Risk factors for sporadic community-acquired Legionnaires' disease. A 3-year national case–control study

OBJECTIVE

Risk factors for sporadic community-acquired Legionnaires' disease (LD) have been studied in the past, well before the widespread introduction of the urinary antigen test. Our objective was to evaluate the impact of the concomitant decrease in underdiagnosis on established and unknown risk factors for LD.

STUDY DESIGN

Prospective case-control study.

METHODS

From 1 July 1998 to 30 June 2001, 228 LD cases and 293 controls were included for a national case-control study. Patients were included upon notification provided that they fulfilled international criteria for confirmed LD.

RESULTS

A history of diabetes mellitus, current tobacco smoking, travelling abroad, spending one or more nights away from home not leaving the country and being a driver by profession were independent risk factors. LD patients who had travelled abroad during their incubation period differed from LD patients who had not. They appeared healthier than non- or domestic travellers with respect to a history of coronary disease, pulmonary disease, current use of corticosteroids or immunosuppressives and any medication. Also the environmental risk factors differed significantly for the two groups.

CONCLUSIONS

The finding of two distinct populations of LD patients calls for a differentiated preventive strategy.

Evaluation of Vircell enzyme-linked immunosorbent assay and indirect immunofluorescence assay for detection of antibodies against Legionella pneumophila

We evaluated the abilities of the Vircell immunoglobulin G (IgG) and IgM indirect immunofluorescence assay (IFA) for Legionella pneumophila serogroup 1, the IgM and IgG enzyme-linked immunosorbent assay (ELISA) for Legionella pneumophila serogroup 1, and the IgM-plus-IgG ELISA for Legionella pneumophila serogroups 1 to 6 to diagnose Legionnaires' disease (LD) in a well-described sample of patients with and without LD. Also, we determined the agreements, sensitivities, and specificities of the different Vircell assays in comparison to a validated ELISA (Serion classic ELISA). Clinical sensitivity and specificity were 74.6% and 96.6%, respectively, for the IgM IFA, 65.1% and 88.0% for the IgG IFA, 92.3% and 100% for the IgM ELISA, 43.3% and 96.6% for the IgG ELISA, and 90.8% and 100% for the IgM-plus-IgG ELISA. Compared to Serion classic ELISA, agreement, sensitivity, and specificity were 80.0%, 83.1%, and 78.4%, respectively, for the IgM IFA, 75.2%, 66.0%, and 79.5% for the IgG IFA, 89.5%, 82.0%, and 97.6% for the IgM ELISA, 81.9%, 88.9%, and 78.0% for the IgG ELISA, and 93.5%, 90.0%, and 96.6% for the IgM-plus-IgG ELISA. The value of a positive diagnostic result obtained by the Vircell IgM IFA, the Vircell IgG IFA, and the Vircell IgG ELISA might not be acceptable for a diagnostic assay. Both the high specificities and sensitivities of the Vircell IgM ELISA and the IgM-plus-IgG ELISA and the high correlation with the Serion classic ELISA indicate that they are useful in the diagnosis of LD.

MyD88-dependent IFN-gamma production by NK cells is key for control of Legionella pneumophila infection

Legionella pneumophila (Lpn) is a ubiquitous Gram-negative bacterium in aquatic systems and an opportunistic intracellular pathogen in immunocompromised humans causing a severe pneumonia known as Legionnaires' disease. Using a mouse model, we investigated molecular and cellular players in the innate immune response to infection with Lpn. We observed robust levels of inflammatory cytokines in the serum upon intranasal or i.v. infection with live, virulent Lpn, but not with inactivated or avirulent bacteria lacking the Icm/Dot type IV secretion system. Interestingly, Lpn-induced serum cytokines were readily detectable regardless of the capacity of Icm/Dot-proficient Lpn to replicate in host cells and the Lpn permissiveness of the host mice. We found NK cell-derived IFN-gamma to be the key cytokine in the resolution of Lpn infection, whereas type I IFNs did not appear to play a major role in our model. Accordingly, NK cell-depleted or IFN-II-R-deficient mice carried severely increased bacterial burdens or failed to control Lpn infection, respectively. Besides the dependence of inflammatory cytokine induction on Lpn virulence, we also demonstrate a strict requirement of MyD88 for this process, suggesting the involvement of TLRs in the recognition of Lpn. However, screening of several TLR-deficient hosts did not reveal a master TLR responsible for the sensing of an Lpn infection, but provided evidence for either redundancy of individual TLRs in Lpn recognition or TLR-independent induction of inflammatory responses.

The impact of genomics on the analysis of host resistance to infectious disease

The advent of new technologies and resources, including the complete sequence of mammalian genomes, has had a dramatic impact on the genetic analysis of susceptibility to infections in humans and in animal models of infection. Genes responsible for simple or complex control of susceptibility to infection with different pathogens have been recently identified and characterized, and are reviewed herein.

Sensitivity of three serum antibody tests in a large outbreak of Legionnaires' disease in the Netherlands

In 1999, an outbreak involving 188 patients with Legionnaires' disease (LD) occurred at a flower show in the Netherlands. This large outbreak provided the opportunity to evaluate serum antibody tests to assay anti-Legionella pneumophila, since limited data are available on the sensitivity of these tests. The sensitivities of an indirect serotype 1-6 immunofluorescence antibody test (IFAT), a rapid micro-agglutination test (RMAT) IgM serotype 1 antibody assay, and an ELISA to detect IgM and IgG serotype 1-7 antibodies, were evaluated using serum samples from LD patients related to the 1999 outbreak. Sensitivity was calculated using positive culture and/or a positive urinary antigen test as the gold standard in outbreak-related patients with radiographically confirmed pneumonia who fulfilled the epidemiological criteria. The IFAT, RMAT and ELISA showed sensitivities of 61, 44 and 64%, respectively. The sensitivity of the three tests combined was 67%. In epidemic situations, however, high standing titres may be included in the laboratory evidence of LD cases. In the study population, high standing titres were found in 16% of cases. If the presence of high standing antibody titres was added to the criteria of a positive test, the sensitivities of IFAT, RMAT and ELISA were 86, 48 and 75%, respectively. The sensitivity was 91% for all tests combined. The higher sensitivity for the combined use of tests is offset by a reduction in specificity to 97.6%. The results of this study indicate that using a combination of serologic tests in pneumonia patients suspected to have LD does not substantially improve sensitivity. The results suggest that in the microbiological diagnosis of LD, both IFAT and ELISA are reasonably sensitive assays. In an epidemic situation, both tests are highly sensitive, the IFAT more so than the ELISA.

Pathogenese, Diagnostik und Therapie der Legionella-Infektion

Legionella species are ubiquitous in aquatic environments. About 50 years ago they entered the engineered (technical) environment, i.e. warm water systems with zones of stagnation. Since that time they represent a hygienic problem. After transmission to humans via aerosols legionellae might cause Legionella pneumonia (legionnaires' disease) or influenza-like respiratory infections (Pontiac fever). Epidemiological data suggest that Legionella strains might differ substantially in their virulence properties. Although the molecular basis is not understood L. pneumophila serogroup 1 especially MAb 3/1-positive strains cause the majority of infections. The main virulence feature is the ability to multiply intracellularly. After uptake into macrophages legionellae multiply in a specialized vacuole and finally lyse their host cells. Several bacterial factors like surface components, secretion systems and iron uptake systems are involved in this process. Since the clinical picture of Legionella pneumonia does not allow differentiation from pneumoniae caused by other pathogens, microbiological diagnostic methods are needed to establish the diagnosis. Cultivation of legionellae from clinical specimens, detection of antigens and DNA in patients' samples and detection of antibodies in serum samples are suitable methods. However, none of the diagnostic tests presently available offers the desired quality with respect to sensitivity and specificity. Therefore, the standard technique is to use several diagnostic tests in parallel. Advantages and disadvantages of the diagnostic procedures are discussed. Therapeutic options for Legionella infections are newer macrolides like azithromycin and chinolones (ciprofloxacin, levofloxacin and moxifloxacin).

Cytosolic recognition of flagellin by mouse macrophages restricts Legionella pneumophila infection

To restrict infection by Legionella pneumophila, mouse macrophages require Naip5, a member of the nucleotide-binding oligomerization domain leucine-rich repeat family of pattern recognition receptors, which detect cytoplasmic microbial products. We report that mouse macrophages restricted L. pneumophila replication and initiated a proinflammatory program of cell death when flagellin contaminated their cytosol. Nuclear condensation, membrane permeability, and interleukin-1β secretion were triggered by type IV secretion-competent bacteria that encode flagellin. The macrophage response to L. pneumophila was independent of Toll-like receptor signaling but correlated with Naip5 function and required caspase 1 activity. The L. pneumophila type IV secretion system provided only pore-forming activity because listeriolysin O of Listeria monocytogenes could substitute for its contribution. Flagellin monomers appeared to trigger the macrophage response from perforated phagosomes: once heated to disassemble filaments, flagellin triggered cell death but native flagellar preparations did not. Flagellin made L. pneumophila vulnerable to innate immune mechanisms because Naip5⁺ macrophages restricted the growth of virulent microbes, but flagellin mutants replicated freely. Likewise, after intratracheal inoculation of Naip5⁺ mice, the yield of L. pneumophila in the lungs declined, whereas the burden of flagellin mutants increased. Accordingly, macrophages respond to cytosolic flagellin by a mechanism that requires Naip5 and caspase 1 to restrict bacterial replication and release proinflammatory cytokines that control L. pneumophila infection.

Induction of protective immunity by Legionella pneumophila flagellum in an A/J mouse model

The capacity of a purified preparation of Legionella pneumophila flagella (FLA) to induce protective immune responses was studied in an A/J mouse model. Animals immunized with FLA promptly mounted an anti-FLA antibody response and also developed a strong activation of both innate and adaptive cell-mediated immunity, as shown by an early release of pro-inflammatory cytokines in the peritoneal cavity, and by a positive cutaneous delayed-type hypersensitivity reaction and in vitro splenic lymphocyte proliferation in response to FLA antigens. Mice treated with FLA either i.v. or i.p. also survived (100% rate) a lethal i.p. challenge with L. pneumophila. Protection induced by FLA lasted for at least 30 days after treatment, but less than 60, and was effective against the challenge with different serogroups of L. pneumophila. Resistance conferred by FLA immunization could be partially transferred to naïve animals by the adoptive transfer of immune splenocytes but not by passive immunization with anti-FLA iperimmune sera. The capacity to induce protective immunity was specifically attributable to flagellar components, as demonstrated by the lack of protection in mice immunized with a sham flagella preparation from a non-flagellated bacterial strain or with protease-digested FLA. In addition, heat-denatured FLA was inactive, suggesting loss of immunogenicity following denaturation. The present study provides evidence that L. pneumophila flagellum is strongly immunogenic and capable to stimulate, without adjuvants, early natural and acquired, T-cell-mediated immune responses and to induce significant protection against a lethal bacterial challenge in A/J mice. Antigenic characterization of this bacterial organelle and elucidation of mechanisms underlying flagella-induced protection would be of great value in understanding the immunopathogenesis of the disease and in developing possible therapeutic strategies for human legionellosis.

Recognition of cytosolic DNA activates an IRF3-dependent innate immune response

Nucleic acid recognition upon viral infection triggers type I interferon production. Viral RNA is detected by both endosomal, TLR-dependent and cytosolic, RIG-I/MDA5-dependent pathways. TLR9 is the only known sensor of foreign DNA; it is unknown whether innate immune recognition of DNA exists in the cytosol. Here we present evidence that cytosolic DNA activates a potent type I interferon response to the invasive bacterium Listeria monocytogenes. The noninvasive Legionella pneumophila triggers an identical response through its type IV secretion system. Activation of type I interferons by cytosolic DNA is TLR independent and requires IRF3 but occurs without detectable activation of NF-kappaB and MAP kinases. Microarray analyses reveal a unique but overlapping gene-expression program activated by cytosolic DNA compared to TLR9- and RIG-I/MDA5-dependent responses. These findings define an innate immune response to DNA linked to type I interferon production.

Bacterial RNA and small antiviral compounds activate caspase-1 through cryopyrin/Nalp3

Missense mutations in the CIAS1 gene cause three autoinflammatory disorders: familial cold autoinflammatory syndrome, Muckle-Wells syndrome and neonatal-onset multiple-system inflammatory disease. Cryopyrin (also called Nalp3), the product of CIAS1, is a member of the NOD-LRR protein family that has been linked to the activation of intracellular host defence signalling pathways. Cryopyrin forms a multi-protein complex termed 'the inflammasome', which contains the apoptosis-associated speck-like protein (ASC) and caspase-1, and promotes caspase-1 activation and processing of pro-interleukin (IL)-1beta (ref. 4). Here we show the effect of cryopyrin deficiency on inflammasome function and immune responses. Cryopyrin and ASC are essential for caspase-1 activation and IL-1beta and IL-18 production in response to bacterial RNA and the imidazoquinoline compounds R837 and R848. In contrast, secretion of tumour-necrosis factor-alpha and IL-6, as well as activation of NF-kappaB and mitogen-activated protein kinases (MAPKs) were unaffected by cryopyrin deficiency. Furthermore, we show that Toll-like receptors and cryopyrin control the secretion of IL-1beta and IL-18 through different intracellular pathways. These results reveal a critical role for cryopyrin in host defence through bacterial RNA-mediated activation of caspase-1, and provide insights regarding the pathogenesis of autoinflammatory syndromes.

[Guideline 'Diagnosis and treatment of community-acquired pneumonia' from the Dutch Thoracic Society]

Community-acquired pneumonia (CAP) is associated with considerable morbidity and mortality. The incidence of CAP in the Netherlands is estimated to be 5-10 per 1000 per year. This guideline can be used for the scientifically-based diagnosis and antibiotic treatment of adults with CAP. Streptococcus pneumoniae is the most frequent causative agent In 30-50% of patients, the aetiological pathogen cannot be identified. In the Netherlands, the resistance of S. pneumoniae to penicillin is less than 1%. In addition to patient history and physical examination, chest radiography is indispensable to the diagnosis of CAP. Cultures of sputum, blood, and, if present, pleural effusion are needed to detect the causative agent. Bronchoscopy can be considered if the patient's condition deteriorates during antibiotic therapy. Urinary antigen detection is important if signs of legionellosis are present; only Legionella pneumophila serotype can be identified with this technique. The severity of CAP and the risk factors can be measured by the pneumonia severity index, which may be helpful in deciding whether to hospitalise a patient. The choice of antibiotic therapy is based on the intention of providing optimal therapy, the epidemiological features ofvarious microorganisms in the Netherlands, and an inference of the most likely pathogen, based on comorbidity. Empirical antibiotic therapy should target primarily S. pneumoniae because of its high incidence. In both seriously ill patients and those suspected of having legionellosis, antibiotic therapy should also target L. pneumophila. Antibiotic therapy should be adjusted if the pathogen is subsequently identified. Parapneumonic effusion frequently occurs in cases of CAP. Drainage is indicated if the pleural fluid contains bacteria or yields a pH < 7.0. Influenza vaccination is recommended in the elderly to prevent CAP.

Components of the Legionella pneumophila flagellar regulon contribute to multiple virulence traits, including lysosome avoidance and macrophage death

Legionella pneumophila is a motile intracellular pathogen of macrophages and amoebae. When nutrients become scarce, the bacterium induces expression of transmission traits, some of which are dependent on the flagellar sigma factor FliA (sigma(28)). To test how particular components of the L. pneumophila flagellar regulon contribute to virulence, we compared a fliA mutant with strains whose flagellar construction is disrupted at various stages. We find that L. pneumophila requires FliA to avoid lysosomal degradation in murine bone marrow-derived macrophages (BMM), to regulate production of a melanin-like pigment, and to regulate binding to the dye crystal violet, whereas motility, flagellar secretion, and external flagella or flagellin are dispensable for these activities. Thus, in addition to flagellar genes, the FliA sigma factor regulates an effector(s) or regulator(s) that contributes to other transmissive traits, notably inhibition of phagosome maturation. Whether or not the microbes produced flagellin, all nonmotile L. pneumophila mutants bound BMM less efficiently than the wild type, resulting in poor infectivity and a loss of contact-dependent death of BMM. Therefore, bacterial motility increases contact with host cells during infection, but flagellin is not an adhesin. When BMM contact by each nonmotile strain was promoted by centrifugation, all the mutants bound BMM similarly, but only those microbes that synthesized flagellin induced BMM death. Thus, the flagellar regulon equips the aquatic pathogen L. pneumophila to coordinate motility with multiple traits vital to virulence.

Involvement of fractalkine/CX3CL1 expression by dendritic cells in the enhancement of host immunity against Legionella pneumophila

Legionnaires' disease is clinically manifested as severe pneumonia caused by Legionella pneumophila. However, the dendritic cell (DC)-centered immunological framework of the host defense against L. pneumophila has not been fully delineated. For this study, we focused on a potent chemoattractant for lymphocytes, fractalkine/CX3CL1, and observed that the fractalkine expression of DCs was somewhat up-regulated when they encountered L. pneumophila. We therefore hypothesized that fractalkine expressed by Legionella-capturing DCs is involved in the induction of T-cell-mediated immune responses against Legionella, which would be enhanced by a genetic modulation of DCs to overexpress fractalkine. In vivo immunization-challenge experiments demonstrated that DCs modified with a recombinant adenovirus vector to overexpress fractalkine (AdFKN) and pulsed with heat-killed Legionella protected immunized mice from a lethal Legionella infection and that the generation of in vivo protective immunity depended on the host lymphocyte subsets, including CD4(+) T cells, CD8(+) T cells, and B cells. Consistent with this, immunization with AdFKN/Legionella/DC induced significantly higher levels of serum anti-Legionella antibodies of several isotypes than those induced by control immunizations. Further analysis of spleen cells from the immunized mice indicated that the AdFKN/Legionella/DC immunization elicited Th1-dominated immune responses to L. pneumophila. These observations suggest that fractalkine may play an important role in the DC-mediated host defense against intracellular pathogens such as L. pneumophila.

Impact of rapid urine antigen tests to determine the etiology of community-acquired pneumonia in adults

STUDY OBJECTIVES

To evaluate the rapid urine antigen tests, including a new rapid immunochromatographic test (ICT) for the detection of the Streptococcus pneumoniae antigen and an enzyme immunoassay (EIA) for the detection of the Legionella antigen, in order to improve the diagnosis of community-acquired pneumonia (CAP) in adults.

DESIGN

Prospective study.

SETTING

A tertiary hospital in Spain.

PATIENTS

We consecutively recruited 107 adults with CAP evaluated at our hospital.

INTERVENTIONS

The analyses included blood and sputum cultures, pleural fluid culture (if present) and serologic studies. The detection of the Legionella pneumophila urinary antigen was performed by EIA, and the detection of S. pneumoniae antigen in urine samples was performed by counterimmunoelectrophoresis (CIE) and a rapid ICT.

RESULTS

Using conventional microbiologic tests we succeeded in performing the etiologic diagnosis of 39 out of the 107 cases (36.4%). The inclusion of rapid antigen detection techniques increased the percentage of diagnosis to 54.2%, which represents a total increase of 17.8% (P=0.034).

CONCLUSIONS

The data obtained in this study indicate that rapid urine antigen tests are very useful to determine CAP etiology in adults and, consequently, to quickly identify a group of patients in whom narrow spectrum antibiotics may be used.

Value of serological testing for diagnosis of legionellosis in outbreak patients

Serum antibody detection tests and a urine antigen detection technique were compared in samples from 116 patients epidemiologically characterized as belonging to a legionellosis outbreak. Sera were tested by enzyme-linked immunosorbent assays (ELISAs) for immunoglobulin M (IgM) and IgG plus IgM and by immunofluorescent assays (IFAs) for IgG, IgM, IgA, and polyimmunoglobulin using commercial kits (Vircell); concentrated urines were tested with the Binax NOW Legionella test. ELISA for IgM, ELISA for IgG plus IgM, antigenuria detection, and IFA for IgM were able to diagnose 72.3%, 60.5%, 53.3%, and 51.4%, respectively, of patients. Antigenuria was present in 53.8% of first samples, ELISA detected IgM in 29.7%, ELISA detected IgG plus IgM in 7.9%, and IFA detected IgM in 3.9%. Ten antigenuria-negative first samples tested serologically positive, 9 of them to IgM by ELISA. Despite the single source of the samples included in the study, detection of IgM using a sensitive technique such as ELISA seems to be a suitable complement to antigenuria detection for the diagnosis of legionellosis.

[Three patients with pneumonia due to Legionella associated with a sauna, a cooling tower and a caravan in The Netherlands]

In three male patients with lower respiratory disease, aged 51, 32 and 63 years, Legionnaires' disease was diagnosed by urinary antigen test and culture of the respiratory-tract fluid. In the second patient, the bronchoalveolar fluid also contained Streptococcus pneumoniae and Haemophilus influenzae. All three patients recovered after treatment with azithromycin in the first, cefotaxime, vancomycin and levofloxacin in the second, and erythromycin and ciprofloxacin in the third, respectively. Legionella pneumophila pneumonia is clinically not clearly distinct from other pneumonias and has a high mortality rate when not treated with the proper antibiotics. For that reason, adequate and swift diagnosis is of great importance. The urinary antigen test meets both of these criteria. Still, it is advisable to use culture and serology as well if Legionnaires' disease is suspected in a patient, since the urinary antigen test has limitations. In addition, patient isolates are ofepidemiological importance for public health. By comparing available patient isolates with Legionella strains from water sources, it is possible to identify sources of infection. In 2002, based on this principle, a project was started in The Netherlands aimed at identifying sources of infection, thereby preventing outbreaks of Legionnaires' disease by swift elimination of the source. Since the start of the project, 29 sources have been identified. In the cases described above these were a sauna, a cooling tower and a caravan, respectively. In suspected cases, respiratory-tract fluid must be collected to make possible such a source investigation.

Legionella pneumophila mediated activation of dendritic cells involves CD14 and TLR2

In this study, we analyzed the activation of bone-marrow derived dendritic cells (BMDCs) from mice lacking the cd14-gene with purified Legionella pneumophila lipopolysaccharide and with viable or formalin-killed L. pneumophila. We found that low concentrations of LPS and doses of L. pneumophila that are relevant to infection are dependent on CD14 to activate BMDCs. Higher concentrations of LPS are able to overcome the lack of CD14 indicating that other receptors areinvolved. We, therefore, included studies using BMDCs from mice lacking functional TLR2 and/or TLR4 molecules. We found that purified L. pneumophila LPS as well as L. pneumophila either viable or formalin-killed are able to activate BMDCs from TLR4-deficient C3H/HeJ mice but fail to activate BMDCs from TLR2-knockout mice. Our data show that not only purified LPS from L. pneumophila but also the microorganism itself stimulate BMDCs via TLR2 and that this stimulation is dependent on CD14 in this mouse model.

Community-acquired pneumonia by Legionella pneumophila serogroups 1–6 in Brazil

A prospective cohort study of adult patients hospitalized due to community-acquired pneumonia was carried out for 1 year in a Brazilian university general hospital to detect the incidence of community-acquired pneumonia by Legionella pneumophila serogroups 1-6. During a whole year, a total of 645 consecutive patients who were hospitalized due to a initial presumptive diagnosis of respiratory disease by ICD-10 (J00-J99), excluding upper respiratory diseases, were screened to detect the patients with community-acquired pneumonia. Fifty-nine consecutive patients hospitalized due to community-acquired pneumonia between July 19, 2000 and July 18, 2001, were included in the study. They had determinations of serum antibodies to L. pneumophila serogroups 1-6 by indirect immunofluorescence antibody test at the Infectious Diseases Laboratory of University of Louisville (KY, USA) and urinary antigen tests for L. pneumophila serogroup 1. Three patients had community-acquired pneumonia by L. pneumophila serogroups 1-6, two patients being diagnosed by seroconversion and positive urinary antigen tests; the other had negative serologies but strongly positive urinary antigen test. The incidence of community-acquired pneumonia by L. pneumophila serogroups 1-6 in our hospital was 5.1%.

Naip5/Birc1e and susceptibility to Legionella pneumophila

Genetic analysis in mice is a powerful approach for the identification of genes and proteins that have a key role at the interface of the host-pathogen interaction. The Lgn1 locus has been found to control the intracellular replication of Legionella pneumophila in murine macrophages. Using functional complementation in transgenic mice, the Naip5/Birc1e gene has been identified as responsible for the Lgn1 effect. The classification of Naip5/Birc1e as a member of the NLR protein family suggests that Naip5/Birc1e acts as an intracellular sensor of L. pneumophila. The nature of the signal transduced by Naip5/Birc1e in response to Legionella products is of great interest but is currently unknown. Here, several possible scenarios are presented.

Maturation of the Legionella pneumophila-containing phagosome into a phagolysosome within gamma interferon-activated macrophages

Legionella pneumophila is an intracellular pathogen that modulates the biogenesis of its phagosome to evade endocytic vesicle traffic. The Legionella-containing phagosome (LCP) does not acquire any endocytic markers and is remodeled by the endoplasmic reticulum during early stages. Here we show that intracellular replication of L. pneumophila is inhibited in gamma interferon (IFN-gamma)-activated, bone marrow-derived mouse macrophages and IFN-gamma-activated, human monocyte-derived macrophages in a dose-dependent manner. This inhibition of intracellular replication is associated with the maturation of the LCP into a phagolysosome, as documented by the acquisition of LAMP-2, cathepsin D, and lysosomal tracer Texas Red ovalbumin, and with the failure of the LCP to be remodeled by the rough endoplasmic reticulum. We conclude that IFN-gamma-activated macrophages override the ability of L. pneumophila to evade endocytic fusion and that the LCP is processed through the "default" endosomal-lysosomal degradation pathway.

Legionella pneumophila evades gamma interferon-mediated growth suppression through interleukin-10 induction in bone marrow-derived macrophages

We examined the roles of Th1-Th2 cytokine cross talk in Legionella pneumophila-infected bone marrow-derived (BM) macrophages in the presence of costimulation with interleukin-12 (IL-12) and IL-18. Treatment with gamma interferon (IFN-gamma) alone or treatment with IL-12 in combination with IL-18 resulted in a 3- or 2-log reduction in bacterial numbers, respectively, in BM macrophages, whereas treatment with IL-12 or IL-18 alone had no effect. Significant amounts of IFN-gamma were detected in the culture supernatants of infected macrophages stimulated with IL-12 and IL-18 in combination but not independently. Neutralization of IFN-gamma by antibody completely abolished the growth inhibitory effects of IL-12 and IL-18. Interestingly, higher infectivity ratios of L. pneumophila or the addition of increasing concentrations of heat-killed bacteria (HKB) suppressed the production of IFN-gamma, which resulted in the increased intracellular growth of bacteria. Significant amounts of IL-10 were detected in culture supernatants when Legionella-infected macrophages were cocultured with HKB. Furthermore, neutralization of IL-10 by antibody resulted in an increase in IFN-gamma production by infected BM macrophages when cocultured with HKB. Treatment of HKB with trypsin but not polymyxin B attenuated the growth-promoting effects of HKB, suggesting the involvement of a protein component(s) in regulation of the growth of L. pneumophila. These findings demonstrate a crucial role of Th1-Th2 cross talk in L. pneumophila-infected BM macrophages. Our results also suggest that L. pneumophila modulates the cytokine balance from IFN-gamma-driven Th1 to more Th2 responses, likely through the induction of IL-10 by a bacterial protein component(s). These data provide new insights not only into the cellular mechanisms of Th1-Th2 cross talk in Legionella-infected macrophages but also into the pathogenesis of L. pneumophila pneumonia in humans.

Heterophile antibodies produce spuriously elevated concentrations of cardiac Troponin I in patients with Legionella pneumophila

We found an unusually high positive rate for cTnI in patients recently infected with Legionella pneumophila. The aim of this study was to examine the possible origin of increased cTnI levels and to test if it could be associated with the immune response to legionellosis. The cTnI was above the cut point in 46.7% of patients infected with legionellosis when measured with reagent lot number RF421A. A strong correlation between high cTnI measurements and positive serologic values for legionellosis was found. With a revised formulation of cTnI reagent, lot number RF421C, the positive rate decreased by over 10-fold to 3.3%. We conclude that the revised lot of cTnI reagent minimized interference by heterophilic antibodies produced in response to legionellosis.