Identification and Characterization of an HtrA Sheddase Produced by Coxiella burnetii.

Having previously shown that soluble E-cadherin (sE-cad) is found in sera of Q fever patients and that infection of BeWo cells by C. burnetii leads to modulation of the E-cad/ß-cat pathway, our purpose was to identify which sheddase(s) might catalyze the cleavage of E-cad. Here, we searched for a direct mechanism of cleavage initiated by the bacterium itself, assuming the possible synthesis of a sheddase encoded in the genome of C. burnetii or an indirect mechanism based on the activation of a human sheddase. Using a straightforward bioinformatics approach to scan the complete genomes of four laboratory strains of C. burnetii, we demonstrate that C. burnetii encodes a 451 amino acid sheddase (CbHtrA) belonging to the HtrA family that is differently expressed according to the bacterial virulence. An artificial CbHtrA gene (CoxbHtrA) was expressed, and the CoxbHtrA recombinant protein was found to have sheddase activity. We also found evidence that the C. burnetii infection triggers an over-induction of the human HuHtrA gene expression. Finally, we demonstrate that cleavage of E-cad by CoxbHtrA on macrophages-THP-1 cells leads to an M2 polarization of the target cells and the induction of their secretion of IL-10, which "disarms" the target cells and improves C. burnetii replication. Taken together, these results demonstrate that the genome of C. burnetii encodes a functional HtrA sheddase and establishes a link between the HtrA sheddase-induced cleavage of E-cad, the M2 polarization of the target cells and their secretion of IL-10, and the intracellular replication of C. burnetii.

Acute kidney injury in acute Q fever.

Coxiella burnetii infection is not known to involve directly the kidneys. Kidney injury associated with Q fever usually manifests in the setting of chronic infection or endocarditis with development of immune complex deposition. Acute kidney injury (AKI) in the context of acute Q fever infection may be more pathologically heterogeneous. We describe two cases of severe AKI secondary to acute Q fever infection, each with marked differences in pathological characteristics, and clinical course.

Risk of chronic Q fever in patients with cardiac valvulopathy, seven years after a large epidemic in the Netherlands.

BACKGROUND: From 2007 through 2010, a large epidemic of acute Q fever occurred in the Netherlands. Patients with cardiac valvulopathy are at high risk to develop chronic Q fever after an acute infection. This patient group was not routinely screened, so it is unknown whether all their chronic infections were diagnosed. This study aims to investigate how many chronic Q fever patients can be identified by routinely screening patients with valvulopathy and to establish whether the policy of not screening should be changed. METHODS: In a cross-sectional study (2016-2017) in a hospital at the epicentre of the Q fever epidemic, a blood sample was taken from patients 18 years and older who presented with cardiac valvulopathy. The sample was tested for IgG antibodies against phase I and II of Coxiella burnetii using an immunofluorescence assay. An IgG phase II titre of ≥1:64 was considered serological evidence of a previous Q fever infection. An IgG phase I titre of ≥1:512 was considered suspicious for a chronic infection, and these patients were referred for medical examination. RESULTS: Of the 904 included patients, 133 (15%) had evidence of a previous C. burnetii infection, of whom 6 (5%) had a chronic infection on medical examination. CONCLUSIONS: In a group of high-risk patients with a heart valve defect, we diagnosed new chronic Q fever infections seven years after the epidemic, emphasizing the need for screening of this group to prevent complications in those not yet diagnosed in epidemic areas.

Characterization of Early Stages of Human Alveolar Infection by the Q Fever Agent Coxiella burnetii.

Human Q fever is caused by the intracellular bacterial pathogen Coxiella burnetii Q fever presents with acute flu-like and pulmonary symptoms or can progress to chronic, severe endocarditis. After human inhalation, C. burnetii is engulfed by alveolar macrophages and transits through the phagolysosomal maturation pathway, resisting the acidic pH of lysosomes to form a parasitophorous vacuole (PV) in which to replicate. Previous studies showed that C. burnetii replicates efficiently in primary human alveolar macrophages (hAMs) in ex vivo human lung tissue. Although C. burnetii replicates in most cell types in vitro, the pathogen does not grow in non-hAM cells of human lung tissue. In this study, we investigated the interaction between C. burnetii and other pulmonary cell types apart from the lung environment. C. burnetii formed a prototypical PV and replicated efficiently in human pulmonary fibroblasts and in airway, but not alveolar, epithelial cells. Atypical PV expansion in alveolar epithelial cells was attributed in part to defective recruitment of autophagy-related proteins. Further assessment of the C. burnetii growth niche showed that macrophages mounted a robust interleukin 8 (IL-8), neutrophil-attracting response to C. burnetii and ultimately shifted to an M2-polarized phenotype characteristic of anti-inflammatory macrophages. Considering our findings together, this study provides further clarity on the unique C. burnetii-lung dynamic during early stages of human acute Q fever.

Characteristics of scrub typhus, murine typhus, and Q fever among elderly patients: Prolonged prothrombin time as a predictor for severity.

BACKGROUND/PURPOSE: The clinical manifestations of scrub typhus, murine typhus and acute Q fever in the elderly are not clear. METHODS: We conducted a retrospective study to identify the characteristics of the elderly aged ≥65 years with a comparison group aged 18-64 years among patients with scrub typhus, murine typhus, or acute Q fever who were serologically confirmed at three hospitals in Taiwan during 2002-2011. RESULTS: Among 441 cases, including 187 cases of scrub typhus, 166 acute Q fever, and 88 murine typhus, 68 (15.4%) cases were elderly patients. The elderly had a higher severe complication rate (10.3% vs. 3.5%, p = 0.022), but did not have a significantly higher mortality rate (1.47% vs. 0.54%, p = 0.396). Compared with those without severe complications, we found the elderly (p = 0.022), dyspnea (p = 0.006), less relative bradycardia (p = 0.004), less febrile illness (p = 0.004), prolonged prothrombin time (PT) (p = 0.002), higher levels of initial C-reactive protein (p = 0.039), blood leukocyte counts (p = 0.01), and lower platelet counts (p = 0.012) are significantly associated with severe complications. Only prolonged prothrombin time was associated with severe complications in multivariate analysis (p = 0.018, CI 95% 0.01-0.66). Among clinical symptoms and laboratory data, multivariate analysis revealed chills was less frequently occurred in the elderly (p = 0.012, 95% confidence interval [CI]: 1.33-9.99). CONCLUSION: The elderly cases with scrub typhus, murine typhus, or acute Q fever would be more likely to have severe complications, for which prothrombin time prolongation is an important predictor for severe complications.

Coxiella burnetii in wild mammals: A systematic review.

Coxiella burnetii is a multi-host bacterium that causes Q fever in humans, a zoonosis that is emerging worldwide. The ecology of C. burnetii in wildlife is still poorly understood and the influence of host, environmental and pathogen factors is almost unknown. This study gathers current published information on different aspects of C. burnetii infection in wildlife, even in species with high reservoir potential and a high rate of interaction with livestock and humans, in order to partially fill the existing gap and highlight future needs. Exposure and/or infection by C. burnetii has, to date, been reported in 109 wild mammal species. The limited sample size of most of the existing studies could suggest an undervalued prevalence of C. burnetii infection. Knowledge on the clinical outcome of C. burnetii infection in wildlife is also very limited, but currently includes reproductive failure in waterbuck (Kobus ellipsiprymnus), roan antelope (Hippotragus niger), dama gazelle (Nanger dama) and water buffalo (Bubalus bubalis) and placentitis in the Pacific harbor seal (Phoca vitulina richardsi), Steller sea lion (Eumetopias jubatus) and red deer (Cervus elaphus). The currently available serological tests need to be optimised and validated for each wildlife species. Finally, there is a huge gap in the research on C. burnetii control in wildlife, despite of the increasing evidence that wildlife is a source of C. burnetii for both livestock and humans.

[Coxiella burnetii and Q fever in Brazil: a public health issue]. / Coxiella burnetii e a febre Q no Brasil, uma questão de saúde pública.

Q fever is a zoonosis that is broadly distributed worldwide, despite few reports associated with its occurrence in Brazil. Coxiella burnetii, namely the causative agent of Q fever is a gram-negative coccobacillus and an obligate intracellular bacterial parasite of the order of Legionellales. The microorganism is generally present in the urine and feces of infected animals and can be found in large quantities in placental membranes of at-term or aborted animals. The inhalation of particles suspended in the air or contaminated aerosols is the most common form of bacterial contact. Q Fever is a self-limited disease, and often progresses in a benign way. In cases where the disease progresses to the chronic form, endocarditis is the most prevalent manifestation. Clinical diagnosis is difficult since the symptoms are similar to many other diseases. In confirmed cases, antibiotic therapy is the treatment indicated. Given the lack of knowledge about the disease and the difficulty of diagnosis, it is believed that Q fever is more common than generally believed in Brazil.

A Febre Q é uma zoonose de ampla distribuição mundial, apesar dos poucos relatos associados a sua ocorrência no Brasil. "Coxiella burnetii", agente etiológico da Febre Q, é um cocobacilo gram-negativo, parasita intracelular obrigatório da ordem Legionellales. O microrganismo geralmente está presente na urina e fezes de animais infectados, podendo ser encontrado em grande quantidade nos restos placentários de animais nascidos a termo ou produtos de aborto. A inalação de células bacterianas suspensas no ar ou aerossóis contaminados é a forma mais comum de entrar em contato com a bactéria. A febre Q é uma doença autolimitada e, geralmente, evolui de forma benigna. Nos casos onde a doença evolui de forma crônica, a endocardite é a manifestação mais frequente. O diagnóstico clínico é difícil, visto que os sintomas assemelham-se a várias outras doenças. Nos casos confirmados a antibioticoterapia é o tratamento indicado. Diante da sintomatologia pouco específica e dificuldade de diagnóstico, acredita-se que no Brasil a doença seja mais comum do que se pensa.

Coxiella burnetii e a febre Q no Brasil, uma questão de saúde pública / Coxiella burnetii and Q fever in Brazil: a public health issue

Resumo A Febre Q é uma zoonose de ampla distribuição mundial, apesar dos poucos relatos associados a sua ocorrência no Brasil. "Coxiella burnetii", agente etiológico da Febre Q, é um cocobacilo gram-negativo, parasita intracelular obrigatório da ordem Legionellales. O microrganismo geralmente está presente na urina e fezes de animais infectados, podendo ser encontrado em grande quantidade nos restos placentários de animais nascidos a termo ou produtos de aborto. A inalação de células bacterianas suspensas no ar ou aerossóis contaminados é a forma mais comum de entrar em contato com a bactéria. A febre Q é uma doença autolimitada e, geralmente, evolui de forma benigna. Nos casos onde a doença evolui de forma crônica, a endocardite é a manifestação mais frequente. O diagnóstico clínico é difícil, visto que os sintomas assemelham-se a várias outras doenças. Nos casos confirmados a antibioticoterapia é o tratamento indicado. Diante da sintomatologia pouco específica e dificuldade de diagnóstico, acredita-se que no Brasil a doença seja mais comum do que se pensa.

Abstract Q fever is a zoonosis that is broadly distributed worldwide, despite few reports associated with its occurrence in Brazil. Coxiella burnetii, namely the causative agent of Q fever is a gram-negative coccobacillus and an obligate intracellular bacterial parasite of the order of Legionellales. The microorganism is generally present in the urine and feces of infected animals and can be found in large quantities in placental membranes of at-term or aborted animals. The inhalation of particles suspended in the air or contaminated aerosols is the most common form of bacterial contact. Q Fever is a self-limited disease, and often progresses in a benign way. In cases where the disease progresses to the chronic form, endocarditis is the most prevalent manifestation. Clinical diagnosis is difficult since the symptoms are similar to many other diseases. In confirmed cases, antibiotic therapy is the treatment indicated. Given the lack of knowledge about the disease and the difficulty of diagnosis, it is believed that Q fever is more common than generally believed in Brazil.

Q fever: A rural disease with potential urban consequences

BACKGROUND: Q fever often presents as an undifferentiated febrile illness. Cases occur throughout Australia, with higher rates occurring in northern New South Wales and southern Queensland. OBJECTIVE: This article aims to provide clinicians with an overview of Q fever, and covers epidemiology, clinical features, laboratory diagnosis, sequelae, management and prevention. DISCUSSION: In Australia, Q fever is the most commonly reported zoonotic disease. Presentation includes fever, rigors, chills, headache, extreme fatigue, drenching sweats, weight loss, arthralgia and myalgia, often in conjunction with abnormal liver function tests. These features make it indistinguishable from many other febrile illnesses. Exposure occurs through contact with livestock and other animals. Coxiella bacteria can survive in dust, where infection may result from inhalation. Laboratory diagnosis is made by serology or polymerase chain reaction. An effective vaccine is available for adults (aged >15 years), but can only be administered after a rigorous pre-vaccination assessment to exclude prior exposure to Coxiella burnetii, requiring a detailed medical history, skin test and serology.

Tache Noire in a Patient with Acute Q Fever.

OBJECTIVE: To describe a rare case of acute Q fever with tache noire. CLINICAL PRESENTATION AND INTERVENTION: A 51-year-old man experienced acute Q fever showing tache noire, generally considered a pathognomonic sign of Mediterranean spotted fever (MSF) and MSF-like illness, but not a clinical feature of Q fever. The patient was treated with doxycycline 100 mg every 12 h. CONCLUSION: In the Mediterranean area, tache noire should be considered pathognomonic of MSF but it should not rule out Q fever. Clinical diagnosis should be supported by accurate laboratory diagnostic tests to guide proper management.

Involvement of matrix metalloproteinases in chronic Q fever.

OBJECTIVES: Chronic Q fever is a persistent infection with the intracellular Gram-negative bacterium Coxiella burnetii, which can lead to complications of infected aneurysms. Matrix metalloproteinases (MMPs) cleave extracellular matrix and are involved in infections as well as aneurysms. We aimed to study the role of MMPs in the pathogenesis of chronic Q fever. METHODS: We investigated gene expression of MMPs through microarray analysis and MMP production with ELISA in C. burnetii-stimulated peripheral blood mononuclear cells (PBMCs) of patients with chronic Q fever and healthy controls. Twenty single nucleotide polymorphisms (SNPs) of MMP and tissue inhibitor of MMP genes were genotyped in 139 patients with chronic Q fever and 220 controls with similar cardiovascular co-morbidity. Additionally, circulating MMPs levels in patients with chronic Q fever were compared with those in cardiovascular controls with and without a history of past Q fever. RESULTS: In healthy controls, the MMP pathway involving four genes (MMP1, MMP7, MMP10, MMP19) was significantly up-regulated in C. burnetii-stimulated but not in Escherichia coli lipopolysaccharide -stimulated PBMCs. Coxiella burnetii induced MMP-1 and MMP-9 production in PBMCs of healthy individuals (both p<0.001), individuals with past Q fever (p<0.05, p<0.01, respectively) and of patients with chronic Q fever (both p<0.001). SNPs in MMP7 (rs11568810) (p<0.05) and MMP9 (rs17576) (p<0.05) were more common in patients with chronic Q fever. Circulating MMP-7 serum levels were higher in patients with chronic Q fever (median 33.5 ng/mL, interquartile range 22.3-45.7 ng/mL) than controls (20.6 ng/mL, 15.9-33.8 ng/mL). CONCLUSION: Coxiella burnetii-induced MMP production may contribute to the development of chronic Q fever.

Fatigue following Acute Q-Fever: A Systematic Literature Review.

BACKGROUND: Long-term fatigue with detrimental effects on daily functioning often occurs following acute Q-fever. Following the 2007-2010 Q-fever outbreak in the Netherlands with over 4000 notified cases, the emphasis on long-term consequences of Q-fever increased. The aim of this study was to provide an overview of all relevant available literature, and to identify knowledge gaps regarding the definition, diagnosis, background, description, aetiology, prevention, therapy, and prognosis, of fatigue following acute Q-fever. DESIGN: A systematic review was conducted through searching Pubmed, Embase, and PsycInfo for relevant literature up to 26th May 2015. References of included articles were hand searched for additional documents, and included articles were quality assessed. RESULTS: Fifty-seven articles were included and four documents classified as grey literature. The quality of most studies was low. The studies suggest that although most patients recover from fatigue within 6-12 months after acute Q-fever, approximately 20% remain chronically fatigued. Several names are used indicating fatigue following acute Q-fever, of which Q-fever fatigue syndrome (QFS) is most customary. Although QFS is described to occur frequently in many countries, a uniform definition is lacking. The studies report major health and work-related consequences, and is frequently accompanied by nonspecific complaints. There is no consensus with regard to aetiology, prevention, treatment, and prognosis. CONCLUSIONS: Long-term fatigue following acute Q-fever, generally referred to as QFS, has major health-related consequences. However, information on aetiology, prevention, treatment, and prognosis of QFS is underrepresented in the international literature. In order to facilitate comparison of findings, and as platform for future studies, a uniform definition and diagnostic work-up and uniform measurement tools for QFS are proposed.

The contribution of genomics to the study of Q fever.

Coxiella burnetii is the etiological agent of Q fever, a worldwide zoonosis that can result in large outbreaks. The birth of genomics and sequencing of C. burnetii strains has revolutionized many fields of study of this infection. Accurate genotyping methods and comparative genomic analysis have enabled description of the diversity of strains around the world and their link with pathogenicity. Genomics has also permitted the development of qPCR tools and axenic culture medium, facilitating the diagnosis of Q fever. Moreover, several pathophysiological mechanisms can now be predicted and therapeutic strategies can be determined thanks to in silico genome analysis. An extensive pan-genomic analysis will allow for a comprehensive view of the clonal diversity of C. burnetii and its link with virulence.

Q-fever patients suffer from impaired health status long after the acute phase of the illness: results from a 24-month cohort study.

OBJECTIVES: During the largest Q-fever outbreak ever reported, a cohort study was established to assess the health status of Q-fever patients over a 24-month period and to identify factors associated with health status. METHODS: Laboratory-confirmed Q-fever patients participated at six time points after onset of illness. Scores on twelve subdomains from two health status instruments were calculated for each time point to determine progression and compare to reference groups. RESULTS: The study included 336 Q-fever patients. There is a significant linear improvement over time in nine of the twelve health status subdomains. For example, the proportion of patients with severe fatigue improved from 73.0% at three months to 60.0% at twelve months and 37.0% at twenty-four months, but this was still high compared to a healthy reference group (2.5%). For the three most severely affected subdomains -'Fatigue', 'General Quality of Life' and 'Role Physical'- the baseline characteristics significantly associated with a long-term reduced health status were being female, being a young adult and having pre-existing health problems. CONCLUSIONS: Despite a significant linear improvement over time in nine of the twelve health status subdomains, more than one out of three patients still suffered from a reduced health status at 24 months.

[Description of a case of severe Q fever].

The paper considers a rare clinical case of severe Q fever in a young man with no compromised premorbid background. It describes and analyzes clinical manifestations and laboratory findings with consideration for the current data available in the literature. The issues of the differential diagnosis, laboratory diagnosis, and treatment of Q fever are discussed.

Latent Q fever endocarditis in patients undergoing routine valve surgery.

BACKGROUND AND AIM OF THE STUDY: Q fever is a worldwide zoonosis caused by a fastidious bacterium, Coxiella burnetii. A recent major outbreak of which in the Netherlands will most likely lead to the emergence of hundreds of cases of C. burnetii endocarditis during the next decade. Patients undergoing cardiac valve surgery may carry undiagnosed Q fever endocarditis with possible disastrous outcomes, and hence may benefit from a screening strategy. The study aim was to evaluate the frequency of unsuspected latent Q fever endocarditis in patients undergoing routine valve surgery. METHODS: At the present authors' institution, all resected cardiac valves/prostheses are examined routinely histologically, microbiologically and on a molecular biological basis, in addition to serological testing for fastidious microorganisms. A retrospective review was conducted of data relating to all patients who had unsuspected Q fever endocarditis that had been diagnosed after routine valve/prosthesis replacement/repair between 2000 and 2013 at the authors' institution. RESULTS: Among 6,401 patients undergoing valve surgery, postoperative examinations of the explanted valves/prostheses led to an unexpected diagnosis of Q fever endocarditis in 14 cases (0.2%), who subsequently underwent appropriate medical treatments. Only two of the patients (14%) had intraoperative findings suggestive of endocarditis. On serological analysis of the blood samples, 11 patients (79%) presented an evocative Phase I IgG antibody titer > or =800. Valvular tissue-sample analyses yielded positive cultures and PCR in the same 13 patients (93%), whereas pathological and immunohistochemical examinations alone were suggestive of endocarditis in only seven Cases (50%). CONCLUSION: This screening strategy led to an unexpected diagnosis of Q fever endocarditis in 0.2% of patients undergoing routine valve surgery, who received subsequent appropriate antibiotic therapy. Systematic serological analysis should be mandatory before performing heart valve surgery in countries where C. burnetii is endemic. A positive serology should lead to appropriate valve-specimen analyses, including microbiological, molecular biological and histological evaluations.

Animal models of Q fever (Coxiella burnetii).

Q fever, caused by the pathogen Coxiella burnetii, is an acute disease that can progress to become a serious chronic illness. The organism leads an obligate, intracellular lifecycle, during which it multiplies in the phagolytic compartments of the phagocytic cells of the immune system of its hosts. This characteristic makes study of the organism particularly difficult and is perhaps one of the reasons why, more than 70 y after its discovery, much remains unknown about the organism and its pathogenesis. A variety of animal species have been used to study both the acute and chronic forms of the disease. Although none of the models perfectly mimics the disease process in humans, each opens a window onto an important aspect of the pathology of the disease. We have learned that immunosuppression, overexpression of IL10, or physical damage to the heart muscle in mice and guinea pigs can induce disease that is similar to the chronic disease seen in humans, suggesting that this aspect of disease may eventually be fully understood. Models using species from mice to nonhuman primates have been used to evaluate and characterize vaccines to protect against the disease and may ultimately yield safer, less expensive vaccines.