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Hendricks K, Martines RB, Bielamowicz H, Boyer AE, Long S, Byers P, Stoddard RA, Taylor K, Kolton CB, Gallegos-Candela M, Roberts C, DeLeon-Carnes M, Salzer J, Dawson P, Brown D, Templeton-LeBouf L, Maves RC, Gulvik C, Lonsway D, Barr JR, Bower WA, Hoffmaster A. Welder's Anthrax: A Tale of 2 Cases. Clin Infect Dis 2022; 75:S354-S363. [PMID: 36251561 PMCID: PMC9649440 DOI: 10.1093/cid/ciac535] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Bacillus anthracis has traditionally been considered the etiologic agent of anthrax. However, anthrax-like illness has been documented in welders and other metal workers infected with Bacillus cereus group spp. harboring pXO1 virulence genes that produce anthrax toxins. We present 2 recent cases of severe pneumonia in welders with B. cereus group infections and discuss potential risk factors for infection and treatment options, including antitoxin.
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Affiliation(s)
- Katherine Hendricks
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Roosecelis Brasil Martines
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hannah Bielamowicz
- Pathology Department, Fort Bend County Medical Examiner Office, Rosenberg, Texas, USA
| | - Anne E Boyer
- Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephen Long
- Houston Laboratory Response Network, Houston Health Department, Houston, Texas, USA
| | - Paul Byers
- Office of Communicable Diseases, Mississippi State Department of Health, Jackson, Mississippi, USA
| | - Robyn A Stoddard
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kathryn Taylor
- Office of Communicable Diseases, Mississippi State Department of Health, Jackson, Mississippi, USA
| | - Cari Beesley Kolton
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maribel Gallegos-Candela
- Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Christine Roberts
- Office of Communicable Diseases, Mississippi State Department of Health, Jackson, Mississippi, USA
| | - Marlene DeLeon-Carnes
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Johanna Salzer
- Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Patrick Dawson
- Office of Science, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dannette Brown
- King Daughters Medical Center, Brookhaven, Mississippi, USA
| | | | - Ryan C Maves
- Departments of Infectious Diseases and Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Chris Gulvik
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Lonsway
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John R Barr
- Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - William A Bower
- Correspondence: W. A. Bower, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, MS H24-12, Atlanta, GA 30329 ()
| | - Alex Hoffmaster
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Hesse EM, Godfred-Cato S, Bower WA. Antitoxin Use in the Prevention and Treatment of Anthrax Disease: A Systematic Review. Clin Infect Dis 2022; 75:S432-S440. [PMID: 36251559 PMCID: PMC9649430 DOI: 10.1093/cid/ciac532] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Bacillus anthracis is a high-priority threat agent because of its widespread availability, easy dissemination, and ability to cause substantial morbidity and mortality. Although timely and appropriate antimicrobial therapy can reduce morbidity and mortality, the role of adjunctive therapies continues to be explored. METHODS We searched 11 databases for articles that report use of anthrax antitoxins in treatment or prevention of systemic anthrax disease published through July 2019. We identified other data sources through reference search and communication with experts. We included English-language studies on antitoxin products with approval by the US Food and Drug Administration (FDA) for anthrax in humans, nonhuman primates, and rabbits. Two researchers independently reviewed studies for inclusion and abstracted relevant data. RESULTS We abstracted data from 12 publications and 2 case reports. All 3 FDA-approved anthrax antitoxins demonstrated significant improvement in survival as monotherapy over placebo in rabbits and nonhuman primates. No study found significant improvement in survival with combination antitoxin and antimicrobial therapy compared to antimicrobial monotherapy. Case reports and case series described 25 patients with systemic anthrax disease treated with antitoxins; 17 survived. Animal studies that used antitoxin monotherapy as postexposure prophylaxis (PEP) demonstrated significant improvement in survival over placebo, with greatest improvements coming with early administration. CONCLUSIONS Limited human and animal evidence indicates that adjunctive antitoxin treatment may improve survival from systemic anthrax infection. Antitoxins may also provide an alternative therapy to antimicrobials for treatment or PEP during an intentional anthrax incident that could involve a multidrug-resistant B. anthracis strain.
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Affiliation(s)
- Elisabeth M Hesse
- Correspondence: E. M. Hesse, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS H24-11, Atlanta, GA 30329 ()
| | - Shana Godfred-Cato
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - William A Bower
- Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Lombarte Espinosa E, Villuendas Usón MC, Arribas García J, Jado García I, Huarte Lacunza R, Zárate Chug P, Claraco Vega LM, Jesús Santed Andrés M, Ríos MJ, Cook R, Simard JM, Boyer AE, Rezusta A. Survival of Patient With Hemorrhagic Meningitis Associated With Inhalation Anthrax. Clin Infect Dis 2022; 75:S364-S372. [PMID: 36251557 DOI: 10.1093/cid/ciac531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
Abstract
This report describes a 49-year-old male construction worker who acquired a Bacillus anthracis infection after working on a sheep farm. He experienced a severe respiratory infection, septic shock, and hemorrhagic meningoencephalitis with severe intracranial hypertension. After several weeks with multiple organ dysfunction syndrome, he responded favorably to antibiotic treatment. Three weeks into his hospitalization, an intracranial hemorrhage and cerebral edema led to an abrupt deterioration in his neurological status. A single dose of raxibacumab was added to his antimicrobial regimen on hospital day 27. His overall status, both clinical and radiographic, improved within a few days. He was discharged 2 months after admission and appears to have fully recovered.
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Affiliation(s)
- Evelyn Lombarte Espinosa
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Isabel Jado García
- Laboratorio de Referencia e Investigación en Patógenos Especiales, Centro Nacional de Microbiología. Instituto de Salud Carlos III, Madrid, Spain
| | - Rafael Huarte Lacunza
- Servicio de Farmacia Hospitalaria, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Paola Zárate Chug
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Luis Manuel Claraco Vega
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - María Jiménez Ríos
- Servicio Medicina Intensiva, UCI Polivalente, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Rachel Cook
- Oak Ridge Institute for Science and Education, CDC Fellowship Program, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - J Marc Simard
- Departments of Neurosurgery, Pathology and Physiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anne E Boyer
- Division of Laboratory Sciences, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Antonio Rezusta
- Servicio Microbiología, Hospital Universitario Miguel Servet, IIS Aragón, Zaragoza, Spain
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Tharmalingam T, Han X, Wozniak A, Saward L. Polyclonal hyper immunoglobulin: A proven treatment and prophylaxis platform for passive immunization to address existing and emerging diseases. Hum Vaccin Immunother 2022; 18:1886560. [PMID: 34010089 PMCID: PMC9090292 DOI: 10.1080/21645515.2021.1886560] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/26/2021] [Accepted: 02/01/2021] [Indexed: 12/13/2022] Open
Abstract
Passive immunization with polyclonal hyper immunoglobulin (HIG) therapy represents a proven strategy by transferring immunoglobulins to patients to confer immediate protection against a range of pathogens including infectious agents and toxins. Distinct from active immunization, the protection is passive and the immunoglobulins will clear from the system; therefore, administration of an effective dose must be maintained for prophylaxis or treatment until a natural adaptive immune response is mounted or the pathogen/agent is cleared. The current review provides an overview of this technology, key considerations to address different pathogens, and suggested improvements. The review will reflect on key learnings from development of HIGs in the response to public health threats due to Zika, influenza, and severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Tharmala Tharmalingam
- Therapeutics Business Unit, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada
| | - Xiaobing Han
- Therapeutics Business Unit, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada
- Department of Immunology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ashley Wozniak
- Therapeutics Business Unit, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada
| | - Laura Saward
- Therapeutics Business Unit, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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5
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Avril A, Tournier JN, Paucod JC, Fournes B, Thullier P, Pelat T. Antibodies against Anthrax Toxins: A Long Way from Benchlab to the Bedside. Toxins (Basel) 2022; 14:toxins14030172. [PMID: 35324669 PMCID: PMC8955606 DOI: 10.3390/toxins14030172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 02/01/2023] Open
Abstract
Anthrax is an acute disease caused by the bacterium Bacillus anthracis, and is a potential biowarfare/bioterrorist agent. Its pulmonary form, caused by inhalation of the spores, is highly lethal and is mainly related to injury caused by the toxins secretion. Antibodies neutralizing the toxins of B. anthracis are regarded as promising therapeutic drugs, and two are already approved by the Federal Drug Administration. We developed a recombinant human-like humanized antibody, 35PA83 6.20, that binds the protective antigen and that neutralized anthrax toxins in-vivo in White New Zealand rabbits infected with the lethal 9602 strain by intranasal route. Considering these promising results, the preclinical and clinical phase one development was funded and a program was started. Unfortunately, after 5 years, the preclinical development was cancelled due to industrial and scientific issues. This shutdown underlined the difficulty particularly, but not only, for an academic laboratory to proceed to clinical development, despite the drug candidate being promising. Here, we review our strategy and some preliminary results, and we discuss the issues that led to the no-go decision of the pre-clinical development of 35PA83 6.20 mAb. Our review provides general information to the laboratories planning a (pre-)clinical development.
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Affiliation(s)
- Arnaud Avril
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; (J.-N.T.); (J.-C.P.); (P.T.); (T.P.)
- Correspondence: ; Tel.: +33-(0)-1-78-65-10-72
| | - Jean-Nicolas Tournier
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; (J.-N.T.); (J.-C.P.); (P.T.); (T.P.)
- Ecole du Val-de-Grâce, 75005 Paris, France
| | - Jean-Charles Paucod
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; (J.-N.T.); (J.-C.P.); (P.T.); (T.P.)
| | - Bénédicte Fournes
- Laboratoire Français du Fractionnement et des Biotechnologies, 91940 Les Ulis, France;
| | - Philippe Thullier
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; (J.-N.T.); (J.-C.P.); (P.T.); (T.P.)
| | - Thibaut Pelat
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; (J.-N.T.); (J.-C.P.); (P.T.); (T.P.)
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A Review of the Efficacy of FDA-Approved B. anthracis Anti-Toxin Agents When Combined with Antibiotic or Hemodynamic Support in Infection- or Toxin-Challenged Preclinical Models. Toxins (Basel) 2021; 13:toxins13010053. [PMID: 33450877 PMCID: PMC7828353 DOI: 10.3390/toxins13010053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/05/2021] [Accepted: 01/09/2021] [Indexed: 12/29/2022] Open
Abstract
Anti-toxin agents for severe B. anthracis infection will only be effective if they add to the benefit of the two mainstays of septic shock management, antibiotic therapy and titrated hemodynamic support. Both of these standard therapies could negate benefits related to anti-toxin treatment. At present, three anthrax anti-toxin antibody preparations have received US Food and Drug Administration (FDA) approval: Raxibacumab, Anthrax Immune Globulin Intravenous (AIGIV) and ETI-204. Each agent is directed at the protective antigen component of lethal and edema toxin. All three agents were compared to placebo in antibiotic-treated animal models of live B. anthracis infection, and Raxibacumab and AIGIV were compared to placebo when combined with standard hemodynamic support in a 96 h canine model of anthrax toxin-associated shock. However, only AIG has actually been administered to a group of infected patients, and this experience was not controlled and offers little insight into the efficacy of the agents. To provide a broader view of the potential effectiveness of these agents, this review examines the controlled preclinical experience either in antibiotic-treated B. anthracis models or in titrated hemodynamic-supported toxin-challenged canines. The strength and weaknesses of these preclinical experiences are discussed.
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7
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Cui X, Wang J, Li Y, Couse ZG, Risoleo TF, Moayeri M, Leppla SH, Malide D, Yu ZX, Eichacker PQ. Bacillus anthracis edema toxin inhibits hypoxic pulmonary vasoconstriction via edema factor and cAMP-mediated mechanisms in isolated perfused rat lungs. Am J Physiol Heart Circ Physiol 2021; 320:H36-H51. [PMID: 33064559 PMCID: PMC7847081 DOI: 10.1152/ajpheart.00362.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 12/31/2022]
Abstract
Bacillus anthracis edema toxin (ET) inhibited lethal toxin-stimulated pulmonary artery pressure (Ppa) and increased lung cAMP levels in our previous study. We therefore examined whether ET inhibits hypoxic pulmonary vasoconstriction (HPV). Following baseline hypoxic measures in isolated perfused lungs from healthy rats, compared with diluent, ET perfusion reduced maximal Ppa increases (mean ± SE percentage of maximal Ppa increase with baseline hypoxia) during 6-min hypoxic periods (FIO2 = 0%) at 120 min (16 ± 6% vs. 51 ± 6%, P = 0.004) and 180 min (11.4% vs. 55 ± 6%, P = 0.01). Protective antigen-mAb (PA-mAb) and adefovir inhibit host cell edema factor uptake and cAMP production, respectively. In lungs perfused with ET following baseline measures, compared with placebo, PA-mAb treatment increased Ppa during hypoxia at 120 and 180 min (56 ± 6% vs. 10 ± 4% and 72 ± 12% vs. 12 ± 3%, respectively, P ≤ 0.01) as did adefovir (84 ± 10% vs. 16.8% and 123 ± 21% vs. 26 ± 11%, respectively, P ≤ 0.01). Compared with diluent, lung perfusion with ET for 180 min reduced the slope of the relationships between Ppa and increasing concentrations of endothelin-1 (ET-1) (21.12 ± 2.96 vs. 3.00 ± 0.76 × 108 cmH2O/M, P < 0.0001) and U46619, a thromboxane A2 analogue (7.15 ± 1.01 vs. 3.74 ± 0.31 × 107 cmH2O/M, P = 0.05) added to perfusate. In lungs isolated from rats after 15 h of in vivo infusions with either diluent, ET alone, or ET with PA-mAb, compared with diluent, the maximal Ppa during hypoxia and the slope of the relationship between change in Ppa and ET-1 concentration added to the perfusate were reduced in lungs from animals challenged with ET alone (P ≤ 0.004) but not with ET and PA-mAb together (P ≥ 0.73). Inhibition of HPV by ET could aggravate hypoxia during anthrax pulmonary infection.NEW & NOTEWORTHY The most important findings here are edema toxin's potent adenyl cyclase activity can interfere with hypoxic pulmonary vasoconstriction, an action that could worsen hypoxemia during invasive anthrax infection with lung involvement. These findings, coupled with other studies showing that lethal toxin can disrupt pulmonary vascular integrity, indicate that both toxins can contribute to pulmonary pathophysiology during infection. In combination, these investigations provide a further basis for the use of antitoxin therapies in patients with worsening invasive anthrax disease.
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Affiliation(s)
- Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Zoe G Couse
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Thomas F Risoleo
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Mahtab Moayeri
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Stephen H Leppla
- Laboratory of Parasitic Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, Maryland
| | - Daniela Malide
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Zu-Xi Yu
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
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Li Y, Cui X, Shiloach J, Wang J, Suffredini DA, Xu W, Liu W, Fitz Y, Sun J, Eichacker PQ. Hydrocortisone decreases lethality and inflammatory cytokine and nitric oxide production in rats challenged with B. anthracis cell wall peptidoglycan. Intensive Care Med Exp 2020; 8:67. [PMID: 33206255 PMCID: PMC7674536 DOI: 10.1186/s40635-020-00358-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/06/2020] [Indexed: 11/16/2022] Open
Abstract
Background Lethal B. anthracis infection produces high proinflammatory peptidoglycan (PGN) burdens in hosts. We investigated whether the lethality and inflammation anthrax PGN can produce are related. Methods At 6 h before and the start of 24 h anthrax PGN infusions, rats (n = 198) were treated with diluent (controls) or one of three IV-doses of either hydrocortisone (125, 12.5 or 1.25 mg/kg) or TNF-soluble receptor (TNFsr; 2000, 1000 or 333 μg/kg), non-selective and selective anti-inflammatory agents, respectively. Results Compared to controls, hydrocortisone 125 and 12.5 mg/kg each decreased 7-day lethality (p ≤ 0.004). Hydrocortisone 125 mg/kg decreased IL-1β, IL-6, TNFα, MCP, MIP-1α, MIP-2, RANTES and nitric oxide (NO) blood levels at 4 and 24 h after starting PGN (except MCP at 24 h). Each decrease was significant at 4 h (except MIP-1α that was significant at 24 h) (p ≤ 0.05). Similarly, hydrocortisone 12.5 mg/kg decreased each measure at 4, 24 and 48 h (except TNFα at 24 h and MIP-1α at 24 and 48 h and NO at 48 h). Decreases were significant for IL-6 and NO at 4 h and RANTES at 48 h (p ≤ 0.05). Hydrocortisone 1.25 mg/kg had non-significant effects. Each TNFsr dose decreased lethality but non-significantly. However, when doses were analyzed together, TNFsr decreased lethality in a potential trend (p = 0.16) and IL-6 and NO significantly at 4 h (p = 0.05). Conclusions Peptidoglycan-stimulated host inflammation may contribute to B. anthracis lethality.
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Affiliation(s)
- Yan Li
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Xizhong Cui
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Joseph Shiloach
- Biotechnology Core Laboratory, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Dante A Suffredini
- Section of Critical Care, Department of Medicine, St. Agnes Hospital, Baltimore, MD, 21229, USA
| | - Wanying Xu
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Wancang Liu
- Biotechnology Core Laboratory, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Yvonne Fitz
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Junfeng Sun
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, NIH Clinical Center, National Institutes of Health, Building 10, Room 2C145, 10 Center Drive, Bethesda, MD, 20892, USA.
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Thouret JM, Rogeaux O, Beaudouin E, Levast M, Ramisse V, Biot FV, Valade E, Thibault F, Gorgé O, Tournier JN. Case Report of an Injectional Anthrax in France, 2012. Microorganisms 2020; 8:microorganisms8070985. [PMID: 32630109 PMCID: PMC7409126 DOI: 10.3390/microorganisms8070985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022] Open
Abstract
(1) Background: Bacillus anthracis is a spore-forming, Gram-positive bacterium causing anthrax, a zoonosis affecting mainly livestock. When occasionally infecting humans, B. anthracis provokes three different clinical forms: cutaneous, digestive and inhalational anthrax. More recently, an injectional anthrax form has been described in intravenous drug users. (2) Case presentation: We report here the clinical and microbiological features, as well as the strain phylogenetic analysis, of the only injectional anthrax case observed in France so far. A 27-year-old patient presented a massive dermohypodermatitis with an extensive edema of the right arm, and the development of drug-resistant shocks. After three weeks in an intensive care unit, the patient recovered, but the microbiological identification of B. anthracis was achieved after a long delay. (3) Conclusions: Anthrax diagnostic may be difficult clinically and microbiologically. The phylogenetic analysis of the Bacillus anthracis strain PF1 confirmed its relatedness to the injectional anthrax European outbreak group-II.
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Affiliation(s)
- Jean-Marc Thouret
- Centre Hospitalier Centre Hospitalier Métropole Savoie, rue Lucien Bizet, 73000 Chambéry, France; (J.-M.T.); (O.R.); (E.B.); (M.L.)
| | - Olivier Rogeaux
- Centre Hospitalier Centre Hospitalier Métropole Savoie, rue Lucien Bizet, 73000 Chambéry, France; (J.-M.T.); (O.R.); (E.B.); (M.L.)
| | - Emmanuel Beaudouin
- Centre Hospitalier Centre Hospitalier Métropole Savoie, rue Lucien Bizet, 73000 Chambéry, France; (J.-M.T.); (O.R.); (E.B.); (M.L.)
| | - Marion Levast
- Centre Hospitalier Centre Hospitalier Métropole Savoie, rue Lucien Bizet, 73000 Chambéry, France; (J.-M.T.); (O.R.); (E.B.); (M.L.)
| | - Vincent Ramisse
- DGA Maîtrise NRBC, 5 rue Lavoisier, 91710 Vert le Petit, France;
| | - Fabrice V. Biot
- CNR-LE Charbon (National Reference Laboratory for Anthrax), Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France; (F.V.B.); (E.V.); (F.T.); (O.G.)
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France
| | - Eric Valade
- CNR-LE Charbon (National Reference Laboratory for Anthrax), Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France; (F.V.B.); (E.V.); (F.T.); (O.G.)
- Direction Centrale du Service de Santé des Armées, 60 Boulevard du Général Martial Valin, 75015 Paris, France
- Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75 005 Paris, France
| | - François Thibault
- CNR-LE Charbon (National Reference Laboratory for Anthrax), Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France; (F.V.B.); (E.V.); (F.T.); (O.G.)
| | - Olivier Gorgé
- CNR-LE Charbon (National Reference Laboratory for Anthrax), Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France; (F.V.B.); (E.V.); (F.T.); (O.G.)
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France
| | - Jean-Nicolas Tournier
- CNR-LE Charbon (National Reference Laboratory for Anthrax), Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France; (F.V.B.); (E.V.); (F.T.); (O.G.)
- Département Microbiologie et Maladies Infectieuses, Institut de Recherche Biomédicale des Armées, 1 Place Général Valérie André, 91220 Brétigny sur Orge, France
- Ecole du Val-de-Grâce, 1 Place Alphonse Laveran, 75 005 Paris, France
- Correspondence: ; Tel.: +33-178-65-1065
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10
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Chugh T. Bioterrorism: Clinical and public health aspects of anthrax. CURRENT MEDICINE RESEARCH AND PRACTICE 2020; 9:110-111. [PMID: 32289055 PMCID: PMC7147222 DOI: 10.1016/j.cmrp.2019.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/13/2019] [Indexed: 12/02/2022]
Abstract
Bioterrorism is intentional use of bioweapons (bacteria, viruses, or fungi or their toxins) to harm people, animals, agriculture, or environment of a country. Its impact can cause high mortality and morbidity and serious disruption of economy and social and political life. Countries must be fully equipped to respond through adequate surveillance systems and management, containment, and preventive policies.
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Affiliation(s)
- Tulsi Chugh
- D-702, Som Vihar Appartments, RK Puram, New Delhi, 110022, India
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11
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Abstract
Inhalational anthrax caused by Bacillus anthracis, a spore-forming Gram-positive bacterium, is a highly lethal infection. Antibodies targeting the protective antigen (PA) binding component of the toxins have recently been authorized as an adjunct to antibiotics, although no conclusive evidence demonstrates that anthrax antitoxin therapy has any significant benefit. We discuss here the rational basis of anti-PA development regarding the pathogenesis of the disease. Inhalational anthrax caused by Bacillus anthracis, a spore-forming Gram-positive bacterium, is a highly lethal infection. Antibodies targeting the protective antigen (PA) binding component of the toxins have recently been authorized as an adjunct to antibiotics, although no conclusive evidence demonstrates that anthrax antitoxin therapy has any significant benefit. We discuss here the rational basis of anti-PA development regarding the pathogenesis of the disease. We argue that inductive reasoning may induce therapeutic bias. We identified anthrax animal model analysis as another bias. Further studies are needed to assess the benefit of anti-PA antibodies in the treatment of inhalational anthrax, while a clearer consensus should be established around what evidence should be proven in an anthrax model.
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12
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Tournier JN, Peyrefitte CN, Biot F, Merens A, Simon F. The threat of bioterrorism. THE LANCET. INFECTIOUS DISEASES 2018; 19:18-19. [PMID: 30587283 DOI: 10.1016/s1473-3099(18)30709-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/13/2018] [Accepted: 11/14/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Jean-Nicolas Tournier
- Microbiology and Infectious Diseases Department, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; Viral Genomics and Vaccination Unit, CNRS UMR-3569, Institut Pasteur, Paris, France; French National Reference Center for Anthrax, Brétigny sur Orge, France.
| | - Christophe N Peyrefitte
- Microbiology and Infectious Diseases Department, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; Unité Mixte de Recherche, Unité des Virus Emergent, IRD-190, French National Institute of Health and Medical Research-1207, Marseille, France; French National Reference Center for Orthopoxviruses, Brétigny sur Orge, France
| | - Fabrice Biot
- Microbiology and Infectious Diseases Department, Institut de Recherche Biomédicale des Armées, 91220 Brétigny-sur-Orge, France; French National Reference Center for Anthrax, Brétigny sur Orge, France
| | - Audrey Merens
- Biology Laboratory, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France
| | - Fabrice Simon
- Infectious Diseases Department, Hôpital d'Instruction des Armées Laveran, Marseille, France
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13
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Gallegos-Candela M, Boyer AE, Woolfitt AR, Brumlow J, Lins RC, Quinn CP, Hoffmaster AR, Meister G, Barr JR. Validated MALDI-TOF-MS method for anthrax lethal factor provides early diagnosis and evaluation of therapeutics. Anal Biochem 2017; 543:97-107. [PMID: 29224733 PMCID: PMC7904043 DOI: 10.1016/j.ab.2017.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/01/2017] [Accepted: 12/06/2017] [Indexed: 01/12/2023]
Abstract
Anthrax lethal factor (LF) is a zinc-dependent endoprotease and a critical virulence factor for Bacillus anthracis, the causative agent of anthrax. The mass spectrometry (MS) method for total-LF quantification includes three steps; 1) LF specific antibody capture/concentration, 2) LF-specific hydrolysis of a peptide substrate, and 3) detection and quantification of LF-cleaved peptides by isotope-dilution MALDI-TOF/MS. Recombinant LF spiked plasma was used for calibration and quality control (QC) materials. Specificity was 100% from analysis of serum and plasma from 383 non-infected humans, 31 rabbits, and 24 rhesus macaques. Sensitivity was 100% from 32 human clinical anthrax cases including infections by inhalation, ingestion, cutaneous and injection exposures and experimental infections for 29 rabbits and 24 rhesus macaques with inhalation anthrax. Robustness evaluation included sample storage, serum and plasma, antimicrobial and antitoxin effects and long-term performance. Data from 100 independent runs gave detection limits 0.01 ng/mL (111 amol/mL) for the 4-h method and 0.0027 ng/mL (30 amol/mL) for an alternate 20-h method. QC precision ranged from 7.7 to 14.8% coefficient of variation and accuracy from 0.2 to 9.8% error. The validated LF MS method provides sensitive quantification of anthrax total-LF using a robust high throughput platform for early diagnosis and evaluation of therapeutics during an anthrax emergency.
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Affiliation(s)
- Maribel Gallegos-Candela
- Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop F-50, Atlanta, GA 30341, USA
| | - Anne E Boyer
- Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop F-50, Atlanta, GA 30341, USA.
| | - Adrian R Woolfitt
- Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop F-50, Atlanta, GA 30341, USA
| | - Judy Brumlow
- Battelle Atlanta Analytical Services, 2987 Clairmont Road NE, Suite 450, Atlanta, GA 30329, USA
| | - Renato C Lins
- Battelle Atlanta Analytical Services, 2987 Clairmont Road NE, Suite 450, Atlanta, GA 30329, USA
| | - Conrad P Quinn
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Alex R Hoffmaster
- Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329, USA
| | - Gabriel Meister
- Battelle Biomedical Research Center, 1425 Plain City Georgesville Rd, West Jefferson, OH 43162, USA
| | - John R Barr
- Centers for Disease Control and Prevention, 4770 Buford Highway Mailstop F-50, Atlanta, GA 30341, USA
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14
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Suffredini DA, Cui X, Xu W, Li Y, Eichacker PQ. The Potential Pathogenic Contributions of Endothelial Barrier and Arterial Contractile Dysfunction to Shock Due to B. anthracis Lethal and Edema Toxins. Toxins (Basel) 2017; 9:toxins9120394. [PMID: 29210983 PMCID: PMC5744114 DOI: 10.3390/toxins9120394] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 01/22/2023] Open
Abstract
Shock with B. anthracis infection is particularly resistant to conventional cardiovascular support and its mortality rate appears higher than with more common bacterial pathogens. As opposed to many bacteria that lack exotoxins directly depressing hemodynamic function, lethal and edema toxin (LT and ET respectively) both cause shock and likely contribute to the high lethality rate with B. anthracis. Selective inhibition of the toxins is protective in infection models, and administration of either toxin alone in animals produces hypotension with accompanying organ injury and lethality. Shock during infection is typically due to one of two mechanisms: (i) intravascular volume depletion related to disruption of endothelial barrier function; and (ii) extravasation of fluid and/or maladaptive dilation of peripheral resistance arteries. Although some data suggests that LT can produce myocardial dysfunction, growing evidence demonstrates that it may also interfere with endothelial integrity thereby contributing to the extravasation of fluid that helps characterize severe B. anthracis infection. Edema toxin, on the other hand, while known to produce localized tissue edema when injected subcutaneously, has potent vascular relaxant effects that could lead to pathologic arterial dilation. This review will examine recent data supporting a role for these two pathophysiologic mechanisms underlying the shock LT and ET produce. Further research and a better understanding of these mechanisms may lead to improved management of B. anthracis in patients.
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Affiliation(s)
- Dante A Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD 20892, USA.
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD 20892, USA.
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15
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Anthrax immune globulin improves hemodynamics and survival during B. anthracis toxin-induced shock in canines receiving titrated fluid and vasopressor support. Intensive Care Med Exp 2017; 5:48. [PMID: 29058092 PMCID: PMC5651533 DOI: 10.1186/s40635-017-0159-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Although anthrax immune globulin (AIG) improved survival in antibiotic-treated Bacillus anthracis-challenged animal models, whether it adds to the benefit of conventional hemodynamic support for B. anthracis toxin-associated shock is unknown. Methods We therefore tested AIG in sedated, mechanically ventilated canines challenged with 24-h B. anthracis lethal and edema toxin infusions and supported for 96 h with a previously demonstrated protective regimen of titrated normal saline and norepinephrine. Results Compared to controls, proportional survival (%) was increased with AIG treatment started 4 h before (33 vs. 100%, n = 6 each) or 2 h (17 vs. 86%, n = 6 and 7 respectively) or 5 h (0 vs. 67%, n = 3 each) after the start of toxin (p ≤ 0.05) and overall [3 survivors of 15 controls (20%) vs. 14 of 16 AIG animals (88%); p = 0.006]. Averaged across treatment times, AIG increased blood pressure at 48 h and decreased norepinephrine requirements at 72 h (p ≤ 0.02), increased left ventricular ejection fraction at 48 and 72 h (p ≤ 0.02), and increased urine output and decreased net fluid balance at 72 and 96 h (p ≤ 0.04). AIG also reduced acidosis and renal and hepatic injury markers between 24 and 96 h. Conclusions These findings further support AIG’s potential benefit for patients with B. anthracis infection and developing toxin-associated shock. Electronic supplementary material The online version of this article (10.1186/s40635-017-0159-9) contains supplementary material, which is available to authorized users.
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16
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Suffredini DA, Li Y, Xu W, Moayeri M, Leppla S, Fitz Y, Cui X, Eichacker PQ. Shock and lethality with anthrax edema toxin in rats are associated with reduced arterial responsiveness to phenylephrine and are reversed with adefovir. Am J Physiol Heart Circ Physiol 2017; 313:H946-H958. [PMID: 28887331 DOI: 10.1152/ajpheart.00285.2017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
Although edema toxin (ETx) and lethal toxin (LTx) contribute to Bacillus anthracis shock and lethality, the mechanisms underlying their cardiovascular effects are unclear. We have previously shown that ETx but not LTx inhibited phenylephrine-stimulated contraction of aortic rings prepared from healthy rats and that adefovir, a selective inhibitor of ETx cAMP production, blocked this effect. Here, we examined arterial function in rats that received 24-h ETx or LTx infusions. Compared with control rats, ETx reduced mean arterial pressure (MAP) and survival over 48 h (P ≤ 0.0003) and increased plasma cAMP at 4, 24, and 48 h (P < 0.0001) and nitric oxide (NO) at 24 and 48 h (P ≤ 0.01). Compared with control animals, at 24- and 48-h phenylephrine stimulation of aortic rings from ETx animals produced decreased maximal contractile force (MCF; P = 0.05 and 0.006) and in vivo phenylephrine infusion in ETx animals produced decreased proportional increases in MAP (P < 0.0001 and P = 0.05). In ETx-treated animals, compared with placebo-treated animals, adefovir treatment prevented all lethality (P = 0.01), increased MAP (P ≤ 0.0001), decreased plasma and aortic tissue cAMP at 24 and 48 h, respectively (P ≤ 0.03), and plasma NO at both times (P ≤ 0.004), and increased phenylephrine-stimulated increases in MCF in aortic rings and MAP in vivo at 48 h (P = 0.02). LTx decreased MAP and survival also, but it did not alter the response to phenylephrine of MCF in aortic rings prepared from LTx animals or of MAP in vivo. In conclusion, in rats, hypotension and lethality are associated with reduced arterial contractile function with ETx but not LTx and adefovir improves ETx-induced hypotension and lethality.NEW & NOTEWORTHY The most important aspects of the present study are the findings that 1) in vivo challenge with anthrax edema but not lethal toxin depresses arterial contractile function measured both ex vivo and in vivo and 2) adefovir inhibits the effects of edema toxin on arterial hypotension and improves survival with lethal dose of edema toxin challenge.
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Affiliation(s)
- Dante A Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Mahtab Moayeri
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Stephen Leppla
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Yvonne Fitz
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; and
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17
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Xu W, Ohanjandian L, Sun J, Cui X, Suffredini D, Li Y, Welsh J, Eichacker PQ. A systematic review and meta-analysis of preclinical trials testing anti-toxin therapies for B. anthracis infection: A need for more robust study designs and results. PLoS One 2017; 12:e0182879. [PMID: 28797061 PMCID: PMC5552191 DOI: 10.1371/journal.pone.0182879] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 07/26/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND B. anthracis anti-toxin agents are approved and included in the Strategic National Stockpile based primarily on animal infection trials. However, in the only anthrax outbreak an approved anti-toxin agent was administered in, survival did not differ comparing recipients and non-recipients, although recipients appeared sicker. OBJECTIVE Employ a systematic review and meta-analysis to investigate preclinical studies supporting anthrax anti-toxin agents. DATA SOURCE PubMed, EMBASE, and Scopus. STUDY ELIGIBILITY Compared survival with an anti-toxin agent versus control in B. anthracis challenged, antibiotic treated animals. STUDY METHODS Examine model and study design and the effect of anti-toxin agents on relative risk of death(95%CI) (RR). RESULTS From 9 studies, 29 experiments were analyzed which included 4 species (748 animals) and 5 agents; LFI, AIG, AVP-21D9, Raxibacumab, and ETI-204. Only five experiments were blinded and no experiment included the cardiopulmonary support sick B. anthracis patients receive. Only one agent in a single un-blinded experiment reduced RR significantly [0.45(0.22,0.940]. However, in six studies testing an agent in more than one experiment in the same species, agents had consistent survival effects across experiments [I2 = 0, p≥0.55 in five and I2 = 42%, p = 0.16 in one]. Within each species, agents had effects on the side of benefit; in one study testing AVP-21D9 in mice [0.11(0.01,1.82)] or guinea pigs [0.70(0.48,1.03)]; across eight rabbit studies testing LFI, Raxibacumab, AIG or ETI-204 [0.62(0.45,0.87); I2 = 17.4%, p = 0.29]; and across three monkey studies testing Raxibacumab, AIG or ETI-204 [0.66(0.34,1.27); I2 = 25.3%, p = 0.26]. Across all agents and species, agents decreased RR [0.64(0.52,0.79); I2 = 5.3%, p = 0.39]. LIMITATIONS Incidence of selective reporting not identifiable. CONCLUSIONS Although overall significant, individually anti-toxin agents had weak beneficial effects. Lack of study blinding and relevant clinical therapies further weakened studies. Although difficult, preclinical studies with more robust designs and results are warranted to justify the resources necessary to maintain anti-toxin agents in national stockpiles.
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Affiliation(s)
- Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lernik Ohanjandian
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Dante Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Judith Welsh
- National Institutes of Health Library, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail:
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18
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Goldstein JM, Lee J, Tang X, Boyer AE, Barr JR, Bagarozzi DA, Quinn CP. Phage Display Analysis of Monoclonal Antibody Binding to Anthrax Toxin Lethal Factor. Toxins (Basel) 2017. [PMCID: PMC5535168 DOI: 10.3390/toxins9070221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AVR1674 and AVR1675 are monoclonal antibodies (mAbs) that bind with high specificity to anthrax toxin lethal factor (LF) and lethal toxin (LTx). These mAbs have been used as pivotal reagents to develop anthrax toxin detection tests using mass spectrometry. The mAbs were demonstrated to bind LF with good affinity (KD 10−7–10−9 M) and to enhance LF-mediated cleavage of synthetic peptide substrates in vitro. Sequence analysis indicated that the mAbs shared 100% amino acid identity in their complementarity determining regions (CDR). A phage display library based on a combinatorial library of random heptapeptides fused to the pIII coat protein of M13 phage was enriched and screened to identify peptide sequences with mAb binding properties. Selection and sequence analysis of 18 anti-LF-reactive phage clones identified a 7-residue (P1–P7) AVR1674/1675 consensus target binding sequence of TP1-XP2-K/RP3-DP4-D/EP5-ZP6-X/ZP7 (X = aromatic, Z = non-polar). The phage peptide sequence with highest affinity binding to AVR1674/1675 was identified as T-F-K-D-E-I-V. Synthetic oligopeptides were designed based on the phage sequences and interacted with mAbs with high affinity (KD ~ 10−9 M). Single amino acid substitutions of A, H, or Q in the peptides identified positions P1–P5 as critical residues for mAb-peptide interactions. CLUSTALW alignment of phage sequences with native LF implicated residues 644–650 (sequence T-H-Q-D-E-I-Y) as a putative linear epitope component located within a structural loop (L2) of LF Domain IV. The activation effects of these mAbs contribute to the analytic sensitivity of function-based LF detection assays.
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Affiliation(s)
- Jason M. Goldstein
- Reagent and Diagnostic Services Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, MS-A03, 1600 Clifton Road, Atlanta, GA 30333, USA; (J.L.); (X.T.); (D.A.B.J.)
- Correspondence: ; Tel.: +1-404-639-2258
| | - Joo Lee
- Reagent and Diagnostic Services Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, MS-A03, 1600 Clifton Road, Atlanta, GA 30333, USA; (J.L.); (X.T.); (D.A.B.J.)
| | - Xiaoling Tang
- Reagent and Diagnostic Services Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, MS-A03, 1600 Clifton Road, Atlanta, GA 30333, USA; (J.L.); (X.T.); (D.A.B.J.)
| | - Anne E. Boyer
- Clinical Chemistry Branch, Division of Laboratory Services, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Atlanta, GA 30341, USA; (A.E.B.); (J.R.B.)
| | - John R. Barr
- Clinical Chemistry Branch, Division of Laboratory Services, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE, Atlanta, GA 30341, USA; (A.E.B.); (J.R.B.)
| | - Dennis A. Bagarozzi
- Reagent and Diagnostic Services Branch, Division of Scientific Resources, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, MS-A03, 1600 Clifton Road, Atlanta, GA 30333, USA; (J.L.); (X.T.); (D.A.B.J.)
| | - Conrad P. Quinn
- Meningitis and Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, MS-D17, 1600 Clifton Road, Atlanta, GA 30333, USA;
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