Coinfections identified from metagenomic analysis of cervical lymph nodes from tularemia patients.

BACKGROUND: Underlying coinfections may complicate infectious disease states but commonly go unnoticed because an a priori clinical suspicion is usually required so they can be detected via targeted diagnostic tools. Shotgun metagenomics is a broad diagnostic tool that can be useful for identifying multiple microbes simultaneously especially if coupled with lymph node aspirates, a clinical matrix known to house disparate pathogens. The objective of this study was to analyze the utility of this unconventional diagnostic approach (shotgun metagenomics) using clinical samples from human tularemia cases as a test model. Tularemia, caused by the bacterium Francisella tularensis, is an emerging infectious disease in Turkey. This disease commonly manifests as swelling of the lymph nodes nearest to the entry of infection. Because swollen cervical nodes are observed from many different types of human infections we used these clinical sample types to analyze the utility of shotgun metagenomics. METHODS: We conducted an unbiased molecular survey using shotgun metagenomics sequencing of DNA extracts from fine-needle aspirates of neck lymph nodes from eight tularemia patients who displayed protracted symptoms. The resulting metagenomics data were searched for microbial sequences (bacterial and viral). RESULTS: F. tularensis sequences were detected in all samples. In addition, we detected DNA of other known pathogens in three patients. Both Hepatitis B virus (HBV) and Human Parvovirus B-19 were detected in one individual and Human Parvovirus B-19 alone was detected in two other individuals. Subsequent PCR coupled with Sanger sequencing verified the metagenomics results. The HBV status was independently confirmed via serological diagnostics, despite evading notice during the initial assessment. CONCLUSION: Our data highlight that shotgun metagenomics of fine-needle lymph node aspirates is a promising clinical diagnostic strategy to identify coinfections. Given the feasibility of the diagnostic approach demonstrated here, further steps to promote integration of this type of diagnostic capability into mainstream clinical practice are warranted.

Unexpected Relations of Historical Anthrax Strain.

In 1998, it was claimed that an 80-year-old glass tube intentionally filled with Bacillus anthracis and embedded in a sugar lump as a WWI biological weapon still contained viable spores. Today, genome sequencing of three colonies isolated in 1998 and subjected to phylogenetic analysis surprisingly identified a well-known B. anthracis reference strain isolated in the United States in 1981, pointing to accidental laboratory contamination.IMPORTANCE Next-generation sequencing and subsequent phylogenetic analyses are useful and reliable tools for the classification of recent and historical samples. The reliability of sequences obtained and bioinformatic algorithms has increased in recent years, and research has uncovered the identity of a presumed bioweapon agent as a contaminant.

Identification and typing of Francisella tularensis with a highly automated genotyping assay.

A PCR assay was developed to genotypically characterize Francisella tularensis and F. novicida. An integrated and partially redundant set of markers was selected to provide positive identification of these species, identify subspecies of F. tularensis and genotype 14 variable number tandem repeat (VNTR) markers. Assay performance was evaluated with 117 Francisella samples. Sample DNA was amplified, and the masses of the PCR products were determined with electrospray ionization/time of flight mass spectrometry (ESI-MS). The base compositions of the PCR amplicons were derived from these high-accuracy mass measurements and contrasted with databased information associated with each of the 25 assay markers. Species and subspecies determinations for all samples were fully concordant with results from established typing methods, and VNTR markers provided additional discrimination among samples. Sequence variants were observed with a number of assay markers, but these did not interfere with sample characterization, and served to increase the genetic diversity detected by the assay.

Phylogeography of Francisella tularensis ssp. holarctica in France.

AIM: To investigate the phylogeography of French Francisella tularensis ssp. holarctica isolates. METHODS AND RESULTS: Canonical SNPs and MLVA were used to genotype 103 French F. tularensis ssp. holarctica isolates. We confirmed the presence of one subclade, the central and western European group (B.Br.FTNF002-00), and identified four major MLVA genotypes with no obvious geographical differentiation. CONCLUSIONS: The lack of geographical resolution among MLVA genotypes suggests rapid dispersal, convergent evolution or a combination of the two. SIGNIFICANCE AND IMPACT OF THE STUDY: This study expands knowledge of the phylogeography of one of the two dominant European F. tularensis ssp. holarctica subclades and illustrates the need for additional SNP discovery within this subclade.

Regulation of chemokine responses in intestinal epithelial cells by stress and Toxoplasma gondii infection.

Infection with Toxoplasma gondii induces chemokine up-regulation in several cell types. Here, we investigated the role of stress products (norepinephrine, NE) on chemokine production in mouse intestinal epithelial cells (IECs). Purified IECs were used to determine the expression levels of chemokines by real-time PCR. There was significantly increased expression in CCL2, CCL3, CCL5, CXCL2, CXCL9 and CXCL10 in IECs following peroral infection with T. gondii (INF) on day eight post-infection (PI) compared to infected mice subjected to cold-water stress (INF+CWS). In vitro studies using the MODE-K cell line showed increased chemokine mRNA and protein expression in infected but not in cells exposed to parasite antigen. Down-regulation of chemokine expression was more pronounced when active infection was used in combination with NE. Chemokine receptor expression was increased in IECs isolated from INF and decreased in the INF+CWS group. In MODE-K cells, there was decreased mRNA expression of chemokine receptors when incubated with ß-adrenergic antagonists. Neither, adrenergic antagonists blocked the effect of infection on chemokine receptor expression. Cold-water stress was able to decrease expression of chemokines and their receptors in IECs in vivo and in vitro. Cold-water stress-mediated modulation of innate intestinal responses are beneficial in C57BL/6 mice during T. gondii infection.

An optimized, multiplexed multi-locus variable-number tandem repeat analysis system for genotyping Francisella tularensis.

We present a truncated, optimized, multiplexed multiple-locus variable-number tandem repeat analysis system for the molecular subtyping of Francisella tularensis that reduces time and cost requirements while retaining high discriminatory power.

Regulation of toll-like receptors in intestinal epithelial cells by stress and Toxoplasma gondii infection.

Intestinal epithelial cells (IECs) form a barrier between invading microorganisms and the underlying host tissues. IECs express toll-like receptors (TLRs) that recognize specific molecular signatures on microbes, which activate intracellular signalling pathways leading to production of proinflammatory cytokines and chemokines. Stress hormones play an important role in modulation of proinflammatory cytokines and down-regulation of immune responses. Here we demonstrated that expression levels of TLR-2, TLR-4, TLR-9 and TLR-11 were significantly increased in mouse IECs following infection with Toxoplasma gondii on day 8 postinfection. In contrast, expression of TLRs was significantly decreased in infected mice subjected to cold water stress (CWS + INF). Expression of TLR-9 and TLR-11 in the mouse MODE-K cell line was significantly increased after infection. Expression of TLR-9 and TLR-11 in cells exposed to norepinephrine (NE) and parasites was significantly decreased when compared to cells exposed to parasites only. A significant increase was observed in SIGIRR, a negative regulator of TLRs in the CWS + INF group when compared to the INF group. Stress components were able to decrease expression levels of TLRs in IECs, decrease parasite load, and increase expression of a negative regulator thereby ameliorating intestinal inflammatory responses commonly observed during per oral T. gondii infection in C57BL/6 mice.

Genomic deletion marking an emerging subclone of Francisella tularensis subsp. holarctica in France and the Iberian Peninsula.

Francisella tularensis subsp. holarctica is widely disseminated in North America and the boreal and temperate regions of the Eurasian continent. Comparative genomic analyses identified a 1.59-kb genomic deletion specific to F. tularensis subsp. holarctica isolates from Spain and France. Phylogenetic analysis of strains carrying this deletion by multiple-locus variable-number tandem repeat analysis showed that the strains comprise a highly related set of genotypes, implying that these strains were recently introduced or recently emerged by clonal expansion in France and the Iberian Peninsula.

A clinical study of the relationship between silicone breast implants and connective tissue disease.

OBJECTIVE: This study was a blinded, concurrent assessment of a historical cohort derived from a provincial registry (1978 to 1986) of breast implant recipients (cosmetic, not reconstructive) and controls (other cosmetic surgery) to test the hypothesis that connective tissue disease (CTD) is increased in breast implant recipients. METHODS: Women who underwent breast implant or other cosmetic surgery during the interval from 1978 to 1986 were contacted confidentially by Alberta Health and asked to participate in the study. Those willing to participate completed an extensive questionnaire and supplied a blood sample, subsequent to which all surgical records were reviewed to confirm implant type(s) or cosmetic surgery(ies). All participants with any suggestion of rheumatic disease were assessed blindly by a rheumatologist for CTD. RESULTS: One thousand five hundred seventy-six breast implant recipients were recruited, including 1112 who had received silicone gel-filled implants (> 13,500 person yrs exposure). Seven hundred twenty-six controls were recruited. Prevalence rates adjusted for sex and age for rheumatoid arthritis, systemic lupus erythematosus, scleroderma, and Sjögren's syndrome (the principal targeted conditions) were consistent with published reports for Caucasian women. While breast implant recipients self-reported significantly greater rates of symptoms than controls, post-surgical diagnoses of the principal targeted conditions did not indicate an increased incidence of typical or atypical CTD. CONCLUSION: The results of the study do not support the hypothesis that silicone gel-filled implants induce or promote CTD.

Gene synthesis and functional expression of a protein exhibiting monodomain IgG Fc binding.

A gene encoding a bacterial IgG Fc binding domain was designed and synthesized. The synthetic DNA fragment was cloned 3' to an inducible trpE promoter such that expression of the gene in Escherichia coli produced abundant Fc binding protein fused to the first seven amino acids of the trpE protein. The recombinant protein contained a single Fc binding domain and demonstrated efficient binding to human IgG in Western blot analysis. This protein degraded rapidly following cell lysis in the absence of protease inhibitors, but could be effectively protected by the addition of protease inhibitor. After purification of the protein by IgG affinity chromatography, IgG Fc binding ability was retained for at least 24 h at either 23 or 37 degrees C and on heating for 15 min at temperatures up to 65 degrees C. No immunoprecipitation was observed in interactions between the monodomain Fc binding protein and IgG molecules. Unlike staphylococcal protein A, no detectable binding of the monodomain IgG Fc binding protein was observed to either IgM or IgA. Truncated proteins, expressed from a series of 3' deletions of the synthetic gene, were used to estimate the minimum portion of a monodomain Fc binding protein that retained Fc binding ability.

A single Fc binding domain--alkaline phosphatase gene fusion expresses a protein with both IgG binding ability and alkaline phosphatase enzymatic activity.

A recombinant gene fusion was created and cloned using a previously constructed gene encoding a monodomain IgG Fc binding protein and the gene coding for bacterial alkaline phosphatase. The construct was able to express and secrete a fusion protein that exhibited both IgG binding and alkaline phosphatase enzymatic activities. Greater than 60% of the protein demonstrating both biological activities was detected from periplasmic space preparations. Nanogram concentrations of the Fc binding--alkaline phosphatase fusion protein allowed primary IgG antibody detection without the use of conjugated secondary antibodies. Removal of the domain coding for alkaline phosphatase resulted in decreased resistance of the protein to proteolytic degradation and the loss of IgG Fc binding ability. Using affinity-purified fusion protein, the specificity of binding to IgG, IgM and IgA was examined; binding was strong to IgG and barely detectable against IgM or IgA. Affinity for binding of the fusion protein to IgG (Kd = 6.7 x 10(-8) M) was determined to be equal to or greater than previously reported for protein A.

Breast cancer diagnosis and survival in women with and without breast implants.

The stage at diagnosis and the survival experience of 41 women who developed breast cancer after cosmetic breast augmentation were compared with those of all other patients with breast cancer (n = 13,246) diagnosed in Alberta from 1973 to 1990 (inclusive). The tumors in women with breast implants were smaller (65.9 percent < or = 2 cm) as compared with the tumors in women without implants (34.1 percent < or = 2 cm), but lymph node and distant metastases were equally frequent in the two groups. The distribution of tumor histologic types did not differ significantly between women with or without implants. Women who had an implant were younger at diagnosis of breast cancer compared with women with breast cancer and no breast implants. The relative 5- and 10-year survival rates did not differ significantly between the two groups, and the Kaplan-Meier survival estimate also was similar. It is concluded that women with breast implants in whom breast cancer develops are not diagnosed in a later stage and do not experience an impaired survival as compared with breast cancer patients without implants.

Breast augmentation: a risk factor for breast cancer?

BACKGROUND: A relation between breast augmentation and the subsequent risk of breast cancer has been postulated. Since an estimated 2 million women in the United States alone have received breast implants, even a small increase in the risk of breast cancer could have considerable public health consequences. METHODS: We performed a population-based nonconcurrent cohort-linkage study. All women in Alberta, Canada, who underwent cosmetic breast augmentation from 1973 through 1986 were included in the implant cohort (n = 11,676). This cohort was compared with the cohort of all women in Alberta in whom a first primary breast cancer was diagnosed (n = 13,557). The expected number of breast-cancer cases in the implant cohort was estimated by applying age-specific and calendar year--specific incidence rates of breast cancer (obtained from the Alberta Cancer Registry) to the implant cohort. Standardized incidence ratios were calculated by dividing the observed by the expected number of breast-cancer cases in the implant cohort. RESULTS: Forty-one patients with implants were subsequently found to have breast cancer. The expected number was 86.2. The standardized incidence ratio was thus 47.6 percent, significantly lower than expected (P less than 0.01). The average length of follow-up in the implant cohort was 10.2 years, and the average length of time from breast augmentation to the diagnosis of breast cancer was 7.5 years. CONCLUSIONS: Women who undergo breast augmentation with silicone implants have a lower risk of breast cancer than the general population. This finding suggests that these women are drawn from a population already at low risk and that the implants do not substantially increase the risk.

Urinary excretion of free toluenediamines in a patient with polyurethane-covered breast implants.

We report the detection of free 2,4-toluenediamine in urine of a patient implanted with polyurethane-covered breast implants. Samples were collected on several dates, ranging from 21 days to seven months after the insertion of the implants, and these samples all showed the presence of free 2,4-toluenediamine at a concentration of about 1 micrograms/L. The chemical was not found in a urine sample collected before implantation. This finding is important for risk assessment of cancer in patients with this type of breast implant because the chemical is a suspected carcinogen. Free 2,6-toluenediamine, an isomer, was also found in all samples from this patient.

Detection of toluenediamines in the urine of a patient with polyurethane-covered breast implants.

Breast prostheses are implanted for augmentation or during reconstructive surgery. One of the more commonly used prostheses is the polyurethane-sponge-covered silicone gel implant. Some clinicians are concerned about the safety of this product because the polyurethane foam disintegrates in vivo, and its subsequent fate is not known. Polyurethane is a polymer formed by reacting diisocyanates and polyols. This study indicates that the polymer sponge breaks down into its reactive monomers, 2,4- and 2,6-toluenediisocyanate, which are converted into their corresponding diamines. We present evidence of the excretion of the diamine metabolites in the urine of a patient implanted with polyurethane-covered prostheses.

Cervical spine injury in patients with facial skeletal trauma.

The records of 2,555 patients admitted to hospital with facial fractures were reviewed for concomitant neck injury. Cervical spine injury occurred in 1.3% of all patients with facial fractures, the incidence rising to 5.5% with facial fractures resulting only from MVA's. Neck injuries occurred most frequently in the setting of MVA's (85%) and multisystem trauma (70%) and tended to involve two main levels of the cervical spine: C2 (31%) and the two lower cervical vertebrae C6 and C7 (50%). Examination of the pattern of cervical spine injury with respect to the pattern of facial skeletal injury does not support the premise of a direct causal relation between them.

Surface localization of sialic acid on Actinomyces viscosus.

This study reports the presence of sialic acid in Actinomyces viscosus strains T14V and T14AV. Mild acid hydrolysis of whole organisms released a compound which reacted positively in the periodate-thiobarbituric acid, direct Ehrlich's and resorcinol assays, and which co-chromatographed on paper with authentic N-acetylneuraminic acid. Strain T14V contained 10-fold greater concentrations of sialic acid than did strain T14AV. Sialic acid content was dependent upon the stage of growth of the culture, reaching a maximum in early stationary phase. Epifluorescence microscopy of fluorescein isothiocyanate (FITC)-conjugated Limulus polyphemus agglutinin (LPA), a lectin specific for sialic acid, revealed a uniform distribution of bound lectin on the surfaces of strains T14V and T14AV. Additional evidence for surface localization was obtained by demonstration of whole-cell agglutination of both strains with LPA. All LPA interactions with A. viscosus were inhibited by the presence of 0.1 M-N-acetylneuraminic acid. Neuraminidases from Clostridium perfringens, Arthrobacter ureafaciens and Vibrio cholerae did not release detectable amounts of sialic acid, but the extracellular enzyme from A. viscosus cleaved amounts equivalent to those obtained by acid hydrolysis. Other laboratory strains (W1053, M100, W859, 5-5S, RC45, ATCC 19246, and 'binder') as well as recent clinical isolates of A. viscosus were agglutinated by LPA and released sialic acid upon mild acid hydrolysis. Surface-available sialic acid has been implicated in the inhibition of alternative complement pathway activation and subsequent opsonophagocytosis. Thus the occurrence of surface sialic acid in A. viscosus may represent a mechanism of pathogenesis for this oral bacterium.

Langmuir and scatchard parameters do not describe the binding of Actinomyces viscosus to saliva-treated hydroxyapatite.

The binding of Actinomyces viscosus T14V to saliva-treated spheroidal hydroxyapatite (SHA) beads was studied. The association constant (K) and the total number of binding sites (N) obtained from the Langmuir plots were in good agreement with those reported by other workers (approx. 3 X 10(-8) and 3 X 10(8), respectively). The values for N obtained from Scatchard plots differed from those obtained from Langmuir plots by factors of 10(6) or more. These results suggest that either these equations are inappropriate to describe binding or certain assumptions regarding this system are not being met. The use of these models requires, among other constraints, that the process be reversible and that measurements be taken at equilibrium. A method was developed which allowed a close examination of the equilibrium dynamics without perturbation of the system. The results suggest that the adsorption process is only poorly reversible. Adsorption to SHA was not at equilibrium after 1.5 h. Even when bacteria were allowed to adsorb for longer periods, and the system appeared to approach equilibrium, the increased time of adherence did not significantly alter the derived K or N values. Our results suggest that the use of Scatchard and Langmuir plots is inappropriate to describe binding of A. viscosus to SHA.

Resolution of prepubertal male gynecomastia following removal of a giant pigmented nevus.

A male infant is reported in whom substantial gynecomastia resolved following removal of a giant pigmented nevus. Endocrinological studies were normal. It is postulated that the nevus contributed to the development of gynecomastia. Surgeons should be aware of a possible relationship between these two seemingly unrelated conditions when making evaluation and management decisions.