Chlamydia pneumoniae DNA in non-coronary atherosclerotic plaques and circulating leukocytes

Pneumonia-Induced Inflammation, Resolution and Cardiovascular Disease: Causes, Consequences and Clinical Opportunities

Pneumonia is inflammation in the lungs, which is usually caused by an infection. The symptoms of pneumonia can vary from mild to life-threatening, where severe illness is often observed in vulnerable populations like children, older adults, and those with preexisting health conditions. Vaccines have greatly reduced the burden of some of the most common causes of pneumonia, and the use of antimicrobials has greatly improved the survival to this infection. However, pneumonia survivors do not return to their preinfection health trajectories but instead experience an accelerated health decline with an increased risk of cardiovascular disease. The mechanisms of this association are not well understood, but a persistent dysregulated inflammatory response post-pneumonia appears to play a central role. It is proposed that the inflammatory response during pneumonia is left unregulated and exacerbates atherosclerotic vascular disease, which ultimately leads to adverse cardiac events such as myocardial infarction. For this reason, there is a need to better understand the inflammatory cross talk between the lungs and the heart during and after pneumonia to develop therapeutics that focus on preventing pneumonia-associated cardiovascular events. This review will provide an overview of the known mechanisms of inflammation triggered during pneumonia and their relevance to the increased cardiovascular risk that follows this infection. We will also discuss opportunities for new clinical approaches leveraging strategies to promote inflammatory resolution pathways as a novel therapeutic target to reduce the risk of cardiac events post-pneumonia.

Presence of bacterial DNA in thrombotic material of patients with myocardial infarction

Infectious agents have been suggested to be involved in etiopathogenesis of Acute Coronary Syndrome (ACS). However, the relationship between bacterial infection and acute myocardial infarction (AMI) has not yet been completely clarified. The objective of this study is to detect bacterial DNA in thrombotic material of patients with ACS with ST-segment elevation (STEMI) treated with Primary Percutaneous Coronary Intervention (PPCI). We studied 109 consecutive patients with STEMI, who underwent thrombus aspiration and arterial peripheral blood sampling. Testing for bacterial DNA was performed by probe-based real-time Polymerase Chain Reaction (PCR). 12 probes and primers were used for the detection of Aggregatibacter actinomycetemcomitans, Chlamydia pneumoniae, viridans group streptococci, Porphyromonas gingivalis, Fusobacterium nucleatum, Tannarella forsythia, Treponema denticola, Helycobacter pylori, Mycoplasma pneumoniae, Staphylococus aureus,  Prevotella intermedia and Streptococcus mutans. Thus, DNA of four species of bacteria was detected in 10 of the 109 patients studied. The most frequent species was viridans group streptococci (6 patients, 5.5%), followed by Staphylococus aureus (2 patients, 1.8%). Moreover, a patient had DNA of Porphyromonas gingivalis (0.9%); and another patient had DNA of Prevotella intermedia (0.9%). Bacterial DNA was not detected in peripheral blood of any of our patients. In conclusion, DNA of four species of endodontic and periodontal bacteria was detected in thrombotic material of 10 STEMI patients. Bacterial DNA was not detected in the peripheral blood of patients with bacterial DNA in their thrombotic material. Bacteria could be latently present in plaques and might play a role in plaque instability and thrombus formation leading to ACS.

Discovery of Human-Specific Immunodominant Chlamydia trachomatis B Cell Epitopes

Current serological assays for species-specific detection of anti-Chlamydia species antibodies suffer from well-known shortcomings in specificity and ease of use. Due to the high prevalences of both anti-C. trachomatis and anti-C. pneumoniae antibodies in human populations, species-specific serology is unreliable. Therefore, novel specific and simple assays for chlamydial serology are urgently needed. Conventional antigens are problematic due to extensive cross-reactivity within Chlamydia spp. Using accurate B cell epitope prediction and a robust peptide ELISA methodology developed in our laboratory, we identified immunodominant C. trachomatis B cell epitopes by screening performed with sera from C. trachomatis-infected women. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins, in addition to confirming 10 host-independent mouse serum peptide antigens that had been identified previously. This extended set of highly specific C. trachomatis peptide antigens can be used in simple ELISA or multiplexed microarray formats and will provide high specificity and sensitivity to human C. trachomatis serodiagnosis.

Chlamydia species-specific serology is compromised by cross-reactivity of the gold standard microimmunofluorescence (MIF) or commercial enzyme-linked immunosorbent assays (ELISAs). This study was conducted to discover novel C. trachomatis-specific peptide antigens that were recognized only by the antibody response of the natural human host. We evaluated a library of 271 peptide antigens from immunodominant C. trachomatis proteins by reactivity with 125 C. trachomatis antibody-positive sera from women with PCR-confirmed C. trachomatis infection and 17 C. trachomatis antibody-negative sera from low-risk women never diagnosed with C. trachomatis infection. These C. trachomatis peptide antigens had been predicted in silico to contain B cell epitopes but had been nonreactive with mouse hyperimmune sera against C. trachomatis. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins (PmpD, IncE, IncG, CT529, CT618, CT442, TarP, CT143, CT813, CT795, CT223, PmpC, CT875, CT579, LcrE, IncA, CT226, CT694, Hsp60, and pGP3). Using these human sera, we also confirmed 10 C. trachomatis B cell epitopes from 6 immunodominant C. trachomatis proteins (OmpA, PmpD, IncE, IncG, CT529, and CT618) as host species-independent epitopes that had been previously identified by their reactivity with mouse hyperimmune sera against C. trachomatis. ELISA reactivities against these peptides correlated strongly with the C. trachomatis microimmunofluorescence (MIF) text results (Pearson’s correlation coefficient [R] = 0.80; P < 10⁻⁶). These C. trachomatis peptide antigens do not cross-react with antibodies against other Chlamydia species and are therefore suitable for species-specific detection of antibodies against C. trachomatis. This study identified an extended set of peptide antigens for simple C. trachomatis-specific ELISA serology.

IMPORTANCE Current serological assays for species-specific detection of anti-Chlamydia species antibodies suffer from well-known shortcomings in specificity and ease of use. Due to the high prevalences of both anti-C. trachomatis and anti-C. pneumoniae antibodies in human populations, species-specific serology is unreliable. Therefore, novel specific and simple assays for chlamydial serology are urgently needed. Conventional antigens are problematic due to extensive cross-reactivity within Chlamydia spp. Using accurate B cell epitope prediction and a robust peptide ELISA methodology developed in our laboratory, we identified immunodominant C. trachomatis B cell epitopes by screening performed with sera from C. trachomatis-infected women. We discovered 38 novel human host-dependent antigens from 20 immunodominant C. trachomatis proteins, in addition to confirming 10 host-independent mouse serum peptide antigens that had been identified previously. This extended set of highly specific C. trachomatis peptide antigens can be used in simple ELISA or multiplexed microarray formats and will provide high specificity and sensitivity to human C. trachomatis serodiagnosis.

Chlamydia Pneumoniae in Asymptomatic Carotid Atherosclerosis

We evaluated, in 415 patients with asymptomatic carotid atherosclerosis: (i) the prevalence of C. pneumoniae DNA in atherosclerotic carotid plaques and peripheral blood mononuclear cells (PBMC); (ii) the distribution of C. pneumoniae in atherosclerotic carotid plaques and PBMC from the same patients; (iii) the correlation between circulating anti-chlamydial antibodies and the presence of C. pneumoniae DNA. Overall, 160 atherosclerotic carotid plaques and 174 PBMC specimens from patients with asymptomatic carotid atherosclerosis were examined by ompA nested touchdown PCR for presence of C. pneumoniae. In addition, C. pneumoniae DNA was detected in 81 specimens of atherosclerotic carotid plaque and PBMC obtained from the same patients. C. pneumoniae DNA was found in 36.9% of atherosclerotic carotid plaques and in 40.2% of PBMC specimens examined (P=NS). With regard to 81 patients, C. pneumoniae DNA was detected in 27.2% of atherosclerotic carotid plaques and in 44.4% of PBMC specimens (P=0.05). In 18 patients, the presence of C. pneumoniae DNA in PBMC specimens and atherosclerotic carotid plaques coincided (P=0.005). No statistically significant association was found between anti-C pneumoniae antibodies (IgG and IgA) and positive PCR results. In conclusion, our results suggest that the detection of C. pneumoniae DNA in PBMC specimens seems to be a first-choice method to identify the patients at risk for endovascular chlamydial infection.

Role of gut microbiota in atherosclerosis

Infections have been linked to the development of cardiovascular disease and atherosclerosis. Findings from the past decade have identified microbial ecosystems residing in different habitats of the human body that contribute to metabolic and cardiovascular-related disorders. In this Review, we describe three pathways by which microbiota might affect atherogenesis. First, local or distant infections might cause a harmful inflammatory response that aggravates plaque development or triggers plaque rupture. Second, metabolism of cholesterol and lipids by gut microbiota can affect the development of atherosclerotic plaques. Third, diet and specific components that are metabolized by gut microbiota can have various effects on atherosclerosis; for example, dietary fibre is beneficial, whereas the bacterial metabolite trimethylamine-N-oxide is considered harmful. Although specific bacterial taxa have been associated with atherosclerosis, which is supported by increasing mechanistic evidence, several questions remain to be answered to understand fully how the microbiota contributes to atherosclerosis and cardiovascular disease. Such knowledge might pave the way for novel diagnostics and therapeutics based on microbiota.

Comparison of Five PCR Assays for DetectingChlamydophila pneumoniaeDNA

We compared five different polymerase chain reaction (PCR) assays for the detection of Chlamydophila pneumoniae DNA using highly purified elementary bodies (EBs) and peripheral blood mononuclear cells (PBMCs) from healthy blood donors. The primers were as follows; two targeting the 16S rRNA gene, one targeting the ompA gene, one targeting the Pst-I gene, and one targeting the 53 kDa outer membrane protein gene. The 16S rRNA touchdown enzyme time release (TETR) PCR, the ompA nested PCR and the 53 kDa nested PCR were the most sensitive assays and could detect one or more EB per assay. These three PCRs also had the same reproducibility, but the minimal amount of C. pneumoniae that could be reproducibly detected (10 of 10 testing positive) was 20 EBs. In a sample of specimens from healthy blood donors, we found 5 of 77 (6.5%) PBMCs specimens to have C. pneumoniae DNA according to the nested ompA PCR. Specimens with the 16S rRNA TETR and 53 kDa nested assays were found to have C. pneumoniae DNA 7 of 77 (9.1%) and 18 of 77 (23.4%) specimens, respectively. The other two assays failed to detect even a single positive. However, the detection rate decreased with repeated testing of the same samples. Our newly designed 53 kDa nested PCR may be as useful as the other four recommended PCR assays and may be a more useful assay for the detection of C. pneumoniae DNA from PBMCs.

Atherosclerosis Induced by Chlamydophila pneumoniae: A Controversial Theory

More than a century ago, inflammation and infection were considered to have atherogenic effects. The old idea that coronary heart disease (CHD) possibly has an infectious etiology has only reemerged in recent years. Atherosclerosis is the main pathological process involved in CHD and is, logically, the first place to look for infectious etiology. The process of atherosclerosis itself provides the first hints of potential infectious cause. Smooth muscle proliferation, with subsequent intimal thickening, luminal narrowing, and endothelial degeneration, constitutes the natural history of atherosclerosis, being with the severity and speed of these changes. Both viral and bacterial pathogens have been proposed to be associated with the inflammatory changes found in atherosclerosis. Recently, Chlamydophila pneumoniae (C. pneumoniae) has been implicated as a possible etiologic agent of coronary artery disease and atherosclerosis. New evidence which supports a role for C. pneumoniae in the pathogenesis of atherosclerosis has emerged. C. pneumoniae has been detected in atherosclerotic arteries by several techniques, and the organism has been isolated from both coronary and carotid atheromas. Recent animal models have suggested that C. pneumoniae is capable of inducing atherosclerosis in both rabbit and mouse models of atherosclerosis. Furthermore, human clinical treatment studies which examined the use of antichlamydial macrolide antibiotics in patients with coronary atherosclerosis have been carried out. The causal relationship has not yet been proven, but ongoing large intervention trials and research on pathogenetic mechanisms may lead to the use of antimicrobial agents in the treatment of CHD in the future.

Chlamydophila pneumoniae infection and cardiovascular disease

Atherosclerosis is a multifactorial vascular inflammatory process; however, the inciting cause for inflammation remains unclear. Two decades ago, Chlamydophila pneumoniae (formerly Chlamydia pneumoniae) infection was proposed as a putative etiologic agent. We performed a PubMed search using the keywords Chlamydia and atherosclerosis in a Boolean query to identify published studies on C. pneumoniae and its role in atherogenesis, and to understand research interest in this topic. We found 1,652 published articles on this topic between 1991 and 2011. We analyzed relevant published studies and found various serological, molecular, and animal modeling studies in the early period. Encouraged by positive results from these studies, more than a dozen antibiotic clinical-trials were subsequently conducted, which did not find clinical benefits of anti-Chlamydophila drug therapy. While many researchers believe that the organism is still important, negative clinical trials had a similar impact on overall research interest. With many novel mechanisms identified for atherogenesis, there is a need for newer paradigms in Chlamydophila-atherosclerosis research.

Atherosclerosis and infection: is the jury still not in?

Atherosclerosis is a chronic inflammatory process accounting for increased cardiovascular and cerebrovascular morbidity and mortality. A wealth of recent data has implicated several infectious agents, mainly Chlamydophila pneumoniae, Helicobacter pylori, CMV and periodontal pathogens, in atherosclerosis. Thus, we sought to comprehensively review the available data on the topic, exploring in particular the pathogenetic mechanisms, and discuss anticipated future directions.

Can infections cause Alzheimer's disease?

Late-onset Alzheimer's disease (AD) is the most prevalent cause of dementia among older adults, yet more than a century of research has not determined why this disease develops. One prevailing hypothesis is that late-onset AD is caused by infectious pathogens, an idea widely studied in both humans and experimental animal models. This review examines the infectious AD etiology hypothesis and summarizes existing evidence associating infectious agents with AD in humans. The various mechanisms through which different clinical and subclinical infections could cause or promote the progression of AD are considered, as is the concordance between putative infectious agents and the epidemiology of AD. We searched the PubMed, Web of Science, and EBSCO databases for research articles pertaining to infections and AD and systematically reviewed the evidence linking specific infectious pathogens to AD. The evidence compiled from the literature linking AD to an infectious cause is inconclusive, but the amount of evidence suggestive of an association is too substantial to ignore. Epidemiologic, clinical, and basic science studies that could improve on current understanding of the associations between AD and infections and possibly uncover ways to control this highly prevalent and debilitating disease are suggested.

Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association

A link between oral health and cardiovascular disease has been proposed for more than a century. Recently, concern about possible links between periodontal disease (PD) and atherosclerotic vascular disease (ASVD) has intensified and is driving an active field of investigation into possible association and causality. The 2 disorders share several common risk factors, including cigarette smoking, age, and diabetes mellitus. Patients and providers are increasingly presented with claims that PD treatment strategies offer ASVD protection; these claims are often endorsed by professional and industrial stakeholders. The focus of this review is to assess whether available data support an independent association between ASVD and PD and whether PD treatment might modify ASVD risks or outcomes. It also presents mechanistic details of both PD and ASVD relevant to this topic. The correlation of PD with ASVD outcomes and surrogate markers is discussed, as well as the correlation of response to PD therapy with ASVD event rates. Methodological issues that complicate studies of this association are outlined, with an emphasis on the terms and metrics that would be applicable in future studies. Observational studies to date support an association between PD and ASVD independent of known confounders. They do not, however, support a causative relationship. Although periodontal interventions result in a reduction in systemic inflammation and endothelial dysfunction in short-term studies, there is no evidence that they prevent ASVD or modify its outcomes.

Pathogens and atherosclerosis: update on the potential contribution of multiple infectious organisms to the pathogenesis of atherosclerosis

It is currently unclear what causes the chronic inflammation within atherosclerotic plaques. One emerging paradigm suggests that infection with bacteria and/or viruses can contribute to the pathogenesis of atherosclerosis either via direct infection of vascular cells or via the indirect effects of cytokines or acute phase proteins induced by infection at non-vascular sites. This paradigm has been supported by multiple epidemiological studies that have established positive associations between the risk of cardiovascular disease morbidity and mortality and markers of infection. It has also been supported by experimental studies showing an acceleration of the development of atherosclerosis following infection of hyperlipidaemic animal models. There are now a large number of different infectious agents that have been linked with an increased risk of cardiovascular disease. These include: Chlamydia pneumoniae, Porphyromonas gingivalis, Helicobacter pylori , influenza A virus, hepatitis C virus, cytomegalovirus, and human immunodeficiency virus. However, there are significant differences in the strength of the data supporting their association with cardiovascular disease pathogenesis. In some cases, the infectious agents are found within the plaques and viable organisms can be isolated suggesting a direct effect. In other cases, the association is entirely based on biomarkers. In the following review, we evaluate the strength of the data for individual or groups of pathogens with regard to atherosclerosis pathogenesis and their potential contribution by direct or indirect mechanisms and discuss whether the established associations are supportive of the infectious disease paradigm. We also discuss the failure of antibiotic trials and the question of persistent infection.

Chlamydia persistence -- a tool to dissect chlamydia--host interactions

Under stress, chlamydiae can enter a non-infectious but viable state termed persistence. In the absence of a tractable genetic system, persistence induction provides an important experimental tool with which to study these fascinating organisms. This review will discuss examples of: i) persistence studies that have illuminated critical chlamydiae/host interactions; and ii) novel persistence models that will do so in the future.

Mycotic DNA in non-atherosclerotic aortic wall of coronary patients is associated with sICAM-1 expression

BACKGROUND

Atherosclerosis is currently being investigated as a chronic inflammatory process and the role of infectious agents is unclear. The presence of mycotic DNA in the wall of the non-atherosclerotic aorta of patients with coronary artery disease (CAD) and its association with levels of soluble intercellular adhesion molecule (sICAM)-1 expression was examined in the present study.

METHODS AND RESULTS

In 40 patients with CAD and a comparative group of 20 patients with aortic valve stenosis (AS) without CAD, specimens of the aortic wall were obtained during cardiac surgery. Mycotic DNA was analyzed by polymerase chain reaction (PCR) using a fungus-specific universal primer pair, ITS3 and ITS4, to amplify a portion of the 5.8S rDNA region, the entire ITS2 region and a portion of the 28S rDNA region, and using a species-specific primer pair, CALB1 and CALB2, to specifically amplify Candida (C.) albicans. The nested PCR method was performed to amplify the intergenic transcribed spacer regions of the rRNAs of Candida species. Before surgery the serum level of sICAM-1 was estimated. Mycotic DNA was detected in 48% of the CAD patients and in 40% of the AS patients, with C. albicans DNA in 58% and 100%, respectively (P>0.05). In CAD patients with a high level of sICAM-1, C. albicans DNA was found more frequently than in patients without elevated levels of sICAM-1 (P<0.05).

CONCLUSIONS

Mycotic DNA was found in the non-atherosclerotic aortic wall of CAD patients as well as in patients with AS. In the CAD patients C. albicans DNA was related to sICAM-1 expression.

Immunoproteomic identification and serological responses to novel Chlamydia pneumoniae antigens that are associated with persistent C. pneumoniae infections

The controversial discussion about the role of Chlamydia pneumoniae in atherosclerosis cannot be solved without a reliable diagnosis that allows discrimination between past and persistent infections. Using a proteomic approach and immunoblotting with human sera, we identified 31 major C. pneumoniae Ags originating from 27 different C. pneumoniae proteins. More than half of the proteins represent Chlamydia Ags not described previously. Using a comparative analysis of spot reactivity Pmp6, OMP2, GroEL, DnaK, RpoA, EF-Tu, as well as CpB0704 and CpB0837, were found to be immunodominant. The comparison of Ab-response patterns of sera from subjects with and without evidence for persisting C. pneumoniae, determined by multiple PCR analysis of PBMC and vasculatory samples, resulted in differential reactivity for 12 proteins, which is not reflected by reactivity of the sera in the microimmunofluorescence test, the current gold standard for serodiagnosis. Although reactivity of sera from PCR-positive donors was increased toward RpoA, MOMP, YscC, Pmp10, PorB, Pmp21, GroEL, and Cpaf, the reactivity toward YscL, Rho, LCrE, and CpB0837 was decreased, reflecting the altered protein expression of persisting C. pneumoniae in vitro. Our data provide the first evidence of a unique Ab-response pattern associated with persistent C. pneumoniae infections, which is a prerequisite for the serological determination of persistently infected patients.

Chlamydia pneumoniae growth inhibition in cells by the steroid receptor antagonist RU486 (mifepristone)

Since steroids are powerful anti-inflammatory agents and increase susceptibility to a variety of infections, including Chlamydia (Chlamydophila) pneumoniae respiratory tract infections, the effect of the steroid receptor antagonist RU486 (mifepristone) on C. pneumoniae growth in epithelial HEp-2 cells was examined. Treatment of HEp-2 cells with RU486 significantly inhibited the growth of C. pneumoniae in a dose-dependent manner. Electron microscopic studies also revealed that the treatment of infected cells with RU486 resulted in a marked destruction of infecting organisms. The addition of the host cell protein synthesis inhibitor cycloheximide to the infected cells did not alter the inhibition of C. pneumoniae growth by RU486. Pretreatment of C. pneumoniae organisms with RU486 before addition to culture also did not result in any modulation of bacterial growth in the cells. However, the binding of RU486 to C. pneumoniae organisms in cells at 24 h after infection was demonstrated by immune electron microscopy with anti-RU486 antibody. Incubation of cells with anti-RU486 antibody completely diminished the inhibition of C. pneumoniae growth by RU486. These results indicate that RU486 may directly bind to the bacteria within cells and cause the destruction of C. pneumoniae. This novel mode of regulation of C. pneumoniae growth in cells by RU486 might provide a new approach to understanding complicated aspects of C. pneumoniae infection.

Role of Chlamydia pneumoniae in atherosclerosis

Cardiovascular disease, resulting from atherosclerosis, is a leading cause of global morbidity and mortality. Genetic predisposition and classical environmental risk factors explain much of the attributable risk for cardiovascular events in populations, but other risk factors for the development and progression of atherosclerosis, which can be identified and modified, may be important therapeutic targets. Infectious agents, such as Chlamydia pneumoniae, have been proposed as contributory factors in the pathogenesis of atherosclerosis. In the present review, we consider the experimental evidence that has accumulated over the last 20 years evaluating the role of C. pneumoniae in atherosclerosis and suggest areas for future research in this field.

Measurement of Chlamydia pneumoniae bacterial load in peripheral blood mononuclear cells may be helpful to assess the state of chlamydial infection in patients with carotid atherosclerotic disease

BACKGROUND

Chlamydia pneumoniae has been repeatedly associated with atherosclerotic cardiovascular diseases. We investigated the pattern of distribution of C. pneumoniae among patients with carotid atherosclerotic disease evaluating chlamydial load in carotid plaque, peripheral blood mononuclear cells (PBMC) and lymph node from same patient.

METHODS AND RESULTS

Thirty carotid plaques, 30 PBMC and 30 lymph nodes were examined by real-time PCR assay. C. pneumoniae DNA was detected, in carotid plaques, PBMC and lymph nodes in 11 patients; in carotid plaques and PBMC in five patients; in PBMC and lymph nodes in four patients; in lymph nodes in two patients; and in PBMC only in one patient. C. pneumoniae DNA in PBMC significantly coincided with the presence of the respective DNA in carotid plaque (p=0.0001) and lymph node (p=0.02). A higher chlamydial load was detected in PBMC than in lymph nodes and carotid plaques. More than 90% of patients with carotid plaques, PBMC and lymph nodes positive to C. pneumoniae were symptomatic, smokers, hypertensives, dyslipidemics and showed carotid plaques with rupture on the surface, hemorrhage and thrombosis.

CONCLUSION

The measurement of chlamydial load in PBMC may be helpful in the future to assess the state of C. pneumoniae infection and the risk of developing sequelae.

No detectable Chlamydia pneumoniae and cytomegalovirus DNA in leukocytes in subjects with echolucent and echogenic carotid artery plaques

BACKGROUND

Controversy exists whether persistent Chlamydia pneumoniae or cytomegalovirus infections cause initiation or progression of atherosclerosis. C. pneumoniae DNA in peripheral blood mononuclear cells (PBMC) has been proposed to be a more reliable marker of cardiovascular risk than are C. pneumoniae antibodies. Reported prevalences of C. pneumoniae DNA among cardiovascular patients vary greatly, indicating methodological limitations. There is an increasing concern that published results may have been biased by extensive use of less specific polymerase chain reaction (PCR) technology.

METHODS

C. pneumoniae DNA and cytomegalovirus DNA were determined by probe-based real-time PCR technology in PBMCs among subjects with echolucent (n=29) or echogenic (n=28) carotid artery plaques, and in controls without carotid plaques (n=38), all recruited from a population-based study. Samples were examined in multiple repeats with PCR assays targeting two different sequences of the genome for both microorganisms.

RESULTS AND CONCLUSION

IgG seropositivity was frequent in all three groups, confirming previous exposure, but C. pneumoniae DNA or cytomegalovirus DNA was not detected in a single PBMC sample by means of probe-based, highly sensitive, and specific real-time PCR assays. Our results indicate that persistent C. pneumoniae or CMV infection is not a common phenomenon in subjects with carotid atherosclerosis.

Staining of Chlamydia trachomatis elementary bodies: A suitable method for identifying infected human monocytes by flow cytometry

Persistence of Chlamydia trachomatis (C. trachomatis) in the joint is the most frequent cause of reactive arthritis following urogenital tract infection. The resulting changes of host cell antigen- and cytokine-expression are not precisely understood. We developed and evaluated a direct cytometric approach to visualize in vitro C. trachomatis-infected monocytes. Infectious elementary bodies (EBs) of C. trachomatis serovar K were labelled by incubation with 5-(and-6)-carboxyfluorescein diacetate succinimidyl ester (CFSE). Afterwards, human peripheral blood monocytes were cultured with the CFSE-labelled EBs and analysed by flow cytometry. Real-time polymerase chain reaction (PCR) was used to demonstrate intracellular uptake and viability of CFSE-labelled C. trachomatis by the determination of gene expression. Labelling EBs with CFSE may become a valuable tool for studying the interaction between C. trachomatis and the host cell.

Differential effects of Chlamydia pneumoniae infection on cytokine levels in human T lymphocyte- and monocyte-derived cell cultures

Continuous cultures of human lymphocyte- and monocyte-derived cell lines were examined for levels of immunoregulatory cytokines important in resistance to the intracellular opportunistic bacterium Chlamydia pneumoniae (Cp), a ubiquitous pathogen widely disseminated in the population and hypothesized to be involved in chronic inflammatory diseases such as atherosclerosis and neurological diseases like multiple sclerosis and Alzheimer's disease. The results of this study showed that the continuous human T lymphocyte cell line MOLT-4 and the continuous monocytic cell line THP-1 were readily infected by Cp in vitro as shown by immunofluorescence microscopy for Cp lipopolysaccharide (LPS). The 16S rRNA expression determined by real-time RT-PCR increased rapidly after infection of either cell line with these bacteria. The THP-1 cells infected with Cp showed increased levels of the immunoregulatory cytokine IL-12 and also of TNFalpha and IL-10 compared to cultures stimulated with heat-killed Cp (KCp) or Escherichia coli LPS as a control. Stimulation of MOLT-4 cells with KCp or E. coli LPS also induced the Th1 cytokines IFNgamma and IL-12 and the Th2 cytokine IL-10, but infection with viable Cp induced higher Th1 cytokine levels. These results suggest that Cp infection induces a predominant Th1 cytokine profile by T cells, in addition to induction of TNFalpha by monocytes/macrophages. Such effects are likely involved in antibacterial immunity against Cp infection.

Circulating Chlamydia pneumoniae DNA and advanced coronary artery disease

BACKGROUND

Chlamydia pneumoniae (C. pneumoniae) has been linked to atherosclerosis. Detection of this pathogen in peripheral blood cells may be valuable in the diagnosis of disease state. This study aimed to evaluate the prevalence of circulating C. pneumoniae DNA and its relationship with severity and extent of coronary artery disease (CAD).

METHODS

Blood samples from 269 patients undergoing coronary angiography were collected. The presence of circulating C. pneumoniae DNA was determined by real-time PCR assay. Data regarding coronary risk factors and severity and extent of CAD were collected. Severity and extent of CAD was defined by the number of major epicardial coronary arteries with >50% stenosis and by the Duke jeopardy score.

RESULTS

Sixteen of 269 specimens (5.9%) from the study cohort were positive for C. pneumoniae DNA. Thirteen specimens among 149 samples from patients with multi-vessel disease (8.7%) were positive for C. pneumoniae DNA compared with 3 of 120 (2.5%) among patients without multi-vessel CAD. The prevalence of circulating C. pneumoniae DNA was significantly associated with multi-vessel disease. The odds ratio was 5.1 (P=0.02) after adjustment for conventional risk factors.

CONCLUSIONS

Presence of circulating C. pneumoniae DNA is associated with advanced CAD, suggesting C. pneumoniae infection as a contributing factor to progression of coronary atherosclerosis.

Successful removal of Chlamydia pneumoniae from plateletpheresis products collected using automated leukoreduction hemapheresis techniques

Chlamydia pneumoniae (Cp) is an obligate intracellular pathogen associated with a variety of maladies. Best known for its involvement in community-acquired pneumonia outbreaks; the potential role of Cp in diverse illnesses is a topic of increasing interest and investigation. Previous studies suggested that white blood cells from normal blood donors harboring this agent may be eliminated through leukoreduction by filtration. Here we examine the ability and efficacy of apheresis-related leukoreduction for its effect on the carriage and potential infectivity of these organisms in the preparation of platelet products. Matched pre-apheresis peripheral blood (PB) samples and product samples obtained from healthy plateletpheresis donors were analyzed for the presence and potential infectivity of Cp organisms by direct smear inspection and tissue culture techniques. Antibody seroreactivity directed towards the organism was assessed using a solid phase immunoassay. Forty-eight percent of the donor blood samples exhibited elevated anti-Cp antibody titers (> or =200). Specimens from 31 (27%) and 34 (30%) of 115 plateletpheresis donors were positive for the presence of Cp organisms in their pre-apheresis PB samples when analyzed by direct smear examination and culture, respectively. Examination of the 115 post-leukodepleted plateletpheresis product samples revealed only two (1.7%) and one (0.009%) product(s) to be smear-positive and culture-positive, respectively. Certain plateletpheresis donors may harbor infectious Cp organisms in circulating WBC. Collections from such donors of apheresis platelet products using standard apheresis leukoreduction strategies appear successful in markedly decreasing or eliminating the organisms found in the final products.

Development of diabetes in non-obese diabetic mice promotes Chlamydia pneumoniae dissemination from lung to peripheral blood

We examined a possible association between development of diabetes in non-obese diabetic (NOD) mice and dissemination of Chlamydia (Chlamydophila) pneumoniae from lung to peripheral blood. By real-time reverse transcription-polymerase chain reaction (RT-PCR) with primers for C. pneumoniae 16S rRNA, following multiple intranasal inoculations, we detected bacteria in lung in NOD mice with diabetes (38.5%) as well as Institute of Cancer Research, USA (ICR) mice (40%), but prevalence of bacteria in NOD mice without diabetes (pre-diabetic NOD mice and non-diabetic retired NOD mice) was very low (4.8%). The bacteria were only detected in peripheral blood mononuclear cells (PBMCs) cultured with hydrocortisone of the NOD mice with diabetes (53.8%). Results of immunostaining with fluorescein isothiocyanate-conjugated antichlamydia monoclonal antibody also showed the presence of bacterial antigens in the lungs and the PBMCs judged as positive by the RT-PCR. However, C. pneumoniae from cultured PBMCs of all NOD mice was undetected by cultivation method with inclusion-forming units assay. In addition, no influence of C. pneumoniae intranasal inoculation on development of diabetes in NOD mice was confirmed. Thus, the development of diabetes in NOD mouse appears to be one of critical factors for promoting the dissemination of C. pneumoniae from lung to peripheral blood.

Induction of tissue factor expression and release as microparticles in ECV304 cell line by Chlamydia pneumoniae infection

The association between Chlamydia pneumoniae (C. pneumoniae) infection and the onset and progression of atherosclerosis has become apparent recently. Moreover, increased expression of tissue factor (TF) as a result of C. pneumoniae infection has been previously demonstrated. We have examined the expression of TF on the surface of endothelial cells and the release of TF-containing cell-derived microparticles, over seven days. Additionally, using cells expressing a procoagulantly active EGFP-TF hybrid protein, we examined the kinetics of TF trafficking on the cells and incorporation into shed microparticles. Finally, in an attempt to associate this with the activation of NFkappaB, we used a luciferase reporter to measure the duration of the activation of this transcription factor. TF-containing microparticles were released within 24h of infection and continued for up to 7 days. Moreover, the initial release of TF containing microparticles was associated with NFkappaB activation and was suppressed on inclusion of an NFkappaB inhibitor, pyrrolidinedithiocarbamate ammonium. Moreover, persistent dissemination of TF-containing microparticles at later stages of infection was associated with the release of the infective C. pneumoniae elementary bodies. The released procoagulant, cellular microparticles are known to be strongly atherogenic and therefore we suggest a mechanism for the involvement of C. pneumoniae in the onset and progression of vascular disease.

Descripción de inmunógenos de Chlamydia pneumoniae reconocidos por el suero de sujetos con enfermedad arterial periférica

BACKGROUND AND OBJECTIVE

The relationship between antibodies to C. pneumoniae and presence of the bacteria was studied in individuals with peripheral arterial disease.

PATIENTS AND METHOD

An observational analytical, case-control study was performed in 118 patients (68 cases, 50 controls) to investigate immunoglobulin (Ig) G and A against C. pneumoniae in serum, using Western-blot (commercial and no commercial methods), ELISA and MIF; DNA of the bacteria in vascular tissue biopsy specimens was studied by polymerase chain reaction.

RESULTS

Using commercial Western-blot, significant presence of IgG anti-39 kDa and anti-54 kDa was found in cases and was related to MIF results and C. pneumoniae DNA findings; IgA anti-LPS, anti-92 kDa and anti-Hsp60 kDa were also found and related to DNA presence. Using no commercial Western-blot, significant presence of 128.8 and 9.2 kDa bands for IgG was detected in cases and associated with DNA presence; 70.8, 58.9, 47.9, 47.5, 18.4, 12.1, 10.6, 8.1, and 7.6 kDa bands for IgG were found in cases; and DNA was present when 54.6 and 1.1 kDa bands for IgG and 79.4, 50.1, and 18.4 kDa bands for IgA were also detected.

CONCLUSIONS

Using Western-blot, a greater serologic response was found against certain proteins of the bacteria in individuals with peripheral arterial disease. This may reflect an initial stage with presence of DNA and specific IgG. Subsequently, even in absence of the bacteria, an immunomediated disease may develop with presence of IgA and IgG.

Chlamydophila pneumoniae and human cytomegalovirus in atherosclerotic carotid plaques--combined presence and possible interactions

The aim of our study was to investigate the combination of Chlamydophila pneumoniae and human cytomegalovirus (HCMV) as a pathogenic factor in atherosclerosis. Accordingly, we tested by means of PCR and immunohistochemistry the presence of these pathogens in the same atherosclerotic carotid specimen. The histology of the samples and the patients' antibodies against these pathogens were evaluated. Further, we examined the impact of C. pneumoniae and HCMV infection on the gene expression of the human monocytic cell line U937. Six of the 22 samples contained only C. pneumoniae, 4 contained only HCMV, 7 contained both C. pneumoniae DNA and/or antigens of both pathogens, and 5 samples were negative. No correlation was found between the presence of these microbes and either the cellular structure of the plaques, or the serostatus of the patients. The infection of U937 cells with HCMV and especially C. pneumoniae induced inflammation and atherosclerosis-related genes. Furthermore, the doubly-infected cells produced higher levels of the mRNA of pro-platelet basic protein and fatty acid binding protein 4. In conclusion, C. pneumoniae is often present in combination with HCMV in atherosclerotic carotid lesions. The in vitro coinfection model reveals that the doubly-infected monocytes are potent expressors of proatherosclerotic genes, suggesting that this coinfected population may accelerate the process of atherosclerosis.

Fate of Chlamydophila pneumoniae in human monocyte-derived dendritic cells: Long lasting infection

Earlier studies from this group demonstrated that Chlamydophila pneumoniae co-localized with dendritic cells (DC) in temporal artery biopsies from patients with giant cell arteritis (GCA). To investigate the interaction of DC with C. pneumoniae we employed an in vitro cell culture system of human monocyte derived DC. These DC were infected with C. pneumoniae and observed at regular time intervals up to 25 days post infection. Chlamydiae were visualized inside DC by both confocal and electron microscopy. Statistical analysis showed an increase in the number of chlamydial antigen during that period (p < 0.00005, chi2-test). Titration of DC lysates on HEp-2 cells showed that infectious progeny was recovered at various intervals but showed no exponential growth. Additionally, RT-PCR analyses of infected DC identified transcripts from dnaA, ftsK and tal throughout a period of 14 days, indicating viable chlamydiae. Thus, human monocyte-derived DC are susceptible to C. pneumoniae infection. These results indicate that C. pneumoniae-infected DC can play an important role in the transmission of these bacteria in GCA and other chlamydial diseases.

Tobacco smoke induces a persistent, but recoverable state in Chlamydia pneumoniae infection of human endothelial cells

We investigated the extent to which tobacco smoke could induce persistence of Chlamydia pneumoniae in human endothelial cells. Aortic and coronary artery endothelia were infected in the absence or presence of non-cytotoxic concentrations of tobacco smoke medium. Following exposure to smoke medium, chlamydial inclusions were smaller and demonstrated fewer genome copies as determined by real-time PCR. Enumeration of inclusion-forming units (IFU) established a significant smoke-mediated, dose-dependent inhibition of elementary bodies (EB). Host cell apoptosis did not contribute to the observed restriction of productive infection. Ultrastructure analysis demonstrated an arrest in chlamydial development following smoke-exposure, with a predominance of reticulate bodies (RB) observed inside inclusions. Recovery of viable IFU was achieved with removal of smoke-medium and addition of L-tryptophan. In the presence of smoke, C. pneumoniae infection demonstrated all the characteristics of persistence in human endothelia cells. This is the first time that primary human arterial endothelial cells have been shown to support chlamydial persistence. Tobacco smoke is a well-characterized risk factor for progression of atherosclerosis, but a novel means of inducing chlamydial persistence in vascular cells. Thus, smoking may additionally contribute to atherosclerotic disease by inducing a persistent chlamydial infection in arterial endothelium.

Depletion of resident Chlamydia pneumoniae through leukoreduction by filtration of blood for transfusion

Current studies indicate that a significant percentage of healthy blood donors carry Chlamydia pneumoniae in their blood. Although the clinical significance of such findings is unknown, eradication of such bacteria from blood components may contribute to transfusion safety. Deletion of C. pneumoniae in Red Blood Cell (RBC) units was accomplished through leukoreduction by filtration. The presence of bacteria in RBC units before and after leukoreduction was assessed by real-time PCR using primers specific for C. pneumoniae 16S rRNA. The eluates of filters used for leukoreduction were also assessed by PCR and immunostaining with fluorescein isothiocyanate-conjugated chlamydial monoclonal antibodies specific for C. pneumoniae determination. Nineteen of 30 RBC units tested showed the presence of C. pneumoniae DNA. Leukofiltration resulted in a marked reduction of leukocytes as well as C. pneumoniae in terms of bacterial number and positive rate for the bacteria. The eluates of filters showed trapped bacteria determined by both PCR and immunostaining assays. Thus, leukoreduction with a filter is an effective method to significantly reduce resident C. pneumoniae levels in RBC components but may not be completely sufficient for total eradication of this pathogen.

Discordant detection of Chlamydia pneumoniae in patients with carotid artery disease using polymerase chain reaction, immunofluorescence microscopy and serological methods

AIM

To determine the presence of Chlamydia pneumoniae in carotid plaque and peripheral blood mononuclear cells (PBMCs) using a combination of serology, direct antigen detection by immunofluorescence (IF) microscopy and polymerase chain reaction (PCR), and to compare the results obtained from each assay.

METHODS

A total of 54 atherosclerotic carotid plaques were tested for the presence of Chlamydia by PCR and IF methods. Of these 54 patients with carotid artery disease (CAD), 43 were also tested for the presence of C. pneumoniae DNA in PBMCs and for Chlamydia antibodies using two methods, the Medac Chlamydien rELISA and Focus Chlamydia microimmunofluorescence (MIF) methods.

RESULTS

Eighteen of the 54 (33%) carotid specimens were positive for the presence of C. pneumoniae DNA, whereas only two of 43 (5%) patients had C. pneumoniae DNA present within their PBMC fraction. Chlamydial antibodies were detected by MIF and/or rELISA in 56% (24/43) of the patients tested. None of the 43 patients was C. pneumoniae positive in all of the test specimens (plaque, PBMCs and serum).

CONCLUSIONS

Chlamydia pneumoniae is commonly found in Australian patients with CAD. Serology and PCR-based detection of C. pneumoniae in PBMCs and plaque give highly discordant results.

Cytokine response of lymphocytes persistently infected with Chlamydia pneumoniae

Chlamydia pneumoniae infection of lymphocytes in blood has been documented, and it is apparent that control of this pathogen in lymphocytes as well as immune functions of the infected lymphocytes may be critical in the development of chronic inflammatory diseases associated with infection by this bacterium. Since immune function of lymphocytes infected with C. pneumoniae has not been well studied, the cytokine response of lymphocytes infected with this pathogen was analyzed using an in vitro infection model of the Molt-4 human lymphoid cell line. C. pneumoniae infection of the cells showed a persistent infection without any vigorous growth of the bacteria. Analysis of the cytokine response of the cells persistently infected with C. pneumoniae showed minimum induction of inflammatory cytokine TNF-alpha message, determined by real-time reverse transcription (RT)-PCR in the lymphocytes, even though the infection of THP-1 monocytic cells showed a marked induction of this cytokine messages. BIC (a lymphocyte activation marker gene) as well as IFN-gamma messages were also minimally induced by the infection in Molt-4 lymphocytes. In contrast, constitutive expression of interleukin 8 (IL-8) messages of Molt-4 cells was suppressed by the infection. Thus, these results suggest that lymphocytes persistently infected with C. pneumoniae may have attenuated cytokine responses.

Tobacco smoke induces persistent infection of Chlamydophila pneumoniae in HEp-2 cells

We examined tobacco smoke exposure and its effect on the life cycle of Chlamydophila pneumoniae (C. pneumoniae) in HEp-2, a human respiratory epithelial cell line. Using noncytotoxic concentrations of smoke medium, chlamydiae were grown in tissue culture and infectious particles were quantitated indirectly by immunocytometry of infected indicator cells. Chlamydial genome copy number was assessed with real-time polymerase chain reaction, and ultrastructure was examined by transmission electron microscopy. There was a significant reduction (56-64%; p<0.05) in the number of infectious elementary bodies following smoke exposure compared to untreated cultures. Under the same conditions, at late time points, smoke-exposed cultures showed significantly fewer chlamydial DNA copies (p<0.04). Moreover, smoke exposure induced large aberrant bodies that predominated within the inclusion. Following in vitro smoke exposure, alterations in the developmental cycle of C. pneumoniae included: inhibition of productive infection, reduced bacterial cell division, and formation of aberrant bodies. Thus, using this novel system, we were able to induce chlamydial persistence. Tobacco smoke exposure may represent a risk for establishment of a chronic reservoir of C. pneumoniae infection within respiratory epithelium.

Genomic, serologic, and clinical case-control study of Chlamydia pneumoniae and peripheral artery occlusive disease

OBJECTIVES

Chlamydia pneumoniae has been related to atherosclerotic disease in both seroepidemiologic and genomic studies. We performed a case-control study to determine seropositivity and DNA detection in arteries of patients with peripheral artery occlusive disease and of healthy subjects.

METHODS

The study included 64 patients with peripheral artery occlusive disease, and 50 control subjects who underwent varicose vein surgery, matched to the patient group for age, sex, and tobacco use. The fibrinogen level in all study subjects was measured as a marker of inflammation. Blood samples were taken from all subjects for determination of immunoglobulin (Ig) G elementary bodies (EB) against C pneumoniae with microimmunofluorescence (MIF) and enzyme-linked immunosorbent assay (ELISA), and of IgA EB with ELISA. The cutoff titers were 1:32 for MIF and 1.1 for ELISA. Biopsy specimens of arterial atheromatous plaque were obtained from patients, and of pudendal artery and saphenous vein from control subjects, and were studied with hemi-nested polymerase chain reaction.

RESULTS

There were no differences in fibrinogen level between patients and controls. The prevalence of IgG anti-EB with MIF was 78% in patients and 24% in control subjects (P =.0001; odds ratio [OR], 11.3; 95% confidence interval [CI], 4.7-27.2). Prevalence of IgG anti-EB with ELISA was 75% in patients and 16% in control subjects (P =.0001; OR, 15.7; 95% CI, 6.1-40). There were no differences in IgA anti-EB titers. Bacterial DNA was detected in 67% of atheromatous plaques versus 12% of pudendal arteries (P =.0001) and 4% of saphenous veins. A weak correlation was found between seropositivity and the presence of intravascular DNA.

CONCLUSIONS

Our results support the hypothesis that C pneumoniae is related to the pathogenesis of atherosclerotic peripheral artery occlusive disease.

CLINICAL RELEVANCE

This study explored the infectious hypothesis in the context of the pathogenesis of atherosclerosis. This hypothesis has been supported by findings that certain infectious agents can cause or accelerate the course of diseases in which the possibility of a microbial cause was not previously proposed, as in the case of peptic ulcer and spongiform encephalopathy. The present study demonstrated the presence of Chlamydia pneumoniae and seropositivity in atheromatous plaques in patients with peripheral artery occlusive disease. These results contribute to a body of research that is opening up the possibility of treating atherosclerotic disease with antibiotic agents, and preventing it with immunization.

Association of Peripheral Mononuclear Cells Containing Chlamydia Pneumoniae DNA with Acute Coronary Syndrome and Stable Coronary Artery Disease in Japanese Subjects

To clarify the association of Chlamydia pneumoniae DNA in peripheral blood mononuclear cells (PBMCs) with acute coronary syndrome (ACS) and stable coronary artery disease (CAD) in Japanese adults, touchdown-nested polymerase chain reaction was used to detect the presence of C. pneumoniae DNA. The prevalence of C. pneumoniae DNA in PBMCs was similar in a comparison of 88 patients (52.3%) with ACS, 164 patients (50.0%) with stable CAD, and 88 control subjects (50.0%). Temporal changes in the prevalence of C. pneumoniae DNA in PBMCs were also assessed every 3 months during a 1-year period (n=59). The prevalence was significantly higher in the first 3-month period (January through March) than in any of the other 3-month periods. In conclusion, the prevalence of C. pneumoniae DNA in PBMCs in patients with ACS or stable CAD was comparable to that in control populations. Furthermore, the presence of circulating C. pneumoniae was strongly associated with seasonal variability.

No evidence of involvement of Chlamydia pneumoniae in severe cerebrovascular atherosclerosis by means of quantitative real-time polymerase chain reaction

BACKGROUND AND PURPOSE

All studies reporting high numbers of Chlamydia pneumoniae DNA positives in stroke patients published to date have used polymerase chain reaction (PCR) techniques highly prone to generate false-positive results. The aim of this study was to analyze the prevalence of C. pneumoniae DNA in plaques of the carotid artery as well as in peripheral blood by means of a new, closed, real-time PCR system.

METHODS

Carotid endarterectomy specimens and preoperative peripheral blood mononuclear cells (PBMC) of 75 individuals with severe cerebrovascular atherosclerosis were analyzed by means of a C. pneumoniae-specific quantitative ompA-based real-time PCR TaqMan system. Plaques were also cultured onto HEp-2 cells. Before the surgical intervention, C. pneumoniae-specific IgM, IgG, and IgA as well as C-reactive protein (CRP) levels were determined.

RESULTS

89% of all patients studied had C. pneumoniae-specific antibodies, but the pathogen was not detected in a single carotid atheroma by real-time PCR and cell culture. However, C. pneumoniae DNA was detected in 4 PBMC samples (5.3%) at very low levels (<1 inclusion/6 mL EDTA blood). No statistical significance was found between symptomatic/asymptomatic patients, C. pneumoniae PCR, results and CRP values after correction for multiplicity-of-test adjustment.

CONCLUSIONS

By means of a closed, highly sensitive, and specific real-time PCR, C. pneumoniae was not detected in cerebrovascular atherosclerosis. PCR on PBMC was not predictive for endovascular chlamydia infection and most likely stem from previous C. pneumoniae respiratory tract infection in individual cases.

Prevalence of viable Chlamydia pneumoniae in peripheral blood mononuclear cells of healthy blood donors

BACKGROUND

Demonstration of viable Chlamydia (Chlamydophila) pneumoniae in peripheral blood mononuclear cells (PBMNCs) is essential to understand the involvement of C. pneumoniae in atherosclerosis. Nevertheless, the prevalence of viable C. pneumoniae in the blood of healthy donors has not yet been studied.

STUDY DESIGN AND METHODS

The presence of C. pneumoniae transcript in PBMNCs from blood of healthy human donors was assessed by real-time reverse transcription-polymerase chain reaction (RT-PCR) with primers for C. pneumoniae 16S rRNA, which is more sensitive than genomic-DNA-based analysis, and by the use of staining with fluorescein isothiocyanate-conjugated chlamydia monoclonal antibody (MoAb).

RESULTS

Thirteen of 70 donors (18.5%) showed the presence of bacterial transcript in cultured PBMNCs. The prevalence of bacterial detection and bacterial numbers was significantly increased in PBMNC cultures incubated with cycloheximide. Immunostaining of PBMNCs with antichlamydial MoAb also revealed the presence of bacterial antigen in the PBMNCs judged as positive. Nevertheless, cultivation of C. pneumoniae from all PCR-positive donors was unsuccessful. There was no significant correlation between the presence of chlamydia and either sex or current smoking habits. A possible age variation, however, in the presence of chlamydia in blood of healthy donors was suggested by the results obtained.

CONCLUSION

The bacterial transcripts in PBMNCs obtained from healthy donors were detected by the RT-PCR method. Viable C. pneumoniae may be present in healthy human PBMNCs.

IFN-gamma induced persistent Chlamydia pneumoniae infection in HL and Mono Mac 6 cells: characterization by real-time quantitative PCR and culture

Growth of Chlamydia pneumoniae during gamma interferon (IFN-gamma) induced persistent infection in epithelial (HL) and monocyte-macrophage (Mono Mac 6) cell lines was studied by a quantitative real-time PCR and passage. When HL cultures were treated with IFN-gamma (25 U/ml), the replication of C. pneumoniae DNA was unaffected while differentiation into infectious elementary bodies (EB) was strongly inhibited, and in contrast to the untreated cultures, no second cycle of infection was observed. The estimated doubling time of C. pneumoniae genomes was 6-7 h in both IFN-gamma treated and untreated HL cultures. At 72 h post inoculation, most infectious EBs were released from untreated cultures, whereas in IFN-gamma treated HL cells >90% of C. pneumoniae genomes were in non-infectious form. A higher dose (1000 U/ml) of IFN-gamma was needed to restrict growth of C. pneumoniae in Mono Mac 6 cells. In untreated Mono Mac 6 cultures, the growth curve of C. pneumoniae resembled that observed in HL cells, except that no second cycle of infection could be detected. In IFN-gamma treated Mono Mac 6 cultures, the number of infectious C. pneumoniae EBs recovered decreased gradually after 3 days post inoculation, while C. pneumoniae genome load remained unaltered suggesting persistence of C. pneumoniae also in these cells.

Chlamydia pneumoniae and atherosclerosis following carotid endarterectomy

BACKGROUND

Seroepidemiological studies have shown an association between raised antibody titres against Chlamydia pneumoniae, and carotid atherosclerosis or stroke. However, direct evidence for a causal link between arterial infection with C. pneumoniae and carotid disease remains weak. We hypothesized that long-term follow-up of patients with pathologically-proven arterial C. pneumoniae infection might provide further insight into the role of C. pneumoniae in carotid atherosclerosis.

METHODS

We followed a cohort of 70 carotid endarterectomy patients for ipsilateral restenosis, contralateral progression, and all-cause mortality (four year median follow-up period). All patients had presence or absence of C. pneumoniae in their carotid plaques documented by immunohistochemistry after endarterectomy. A survival function was generated and the log-rank test was used to assess the difference in survival between subjects with and without documented chlamydial infection in their plaque.

RESULTS

Baseline demographic and cardiovascular risk factors were similar between the two groups, and survival analysis demonstrated no difference (p>0.05) in all-cause mortality, or all-cause mortality combined with restenosis and progression.

CONCLUSIONS

Our data finds no causal role for C. pneumoniae in restenosis or progression of carotid disease or mortality in this patient population with advanced carotid atherosclerosis.

Monitoring intracellular replication of Chlamydophila (Chlamydia) pneumoniae in cell cultures and comparing clinical samples by real-time PCR

Strains of Chlamydophila pneumoniae may be associated with respiratory disease or atherosclerosis. Two real-time quantitative PCR assays targeting the species-specific genes Cpn0278 and ArgR were developed to compare the in vitro growth of respiratory strains AR39 and K6 with that of atherosclerotic strain A03 and to quantify C. pneumoniae in clinical samples. A third real-time PCR assay was designed to assess contamination with Mycoplasma spp. The assays targeting C. pneumoniae detected DNA concentrations corresponding to 10(4) to 10(-4) inclusion-forming units (IFU)/reaction and were highly specific. AR39 exhibited the longest lag phase and period of exponential growth; K6 augmented growth rates at higher inocula; and A03 grew at highest rates. Contamination with Mycoplasma spp. of AR39 and A03 unlikely accounted for growth differences between them. Numbers of IFU in C. pneumoniae-positive respiratory secretions varied within 4 to 5 orders of magnitude. The assays described may prove valuable for pathogenicity studies.

Early atherosclerosis and Chlamydia pneumoniae infection in the coronary arteries

In non-atheromatous segments of coronary arteries a sequence of preatherosclerotic changes was identified which consisted of medial thickening followed by intimal thickening. More recently, Chlamydia pneumoniae seropositivity was associated with enhanced intima-media thickness of arteries. In the present study the intimal and medial thickness of coronary artery of young adults were measured, and were correlated with the presence of Chlamydia pneumoniae antigens. Proximal and distal segments of the left anterior descending coronaries (LAD) obtained at autopsy from young adults (15-34 years) were studied. The thickness and cellular density of the intima and of the media without clear-cut atherosclerotic changes were measured by image analysis. The hypertrophy index was calculated as the ratio of cell density and the thickness of the respective layer. Atherosclerotic lesions occurring elsewhere in the same coronary were noted and graded by severity. The presence of Chlamydia pneumoniae verified by immunohistochemistry was correlated with the severity of lesions and with the hypertrophy index. In the proximal segments, atherosclerosis of LAD was associated with the widening of both the intima and the media of lesion free-sites. In the distal coronary segments the proportion of the intimal thickening had a significant association with atherosclerosis. Compared to non-infected arteries, Chlamydia pneumoniae infection was associated with higher hypertrophy index in the intima as well as in the media. The rate of Chlamydia pneumoniae positivity increased with the severity of lesions. As a conclusion: in the LAD coronary, the intimal thickening is the main preatherosclerotic change. Chlamydia pneumoniae may favour arterial wall hypertrophy and plays a role in lesion progression.

Chlamydia pneumoniae in carotid artery atherosclerosis: a comparison of its presence in atherosclerotic plaque, healthy vessels, and circulating leukocytes from the same individuals

BACKGROUND AND PURPOSE

There is growing clinical and experimental evidence that infections with Chlamydia pneumoniae might contribute to the development and progression of atherosclerosis. However, studies detecting the pathogen in atherosclerotic lesions examined either only atherosclerotic vessels or control vessels without atherosclerosis obtained from a different group of individuals. We analyzed atherosclerotic plaques of the carotid artery, samples of apparently healthy greater saphenous veins, and circulating leukocytes from the same individual patients for the presence of C pneumoniae.

METHODS

From each of 46 patients undergoing carotid endarterectomy for symptomatic carotid artery stenosis, these samples were analyzed by nested polymerase chain reaction for C pneumoniae-specific DNA. Furthermore, we determined IgA and IgG titers specific for the pathogen and plasma levels of C-reactive protein in these patients.

RESULTS

C pneumoniae DNA was detected in 86.9% of the leukocytes and in 82.6% of the atherosclerotic plaques but in only 6.5% of the saphenous veins. In 85% of patients who also had leukocytes positive for C pneumoniae, the atherosclerotic plaques were positive and the saphenous veins were negative. The presence of C pneumoniae-specific DNA in leukocytes significantly coincided with the presence of the respective DNA in the plaques of the carotid arteries (P=0.0002). No association between the presence of C pneumoniae and specific IgA or IgG levels was seen. C-reactive protein levels were significantly higher in patients with chlamydia-positive atherosclerotic plaques and with positive leukocytes than in patients with negative plaques of the carotid arteries or negative leukocytes, respectively (P<0.01, P<0.05).

CONCLUSIONS

Our observation of >80% incidence of C pneumoniae in atherosclerotic plaques of the carotid artery does not prove causality between an infection with the pathogen and the development of atherosclerosis. It must be emphasized, however, that >90% of apparently healthy saphenous veins were negative for C pneumoniae. Given the structural and functional differences between veins and arteries, careful interpretation of our results regarding a possible causative role of C pneumoniae seems warranted.

Association of circulating Chlamydia pneumoniae DNA with cardiovascular disease: a systematic review

BACKGROUND

Chlamydia pneumoniae antigens, nucleic acids, or intact organisms have been detected in human atheroma. However, the presence of antibody does not predict subsequent cardiovascular (CV) events. We performed a systematic review to determine whether the detection of C. pneumoniae DNA in peripheral blood mononuclear cells (PBMC) was associated with CV disease.

METHODS

We sought studies of C. pneumoniae DNA detection in PBMC by polymerase chain reaction (PCR) among patients with CV disease or other clinical conditions. We pooled studies in which CV patients were compared with non-diseased controls. We analyzed differences between studies by meta-regression, to determine which epidemiological and technical characteristics were associated with higher prevalence.

RESULTS

Eighteen relevant studies were identified. In nine CV studies with control subjects, the prevalence of circulating C. pneumoniae DNA was 252 of 1763 (14.3%) CV patients and 74 of 874 (8.5%) controls, for a pooled odds ratio of 2.03 (95% CI: 1.34, 3.08, P < 0.001). Prevalence was not adjusted for CV risk factors. Current smoking status, season, and age were associated with C. pneumoniae DNA detection. High prevalence (>40%) was found in patients with cardiac, vascular, chronic respiratory, or renal disease, and in blood donors. Substantial differences between studies were identified in methods of sampling, extraction, and PCR targets.

CONCLUSIONS

C. pneumoniae DNA detection was associated with CV disease in unadjusted case-control studies. However, adjustment for potentially confounding measures such as smoking or season, and standardization of laboratory methods, are needed to confirm this association.

The intracellular life of chlamydiae

The ability to cause persistent infection is one of the major characteristics of all chlamydial species in their appropriate hosts. Persistent infection with Chlamydia trachomatis and Chlamydia pneumoniae has been implicated in the pathogenesis of many chronic diseases, some initially not thought to be infectious, including pelvic inflammatory disease, arthritis, asthma, and atherosclerosis. Chlamydiae have a unique developmental cycle with morphologically distinct infectious and reproductive forms: elementary (EB) and reticulate bodies (RB). Chlamydiae appear to circumvent the host endocytic pathway and inhabit a nonacidic vacuole that is dissociated from late endosomes and lysosomes. Chlamydiae also have been demonstrated to enter a persistent state after treatment with cytokines such as interferon-gamma (IFN-gamma), treatment with antibiotics, or restriction of certain nutrients, or to enter this state spontaneously under certain culture conditions. While the organism is in the persistent state, metabolic activity is reduced, and the organism is often refractory to antibiotic treatment. Ultrastructural analysis of IFN-gamma-treated C pneumoniae demonstrates atypical inclusions containing large reticulate-like aberrant bodies with no evidence of redifferentiation into EBs. Persistent C pneumoniae infection appears to be associated with continued expression of genes associated with DNA replication but not with those genes involved with bacterial cell division. The latter observation may explain the appearance of the large abnormal RBs seen in ultrastructural studies. Studies of the association of chlamydiae with chronic disease have been hampered by difficulties in diagnosing chronic, persistent infection with the organism, which, in turn, render determining the efficacy of antibiotic therapy very difficult.

Chlamydia pneumoniae in different coronary artery segments in the young

Chlamydia pneumoniae has emerged as the most likely pathogen to have a causative role in the development and/or for progression of atherosclerosis. Evidence for this is based on epidemiological and pathological studies. In an effort to better understand the significance of finding C. pneumoniae in atheromata, we examined coronary artery segments of young adults (15-34 years) with and without atherosclerosis. Left anterior descending coronary arteries (LAD) of 74 young adults who died suddenly were examined histologically and for the presence of C. pneumoniae by immunohistochemistry. C. pneumoniae was identified in advanced lesions (Stary types III to VI) in 17 of 32 cases (53%), and in early lesions (Stary type I-II) in 8 of 37 cases (21%), mainly at the proximal segments of the LAD. C. pneumoniae was not found in the intimal and medial layer of normal-appearing coronary arteries. C. pneumoniae was detected in the adventitia in 51 (67%) coronary arteries: in 27 of normal arteries and early lesions (64%), and in 24 of atherosclerotic lesions (75%). C. pneumoniae was found most often in macrophages, less offen in smooth muscle cells. We also observed a correlation between C. pneumoniae positivity and cigarette smoking.

IN CONCLUSION

C. pneumoniae may relate to the severity of atherosclerosis in young people, and it may thus initiate atherosclerotic injury or facilitate its progression with other risk factors.