Evaluation of 5 serologic assays to detect Rhodococcus equi pneumonia in foals

Fecal concentration of Rhodococcus equi determined by quantitative polymerase chain reaction of rectal swab samples to differentiate foals with pneumonia from healthy foals

BACKGROUND

Diagnostic accuracy of real-time, quantitative PCR (qPCR) assays to quantify virulent Rhodococcus equi using rectal swab samples has not been systematically evaluated.

OBJECTIVE

To evaluate the accuracy of qPCR of rectal swab samples to differentiate foals with pneumonia from healthy foals of similar age from the same environment.

ANIMALS

One hundred privately owned foals born in 2021 from 2 farms in New York.

METHODS

An incident case-control study design was used. Rectal swabs were collected from all foals diagnosed with R. equi pneumonia at 2 horse-breeding farms (n = 47). Eligible pneumonia cases (n = 39) were matched by age to up to 2 healthy (n = 53) control foals; rectal swabs were collected from control foals on the day of diagnosis of the index case. DNA was extracted from fecal swabs and the concentration of virulent R. equi (ie, copy numbers of the virulence-associated protein A gene [vapA] per 100 ng fecal DNA) was estimated by qPCR.

RESULTS

The area under the ROC curve for qPCR of fecal swabs was 83.7% (95% CI, 74.9-92.6). At a threshold of 14 883 copies of vapA per 100 ng fecal DNA, specificity of the assay was 83.0% (95% CI, 71.7-92.4) and sensitivity was 79.5% (95% CI, 66.7-92.3).

CONCLUSIONS AND CLINICAL IMPORTANCE

Although fecal concentrations of virulent R. equi are significantly higher in pneumonic foals than healthy foals of similar age in the same environment, qPCR of rectal swabs as reported here lacks adequate diagnostic accuracy for clinical use.

Rhodococcus equi Foal Pneumonia: Update on Epidemiology, Immunity, Treatment, and Prevention

Pneumonia in foals caused by the bacterium Rhodococcus equi has a worldwide distribution and is a common cause of disease and death for foals. The purpose of this narrative review is to summarise recent developments pertaining to the epidemiology, immune responses, treatment, and prevention of rhodococcal pneumonia of foals. Screening tests have been used to implement earlier detection and treatment of foals with presumed subclinical R. equi pneumonia to reduce mortality and severity of disease. Unfortunately, this practice has been linked to the emergence of antimicrobial resistant R. equi in North America. Correlates of protective immunity for R. equi infections of foals remain elusive, but recent evidence indicates that innate immune responses are important both for mediating killing and orchestrating adaptive immune responses. A macrolide antimicrobial in combination with rifampin remains the recommended treatment for foals with R. equi pneumonia. Great need exists to identify which antimicrobial combination is most effective for treating foals with R. equi pneumonia and to limit emergence of antimicrobial-resistant strains. In the absence of an effective vaccine against R. equi, passive immunisation remains the only commercially-available method for effectively reducing the incidence of R. equi pneumonia. Because passive immunisation is expensive, labour-intensive, and carries risks for foals, great need exists to develop alternative approaches for passive and active immunisation.

Seroprevalence of Rhodococcus equi in horses in Israel

Rhodococcus equi is a common cause of pneumonia in foals and has extensive clinical, economic and possibly zoonotic consequences. This bacterium survives well in the environment and may be considered as normal flora of adult horses. Certain strains of this bacterium are extremely virulent in foals, and early identification and intervention is crucial for prognosis. Rhodococcus equi is endemic in many parts of the world and occasionally isolated in Israel. This study was designed to evaluate R. equi seroprevalence in adult horses in Israel to indirectly indicate the potential level of exposure of susceptible foals. Sera were collected from 144 horses during spring 2011 and from 293 horses during fall 2014, and the presence of antibodies against virulent R. equi was detected by enzyme-linked immunosorbent assay. Equine seroprevalence of R. equi was found to be 7.6% in 2011 and 5.1% in 2014. Only one farm had seropositive horses in 2011, whereas several farms had seropositive horses in 2014. No significant risk factors for seropositivity were found. Rhodococcus equi appears to be endemic in Israel. This is the first survey of R. equi in Israel that provides information on the epidemiology of this important bacterium.

Estimating the Sensitivity and Specificity of Real-Time Quantitative PCR of Fecal Samples for Diagnosis of Rhodococcus equi Pneumonia in Foals

BACKGROUND

Real-time, quantitative PCR (qPCR) methods for detecting Rhodococcus equi in feces have been developed as a noninvasive, rapid diagnostic test for R. equi pneumonia, but have not been evaluated in a large population of foals.

OBJECTIVE

The objective of this study was to evaluate the clinical utility of fecal PCR as a diagnostic test for R. equi pneumonia in foals using receiver operating characteristic (ROC) methods.

ANIMALS

186 foals born in 2011 at an R. equi-endemic ranch in Texas.

METHODS

Fecal samples were collected at the time of onset of clinical signs for pneumonic foals (n = 31). Foals with pneumonia were matched by age and birth date to healthy (n = 31) and subclinical (n = 124) control foals; fecal samples were collected from these controls. DNA was extracted from feces using commercial kits and concentration of virulent R. equi in feces was determined by qPCR.

RESULTS

Concentration of R. equi in feces differed significantly (P < .05) among groups. The area under the ROC curve for fecal qPCR for diagnosis of R. equi pneumonia was 89% (95% CI, 83-99), with a sensitivity of 94% and specificity of 72%.

CONCLUSIONS AND CLINICAL IMPORTANCE

qPCR of feces can be useful as an alternative to tracheobronchial aspiration for the diagnosis of R. equi in foals with clinical signs of pneumonia. Caution should be used in extrapolating results of this study to other populations because fecal concentration of R. equi might vary by geographic location or management practices.

Validation and evaluation of VapA-specific IgG and IgG subclass enzyme-linked immunosorbent assays (ELISAs) to identify foals with Rhodococcus equi pneumonia

REASONS FOR PERFORMING STUDY

Rhodococcus equi (Rhodococcus hoagii/Prescottella equi) is a common cause of foal pneumonia, but its diagnosis remains a challenge for equine veterinarians. While the VapA-specific (virulence-associated protein A) immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) has low sensitivity and specificity for detecting pneumonic foals, little is known about VapA-specific IgG subclasses.

OBJECTIVES

To evaluate the performance of VapA-specific ELISA for IgG and its subclasses IgGa, IgGb and IgG(T) in the early diagnosis of pneumonia caused by R. equi.

STUDY DESIGN

Assay validation followed by assessment of diagnostic performance using archived samples from animals of known status.

METHODS

Serum samples from exposed (n = 125) and nonexposed adult horses (n = 10) and from experimentally challenged and naturally infected foals were used for ELISA validation. Post mortem and tissue culture records of the last 24 years from the Institute for Experimental Pathology at the University of Iceland in Keldur, Iceland laboratory were evaluated to confirm the absence of R. equi cases in Iceland. The diagnostic performance of VapA-specific IgG and its subclasses was evaluated using banked serum samples from pneumonic (n = 21) and healthy foals (n = 80). To evaluate each IgG assay, a cut-off value was selected based on receiver operating characteristic curve analysis and used to calculate sensitivity and specificity. The intra- and interassay coefficients of variation were calculated for each ELISA.

RESULTS

Using sera from Iceland, where R. equi infection has not been reported, the VapA-specific IgG ELISA differentiated exposed from nonexposed horses. When used to identify infected foals, VapA-specific IgG, IgGa and IgGb had no diagnostic value. In contrast, IgG(T) had high sensitivity and specificity.

CONCLUSIONS

Horses from Iceland are not exposed to VapA(+) R. equi and can serve as negative controls. VapA-specific IgG subclasses, with the exception of IgG(T), are poor predictors of disease. Further investigation on the use of IgG(T) as a diagnostic tool in field conditions is needed.

Rhodococcus equi: the many facets of a pathogenic actinomycete

Rhodococcus equi is a soil-dwelling pathogenic actinomycete that causes pulmonary and extrapulmonary pyogranulomatous infections in a variety of animal species and people. Young foals are particularly susceptible and develop a life-threatening pneumonic disease that is endemic at many horse-breeding farms worldwide. R. equi is a facultative intracellular parasite of macrophages that replicates within a modified phagocytic vacuole. Its pathogenicity depends on a virulence plasmid that promotes intracellular survival by preventing phagosome-lysosome fusion. Species-specific tropism of R. equi for horses, pigs and cattle appears to be determined by host-adapted virulence plasmid types. Molecular epidemiological studies of these plasmids suggest that human R. equi infection is zoonotic. Analysis of the recently determined R. equi genome sequence has identified additional virulence determinants on the bacterial chromosome. This review summarizes our current understanding of the clinical aspects, biology, pathogenesis and immunity of this fascinating microbe with plasmid-governed infectivity.

Development of ELISA test for determination of the level of antibodies against Rhodococcus equi in equine serum and colostrum

Rhodococcus equi infection occurs worldwide and is one of the major causes of losing foals in the first six months of life. The application of serological tests in the diagnostics of rhodococcosis is limited, however they play a crucial role in immunological studies. The objective of this study was to develop and standardize ELISA test for the determination of the level of antibodies against Rhodococcus equi in equine serum and colostrum.Bacterial cell lysate was used as antigen. The test was standardized on 175 sera obtained from adult horses kept on rhodococcosis-free and endemic farms. Positive and negative control sera were used. The test detected IgG antibodies mainly against VapA protein, which was confirmed by Western blot analysis. The test was easy to perform, did not require inactivation of sera and had low well-to-well variation. The shelf life of antigen-coated ELISA plates was 21 days.The test allowed to reveal significant increase of R. equi-specific antibodies in both serum and colostrum in response to the vaccination (p<0.001). Therefore it can be applied to the evaluation of efficacy of immunization. Moreover, no statistically significant difference in the baseline antibody level in adult horses from rhodococcosis-free and endemic farm was revealed (α=0.05).

Diagnosis, treatment, control, and prevention of infections caused by Rhodococcus equi in foals

Rhodococcus equi, a gram-positive facultative intracellular pathogen, is one of the most common causes of pneumonia in foals. Although R. equi can be cultured from the environment of virtually all horse farms, the clinical disease in foals is endemic at some farms, sporadic at others, and unrecognized at many. On farms where the disease is endemic, costs associated with morbidity and mortality attributable to R. equi may be very high. The purpose of this consensus statement is to provide recommendations regarding the diagnosis, treatment, control, and prevention of infections caused by R. equi in foals.

Current understanding of the equine immune response to Rhodococcus equi. An immunological review of R. equi pneumonia

Rhodococcus equi is recognised to cause chronic purulent bronchopneumonia in foals of less than 6 months of age. Virulent strains of the bacteria possess a large 80-90 kb plasmid encoding several virulence-associated proteins, including virulence-associated protein A (VapA), which is associated with disease. R. equi pneumonia can represent significant costs and wastage to the equine breeding industry, especially on stud farms where the disease is endemic. This article reviews knowledge of the equine immune response, both in the immune adult and susceptible neonate, with respect to this pathogen. Humoral immune responses are addressed, with a discussion on the use of hyperimmune and normal adult equine plasma as prophylactic tools. The role that innate immune mechanisms play in the susceptibility of some foals to R. equi infection is also highlighted. Likewise, cell-mediated immune components are reviewed, with particular attention directed towards research undertaken to develop an effective vaccine for foals. It is possible that the implementation of a single immunoprophylaxis strategy to prevent R. equi infection on farms will yield disappointing results. Combined prophylactic protocols that address husbandry practices, environmental and aerosol contamination levels, enhancement of innate immunity, good quality hyperimmune plasma for the neonate, and vaccinal efficacy in the developing foal may be required.

RHODOCOCCUS EQUI

RESUMO Rhodococcus equi é uma importante causa de broncopneumonia em potros com menos de seis meses de idade, sendo responsável pela mortalidade de eqüinos no mundo inteiro. É um microrganismo intracelular capaz de sobreviver e se multiplicar no interior de macrófagos. Apresenta três níveis de virulência de acordo com os diferentes antígenos expressos em sua superfície. Cepas virulentas apresentam um plasmídeo que codifica a proteína de superfície VapA e são isoladas principalmente de potros com pneumonia e de alguns pacientes humanos. Cepas com virulência intermediária expressam a proteína VapB e predominam em suínos e humanos com AIDS. Cepas avirulentas não expressam antígenos de superfície e são encontradas principalmente no ambiente e em pacientes humanos. Um dos fatores responsáveis pela ampla distribuição da enfermidade em potros é a imaturidade do sistema imunológico dos animais acometidos pela infecção, que pode se tornar endêmica em alguns criatórios. Em humanos, as formas de infecção são ainda desconhecidas, mas o contato com eqüinos é relatado em um terço dos casos. Devido à importância clínica da doença, são necessários métodos diagnósticos que promovam sua identificação precoce, facilitando e aumentando as chances de sucesso com o tratamento. Os métodos mais utilizados atualmente são o cultivo microbiológico, testes sorológicos para detecção de anticorpos séricos nos animais e técnicas de PCR que detectam a região 16S do rDNA e o fragmento do gene vapA do microrganismo.

Evaluation of fecal samples from mares as a source of Rhodococcus equi for their foals by use of quantitative bacteriologic culture and colony immunoblot analyses

OBJECTIVE

To determine whether mares are a clinically important source of Rhodococcus equi for their foals.

SAMPLE POPULATION

171 mares and 171 foals from a farm in Kentucky (evaluated during 2004 and 2005).

PROCEDURES

At 4 time points (2 before and 2 after parturition), the total concentration of R equi and concentration of virulent R equi were determined in fecal specimens from mares by use of quantitative bacteriologic culture and a colony immunoblot technique, respectively. These concentrations for mares of foals that developed R equi-associated pneumonia and for mares with unaffected foals were compared. Data for each year were analyzed separately.

RESULTS

R equi-associated pneumonia developed in 53 of 171 (31%) foals. Fecal shedding of virulent R equi was detected in at least 1 time point for every mare; bacteriologic culture results were positive for 62 of 171 (36%) mares at all time points. However, compared with dams of unaffected foals, fecal concentrations of total or virulent R equi in dams of foals with R equi-associated pneumonia were not significantly different.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicate that dams of foals with R equi-associated pneumonia did not shed more R equi in feces than dams of unaffected foals; therefore, R equi infection in foals was not associated with comparatively greater fecal shedding by their dams. However, detection of virulent R equi in the feces of all mares during at least 1 time point suggests that mares can be an important source of R equi for the surrounding environment.

Clinical evaluation of a peptide-ELISA based upon N-terminal B-cell epitope of the VapA protein for diagnosis of Rhodococcus equi pneumonia in foals

A total of 227 field samples from naturally exposed foals aged between 3 weeks and 6 months were used in an evaluation of a peptide-based enzyme-linked immunosorbent assay (ELISA) for diagnosis of Rhodococcus equi infection. A biotinylated peptide derived from the virulence-associated protein A (VapA) of R. equi, a horse pathogen, was synthesized and designated as PN11-14. The peptide corresponds to the N-terminal B-cell epitope TSLNLQKDEPNGRASDTAGQ of the VapA protein. Based upon a serum immunoglobulin (Ig)G titre of 512 as a positive cut-off value for the R. equi infection, the ELISA provided the overall sensitivity of 47.62%, specificity of 69.67% and an accuracy of 59.47% with a positive predictive value of 57.47% for true R. equi pneumonia. The assay was improved by detecting VapA-specific IgGb antibodies against N-terminal B-cell epitope of the VapA protein rather than IgG antibodies. The VapA-IgGb ELISA showed the overall sensitivity of 70.47%, specificity of 72.13% and accuracy of 71.36% with a positive predictive value of 68.52%. Diagnosis of R. equi disease in 6-week-old foals showed that the VapA-IgGb ELISA provided an increasing trend (P=0.0572) in sensitivity of 82.4% in comparison with the VapA-IgG ELISA which showed the sensitivity of 58.8%. However, differences in specificity of both tests were statistically insignificant (P=0.357) as analysed by the McNemar test. These results indicated that detection of VapA-specific IgGb antibodies may be a better predictor of R. equi disease in foals.

Study of serum amyloid A concentrations as a means of achieving early diagnosis of Rhodococcus equi pneumonia

REASONS FOR PERFORMING STUDY

Prognosis of Rhodococcus equi pneumonia can be challenging because the course of the disease is often insidious and overt clinical signs are subtle. Early diagnosis is considered desirable because it may offer the chance of more successful implementation of treatment and, thereby, improved outcome. Serological tests have previously failed to be accurate for early detection or diagnosis. Measurement of serum amyloid A (SAA) prior to and at the time of clinical signs was therefore chosen in order to assess its potential clinical use.

OBJECTIVE

To determine whether SAA concentrations differentiate foals affected with R. equi pneumonia from unaffected foals, either prior to the onset of disease or at the time of onset of clinical signs.

HYPOTHESIS

SAA concentrations are significantly higher among foals that develop R. equi pneumonia than in foals from the same environment that remain clinically unaffected.

METHODS

Serum samples were obtained from 212 foals 7-14 days and 196 foals 21-28 days post partum, and from affected foals and age-matched controls at the time of onset of signs of pneumonia. SAA concentration was determined for each sample.

RESULTS

There were no significant differences between SAA concentrations of foals with R. equi and clinically unaffected foals during the 2 periods of examination or at the time of onset of clinical signs of R. equi pneumonia.

CONCLUSIONS

Concentrations of SAA are variable among foals with R. equi pneumonia and cannot be used reliably either as an ancillary diagnostic tool or to screen for early detection of disease during the first month post partum.

POTENTIAL RELEVANCE

Bimonthly monitoring concentration of SAA is not useful as a screening test for early detection of R. equi pneumonia and does not facilitate diagnosis of this disease when used according to the protocol of this study.

Recognition of a B-cell Epitope of the VapA Protein of Rhodococcus equi in Newborn and Experimentally Infected Foals

The aim of this study was to evaluate the usefulness of the previously identified B-cell epitope TSLNLQKDEPNGRASDTAGQ of the VapA protein of Rhodococcus equi and its association with R. equi pneumonia. A modified peptide designated PN11-14 corresponding to the epitope was recognized by all sera from experimentally infected foals with virulent R. equi ATCC103+ containing the virulence plasmid but not by its plasmid-cured derivative ATCC103- strain. Marked levels of VapA-specific immunoglobulin (Ig)G were detected in all sera from the ATCC103+ infected foals at 2 weeks after the infection. One control animal had high titres as determined by the peptide enzyme-linked immunosorbent assay (ELISA), indicating the ELISA may not absolutely differentiate between foals with R. equi pneumonia and healthy exposed foals in farms where the prevalence of disease is high. However, numbers of animals used were small. Further evaluation of the peptide ELISA with field samples is necessary to determine whether the assay is diagnostically useful. This study showed that levels of passive transfer of maternal IgG antibodies to the epitope in newborn foals could be measured. Interestingly, the maternally derived antibodies were found to significantly (P<0.05 by Student's t-test) decline 2 weeks after birth. Seroconversion against naturally occurring VapA expressing R. equi could be detected in some foals at 4 weeks of age. Antibodies to the epitope peaked and were significantly (P<0.05) greater in foals aged between 6 and 8 weeks. These results indicated that the peptide ELISA could be used to monitor anti-VapA antibodies in foals, particularly those at the age of 4-6 weeks. It is possible that the ELISA may be of some use as a diagnostic test on farms where R. equi is non-endemic. Further studies using large number of field samples are needed to verify this assumption.