Molecular Diagnosis of Cat Scratch Disease: a 25-Year Retrospective Comparative Analysis of Various Clinical Specimens and Different PCR Assays.

Cat-scratch disease (CSD), caused primarily by Bartonella henselae, is a common etiology of infectious regional lymphadenopathy. Lymphadenopathy is preceded by a primary inoculation lesion and may progress to suppuration. Laboratory diagnosis of CSD is hampered by the limitations of available confirmatory tests. PCR, in general, is highly sensitive and specific; however, clinical sensitivity in CSD varies greatly between studies. We aimed to identify clinical specimens and PCR assays best suited for CSD diagnosis using a national CSD registry and a uniform case definition. Different clinical specimens and PCR assays, including conventional and real-time PCR, were evaluated. PCR was positive in 335/390 (86%) CSD patients and 425/482 (88%) PCR tests. The highest PCR sensitivity was achieved in lymph node pus aspirates (96%; n = 278 tests) followed by primary lesions (88%; n = 50), lymph node fine needle aspirations (85%; n = 46), lymph node biopsy specimens (73%; n = 91) and paraffin-embedded lymph nodes (59%; n = 17), (P < 0.001). Sensitivity was similar in all types of PCR assays studied. PCR negative predictive value of pus aspirate and lymph node biopsy specimen patient groups was 82% and 72%, respectively. Specificity was 100% based on 125 non-CSD patients with negative PCR. In conclusion, the specimen type rather than the PCR assay type has a major impact on CSD molecular diagnosis. We assume that the inadequate sensitivity of the biopsy specimens was due to sampling errors or the presence of inhibitory factors. Primary lesions should be sampled more frequently for CSD diagnosis. Physicians should be aware of the low PCR negative predictive value of lymph node biopsy specimens. IMPORTANCE Polymerase chain reaction (PCR) for the detection of Bartonella henselae is an important tool for the diagnosis of cat scratch disease (CSD); however, clinical sensitivity varies greatly between studies. The current study shows that the specimen type, with pus aspiration, fine needle aspiration, and primary inoculation lesion having significantly higher sensitivity than fresh or formalin-fixed paraffin-embedded lymph node biopsy specimen, rather than the type of the PCR assay, whether a conventional or a real-time assay, has a major impact on the performance of diagnostic PCR for CSD. The new data provide new tools for the clinical microbiologist when interpreting the results of the PCR assays. Primary inoculation lesions, although easily accessible, are often neglected and should be sampled more frequently for molecular diagnosis of CSD. Physicians should be aware that negative PCR, particularly if performed on fresh or paraffin-embedded lymph node biopsy specimens, does not exclude CSD.

Laboratory Diagnosis of 37 Cases of Bartonella Endocarditis Based on Enzyme Immunoassay and Real-Time PCR.

Bartonella spp., mostly Bartonella quintana and B. henselae, are a common cause of culture-negative endocarditis. Serology using immunofluorescence assay (IFA) and PCR performed on cardiac tissues are the mainstays of diagnosis. We developed an enzyme immunoassay (EIA) and a novel multiplex real-time PCR assay, utilizing Bartonella genus-specific, B. henselae-specific, and B. quintana-specific SimpleProbe probes, for diagnosis of Bartonella endocarditis. We aimed to evaluate the performance of these assays. Thirty-seven patients with definite endocarditis, 18 with B. henselae, 18 with B. quintana, and 1 with B. koehlerae, were studied. Diagnosis was confirmed by conventional PCR and DNA sequencing of surgical cardiac specimens. Similar to the case with IFA, anti-Bartonella IgG titers of ≥1:800 were found in 94% of patients by EIA; cross-reactivity between B. henselae and B. quintana precluded species-specific serodiagnosis, and frequent (41%) but low-titer cross-reactivity between Coxiella burnetii antibodies and B. henselae antigen was found in patients with Q fever endocarditis. Low-titer (1:100) cross-reactivity was uncommonly found also in patients with brucellosis and culture-positive endocarditis, particularly Enterococcus faecalis endocarditis. Real-time PCR performed on explanted heart valves/vegetations was in complete agreement with results of sequence-based diagnosis with characteristic melting curves. The genus-specific probe identified five additional endocarditis-associated Bartonella spp. at the genus level. In conclusion, EIA coupled with a novel real-time PCR assay can play an important role in Bartonella endocarditis diagnosis and expand the diagnostic arsenal at the disposal of the clinical microbiologist. Since serology remains a major diagnostic tool, recognizing its pitfalls is essential to avoid incorrect diagnosis.

The prevalence of Middle East respiratory syndrome coronavirus (MERS-CoV) antibodies in dromedary camels in Israel.

Middle East respiratory syndrome coronavirus, MERS-CoV, was identified in Saudi Arabia in 2012, and as of January 29, 2018, there were 2,123 laboratory-confirmed MERS-CoV cases reported to WHO (WHO, 2018, https://www.who.int/emergencies/mers-cov/en/). Multiple studies suggest that dromedary camels are a source for human MERS-CoV infection. MERS-CoV-specific antibodies have been detected in the serum of dromedary camels across Northern Africa and across the Arabian Peninsula. Israel's geographic location places Israel at risk for MERS-CoV infection. To date, MERS-CoV-related illness has not been reported and the burden of MERS-CoV infection in the Israeli population is unknown. The seroprevalence of MERS-CoV-specific antibodies in Israeli dromedary camels is unknown. The objective of this study was to determine the prevalence of MERS-CoV seropositivity in dromedary camels in Israel. The prevalence of MERS-CoV antibodies in Israeli camels was examined in 71 camel sera collected from four farms across Israel by MERS-CoV-specific microneutralization (Mnt) assay and confirmed by MERS-CoV-specific immunofluorescence assay (IFA). Although this study cannot rule out potential antibody cross-reactivity by IFA, the presence of bovine coronavirus-specific antibodies do not appear to impact detection of MERS-CoV antibodies by Mnt. MERS-CoV neutralizing antibodies were detectable in 51 (71.8%) camel sera, and no association was observed between the presence of neutralizing antibodies and camel age or gender. These findings extend the known range of MERS-CoV circulation in Middle Eastern camels. The high rate of MERS-CoV-specific antibody seropositivity in dromedary camels in the absence of any reported human MERS cases suggests that there is still much to be learned about the dynamics of camel-to-human transmission of MERS-CoV.

Bartonella dromedarii sp. nov. isolated from domesticated camels (Camelus dromedarius) in Israel.

Bartonella spp. are fastidious, Gram-negative bacilli that cause a wide spectrum of diseases in humans. Most Bartonella spp. have adapted to a specific host, generally a domestic or wild mammal. Dromedary camels (Camelus dromedarius) have become a focus of growing public-health interest because they have been identified as a reservoir host for the Middle East respiratory syndrome coronavirus. Nevertheless, data on camel zoonoses are limited. We aimed to study the occurrence of Bartonella bacteremia among dromedaries in Israel. Nine of 51 (17.6%) camels were found to be bacteremic with Bartonella spp.; bacteremia levels ranged from five to >1000 colony-forming units/mL. Phylogenetic reconstruction based on the concatenated sequences of gltA and rpoB genes demonstrated that the dromedary Bartonella isolates are closely related to other ruminant-derived Bartonella spp., with B. bovis being the nearest relative. Using electron microscopy, the novel isolates were shown to be flagellated, whereas B. bovis is nonflagellated. Sequence comparisons analysis of the housekeeping genes ftsZ, ribC, and groEL showed the highest homology to B. chomelii, B. capreoli, and B. birtlesii, respectively. Sequence analysis of the gltA and rpoB revealed ∼96% identity to B. bovis, a previously suggested cutoff value for sequence-based differentiation of Bartonella spp., suggesting that this approach does not have sufficient discriminatory power for differentiating ruminant-related Bartonella spp. A comprehensive multilocus sequence typing (MLST) analysis based on nine genetic loci (gltA, rpoB, ftsZ, internal transcribed spacer (ITS), 16S rRNA, ribC, groEL, nuoG, and SsrA) identified seven sequence types of the new dromedary isolates. This is the first description of a Bartonella sp. from camelids. On the basis of a distinct reservoir and ecological niche, sequence analyses, and expression of flagella, we designate these isolates as a novel Bartonella sp. named Bartonella dromedarii sp. nov. Further studies are required to explore its zoonotic potential.

First description of Bartonella bovis in cattle herds in Israel.

Bartonella bovis has been described in beef and dairy cattle worldwide, however the reported prevalence rates are inconsistent, with large variability across studies (0-89%). This study describes the first isolation and characterization of B. bovis among cattle herds in the Middle East. Blood samples from two beef cattle herds (each sampled thrice) and one dairy herd (sampled twice) in Israel were collected during a 16-months period. Overall, 71 of 95 blood samples (75%) grew Bartonella sp., with prevalence of 78% and 59% in beef and dairy cattle, respectively. High level bacteremia (≥100,000 colony forming units/mL) was detected in 25 specimens (26%). Such high-level bacteremia has never been reported in cattle. Two dairy cows and one beef cow remained bacteremic when tested 60 or 120 days apart, respectively, suggesting that cattle may have persistent bacteremia. One third of animals were infested with ticks. Sequence analysis of a gltA fragment of 32 bacterial isolates from 32 animals revealed 100% homology to B. bovis. Species identification was confirmed by sequence analysis of the rpoB gene. Phylogenetic analysis based on the concatenated sequences of gltA and rpoB demonstrated that the isolates described herein form a monophyletic group with B. bovis strains originating from cattle worldwide. Taken together, the high prevalence of bacteremia, including high-level bacteremia, in beef and dairy cattle, the potential to develop prolonged bacteremia, the exposure of cattle to arthropod vectors, and proximity of infected animals to humans, make B. bovis a potential zoonotic agent.

Identification of Legionella pneumophila effectors regulated by the LetAS-RsmYZ-CsrA regulatory cascade, many of which modulate vesicular trafficking.

Legionella pneumophila, the causative agent of Legionnaires' disease, is an intracellular human pathogen that utilizes the Icm/Dot type IVB secretion system to translocate a large repertoire of effectors into host cells. To find coregulated effectors, we performed a bioinformatic genomic screen with the aim of identifying effector-encoding genes containing putative CsrA regulatory elements. The regulation of these genes by the LetAS-RsmYZ-CsrA regulatory cascade was experimentally validated by examining their levels of expression in deletion mutants of relevant regulators and by site-directed mutagenesis of the putative CsrA sites. These analyses resulted in the identification of 26 effector-encoding genes regulated by the LetAS-RsmYZ-CsrA regulatory cascade, all of which were expressed at higher levels during the stationary phase. To determine if any of these effectors is involved in modulating the secretory pathway, they were overexpressed in wild-type yeast as well as in a yeast sec22 deletion mutant, which encodes an R-SNARE that participates in the endoplasmic reticulum (ER)-Golgi trafficking. This examination identified many novel LetAS-RsmYZ-CsrA regulated effectors which are involved in this process. To further characterize the role of these 26 effectors in vesicular trafficking, they were examined in yeast arf and arl deletion mutants, which encode small GTPases that regulate ER-Golgi trafficking. This analysis revealed that the effectors examined manipulate different processes of the secretory pathway. Collectively, our results demonstrate that several of the L. pneumophila effectors which are coregulated in the bacterial cell are involved in the modulation of the same eukaryotic pathway.

The LetA-RsmYZ-CsrA regulatory cascade, together with RpoS and PmrA, post-transcriptionally regulates stationary phase activation of Legionella pneumophila Icm/Dot effectors.

Legionella pneumophila utilize the Icm/Dot type-IV secretion system to translocate effector proteins into host cells. Some of these effectors were shown before to be regulated at the transcriptional level by the PmrAB and CpxRA two-component systems. In addition, the stationary phase-related regulators LetA and CsrA, which are both members of the same post-transcriptional regulatory cascade, were shown to be involved in L. pneumophila virulence. In this report, we identified two small non-coding RNAs which are part of the LetA-CsrA regulatory cascade and three effector-encoding genes which are directly controlled by this regulatory system. We found that the small non-coding RNAs RsmY and RsmZ, were upregulated by LetA at stationary phase, and relieve the repression of CsrA from its target genes. The three effector-encoding genes were found to be post-transcriptionally upregulated at stationary phase and to contain CsrA regulatory elements that were found to be essential for their stationary phase activation. In addition, rsmY and rsmZ were found to be regulated by the RpoS sigma-factor and the csrA encoding gene was found to be regulated by PmrA. Our results demonstrate that L. pneumophila effectors are regulated at both the transcriptional and the post-transcriptional levels by a complicated regulatory network.

Evolution of the metazoan protein phosphatase 2C superfamily.

Members of the protein phosphatase 2C (PP2C) superfamily are Mg(2+)/Mn(2+)-dependent serine/threonine phosphatases, which are essential for regulation of cell cycle and stress signaling pathways in cells. In this study, a comprehensive genomic analysis of all available metazoan PP2C sequences was conducted. The phylogeny of PP2C was reconstructed, revealing the existence of 15 vertebrate families which arose following a series of gene duplication events. Relative dating of these duplications showed that they occurred in two active periods: before the divergence of bilaterians and before vertebrate diversification. PP2C families which duplicated during the first period take part in different signaling pathways, whereas PP2C families which diverged in the second period display tissue expression differences yet participate in similar signaling pathways. These differences were found to involve variation of expression in tissues which show higher complexity in vertebrates, such as skeletal muscle and the nervous system. Further analysis was performed with the aim of identifying the functional domains of PP2C. The conservation pattern across the entire PP2C superfamily revealed an extensive domain of more than 50 amino acids which is highly conserved throughout all PP2C members. Several insertion or deletion events were found which may have led to the specialization of each PP2C family.