A pilot serosurvey of Babesia microti in Chinese blood donors.

BACKGROUND AND OBJECTIVES: Babesia spp. are tick-borne, intraerythrocytic protozoan parasites, several of which are transfusion-transmissible. Transfusion-transmitted babesiosis poses serious risk to a diverse patient population, including neonates, patients aged >50 years, the asplenic and the immunocompromised that are over-represented among transfusion recipients. Despite reports of B. microti and B. venatorum in People's Republic of China (PRC), no surveillance of blood donors for Babesia has previously been undertaken. We sought to determine the rates of B. microti seroreactivity in a sample of blood donors in the PRC. MATERIALS AND METHODS: A pilot serosurvey was conducted of community blood donors (n = 1000) who donated July-August 2016 at Mudanjiang Blood Center (Heilongjiang Province) using indirect fluorescent antibody testing for antibodies against B. microti. The slides were prepared using B. microti-infected hamster blood. Samples that were initially positive to a titre of 64 were subjected to repeat IFA testing. Final seroreactivity was based on repeat reactivity to ≥64. RESULTS: A total of 1000 individual donor samples were evaluated, comprising 888 whole blood and 112 platelet donations. Thirteen of 1000 (1·3%) donors were seroreactive for B. microti [8 (0·8%) and five (0·05%) at titres of 64 and 128, respectively]. CONCLUSION: Our preliminary findings support the need for expanded Babesia surveillance in Chinese blood donors, replete with molecular evaluation, to evaluate the risk to the blood supply.

Babesiosis and blood transfusion: flying under the radar.

Infectious agents of disease continue to plague transfusion medicine as an increasing number of pathogens are described that pose a potential blood safety risk. While the recent focus has been on newly emerged agents, several well-established pathogens provide timely reminders that other agents continue to pose threats, but invariably 'fly under the radar', thereby failing to elicit adequate measures to prevent their transmission by blood transfusion. Perhaps foremost among this group of agents are the Babesia spp., which have been known to cause human disease, in the USA, for close to 40 years. B. microti, B. divergens and several Babesia-like agents are responsible for a growing number of human babesiosis infections. Concomitantly, in the USA, there has been a sharp rise in the number of transfusion-transmitted infections of Babesia spp., attributable almost exclusively to B. microti. Despite the obvious public health issues posed by Babesia spp., options for preventing their transmission by blood transfusion remain limited. However, recognition that the Babesia spp. are indeed an ongoing and expanding blood safety threat will probably prove instrumental in the development of viable interventions to limit transmission of these agents.

Emerging infectious agents.

As new agents of infectious disease continue to emerge and old antagonists reemerge, it is clear that the war on infectious disease is far from over. Indeed, the appearance of SARS during the past year is the latest example of the continuing challenges posed by agents of infectious disease. Emerging agents are threats not only to the general population, but also to recipients of blood transfusions. Today a variety of emerging agents are of concern to transfusion safety including Trypanosoma cruzi, West Nile virus, and Babesia microti to name but a few. These and other emerging agents have arisen or have been introduced partly through changes in donor demographics, international travel, microbial adaptations, land use, and human behaviour. Unfortunately, for many of these agents there is an absence of viable tests or other sound interventions to prevent their transmission at this time.

Evidence of Trypanosoma cruzi infection (Chagas' disease) among patients undergoing cardiac surgery.

BACKGROUND: Trypanosoma cruzi, the agent of Chagas' heart disease, is transmitted by triatomine insects and by blood transfusion. The emigration of several million people from T cruzi-endemic countries to the United States has raised concerns regarding a possible increase in cases of Chagas' heart disease here, as well as an increased risk of transfusion-transmitted T cruzi. To investigate these 2 possible outcomes, we tested a repository of blood specimens from multiply transfused cardiac surgery patients for antibodies to T cruzi. METHODS AND RESULTS: Postoperative blood specimens from 11 430 cardiac surgery patients were tested by enzyme immunoassay, and if repeat-reactive, were confirmed by radioimmunoprecipitation. Six postoperative specimens (0.05%) were confirmed positive. Corresponding preoperative specimens, available for 4 of these patients, were also positive. The other 2 patients had undergone heart transplantations. Tissue samples from their excised hearts were tested for T cruzi by polymerase chain reaction and were positive. Despite the fact that several of these 6 patients had histories and clinical findings suggestive of Chagas' disease, none of them were diagnosed with or tested for it. Patient demographics showed that 5 of 6 positive patients were Hispanic, and overall, 2. 7% of Hispanic patients in the repository were positive. CONCLUSIONS: No evidence for transfusion-transmitted T cruzi was found. All 6 seropositive patients apparently were infected with T cruzi before surgery; however, a diagnosis of Chagas' disease was not known or even considered in any of these patients. Indeed, Chagas' disease may be an underdiagnosed cause of cardiac disease in the United States, particularly among patients born in countries in which T cruzi is endemic.

Clonal diversity in the expression and stability of the metastatic capability of Leishmania guyanensis in the golden hamster.

Metastatic disease is a major concern of dermal leishmaniasis caused by Leishmania of the Viannia subgenus. The golden hamster provides an experimental model of systemic dissemination and cutaneous metastasis of Leishmania Viannia. We have exploited this model to examine the expression of parasite virulence in cloned populations derived from a strain of L. guyanensis previously shown to be highly metastatic in the hamster. Metastatic capacity manifested as dissemination throughout the lymphoid organs; cachexia and secondary cutaneous lesions were found to differ among clones, yielding a spectrum of virulence. The metastatic phenotype of clonal populations was stable over 5 sequential passages in hamsters. In addition, the low or high propensity to disseminate and produce cutaneous metastatic lesions was reproduced. Capacity to disseminate from the inoculation site was conserved following subcloning of metastatic clones that had been passaged in culture for several generations; clinical manifestations, cachexia, and cutaneous metastatic lesions were variably expressed. Dissemination of parasites and cachexia were significantly related (P = 0.004). Overall, cachexia was an earlier manifestation of dissemination than cutaneous metastases (P < 0.001). The reproducible expression of virulence phenotypes by discrete populations of Leishmania in the golden hamster provides an experimental model for clinically relevant expression of virulence in human leishmaniasis.

Serologic testing for Trypanosoma cruzi: comparison of radioimmunoprecipitation assay with commercially available indirect immunofluorescence assay, indirect hemagglutination assay, and enzyme-linked immunosorbent assay kits.

The radioimmunoprecipitation assay (RIPA) has been used as a confirmatory test in several ongoing and published studies of Trypanosoma cruzi in blood donors in the United States. Despite its use as a confirmatory test, few studies are available comparing RIPA to commercially available serologic test methods. Thus, we compared RIPA with two indirect hemagglutination assays (Biolab Diagnostica SA, São Paulo, Brazil; Hemagen Diagnostics, Inc., Waltham, Mass.) and four different enzyme-linked immunosorbent assays (Abbott Laboratories, Abbott Park, Ill.; Embrabio, São Paulo, Brazil; Organon Teknika, São Paulo, Brazil; and Gull Laboratories, Salt Lake City, Utah) using a panel of 220 serum specimens from Brazilian blood donors with a range of T. cruzi antibody titers as determined by indirect immunofluorescence assay (IFA). A titer of 1:20 was used as the baseline for seropositivity. All IFA-negative serum specimens (n = 19) were nonreactive on all tests. At a titer of 1:20 (n = 9), reactivity rates varied considerably among the tests, with only the RIPA and the Organon and Gull assays identifying reactive specimens. For specimens at a 1:40 titer (n = 35), most assays identified at least 32 of 35 (91%) specimens as reactive, but the Biolab assay only identified 24 (69%). At higher titers (1:80, n = 56; 1:160, n = 101) the assays were comparable, with the exception of the Biolab assay, demonstrating rates of agreement with IFA of >/=98%. Overall, when compared with several other test formats, RIPA demonstrated equivalent or superior rates of agreement with IFA-positive specimens across all titers examined. In particular, at titers of >1:40, the RIPA compared favorably with other test methods currently in use, supporting its application as a confirmatory test, particularly in a research setting.

Trypanosoma cruzi in a low- to moderate-risk blood donor population: seroprevalence and possible congenital transmission.

BACKGROUND: Several recent studies documented the seroprevalence of Trypanosoma cruzi in blood donors at high risk for infection, but little information is available regarding donors with lower levels of risk. Thus, the present study was designed to measure the seroprevalence of T. cruzi in a donor population with a low to moderate risk for infection. STUDY DESIGN AND METHODS: During a 10-month period, donations from all allogeneic blood donors in the American Red Cross Southwest Region were tested for T. cruzi antibodies by enzyme immunoassay, and results were confirmed by radioimmunoprecipitation. Confirmed-seropositive donors were counseled and lookback investigations were initiated for those who were repeat donors. RESULTS: A total of 100,089 donations were tested: 150 were repeatably reactive, and 3 (0.003%) were confirmed as positive for T. cruziantibodies. All three seropositive donors were from the Waco, TX, area, where the estimated seroprevalence rate was 1 in 7700. Two of these three donors reported no risk factors; both were born in the United States and had not traveled to an endemic area. Both had extensive familial histories of cardiac disease and complications. CONCLUSION: Blood donors seropositive for T. cruzi are present in populations with low to moderate risk, albeit at lower rates. The presence of seropositive blood donors without the usual identifiable risk factors argues against the use of a geographic screening question and also suggests that other routes of transmission, including the congenital route, should be considered in efforts to increase blood safety.

A multi-epitope synthetic peptide and recombinant protein for the detection of antibodies to Trypanosoma cruzi in radioimmunoprecipitation-confirmed and consensus-positive sera.

Peptide epitopes of Trypanosoma cruzi have been identified through expression cloning. A tripeptide (2/D/E) containing three epitopes (TcD, TcE, PEP-2) was used in ELISA to detect antibodies to T. cruzi in 239 of 240 consensus-positive sera and 41 of 42 sera confirmed positive by radioimmunoprecipitation assay. The 1 discrepant consensus-positive serum was used to expression-clone a novel gene that contained a repeat sequence. A peptide corresponding to this sequence, TcLo1.2, was specific for T. cruzi. This antigen detected the discrepant consensus-positive serum and enhanced reactivity of low-positive sera in the tripeptide assay. A branched synthetic peptide, 2/D/E/Lo1.2, or a linear recombinant, r2/D/E/Lo1.2, realized all of the diagnostic features of the four epitopes, including the ability to boost reactivity of low-reactive sera. These studies show that peptides and recombinants containing multiple repeat epitopes are powerful tools for developing assays for T. cruzi antibody detection and have direct application in blood screening.

Negligible prevalence of antibodies against Trypanosoma cruzi among blood donors in the southeastern United States.

Trypanosoma cruzi, a hemoflagellate, causes Chagas' disease and is endemic throughout Latin America. Increasing Latin American immigration to the United States has enhanced concern about transmission of Chagas' disease by infected donor blood. The insect vector and parasites also have been found in the southeastern United States. Autochthonous infection of several species of wild and domesticated mammals suggests that the general human population also may be at risk. To assess the prevalence of antibodies to T cruzi in humans, randomly selected donor blood was screened. Initial screening was performed by indirect hemagglutination (1:4 initial serum dilution) and at least one of three different enzyme immunoassays. All samples testing positive by at least one screening method were tested by radioimmunoprecipitation and indirect immunofluorescence supplemental methods, which were used for confirmation and calculation of specificity. Of the 6,013 serum samples evaluated, 85 tested positive by one screening method. Only 10 of the samples tested positive by more than one method. The percentages of positive screening tests are 0.05% by indirect hemagglutination and 0.06%, 0.91%, 3.97% by Abbott Laboratories (Abbott Park, Ill), Gull (Gull Laboratories, Salt Lake City, Utah), and Polychaco (Polychaco S.A.I.C., Buenos Aires, Argentina) enzyme immunoassays, respectively. All samples were negative by radioimmunoprecipitation and indirect immunofluorescence. These results suggest that although parasite and vector are found in the southeastern United States and both infect mammals, the risk of natural infection to humans in this region seems to be negligible. There was variation in positivity among different screening methods. The highest percentage of positive results was with the enzyme immunoassay, in which the binding of serum antibodies to antigens is amplified by enzymatic reactions.

Seroepidemiology of Trypanosoma cruzi, etiologic agent of Chagas' disease, in US blood donors.

A comprehensive seroepidemiologic study was conducted in two Red Cross regions (Los Angeles and Miami) to determine the prevalence of Trypanosoma cruzi antibodies in at-risk blood donors, to identify additional risk factors, and to assess the likelihood of transmitting T. cruzi by transfusion. At-risk and control donors were stratified by a broad risk question, tested for T. cruzi antibodies, and if confirmed as seropositive, enrolled in case-control and lookback investigations. A total of 299,398 donors were queried; 23,978 at-risk and 25,587 control donations were tested, and T. cruzi antibodies were confirmed in 34 donors (33 and 1, respectively). Seropositive donors shared one risk factor; birth/extensive time in a T. cruzi-endemic area. Lookback studies identified 11 recipients, all negative for T. cruzi antibodies. Screening strategies that use a question are unlikely to identify all seropositive donors. The lack of definitive data on the risk of transmission by transfusion indicates additional studies of donors and recipients are needed.

Carbohydrate and LPG expression in Leishmania viannia subgenus.

Glycosylated molecules expressed on the cell surface of Leishmania promastigotes contribute to the outcome of contact between the parasite and its invertebrate and vertebrate hosts. The expression of several such molecules is growth phase dependent. Information on the expression of carbohydrates by Leishmania of the Viannia subgenus (braziliensis complex), a widespread cause of morbidity in the Americas, is fragmentary. We have examined the relationship between growth phase and the expression of glycosylated surface structures in WHO reference strains of 3 species of the Viannia subgenus, i.e., L. panamensis, L. guyanensis, and L. braziliensis. Agglutination with lectins and the monoclonal antibody specific for the repeat unit of L. donovani lipophosphoglycan, CA7AE, distinguished logarithmic and stationary-phase promastigotes of all 3 species. Flow cytometry revealed increased heterogeneity and disparity in the expression of the repeat unit epitope in stationary-as compared to logarithmic-phase promastigotes. Biochemical analyses showed the LPG repeat unit of all 3 species reference strains to be constituted by mannose and galactose with little or no substitution and, hence, to be similar to the LPG of L. donovani. Initial quantitative analyses of L. braziliensis LPG indicated a 10-fold lower quantity of LPG in this species than L. donovani and an increase in the size of LPG in the stationary phase. These findings provide bases for isolating and biologically characterizing phenotypically distinct populations of promastigotes and for identifying molecular determinants of the host parasite-relationship among Leishmania Viannia.

A retrospective analysis of microbial contaminants in outdated random-donor platelets from multiple sites.

BACKGROUND: Platelet components contaminated with bacteria are an important source of transfusion-associated bacterial sepsis. Estimates of contamination rates vary widely (0-10%) and are highly controversial. The present study, designed with stringent testing regimens, retrospectively determined the prevalence of microbial contaminants in platelets from four collection regions. STUDY DESIGN AND METHODS: During a 9-month period, outdated platelet units were assayed by spreading aliquots from the unit, and from thioglycollate broth medium inoculated with part of the unit, onto 5-percent sheep blood agar media. Cultures were examined after 72-hour incubation at 37 degrees C, and, if bacterial growth was present, the assay processes were repeated with fresh inocula. Units were considered contaminated only if repeatedly positive. RESULTS: Four (0.08%) of 4995 units sampled were contaminated, two with Corynebacterium sp. and one each with Propionibacterium acnes and Aspergillus terreus. Contaminants were present at low, subclinical levels and were detected only after amplification in thioglycollate. The contaminated units were cultured 1, 2, 3, and 7 days after expiration. CONCLUSION: Contamination rates were low and did not vary by region. The identification of A. terreus suggests the role that transfusion may play in transmitting fungal infections should be reassessed. The persistent detection of contaminated platelet units supports the need for a test to detect clinically relevant levels of microbial contaminants in blood components.

Growth of Francisella tularensis LVS in macrophages: the acidic intracellular compartment provides essential iron required for growth.

Murine macrophages supported exponential intracellular growth of Francisella tularensis LVS in vitro with a doubling time of 4 to 6 h. LVS was internalized and remained in a vacuolar compartment throughout its growth cycle. The importance of endosome acidification to intracellular growth of this bacterium was assessed by treatment of LVS-infected macrophages with several different lysosomotropic agents (chloroquine, NH4Cl, and ouabain). Regardless of the agent used or its mechanism of action, macrophages treated with agents that blocked endosome acidification no longer supported replication of LVS. Over several experiments for each lysosomotropic agent, the number of CFU of LVS recovered from treated macrophage cultures was equivalent to the input inoculum (approximately 10(4) CFU) at 72 h. In contrast, over 10(8) CFU was consistently recovered from untreated cultures. Pretreatment of macrophages with these endosome acidification inhibitors did not alter their ingestion of bacteria. Further, the effects of the inhibitors were completely reversible: inhibitor-pretreated LVS-infected macrophages washed free of the agent and cultured in medium fully supported LVS growth over 72 h. Endosome acidification is an important cellular event essential for release of iron from transferrin. The growth-inhibitory effects of both chloroquine and NH4Cl were completely reversed by addition of ferric PPi, a transferrin-independent iron source, at a neutral pH but not by addition of excess holotransferrin. Thus, intracellular localization in an acidic vesicle which facilitates the availability of iron essential for Francisella growth is a survival tactic of this bacterium, and iron depletion is one mechanism that macrophages use to inhibit its growth.

Macrophage activation: a riddle of immunological resistance.

Various lines of defense against infection are present in all living creatures. The balance between symbiosis and parasitism is determined by the mechanisms through which the host resists infection and by the extent of injury induced by the parasite: both factors contribute to disease. Lines of host defense can be arbitrarily divided into three components: 1) barrier functions of skin and mucous membranes and their innate physical and secretory antimicrobial components; 2) elements of host defense that do not necessarily require prior exposure to an infectious agent or immunologic memory (mast cells, granulocytes, macrophages, NK cells, gamma/delta T cells); and 3) immune responses directed against specific epitopes on the infectious agent induced by prior exposure and immunologic memory (alpha/beta T cells, B cells). Analysis of such host defense mechanisms repeatedly documents tremendous redundancy and overlap between these lines of defense. Further, there is open communication, so that a change at any one level ripples throughout the system. Acquired nonspecific resistance to infection is an example of such a ripple. Host response to one infection alerts the immune system, so that the general level of resistance to other infectious agents is increased. This response is initiated by an immune response (third line of defense) but effected by nonspecific elements (second line of defense). The survival value of such responses is obvious. There are numerous examples in both mouse and man of the operation of these systems in response to infection. Further, the menus of antimicrobial components available to both mouse and man for resistance to infection are very similar, but not identical. Indeed, it is said that the genetic basis for differences between mice and man revolve around a difference of less than 10% in DNA sequences. But there are differences! Mouse macrophages produce IFN-beta in response to infection, human cells produce IFN-alpha. Mouse macrophages effect antimicrobial activity principally through induction of NO synthase and the generation of toxic nitrogen oxides. This pathway has yet to be described with human macrophages. In both man and mouse, F. tularensis is an obligate intracellular parasite of macrophages that requires an essential component provided by the cell for its replication. That mouse and man are not so different is well illustrated by the effector mechanisms induced by IFN-gamma for antimicrobial activity against F. tularensis.(ABSTRACT TRUNCATED AT 400 WORDS)

IFN-gamma produced in vivo during the first two days is critical for resolution of murine Leishmania major infections.

Resolution of murine infection with Leishmania major is dependent upon the presence of IFN-gamma during the first week of infection. To more precisely determine the period during which IFN-gamma is critical, we infected footpads of resistant C3H/HeN mice with amastigotes of L. major and treated these mice with neutralizing monoclonal Ab (MAb) specific for IFN-gamma on successive days. Mice treated with anti-IFN-gamma MAb on or before day 2 had significantly enlarged lesions, and increased parasites in lesions, compared with mice treated with an isotype control MAb. In contrast, mice treated with anti-IFN-gamma MAb on day 3 or later resolved their lesions and had no parasites at the inoculation site. Related experiments obtained with a neutralizing MAb specific for TNF-alpha demonstrated the critical role TNF-alpha plays in resolution of Leishmania infection. Thus, IFN-gamma and TNF-alpha were both critical for resolution of infection with L. major, with IFN-gamma's role limited to the first 2 days.