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Agina OA, Shaari MR, Isa NMM, Ajat MMM, Zamri-Saad M, Samad MJ, Hamzah H. Differential responses of monocyte-derived macrophages from Theileria orientalis infected carrier cattle to Pasteruella multocida B:2 infection and latex beads: A preliminary study. Res Vet Sci 2023; 165:105073. [PMID: 37939633 DOI: 10.1016/j.rvsc.2023.105073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/22/2023] [Accepted: 10/30/2023] [Indexed: 11/10/2023]
Abstract
This study aims to evaluate the responses of peripheral blood monocyte-derived macrophages (PBMDMs) from Theileria orientalis carrier cattle following exposure to Pasteruella multocida B:2 (PM B:2) and latex beads. Twenty-six male crossbred Kedah-Kelantan (KK) cattle were sampled for this study and quantitative PCR (qPCR) was employed in the detection of T. orientalis MPSP gene. Bactericidal assay using a 10:1 multiplicity of infection was performed to measure the phagocytosis and intracellular killing of PM B:2 by PBMDMs. The cell cultures were inoculated with 107 cfu/mL of PM B:2 and incubated in a humidified incubator. The absence of clinical signs, previous history of T. orientalis infection and an MPSP gene copy number below 15,000 GC/μL suggest that the cattle were asymptomatic chronic carriers. A non-significant phagocytic and mean cell death rates were observed in the PBMDMs of T. orientalis positive cattle relative to clinically healthy cattle (CHC) (p > 0.05). The PBMDMs of T. orientalis positive cattle had the lowest mean rate of intracellular killing relative to the CHC at the 30th minute post-infection only (p < 0.05). Exposure to latex beads caused an increase in the appearance of multinucleated macrophages following incubation of PBMDMs from T. orientalis positive cattle. Furthermore, the phagocytic index of PBMDMs of T. orientalis positive cattle were low or poor compared to that of CHC (p = 0.000). Therefore, our findings suggest that PBMDMs from cattle with chronic T. orientalis infection can efficiently phagocytise and kill PM: B2 but exhibited poor phagocytosis ability for foreign bodies despite appearance of multinucleated macrophages.
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Affiliation(s)
- Onyinyechukwu Ada Agina
- Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia; Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, University of Nigeria Nsukka, 410001 Enugu State, Nigeria.
| | - Mohd Rosly Shaari
- Animal Science Research Centre, Malaysian Agricultural Research and Development Institute, Headquarters 43400, Serdang, Selangor, Malaysia
| | - Nur Mahiza Md Isa
- Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia
| | - Mohd Mokrish Mohd Ajat
- Department of Pre-Clinical Sciences, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia
| | - Mohd Zamri-Saad
- Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia
| | - Mohd Jamil Samad
- Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia
| | - Hazilawati Hamzah
- Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, Serdang Selangor 43400, Malaysia.
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2
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Hasnan Q, Puspitasari Y, Othman S, Zamri-Saad M, Salleh A. Phagocytosis and intracellular killing of Pasteurella multocida B:2 by macrophages: A comparative study between buffalo and cattle. Vet World 2022; 15:275-280. [PMID: 35400946 PMCID: PMC8980368 DOI: 10.14202/vetworld.2022.275-280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/06/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aim: Pasteurella multocida B:2 is the causative agent of hemorrhagic septicemia (HS) in buffalo and cattle. Buffaloes are known to be more susceptible to HS than cattle, but the reason for this remains unknown. This study aimed to compare the in vitro efficiency with which buffalo and cattle macrophages can kill P. multocida B:2. Materials and Methods: Monocyte-derived macrophages of buffalo and cattle were used in this study. They were exposed to 1×106 colony-forming unit/mL of live P. multocida B:2 before the cells were harvested at 0, 30, 60, and 120 min post-exposure and viewed under a fluorescence microscope to count viable and non-viable macrophages and the macrophages with phagocytosing P. multocida B:2 cells. The phagocytosis, intracellular bacterial killing, and macrophage death rates were calculated and compared between the two species and sampling points. Results: In general, the rates of phagocytosis, intracellular killing, and macrophage death increased with time of exposure for both animal species. No significant (p>0.05) differences were noted between the phagocytosis rates by the macrophages of buffalo and cattle throughout the experiment. However, the rates of intracellular killing were significantly (p<0.05) higher in cattle macrophages at 30 min and 120 min post-exposure than those of buffalo. The death rates of buffalo macrophages were significantly (p<0.05) higher than those of cattle at 60 min and 120 min post-exposure. Conclusion With higher bacteria killing ability and lower macrophage death, cattle appeared to be more efficient at handling P. multocida B:2 infection than buffalo.
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Affiliation(s)
- Qistina Hasnan
- Department of Veterinary Laboratory Diagnosis, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Yulianna Puspitasari
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Universitas Airlangga, East Java, 60115, Indonesia
| | - Sarah Othman
- Department of Cell and Molecular Biology, Faculty of Biotechnology and Biomolecular Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Mohd Zamri-Saad
- Department of Veterinary Laboratory Diagnosis, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia
| | - Annas Salleh
- Department of Veterinary Laboratory Diagnosis, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia; Laboratory of Sustainable Animal Production and Biodiversity, Institute of Tropical Agriculture and Food Security, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
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Zhao X, Shen H, Liang S, Zhu D, Wang M, Jia R, Chen S, Liu M, Yang Q, Wu Y, Zhang S, Huang J, Ou X, Mao S, Gao Q, Zhang L, Liu Y, Yu Y, Pan L, Cheng A. The lipopolysaccharide outer core transferase genes pcgD and hptE contribute differently to the virulence of Pasteurella multocida in ducks. Vet Res 2021; 52:37. [PMID: 33663572 PMCID: PMC7931556 DOI: 10.1186/s13567-021-00910-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/09/2021] [Indexed: 12/13/2022] Open
Abstract
Fowl cholera caused by Pasteurella multocida exerts a massive economic burden on the poultry industry. Lipopolysaccharide (LPS) is essential for the growth of P. multocida genotype L1 strains in chickens and specific truncations to the full length LPS structure can attenuate bacterial virulence. Here we further dissected the roles of the outer core transferase genes pcgD and hptE in bacterial resistance to duck serum, outer membrane permeability and virulence in ducks. Two P. multocida mutants, ΔpcgD and ΔhptE, were constructed, and silver staining confirmed that they all produced truncated LPS profiles. Inactivation of pcgD or hptE did not affect bacterial susceptibility to duck serum and outer membrane permeability but resulted in attenuated virulence in ducks to some extent. After high-dose inoculation, ΔpcgD showed remarkably reduced colonization levels in the blood and spleen but not in the lung and liver and caused decreased injuries in the spleen and liver compared with the wild-type strain. In contrast, the ΔhptE loads declined only in the blood, and ΔhptE infection caused decreased splenic lesions but also induced severe hepatic lesions. Furthermore, compared with the wild-type strain, ΔpcgD was significantly attenuated upon oral or intramuscular challenge, whereas ΔhptE exhibited reduced virulence only upon oral infection. Therefore, the pcgD deletion caused greater virulence attenuation in ducks, indicating the critical role of pcgD in P. multocida infection establishment and survival.
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Affiliation(s)
- Xinxin Zhao
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Hui Shen
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Sheng Liang
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Dekang Zhu
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Mingshu Wang
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Renyong Jia
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Shun Chen
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Mafeng Liu
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Qiao Yang
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Ying Wu
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Shaqiu Zhang
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Juan Huang
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Xumin Ou
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Sai Mao
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Qun Gao
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Ling Zhang
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Yunya Liu
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Yanling Yu
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Leichang Pan
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Anchun Cheng
- Research Center of Avian Diseases, College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China.
- Key Laboratory of Animal Disease and Human Health of Sichuan Province, Chengdu, 611130, Sichuan, China.
- Institute of Preventive Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China.
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Li P, He F, Wu C, Zhao G, Hardwidge PR, Li N, Peng Y. Transcriptomic Analysis of Chicken Lungs Infected With Avian and Bovine Pasteurella multocida Serotype A. Front Vet Sci 2020; 7:452. [PMID: 32851030 PMCID: PMC7433353 DOI: 10.3389/fvets.2020.00452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Pasteurella multocida (P. multocida) is a common animal pathogen responsible for many animal diseases. Strains from different hosts exhibit disparate degrees of effect in other species. Here, we characterize an avian P. multocida serogroup A strain (PmQ) showing high lethality to chickens and a bovine P. multocida serogroup A strain (PmCQ2) with no lethality to chickens. We used RNA-seq to profile the transcriptomes of chicken lungs infected with PmQ and PmCQ2. A total of 1,649 differentially expressed genes (DEGs) due to PmQ infection (831 upregulated genes and 818 downregulated genes) and 1427 DEGs (633 upregulated genes and 794 downregulated genes) due to PmCQ2 infection were identified. Functional analysis of these DEGs demonstrated that the TNF signaling pathway, the toll-like receptor signaling pathway, complement and coagulation cascades, and cytokine–cytokine receptor interaction were both enriched in PmQ and PmCQ2 infection. STAT and apoptosis signaling pathways were uniquely enriched by PmQ infection, and the NOD-like receptor signaling pathway was enriched only by PmCQ2 infection. Cell-type enrichment analysis of the transcriptomes showed that immune cells, including macrophages and granulocytes, were enriched in both infection groups. Collectively, our study profiled the transcriptomic response of chicken lungs infected with P. multocida and provided valuable information to understand the chicken responses to P. multocida infection.
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Affiliation(s)
- Pan Li
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China
| | - Fang He
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China
| | - Chenlu Wu
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China
| | - Guangfu Zhao
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China.,The College of Life Sciences, Sichuan University, Chengdu, China
| | - Philip R Hardwidge
- College of Veterinary Medicine, Kansas State University, Manhattan, KS, United States
| | - Nengzhang Li
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China
| | - Yuanyi Peng
- Chongqing Key Laboratory of Forage & Herbivore, College of Animal Science and Technology, Southwest University, Chongqing, China
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5
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Puspitasari Y, Salleh A, Zamri-Saad M. Ultrastructural changes in endothelial cells of buffaloes following in-vitro exposure to Pasteurella multocida B:2. BMC Vet Res 2020; 16:186. [PMID: 32517749 PMCID: PMC7285459 DOI: 10.1186/s12917-020-02415-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 06/05/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pasteurella multocida B:2 causes haemorrhagic septicaemia in cattle and buffaloes. However, buffaloes are found to be more susceptible to the infection than cattle. Upon infection, the pathogen rapidly spread from the respiratory tract to the blood circulation within 16-72 h, causing septicaemia. So far, limited study has been conducted to evaluate the response of endothelial cells of buffalo towards P. multocida B:2 and its lipopolysaccharide (LPS). This study aimed to evaluate the ultrastructural changes in the aortic endothelium of buffaloes (BAEC) following exposure to P. multocida B:2 and its endotoxin. The endothelial cells were harvested from the aorta of healthy buffaloes and were prepared as monolayer cell cultures. The cultures were divided into 3 groups before Group 1 was inoculated with 107 cfu/ml of whole cell P. multocida B:2, Group 2 with LPS, which was extracted earlier from 107 cfu/ml of P. multocida B:2 and Group 3 with sterile cell culture medium. The cells were harvested at 0, 6, 12, 18, 24, 36, and 48 h post-inoculation for assessment of cellular changes using transmission electron microscopy. RESULTS The BAEC of Groups 1 and 2 demonstrated moderate to severe endothelial lysis, suggestive of acute cellular injury. In general, severity of the ultrastructural changes increased with the time of incubation but no significant difference (p > 0.05) in the severity of the cellular changes between Groups 1 and 2 was observed in the first 18 h. The severity of lesions became significant (p < 0.05) thereafter. Both treated Groups 1 and 2 showed significantly (p < 0.05) more severe cellular changes compared to the control Group 3 from 6 h post-inoculation. The severity reached peak at the end of the study period with score 3 for Group 1 and score 2.8 for Group 2. CONCLUSIONS This study revealed that both whole cells P. multocida B:2 and LPS endotoxin showed similar moderate to severe cellular damage, but whole-cell P. multocida B:2 appeared to be more potent in causing much severe damage than LPS alone.
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Affiliation(s)
- Yulianna Puspitasari
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia.,Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Universitas Airlangga, East Java, 60115, Indonesia
| | - Annas Salleh
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia.
| | - Mohd Zamri-Saad
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia
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Puspitasari Y, Annas S, Adza-Rina MN, Zamri-Saad M. In-vitro phagocytosis and intracellular killing of Pasteurella multocida B:2 by phagocytic cells of buffaloes. Microb Pathog 2019; 131:170-174. [PMID: 30978429 DOI: 10.1016/j.micpath.2019.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/08/2019] [Accepted: 04/08/2019] [Indexed: 02/01/2023]
Abstract
Pasteurella multocida B:2 is a Gram-negative organism causing haemorrhagic septicaemia (HS) in buffaloes. It causes severe pulmonary infection, leading to infiltration of numerous macrophages and neutrophils. Despite the inflammatory response, buffaloes succumb to HS. This study aims to evaluate the in-vitro efficacy of macrophages and neutrophils of buffalo following exposure to P. multocida B:2. In-vitro infections were done using 107 cfu/ml of P. multocida B:2 for Group 1, Escherichia coli for Group 2 and Mannhaemia haemolytica A:2 for Group 3 cells. The inoculated cell cultures were harvested at 0, 30, 60 and 120 min post-exposure and the phagocytic, killing and cell death rates were determined. Both phagocytosis and killing rates of all bacteria increased over time. Phagocytosis involved between 71% and 73% neutrophils and between 60% and 64% macrophages at 120 min. Killing rate of all bacteria involved between 76% and 79% for neutrophils and between 70% and 74% for macrophages at 120 min. Death rate of neutrophils ranged between 67% in Group 3, and 88% in Group 1 at 120 min, significantly (p < 0.05) higher than Group 3 but insignificant (p > 0.05) than Group 2. Similar pattern was observed for death rate of macrophages. The phagocytosis and killing rates of P. multocida B:2 were similar to other bacterial species used in this study but more neutrophils and macrophages were dead following infection by P. multocida B:2 than M. haemolytica A:2.
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Affiliation(s)
- Y Puspitasari
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia
| | - S Annas
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia.
| | - M N Adza-Rina
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia
| | - M Zamri-Saad
- Research Centre for Ruminant Diseases, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Malaysia
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