STUDIES OF GONOCOCCAL INFECTION. II. THE BACTERIOLYTIC POWER OF THE WHOLE DEFIBRINATED BLOOD OF PATIENTS WITH GONOCOCCAL ARTHRITIS

Gonococcal endocarditis: a case series demonstrating modern presentation of an old disease

Gonococcal endocarditis appeared with striking frequency in the preantibiotic era compared with its surprising rarity today. We present a series of four episodes of gonococcal endocarditis, which presented to our institution in the last 2 years, after no cases in the previous decade. Three episodes involved the aortic valve and required emergency aortic valve replacement. One episode involved the tricuspid valve and was successfully cured with antibiotic infusion alone. Combining our four patients with the available 25 well-documented gonococcal endocarditis cases reported in the English medical literature during the antibiotic era, we demonstrated that the disease incidence may be increasing, that infections more often involve left-sided cardiac structures (particularly the aortic valve), and that the association with a quotidian fever curve, rash and arthritis, and overt gonococcal infection is less common than previously reported. These patients frequently present with fulminant and dramatic valvular insufficiency without immediately positive blood cultures and complete echocardiographic evaluation seems to provide a valuable aid in making a presumptive diagnosis of endocarditis and directing appropriate clinical management.

Susceptibility of Pasteurella haemolytica to the bactericidal effects of serum, nasal secretions and bronchoalveolar washings from cattle

Several isolates of logarithmic-phase organisms of Pasteurella haemolytica were shown to be sensitive to an antibody and complement-mediated killing mechanism in adult bovine serum. Data suggested that the classical complement pathway was important in the induction of bactericidal activity of serum. Sera from calves after colostrum feedings (post-colostral sera) killed only 30% of the bacteria in spite of the presence of high levels of antibodies against P. haemolytica. Addition of post-colostral serum to heat-inactivated adult bovine serum decreased the bactericidal capacity of the latter. It was speculated that this inhibition may have been caused by the presence of blocking antibodies (IgA) found in the post-colostral serum. Undiluted nasal secretions collected from adult cattle were not bactericidal to P. haemolytica. The results also suggest that the bronchoalveolar washings (BAW) from vaccinated calves, in spite of having a high antibody titer, were less bactericidal to P. haemolytica than BAW from sham-vaccinated calves (71.12% vs. 83.12%). The bactericidal factor(s) present in BAW from sham-vaccinated calves was heat stable, not complement dependent, and was not related to lysozyme concentration.

Bactericidal and bacteriolytic activity of serum against gram-negative bacteria

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Activation of complement by serum-resistant Neisseria gonorrhoeae. Assembly of the membrane attack complex without subsequent cell death

Interaction of the human complement system in normal human serum (NHS) with serum-resistant and -sensitive Neisseria gonorrhoeae was evaluated to better understand the mechanism of serum-resistance. Complement activity (CH50) was depleted from NHS in a dose-dependent fashion by both serum-resistant and -sensitive N. gonorrhoeae. No detectable CH50 remained in NHS incubated with 10(9) colony-forming units (CFU)/ml serum of either resistant or sensitive strains. When smaller numbers of bacteria were incubated with NHS, lesser, yet comparable, amounts of CH50 were depleted by both resistant and sensitive strains. Hemolytic C2 activity was diminished by 33% in the case of resistant N. gonorrhoeae (10(8) CFU/ml serum) and by 48% in the case of a sensitive strain. No detectable decreases in hemolytic C4 or C7 activities were found with either sensitive or resistant strains at this concentration. Both resistant and sensitive strains activated C1s in NHS. Resistant strains specifically activated 19-21% of radiolabeled C1s in NHS, whereas sensitive strains activated 18-32%. Both resistant and sensitive strains also activated C5 in NHS. In binding assays using radiolabeled C5 and C9 in NHS, resistant and sensitive strains bound comparable amounts of C5 and C9. The number of bound C5 and C9 molecules varied according to the number of bacteria or amount of serum used in the assay. The ratio of C9/C5 bound to a sensitive strain was 6.8, and to a resistant strain was 8.2, suggesting that C5 and C9 were incorporated into membrane attack complexes (MAC). Electron microscopic examination of resistant and sensitive strains incubated with NHS revealed that MAC is bound to the surfaces of the resistant strain as well as the sensitive strain.

Natural bactericidal activity of human serum against Neisseria meningitidis isolates of different serogroups and serotypes

We used a microtiter assay, standardized with serum-sensitive and serum-resistant strains of Neisseria gonorrhoeae, to determine the serum sensitivity of Neisseria meningitidis isolates of different serogroups and serotypes. Numbers of serum-resistant isolates varied among serogroups: group A = 7/8 (88%), group B = 26/50 (52%), group C = 5/8 (63%), group Y = 4/6 (67%), group W135 = 5/8 (63%), group 29E (Z') = 0/8 (0%), nongroupable isolates = 0/8 (0%). In comparison to group B isolates, group A isolates were more serum resistant (P less than 0.06), and group 29E and nongroupable isolates were more serum sensitive (P less than 0.001). Poor correlation was observed between serum sensitivity results and group-specific levels of bactericidal antibody in the normal human serum of volunteers. The frequency of serum-resistant strains among group B disease isolates (45%) was not significantly different from throat isolates of asymptomatic carriers (52%). Serotype 2 isolates of group B were no more serum resistant than were other serotypes examined. The serum sensitivity of meningococci appears to involve both capsular and noncapsular antigens and varies between serogroups. The increased serum sensitivity of nongroupable and group 29E isolates may account for the low incidence of disease caused by these organisms.

Effects of iron and culture filtrates on killing of Neisseria gonorrhoeae by normal human serum

Neisseria gonorrhoeae GC9, both colony types T2 and T4, were killed by normal human serum, although populations of colony type T4 were more susceptible. Ferric ammonium citrate prevented the killing of populations of both T2 and T4 colony types. Other iron compounds tested showed no protective effect, nor did ammonium citrate or the divalent cations magnesium or calcium. A filtrate from cultures of an N. gonorrhoeae strain grown in a liquid defined medium showed a similar protective effect in the serum assay. The filtrate appeared to chelate iron, as measured by decreased ability of iron-free transferin to bind iron in the presence of the filtrate. However, the two effects did not appear to be related. Neither ferric ammonium citrate nor the culture filtrate sufficiently inactivated complement to account for protection.

Neisseria gonorrhoeae acquire a new principal outer-membrane protein when transformed to resistance to serum bactericidal activity

Resistance to the complement-dependent bactericidal activity of normal human serum is found in nearly all Neisseria gonorrhoeae strains causing disseminated gonococcal infection. Transformation of serum-sensitive gonococcal strain NRL 7189 to serum resistance using deoxyribonucleic acid from three separate disseminated-infection gonococci was accompanied by simultaneous structural and antigenic changes in the principal outer-membrane protein (POMP) of the transformants. In each of 10 separate transformations, there was a reduction in subunit molecular weight of the POMP from that in the recipient (39,000) to that in the deoxyribonucleic acid donors (36,500). Also, in each instance the POMP antigenic type, as measured by enzyme-linked immunosorbent assay, converted from that of the recipient to an antigenic type common to each DGI donor strain. This conversion of POMP antigen was reflected in part by changes in the surface fluorescence of the transformed gonococci to the microimmunofluorescence pattern of the donor strains. These results suggested that serum resistance of gonococci is related to the possession of a POMP of characteristic subunit molecular weight and antigenicity.

Characterization of gonococcal antigens responsible for induction of bactericidal antibody in disseminated infection

The role of gonococcal antigens in serum bactericidal activity was determined for an isolate of Neisseria gonorrhoeae from a patient with disseminated gonococcal infection (DGI). Gonococcal outer membranes were purified by differential ultracentrifugation of sheared organisms treated with EDTA. The membranes were solubilized in an endotoxin-disaggregating buffer, and the proteins were separated from the endotoxin by molecular sieve chromatography. Chemical characterization of the endotoxin from the DGI strain revealed the presence of heptose (7.8% of carbohydrate composition) and 2-keto-3-deoxyoctonate (6.1%, wt/wt) in concentrations similar to rough endotoxins of gram-negative enteric bacteria. Dermal Schwartzman reactions were positive for this endotoxin (4 mug) and the corresponding outer membrane (139 mug), but negative for the protein fraction (>500 mug). The patient's whole serum or the IgG fraction, each with complement, reduced the number of the infecting organisms by greater than 1 log(10) in a bactericidal assay. Outer membrane and its protein and endotoxin fractions (0.8-500 mug) from the DGI strain were separately preincubated with the patient's convalescent serum and specific inhibition of bactericidal activity occurred with the endotoxin fraction (25 mug) and the outer membrane (100 mug); the protein (500 mug) exhibited no inhibition. Similar results were obtained by inhibiting the bactericidal activity of rabbit antiserum, prepared by intravenous inoculation of an isolate from a patient with pelvic inflammatory disease, with antigen purified from that strain. That this was specific immune inhibition and not anticomplementary activity was shown by the failure of these antigens to inhibit other complement-dependent bactericidal systems.

Gonococci causing disseminated gonococcal infection are resistant to the bactericidal action of normal human sera

The susceptibility of strains of Neisseria gonorrhoeae to the bactericidal action of normal human sera was determined for isolates from patients with disseminated gonococcal infection and uncomplicated gonorrhea. Serum susceptibility was correlated with penicillin susceptibility and auxotype. 38 of 39 strains (97%) of N. gonorrhoeae from Seattle patients with disseminated gonococcal infection were resistant to the complement-dependent bactericidal action of normal human sera. 36 of these were inhibited by less than or equal to mug/ml of penicillin G and required arginine, hypoxanthine, and uracil for growth on chemically defined medium (Arg-Hyx-Ura- auxotype). 12 of 43 isolates from patients with uncomplicated gonorrhea were also of the Arg-Hyx-Ura-auxotype, inhibited by less than or equal to 0.030 mug/ml of penicillin G, and serum resistant. Of the 31 remaining strains of other auxotypes isolated from patients with uncomplicated gonorrhea, 18 (58.1%) were sensitive to normal human sera in titers ranging from 2 to 2,048. The bactericidal action of normal human sera may prevent the dissemination of serum-sensitive gonococci. However, since only a small proportion of individuals infected by serum-resistant strains develop disseminated gonococcal infection, serum resistance appears to be a necessary but not a sufficient virulence factor for dissemination. Host factors such as menstruation and pharyngeal gonococcal infection may favor the dissemination of serum-resistant strains. Since serum-resistant Arg-Hyx-Ura strains are far more frequently isolated from patients with disseminated gonococcal infection than serum-resistant strains of other auxotypes, Arg-Hyx-Ura-strains may possess other virulence factors in addition to serum resistance.