >1000 pg/ml predicted a poor pregnancy outcome (44.4 versus 22.7% pregnancy loss, IL-2 sRalpha >or=1000 versus IL-2 sRalpha <1000 pg/ml; P = 0.02). IFN-gamma-positive patients had twice the risk for poor IVF pregnancy outcome compared with IFN-gamma-negative subjects (40.8 versus 20.0%, respectively; P < 0.02), including a significantly lower implantation rate (37.6 +/- 0.05 versus 50.0 +/- 0.03%, respectively; P = 0.02). There was no difference in pregnancy outcome based upon serum levels, or the ability to detect the presence of TNF-alpha. No differences in levels of these cytokines were found based on the aetiology of the patients' infertility.

CONCLUSIONS

Elevated maternal serum levels of IL-2 sRalpha and IFN-gamma as early as 11 days after embryo transfer are associated with poor IVF pregnancy outcome.

Antibodies reactive with the mouse mammary tumor virus in sera of breast cancer patients

IgG binding to purified mouse mammary tumor virus (MuMTV) was quantitated by an enzyme-linked immunoassay (ELISA) using sera from patients with breast cancer or benign breast disease, or from healthy age-matched controls. Significantly greater binding (p<0.01) was found in breast-cancer-derived sera than in the other categories. In addition to IgG reactivity, three breast cancer sera also possessed IgA and IgM reactive with MuMTV by the ELISA assay. Only IgG was reactive in the majority of sera while two sera possessed MuMTV binding activity only in the IgM fraction. Both IgG binding and virolysis of MuMTV were greatly reduced by preincubation of sera with MuMTV. The specificity for MuMTV was further explored with IgG of serum from one breast cancer patient. Human antibody reactive with MuMTV was progressively diminished by preincubating the human serum with increasing concentrations of MuMTV but not by incubation with the type-C AKR murine leukemia virus. Preincubation of MuMTV with a breast cancer serum partially blocked the reactivity of gp52 antiserum with the virus. The results suggest that an antigen related to an MuMTV envelope component is expressed in breast cancer.

Heat shock protein expression and immunity: relevance to gynecologic oncology

Heat shock proteins function as molecular chaperones, guiding the transport, assembly and degradation of intracellular polypeptides. Under the influence of non-physiological conditions heat shock protein synthesis is accelerated to aid cell survival. Thus, over-production of heat shock proteins protects malignantly transformed cells from apoptotic cell death and fosters resistance to chemotherapeutic agents and irradiation. Individual heat shock proteins, such as the 27 kDa (hsp27) and 70 kDa (hsp70) heat shock proteins, their antibodies and/or genotypes of polymorphic genes may have diagnostic and prognostic value for different gynecologic malignancies. The possible exploitation of the properties of heat shock proteins for development of unique anti-cancer therapies in individuals resistant to traditional treatment is currently under active investigation.

Autologous endometrial coculture in patients with in vitro-fertilization (IVF) failure: correlations of outcome with leukemia inhibiting factor (LIF) production

PROBLEM

To determine if LIF produced by autologous endometrial co-culture (ECC) was associated with outcome in 46 patients with a history of multiple IVF failures.

METHOD OF STUDY

The conditioned media (CM) from ECC cells exposed or non-exposed to human embryos was analyzed for LIF.

RESULTS

Exposure or non-exposure to an embryo did not result in differing levels of LIF in the CM. LIF levels were significantly greater in the CM than in the serum controls (LIF was not found in the serum controls). Embryos grown on ECC demonstrated a significant improvement in number of blastomeres and fragmentation when compared to embryos grown in conventional media without ECC (6.7 +/- 1.3 vs. 5.6 +/- 1.2 blastomeres and 17.6% +/- 9.3 vs. 26.4% +/- 9.8 fragmentation; P < 0.05). When LIF levels were detectable in the CM, the embryos grown in ECC were of improved quality as compared to the embryos grown only in conventional media and demonstrated a non-significant increase in pregnancy rates (60 vs. 48%, P = 0.50).

CONCLUSIONS

We have demonstrated a significant improvement in embryo quality with ECC. The cells in the ECC express LIF. The presence of LIF in the CM was associated with embryonic development and clinical pregnancy.

Lipopolysaccharide stimulation of 70 kilo Dalton heat shock protein messenger ribonucleic acid production in cultured human fetal membranes

OBJECTIVE

The 70 kilo Dalton heat shock protein is up-regulated when cells are under physiological stress. It prevents protein denaturation and incorrect polypeptide assembly, and inhibits apoptosis as well as the transcription of genes coding for pro-inflammatory cytokines. To evaluate if up-regulation of heat shock protein 70 can occur during pregnancy, we examined whether addition of bacterial lipopolysaccharide to human amniochorion membranes in vitro stimulated heat shock protein 70 gene transcription.

MATERIALS AND METHODS

Amniochorionic membranes (n = 5), collected at the time of elective repeat cesarean section prior to labor from normal term gestations, were placed in an organ explant system. After 48 hour in culture, the membranes were stimulated with lipopolysaccharide for 24 hours. Total RNA was extracted and subjected to an oligo dT primed reverse transcriptase reaction followed by polymerase chain reaction (PCR) using heat shock protein 70 specific primers. PCR products were hybridized with biotinylated internal probes and identified by enzyme-linked immunosorbent assay (ELISA). Results were analyzed by Mann-Whitney U test. A p < 0.05 was significant.

RESULTS

Heat shock protein 70 messenger RNA was expressed by all fetal membrane preparations both prior to and following in vitro culture. Addition of lipopolysaccharide increased the concentrations of heat shock protein 70 messenger RNA in each sample tested from a mean of 35.5 +/- 29.6 ng/milliliter (12.1-80.1 ng/milliliter) to 169.6 +/- 69.9 ng/ml (51.7-218.2 ng/milliliter) (p = 0.03).

CONCLUSION

Human fetal membranes constitutively express heat shock protein 70 messenger ribonucleic acid. Bacterial lipopolysaccharide markedly stimulated heat shock protein 70 messenger RNA gene transcription in human fetal membranes. Thus, heat shock protein 70 is inducible in fetal membranes and may facilitate fetal survival under adverse conditions.

Relationship of abnormal vaginal flora, proinflammatory cytokines and idiopathic infertility in women undergoing IVF

OBJECTIVE

To investigate the prevalence of bacterial vaginosis (BV) and abnormal bacterial vaginal flora in an infertile population and correlate with cervical cytokine production and in vitro fertilization (IVF) outcome.

STUDY DESIGN

In a blinded study, 331 asymptomatic IVF patients were evaluated for BV, abnormal vaginal flora and cervical cytokine production (interleukin 1 beta [IL-1 beta] and IL-8) on the day of oocyte retrieval. All patients received tetracycline prophylaxis at the time of oocyte retrieval.

RESULTS

BV was identified in 4.2% (14/331) of the patients. Patients with idiopathic infertility were more likely to have BV than were women with other causes of infertility (P = .02 vs. male factor, P = .03 vs. tubal factor and P < .01 vs. endometriosis-associated infertility). Patients with abnormal vaginal flora had higher cervical IL-1 beta and IL-8 cytokine levels as compared to patients with normal vaginal flora. IL-1 beta and IL-8 levels in the study subjects correlated highly. No differences were detected in IVF outcome parameters based on the vaginal flora determined at the time of retrieval.

CONCLUSION

Abnormal vaginal flora, including that causing BV, is associated with elevated cervical levels of IL-1 beta and IL-8. The induction of proinflammatory cytokines by an altered vaginal ecosystem may be a previously unrecognized cause of idiopathic infertility.

Temperature stability of vaginal specimens for Chlamydia trachomatis detection by Amplicor polymerase chain reaction assay

Vaginal introital specimens were collected from 17 women - 10 positive and 7 negative for Chlamydia trachomatis, and kept in Amplicor collection medium at ambient temperature. Aliquots were removed at intervals for up to 34 days and frozen at -80 degrees C. Samples were thawed and assayed for C. trachomatis by polymerase chain reaction (PCR). The results of all specimens remained unchanged over this time interval.

Interleukin-1 receptor antagonist gene polymorphism and circulating levels of human immunodeficiency virus type 1 RNA in Brazilian women

Interleukin-1 receptor antagonist (IL-1ra) gene polymorphisms in 83 human immunodeficiency virus (HIV)-seropositive women were evaluated. Fourteen of the subjects (16.9%) were homozygous for IL-1ra allele 2 (IL-1RN*2). These women had a lower median level of HIV RNA than did women homozygous for allele 1 (IL-1RN*1) (P = 0.01) or heterozygous for both alleles (P = 0.04). Among 46 subjects not receiving antiretroviral treatment, HIV levels were also reduced in IL-1RN*2 homozygous individuals (P < 0.05). There was no relation between IL-1ra alleles and CD4 levels.

IgA antibodies to the 27-kDa heat-shock protein in the genital tracts of women with gynecologic cancers

Heat-shock proteins promote cell survival under adverse environmental conditions. Synthesis of the 27-kDa (HSP27), 70-kDa (HSP70), and 90-kDa (HSP90) heat-shock proteins is increased in malignantly transformed cells and has been associated with tumor proliferation, metastasis, and resistance to chemotherapeutic agents. The increased expression of heat-shock proteins and their association with tumor-specific antigens may result in local immunity to the heat-shock proteins. We examined the occurrence of IgA antibodies to HSP27, HSP70, and HSP90 in the lower genital tracts of women with possible gynecologic cancers. Cervical samples were obtained from 119 consecutive women being evaluated for a gynecologic malignancy or returning for a follow-up examination following cancer treatment. Aliquots were tested for IgA anti-heat-shock protein antibodies by ELISA. Aliquots were also tested for IgG antibodies to HSP27 as well as for human papillomavirus. Anti-HSP27 IgA was detected in 85.7% of 21 women with endometrial cancer tested prior to diagnosis and in 41.1% of 17 women tested after treatment. In women with ovarian cancer, 77.8% of 9 women tested prior to diagnosis and 75.0% of 24 women evaluated after treatment were anti-HSP27 IgA-positive. Of 6 women with cervical cancer tested prior to diagnosis, 5 were positive for this antibody. None of 25 women with benign diagnoses or 46 healthy women were cervical IgA anti-HSP27-positive (P < 0.0001). In contrast, anti-HSP27 IgG was not associated with a gynecologic malignancy. HSP27 cervical antibodies were not associated with the presence of human papillomavirus. Cervical IgA antibodies to HSP90 were associated with ovarian cancer; antibodies to HSP70 were not cancer-associated. We conclude that cervical IgA antibodies to HSP27 may be indicators of a gynecologic malignancy.

Serum antibodies to the 27-kd heat shock protein in women with gynecologic cancers

OBJECTIVES

Among women the association between heat shock protein immunity and cancer has been examined primarily for breast cancer. Autoantibodies to the 27-kd heat shock protein were detected in some patients with breast cancer but not in control subjects, and the presence of these antibodies was correlated with improved survival. We examined the relationship between autoimmunity to heat shock proteins and the diagnosis of malignancies of the female genital tract.

STUDY DESIGN

Serum samples from women seen for possible gynecologic malignancies or returning for evaluation after surgery, radiation, chemotherapy, or a combination for gynecologic cancers were tested for immunoglobulin G antibodies to the 27-kd, 60-kd, 70-kd, and 90-kd heat shock proteins by enzyme-linked immunosorbent assay with the purified recombinant proteins bound to wells of a microtiter plate. Serum samples from women with no history of malignancies served as control preparations.

RESULTS

Antibodies to the 27-kd heat shock protein were detected in only 1 of 29 healthy control subjects (3.4%) and 1 of 23 women whose lesions were benign (4.3%). In marked contrast, 39 of 96 women with gynecologic cancers (40.6%) had positive antibody detection (P =.0004 vs benign). The percentages of positive results seen for ovarian (17/34, 50%), endometrial (13/34, 38.2%), cervical and uterine (3/10, 30%), vaginal and vulvar (3/5, 60%), and other (3/13, 23.1%) cancers were not significantly different from each other. Similar prevalences of antibodies to the 27-kd heat shock protein were seen among patients with cancer who had untreated active disease and after treatment. Unlike the results with antibodies to the 27-kd heat shock protein there was no relationship between antibodies to the other heat shock proteins and any gynecologic cancer.

CONCLUSION

Circulating autoantibodies to the 27-kd heat shock protein were found to be associated with malignancies of the female genital tract.

Indomethacin blocks interleukin 1beta-induced myometrial contractions in pregnant rhesus monkeys

OBJECTIVE

We sought to determine whether blockade of prostaglandin synthesis with indomethacin prevents interleukin 1beta-induced increases in uterine contractions in a nonhuman primate model.

STUDY DESIGN

Maternal and fetal vascular catheters, intra-amniotic fluid pressure catheters, and fetal electrocardiographic and myometrial electromyographic electrodes were implanted in 11 rhesus monkeys at 124 +/- 2 days' gestation (term, 167 days). After postsurgical stabilization (136 +/- 2 days) indomethacin 50 mg was administered orally twice daily for 5 days (n = 6). On day 3 human recombinant interleukin 1beta 10 microg was infused into the amniotic cavity over 2 hours. Five days after the last indomethacin dose the study was repeated without indomethacin treatment. Uterine activity was continuously monitored and quantified as the hourly contraction area (millimeters of mercury. seconds per hour) in the experimental group and a control group (n = 5) that received interleukin 1beta alone. At timed intervals amniotic fluid was sampled for leukocyte counts and assayed for prostaglandin E(2) and F(2alpha), the inflammatory cytokines interleukin 1beta, interleukin 6, interleukin 8, tumor necrosis factor alpha, and interleukin 1 receptor antagonist by specific assays.

RESULTS

Uterine activity was increased severalfold from baseline after interleukin 1beta infusion alone and in the absence of indomethacin treatment (P <.05). There was no increase in uterine contractility when interleukin 1beta was infused concurrently with indomethacin treatment. Concentrations of amniotic fluid leukocytes and cytokines increased significantly after interleukin 1beta infusion in both the presence and absence of indomethacin. Amniotic fluid prostaglandins E(2) and F(2alpha) were suppressed during indomethacin treatment but rose significantly after interleukin 1beta infusion in the absence of indomethacin. Except for higher interleukin 6, cytokine levels were unaltered by indomethacin.

CONCLUSIONS

After interleukin 1beta infusion, indomethacin blocked the development of uterine activity. Amniotic fluid prostaglandins were suppressed by indomethacin treatment, but cytokines and leukocytes were not. These results suggest that prostaglandins or possibly other indomethacin-suppressible compounds stimulate uterine activity after interleukin 1beta infusion in late-gestation rhesus monkeys or that indomethacin has direct tocolytic effects.

Individual immunity and susceptibility to female genital tract infection

The responses to genital tract infection vary among different women to a far greater extent than has previously been appreciated. All women are not genetically identical and have not been exposed to identical environments; therefore it is naive to expect that a particular microorganism will elicit the identical response and have the identical sequelae for each infected individual. The genes inherited from one's parents, which contain specific polymorphisms in immune response genes, greatly influence the direction and magnitude of the immune response to microorganisms. Similarly, extrinsic variables, such as the type or quantity of a specific infection, whether there is a coinfection with another microorganism, such as an intracellular parasite, and whether an immediate hypersensitivity response is concurrently induced also determine the nature of the host response and thus the consequences of microbial exposure. Finally, factors such as the frequency of sexual intercourse and previous immune sensitization to spermatozoa or other components of a particular ejaculate also influence the outcome. An increased awareness of the uniqueness of each host will lead to the development of more precise individualized treatments and improvements in combating infectious diseases of the female genital tract.

Testing for high-risk human papillomavirus types will become a standard of clinical care

Testing for high-risk human papillomavirus types should become a standard of care for women in the United States because cervical cancer is an infectious disease. Current care is based on cytologic screening and a pathologic staging of cellular tissue changes. Before these cellular modifications, there is a demonstrable pattern of human papillomavirus infection. Human papillomavirus is the most frequently acquired sexually transmitted disease in women and is usually eliminated without treatment. Persistence of high-risk human papillomavirus types can lead to abnormal cervical cellular changes. When these cervical cellular changes occur, physician interventions hasten human papillomavirus elimination. Currently, adding human papillomavirus screening to the Papanicolaou smear identifies a population for closer follow-up studies. In the future a vaccine should be introduced to prevent infections, and medical treatments to hasten the elimination of high-risk human papillomavirus types should become part of standard medical practice.