1
|
Klontz EH, Solomon IH, Turbett SE, Lemieux JE, Branda JA. Cerebrospinal fluid metagenomics has greatest added value as a test for Powassan virus among patients in New England with suspected central nervous system infection. Diagn Microbiol Infect Dis 2024; 108:116169. [PMID: 38295682 DOI: 10.1016/j.diagmicrobio.2023.116169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 02/27/2024]
Abstract
Cerebrospinal fluid (CSF) metagenomic next generation sequencing (mNGS) can detect diverse pathogens in patients with central nervous system infection. Due to its high cost and unclear clinical utility, it is typically reserved for patients with unrevealing routine workups. A multi-center retrospective analysis of real-world CSF mNGS was performed involving orders between 2017 and 2022 at a large New England healthcare system. CSF mNGS was performed 64 times with 17 positive results (27 %). In 11/17 positive samples (65 %), the infectious agent had not been previously detected using routine methods. Arboviruses (n = 8) were the most frequently detected agents, particularly Powassan virus (n = 6). Results changed therapy in 3/64 cases (5 %). Positive results were associated with immunodeficiency (p = 0.06), especially anti-B-cell therapy (p = 0.02), and earlier sample collection (p = 0.06). The association with compromised humoral immunity was stronger in the arbovirus and Powassan virus subgroups (p = 0.001), whose constituents were older than the overall cohort and had higher mortality rates.
Collapse
Affiliation(s)
- Erik H Klontz
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah E Turbett
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jacob E Lemieux
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
2
|
Allan-Blitz LT, Sanders G, Shah P, Adams G, Jarolimova J, Ard K, Branda JA, Klausner JD, Sabeti PC, Lemieux JE. Clinical Performance of Cas13a-based Point-of-Care Lateral Flow Assay for Detecting Neisseria gonorrhoeae. medRxiv 2024:2024.03.01.24303603. [PMID: 38496586 PMCID: PMC10942539 DOI: 10.1101/2024.03.01.24303603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background Diagnosis of Neisseria (N.) gonorrhoeae is dependent on nucleic acid amplification testing (NAAT), which is not available in resource-limited settings where the prevalence of infection is highest. Recent advances in molecular diagnostics leveraging the high specificity of CRISPR enzymes can permit field-deployable, point-of-care lateral flow assays. We previously reported on the development and in vitro performance of a lateral flow assay for detecting N. gonorrhoeae. Here we aimed to pair that assay with point-of-care DNA extraction techniques and assess the performance on clinical urine specimens. Methods We collected an additional urine specimen among individuals enrolling in an ongoing clinical trial at the Massachusetts General Hospital Sexual Health Clinic who presented with symptoms of urethritis or cervicitis (urethral or vaginal discharge, dysuria, or dyspareunia). We then assessed thermal, detergent, and combination DNA extraction conditions, varying the duration of heat at 95°C and concentration of Triton X. We assessed the efficacy of the various DNA extraction methods by quantitative polymerase chain reaction (qPCR). Once an extraction method was selected, we incubated samples for 90 minutes to permit isothermal recombinase polymerase amplification. We then assessed the performance of lateral flow Cas13a-based detection using our previously designed porA probe and primer system for N. gonorrhoeae detection, comparing lateral flow results with NAAT results from clinical care. Results We assessed DNA extraction conditions on 3 clinical urine specimens. There was no consistent significant difference in copies per microliter of DNA obtained using more or less heat. On average, we noted that 0.02% triton combined with 5 minutes of heating to 95°C resulted in the highest DNA yield, however, 0.02% triton alone resulted in a quantity of DNA that was above the previously determined analytic sensitivity of the assay. Given that detergent-based extraction is more easily deployable, we selected that as our method for extraction. We treated 23 clinical specimens with 0.02% triton, which we added to the Cas13a detection system. We ran all lateral flow detections in duplicate. The Cas13a-based assay detected 8 of 8 (100%) positive specimens, and 0 of 15 negative specimens. Conclusion Using point-of-care DNA extraction, isothermal amplification, and Cas13a-based detection, our point-of-care lateral flow N. gonorrhoeae assay correctly identified 23 clinical urine specimens as either positive or negative. Further evaluation of this assay among larger samples and more diverse sample types is warranted.
Collapse
Affiliation(s)
- Lao-Tzu Allan-Blitz
- Division of Global Health Equity: Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gabriela Sanders
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Palak Shah
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gordon Adams
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jana Jarolimova
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Kevin Ard
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Jeffrey D. Klausner
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Pardis C. Sabeti
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
| | - Jacob E. Lemieux
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
3
|
Bowman KA, Wiggins CD, DeRiso E, Paul S, Strle K, Branda JA, Steere AC, Lauffenburger DA, Alter G. Borrelia-specific antibody profiles and complement deposition in joint fluid distinguish antibiotic-refractory from -responsive Lyme arthritis. iScience 2024; 27:108804. [PMID: 38303696 PMCID: PMC10830897 DOI: 10.1016/j.isci.2024.108804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/24/2023] [Accepted: 01/02/2024] [Indexed: 02/03/2024] Open
Abstract
Lyme arthritis, caused by the spirochete Borrelia burgdorferi, is the most common feature of late disseminated Lyme disease in the United States. While most Lyme arthritis resolves with antibiotics, termed "antibiotic-responsive", some individuals develop progressive synovitis despite antibiotic therapy, called "antibiotic-refractory" Lyme arthritis (LA). The primary drivers behind antibiotic-refractory arthritis remain incompletely understood. We performed a matched, cross-compartmental comparison of antibody profiles from blood and joint fluid of individuals with antibiotic-responsive (n = 11) or antibiotic-refractory LA (n = 31). While serum antibody profiles poorly discriminated responsive from refractory patients, a discrete profile of B.burgdorferi-specific antibodies in joint fluid discriminated antibiotic-responsive from refractory LA. Cross-compartmental comparison of antibody glycosylation, IgA1, and antibody-dependent complement deposition (ADCD) revealed more poorly coordinated humoral responses and increased ADCD in refractory disease. These data reveal B.burgdorferi-specific serological markers that may support early stratification and clinical management, and point to antibody-dependent complement activation as a key mechanism underlying persistent disease.
Collapse
Affiliation(s)
- Kathryn A. Bowman
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
- Brigham and Women’s Hospital, Division of Infectious Diseases, Boston, MA 02115, USA
| | - Christine D. Wiggins
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Elizabeth DeRiso
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Steffan Paul
- Marks Group, Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Klemen Strle
- Tufts University School of Medicine Boston, Boston, MA, USA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Allen C. Steere
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Douglas A. Lauffenburger
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
- Moderna Therapeutics Inc., Cambridge, MA 02139, USA
| |
Collapse
|
4
|
Welch NL, Zhu M, Hua C, Weller J, Mirhashemi ME, Nguyen TG, Mantena S, Bauer MR, Shaw BM, Ackerman CM, Thakku SG, Tse MW, Kehe J, Uwera MM, Eversley JS, Bielwaski DA, McGrath G, Braidt J, Johnson J, Cerrato F, Moreno GK, Krasilnikova LA, Petros BA, Gionet GL, King E, Huard RC, Jalbert SK, Cleary ML, Fitzgerald NA, Gabriel SB, Gallagher GR, Smole SC, Madoff LC, Brown CM, Keller MW, Wilson MM, Kirby MK, Barnes JR, Park DJ, Siddle KJ, Happi CT, Hung DT, Springer M, MacInnis BL, Lemieux JE, Rosenberg E, Branda JA, Blainey PC, Sabeti PC, Myhrvold C. Author Correction: Multiplexed CRISPR-based microfluidic platform for clinical testing of respiratory viruses and identification of SARS-CoV-2 variants. Nat Med 2024; 30:307. [PMID: 37946059 PMCID: PMC10803257 DOI: 10.1038/s41591-023-02684-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Affiliation(s)
- Nicole L Welch
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Harvard Program in Virology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA.
| | - Meilin Zhu
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Catherine Hua
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juliane Weller
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | | | - Tien G Nguyen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Matthew R Bauer
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA, USA
| | - Bennett M Shaw
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Cheri M Ackerman
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Sri Gowtham Thakku
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Megan W Tse
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jared Kehe
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Jacqueline S Eversley
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Derek A Bielwaski
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Graham McGrath
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Braidt
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Gage K Moreno
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lydia A Krasilnikova
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - Brittany A Petros
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Cambridge, MA, USA
- Harvard/Massachusetts Institute of Technology MD-PhD Program, Harvard Medical School, Boston, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | | | - Ewa King
- State Health Laboratories, Rhode Island Department of Health, Providence, RI, USA
| | - Richard C Huard
- State Health Laboratories, Rhode Island Department of Health, Providence, RI, USA
| | | | - Michael L Cleary
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Sandra C Smole
- Massachusetts Department of Public Health, Boston, MA, USA
| | | | | | - Matthew W Keller
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Malania M Wilson
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marie K Kirby
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John R Barnes
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Daniel J Park
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Katherine J Siddle
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - Christian T Happi
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- African Centre of Excellence for Genomics of Infectious Diseases, Redeemer's University, Ede, Nigeria
- Department of Biological Sciences, College of Natural Sciences, Redeemer's University, Ede, Nigeria
| | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Molecular Biology Department and Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Springer
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Bronwyn L MacInnis
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Jacob E Lemieux
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Rosenberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul C Blainey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research at Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Pardis C Sabeti
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA.
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
- Koch Institute for Integrative Cancer Research at Massachusetts Institute of Technology, Cambridge, MA, USA.
- Howard Hughes Medical Institute, Chevy Chase, MD, USA.
| | - Cameron Myhrvold
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
| |
Collapse
|
5
|
Lee-Lewandrowski E, Turbett S, Branda JA, Lewandrowski K. Evaluation of the rapid Quidel Sofia Lyme fluorescent immunoassay as a first-tier test in a modified 2-tier testing algorithm for Lyme disease: A comparison with the Zeus ELISA Borrelia VlsE1/pepC10 lgG/IgM assay followed by the Zeus monovalent IgM/IgG confirmatory assay. Am J Clin Pathol 2023; 160:599-602. [PMID: 37549102 DOI: 10.1093/ajcp/aqad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/17/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVES Recently modified 2-tier testing (MTTT) algorithms using 2 enzyme immunoassays (EIAs) as opposed to an EIA followed by immunoblot have been approved by the US Food and Drug Administration (FDA) for the screening and confirmation of Lyme disease. The Quidel Sofia Lyme fluorescent immunoassay is a rapid lateral-flow method that can be performed in real time, permitting on-demand testing. We evaluated the performance of the Sofia assay as a first-tier test in an MTTT algorithm. METHODS We compared the Sofia Lyme test with the Zeus ELISA Borrelia VlsE1/pepC10 lgG/IgM test, followed by the Zeus monovalent IgM/IgG EIA as the confirmatory test. RESULTS When used as a first-tier test compared with a standard Zeus MTTT assay, the positive percentage agreement was 91.4%% (95% CI, 77.6%-97.0%). The negative percentage agreement was 100% (95% CI, 94.0%-100%). The overall agreement was 98.3% (95% CI, 94.2%-99.4%). κ = 0.945, indicating "almost perfect agreement." CONCLUSIONS The Sofia Lyme test performs well compared with an FDA-approved MTTT.
Collapse
Affiliation(s)
- Elizabeth Lee-Lewandrowski
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, US
| | - Sarah Turbett
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, US
| | - John A Branda
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, US
| | - Kent Lewandrowski
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Massachusetts General Hospital
- Harvard Medical School, Boston, MA, US
| |
Collapse
|
6
|
Thompson AD, Balamuth F, Neville DN, Chapman LL, Levas MN, Kharbanda AB, Branda JA, Ladell MM, Loiselle C, Nigrovic LE. Sensitivity of Two-Tiered Lyme Disease Serology in Children With an Erythema Migrans Lesion. J Pediatric Infect Dis Soc 2023; 12:553-555. [PMID: 37756491 DOI: 10.1093/jpids/piad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
In our prospective cohort of 192 children with a physician-diagnosed erythema migrans (EM) lesion, two-tier Lyme disease serology had higher sensitivity in children with multiple EM lesions (76.8% multiple lesions vs. 38.1% single EM; difference 38.7%, 95% confidence interval 24.8%-50.4%). The diagnosis of cutaneous Lyme disease should be based on careful physical examination rather than laboratory testing.
Collapse
Affiliation(s)
- Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware, USA
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh and University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura L Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Meagan M Ladell
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Claire Loiselle
- Department of Research, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Allan-Blitz LT, Shah P, Adams G, Branda JA, Klausner JD, Goldstein R, Sabeti PC, Lemieux JE. Development of Cas13a-based assays for Neisseria gonorrhoeae detection and gyrase A determination. mSphere 2023; 8:e0041623. [PMID: 37732792 PMCID: PMC10597441 DOI: 10.1128/msphere.00416-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 07/28/2023] [Indexed: 09/22/2023] Open
Abstract
Neisseria gonorrhoeae is one of the most common bacterial sexually transmitted infections. The emergence of antimicrobial-resistant N. gonorrhoeae is an urgent public health threat. Currently, the diagnosis of N. gonorrhoeae infection requires expensive laboratory infrastructure, while antimicrobial susceptibility determination requires bacterial culture, both of which are infeasible in low-resource areas where the prevalence of infection is highest. Recent advances in molecular diagnostics, such as specific high-sensitivity enzymatic reporter unlocking (SHERLOCK) using CRISPR-Cas13a and isothermal amplification, have the potential to provide low-cost detection of pathogen and antimicrobial resistance. We designed and optimized RNA guides and primer sets for SHERLOCK assays capable of detecting N. gonorrhoeae via the porA gene and of predicting ciprofloxacin susceptibility via a single mutation in the gyrase A (gyrA) gene. We evaluated their performance using both synthetic DNA and purified N. gonorrhoeae isolates. For porA, we created both a fluorescence-based assay and lateral flow assay using a biotinylated fluorescein reporter. Both methods demonstrated sensitive detection of 14 N. gonorrhoeae isolates and no cross-reactivity with 3 non-gonococcal Neisseria isolates. For gyrA, we created a fluorescence-based assay that correctly distinguished between 20 purified N. gonorrhoeae isolates with phenotypic ciprofloxacin resistance and 3 with phenotypic susceptibility. We confirmed the gyrA genotype predictions from the fluorescence-based assay with DNA sequencing, which showed 100% concordance for the isolates studied. We report the development of Cas13a-based SHERLOCK assays that detect N. gonorrhoeae and differentiate ciprofloxacin-resistant isolates from ciprofloxacin-susceptible isolates. IMPORTANCE Neisseria gonorrhoeae, the cause of gonorrhea, disproportionately affects resource-limited settings. Such areas, however, lack the technical capabilities for diagnosing the infection. The consequences of poor or absent diagnostics include increased disease morbidity, which, for gonorrhea, includes an increased risk for HIV infection, infertility, and neonatal blindness, as well as an overuse of antibiotics that contributes to the emergence of antibiotic resistance. We used a novel CRISPR-based technology to develop a rapid test that does not require laboratory infrastructure for both diagnosing gonorrhea and predicting whether ciprofloxacin can be used in its treatment, a one-time oral pill. With further development, that diagnostic test may be of use in low-resource settings.
Collapse
Affiliation(s)
- Lao-Tzu Allan-Blitz
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Palak Shah
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gordon Adams
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey D. Klausner
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert Goldstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pardis C. Sabeti
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, Massachusetts, USA
| | - Jacob E. Lemieux
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Lemieux JE, Huang W, Hill N, Cerar T, Freimark L, Hernandez S, Luban M, Maraspin V, Bogovič P, Ogrinc K, Ruzič-Sabljič E, Lapierre P, Lasek-Nesselquist E, Singh N, Iyer R, Liveris D, Reed KD, Leong JM, Branda JA, Steere AC, Wormser GP, Strle F, Sabeti PC, Schwartz I, Strle K. Whole genome sequencing of human Borrelia burgdorferi isolates reveals linked blocks of accessory genome elements located on plasmids and associated with human dissemination. PLoS Pathog 2023; 19:e1011243. [PMID: 37651316 PMCID: PMC10470944 DOI: 10.1371/journal.ppat.1011243] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/13/2023] [Indexed: 09/02/2023] Open
Abstract
Lyme disease is the most common vector-borne disease in North America and Europe. The clinical manifestations of Lyme disease vary based on the genospecies of the infecting Borrelia burgdorferi spirochete, but the microbial genetic elements underlying these associations are not known. Here, we report the whole genome sequence (WGS) and analysis of 299 B. burgdorferi (Bb) isolates derived from patients in the Eastern and Midwestern US and Central Europe. We develop a WGS-based classification of Bb isolates, confirm and extend the findings of previous single- and multi-locus typing systems, define the plasmid profiles of human-infectious Bb isolates, annotate the core and strain-variable surface lipoproteome, and identify loci associated with disseminated infection. A core genome consisting of ~900 open reading frames and a core set of plasmids consisting of lp17, lp25, lp36, lp28-3, lp28-4, lp54, and cp26 are found in nearly all isolates. Strain-variable (accessory) plasmids and genes correlate strongly with phylogeny. Using genetic association study methods, we identify an accessory genome signature associated with dissemination in humans and define the individual plasmids and genes that make up this signature. Strains within the RST1/WGS A subgroup, particularly a subset marked by the OspC type A genotype, have increased rates of dissemination in humans. OspC type A strains possess a unique set of strongly linked genetic elements including the presence of lp56 and lp28-1 plasmids and a cluster of genes that may contribute to their enhanced virulence compared to other genotypes. These features of OspC type A strains reflect a broader paradigm across Bb isolates, in which near-clonal genotypes are defined by strain-specific clusters of linked genetic elements, particularly those encoding surface-exposed lipoproteins. These clusters of genes are maintained by strain-specific patterns of plasmid occupancy and are associated with the probability of invasive infection.
Collapse
Affiliation(s)
- Jacob E. Lemieux
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Weihua Huang
- New York Medical College, Valhalla, New York, United States of America
- East Carolina University, Greenville, North Carolina, United States of America
| | - Nathan Hill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Tjasa Cerar
- University of Ljubljana, Ljubljana, Slovenia
| | - Lisa Freimark
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Sergio Hernandez
- Wadsworth Center, New York State Department of Health, Albany, New York, United States of America
| | - Matteo Luban
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
| | - Vera Maraspin
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Petra Bogovič
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | | | - Pascal Lapierre
- Wadsworth Center, New York State Department of Health, Albany, New York, United States of America
| | - Erica Lasek-Nesselquist
- Wadsworth Center, New York State Department of Health, Albany, New York, United States of America
| | - Navjot Singh
- Wadsworth Center, New York State Department of Health, Albany, New York, United States of America
| | - Radha Iyer
- New York Medical College, Valhalla, New York, United States of America
| | - Dionysios Liveris
- New York Medical College, Valhalla, New York, United States of America
| | - Kurt D. Reed
- University of Wisconsin, Madison, Wisconsin, United States of America
| | - John M. Leong
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - John A. Branda
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Allen C. Steere
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Gary P. Wormser
- New York Medical College, Valhalla, New York, United States of America
| | - Franc Strle
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Pardis C. Sabeti
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Harvard University, Cambridge, Massachusetts, United States of America
- Harvard T.H.Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ira Schwartz
- New York Medical College, Valhalla, New York, United States of America
| | - Klemen Strle
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Wadsworth Center, New York State Department of Health, Albany, New York, United States of America
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| |
Collapse
|
9
|
Kahane CG, Nigrovic LE, Kharbanda AB, Neville D, Thompson AD, Balamuth F, Chapman L, Levas MN, Branda JA, Kellogg MD, Monuteaux MC, Lyons TW. Biomarkers for Pediatric Bacterial Musculoskeletal Infections in Lyme Disease-Endemic Regions. Pediatrics 2023:e2023061329. [PMID: 37409396 DOI: 10.1542/peds.2023-061329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES Bacterial musculoskeletal infections (MSKIs) are challenging to diagnose because of the clinical overlap with other conditions, including Lyme arthritis. We evaluated the performance of blood biomarkers for the diagnosis of MSKIs in Lyme disease-endemic regions. METHODS We conducted a secondary analysis of a prospective cohort study of children 1 to 21 years old with monoarthritis presenting to 1 of 8 Pedi Lyme Net emergency departments for evaluation of potential Lyme disease. Our primary outcome was an MSKI, which was defined as septic arthritis, osteomyelitis or pyomyositis. We compared the diagnostic accuracy of routinely available biomarkers (absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate, and procalcitonin) to white blood cells for the identification of an MSKI using the area under the receiver operating characteristic curve (AUC). RESULTS We identified 1423 children with monoarthritis, of which 82 (5.8%) had an MSKI, 405 (28.5%) Lyme arthritis, and 936 (65.8%) other inflammatory arthritis. When compared with white blood cell count (AUC, 0.63; 95% confidence interval [CI], 0.55-0.71), C-reactive protein (0.84; 95% CI, 0.80-0.89; P < .05), procalcitonin (0.82; 95% CI, 0.77-0.88; P < .05), and erythrocyte sedimentation rate (0.77; 95% CI, 0.71-0.82; P < .05) had higher AUCs, whereas absolute neutrophil count (0.67; 95% CI, 0.61-0.74; P < .11) had a similar AUC. CONCLUSIONS Commonly available biomarkers can assist in the initial approach to a potential MSKI in a child. However, no single biomarker has high enough accuracy to be used in isolation, especially in Lyme disease-endemic areas.
Collapse
Affiliation(s)
- Caroline G Kahane
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anupam B Kharbanda
- Department of Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| | - Desiree Neville
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children's Hospital and Sidney Kimmel Medical College of Thomas Jefferson University, Wilmington, Delaware
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Chapman
- Division of Pediatric Emergency Medicine, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children's Hospital and Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
10
|
Allan-Blitz LT, Shah P, Adams G, Branda JA, Klausner JD, Goldstein R, Sabeti PC, Lemieux JE. Development of Cas13a-based Assays for Neisseria gonorrhoeae Detection and Gyrase A Determination. medRxiv 2023:2023.05.21.23290304. [PMID: 37293004 PMCID: PMC10246164 DOI: 10.1101/2023.05.21.23290304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Background Neisseria gonorrhoeae is one of the most common bacterial sexually transmitted infections. The emergence of antimicrobial-resistant N. gonorrhoeae is an urgent public health threat. Currently, diagnosis of N. gonorrhoeae infection requires expensive laboratory infrastructure, while antimicrobial susceptibility determination requires bacterial culture, both of which are infeasible in low-resource areas where prevalence is highest. Recent advances in molecular diagnostics, such as Specific High-sensitivity Enzymatic Reporter unLOCKing (SHERLOCK) using CRISPR-Cas13a and isothermal amplification, have the potential to provide low-cost detection of pathogen and antimicrobial resistance. Methods and Results We designed and optimized RNA guides and primer-sets for SHERLOCK assays capable of detecting N. gonorrhoeae via the por A gene and of predicting ciprofloxacin susceptibility via a single mutation in the gyrase A ( gyr A) gene. We evaluated their performance using both synthetic DNA and purified N. gonorrhoeae isolates. For por A, we created both a fluorescence-based assay and lateral flow assay using a biotinylated FAM reporter. Both methods demonstrated sensitive detection of 14 N. gonorrhoeae isolates and no cross-reactivity with 3 non-gonococcal Neisseria isolates. For gyr A, we created a fluorescence-based assay that correctly distinguished between 20 purified N. gonorrhoeae isolates with phenotypic ciprofloxacin resistance and 3 with phenotypic susceptibility. We confirmed the gyr A genotype predictions from the fluorescence-based assay with DNA sequencing, which showed 100% concordance for the isolates studied. Conclusion We report the development of Cas13a-based SHERLOCK assays that detect N. gonorrhoeae and differentiate ciprofloxacin-resistant isolates from ciprofloxacin-susceptible isolates.
Collapse
Affiliation(s)
- Lao-Tzu Allan-Blitz
- Division of Global Health Equity: Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Palak Shah
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Gordon Adams
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Jeffrey D. Klausner
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert Goldstein
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Pardis C. Sabeti
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
| | - Jacob E. Lemieux
- Broad Institute of Massachusetts Institute of Technology and Harvard, Boston, MA
- Division of Infectious Diseases: Department of Medicine, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
11
|
Nigrovic LE, Neville D, Chapman L, Balamuth F, Levas MN, Thompson AD, Kharbanda A, Gerstbrein D, Branda JA, Buchan BW. Multiplexed high-definition PCR assay for the diagnosis of tick-borne infections in children. Open Forum Infect Dis 2023; 10:ofad121. [PMID: 37089773 PMCID: PMC10114523 DOI: 10.1093/ofid/ofad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Abstract
Background
Ixodes scapularis ticks can carry Borrelia species as well as other pathogens that cause human disease. The frequency of tick-borne infections and co-infections in children with suspected Lyme disease is unknown, creating clinical uncertainty about the optimal approach to diagnosis.
Methods
We enrolled children aged 1 to 21 years presenting to one of eight Pedi Lyme Net emergency departments for evaluation of Lyme disease. We selected cases with serologically or clinically diagnosed Lyme disease (erythema migrans or early neurologic disease) matched by symptoms, age, gender and center to control subjects without Lyme disease. We tested whole blood samples collected at the time of diagnosis using a high-definition multiplex polymerase chain reaction (HDPCR) panel to identify 9 bacterial or protozoan pathogens associated with human disease. We compared the frequency of tick-borne co-infections in children with Lyme disease to matched controls.
Results
Of the 612 selected samples, 594 (97.1%) had an interpretable multiplex HDPCR result. We identified the following non-Borrelia tick-borne infections: Anaplasma phagocytophilum (2), Ehrlichia chaffeensis (1) and Babesia microti (12). Children with Lyme disease were more likely to have another tick-borne pathogen identified than matched controls [15/297 (5.1%) Lyme cases vs. 0/297 (0%); difference 5.1% 95% CI 2.7, 8.2%).
Conclusions
Although a substantial minority of children with Lyme disease had another tick-borne pathogen identified, either first-line Lyme disease antibiotics provided adequate treatment or the coinfection was subclinical and did not require specific treatment. Further studies are needed to establish the optimal approach to testing for tick-borne co-infections in children.
Collapse
Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital; United States
| | - Desiree Neville
- Division of Emergency Medicine, Children’s Hospital of Pittsburgh; United States
| | - Laura Chapman
- Department of Emergency Medicine, Rhode Island Hospital; United States
| | - Fran Balamuth
- Division of Emergency Medicine, Children's Hospital of Philadelphia; United States
| | - Michael N Levas
- Division of Emergency Medicine , Children’s Wisconsin ; United States
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours Children’s Health ; United States
| | - Anupam Kharbanda
- Department of Emergency Medicine, Children's Hospitals and Clinics of Minnesota; United States
| | | | - John A Branda
- Department of Pathology, Massachusetts General Hospital; United States
| | - Blake W Buchan
- Department of Pathology , Children’s Wisconsin ; United States
| | | |
Collapse
|
12
|
Lewandrowski EL, Branda JA, Lewandrowski K, Turbett S. Evaluation of the Rapid Quidel Sofia 2 Lyme Immunoassay as a First-Tier Test in a Two-Tier Testing Algorithm for Lyme Disease: Comparison to the Zeus ELISA Borrelia VlsE1/pepC10 IgG/IgM Assay Followed by Immunoblot. Am J Clin Pathol 2023:7070530. [PMID: 36881650 DOI: 10.1093/ajcp/aqad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/23/2023] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVES Two-tiered serologic testing for Lyme disease is usually performed using an enzyme-linked immunosorbent assay (ELISA) as the first-tier test. The Quidel Sofia 2 Lyme test is a relatively new lateral flow method to provide more rapid turnaround time. We evaluated its performance in comparison to an established ELISA method. The test can be performed on demand rather than batching assays in a central laboratory. METHODS We compared the Sofia 2 assay to the Zeus VlsE1/pepC10 IgG/IgM test in a standard two-tiered testing algorithm. RESULTS Comparison of the Sofia 2 to the Zeus VlsE1/pepC10 IgG/IgM showed an overall agreement of 89.9% (κ statistic of 0.750, indicating "substantial agreement"). When the tests were followed by immunoblot in a two-tier algorithm, the agreement was 98.9% (κ statistic of 0.973, indicating "almost perfect" agreement). CONCLUSIONS The Sofia 2 Lyme test performs well when compared with the Zeus VlsE1/pepC10 IgG/IgM in a two-tiered testing algorithm.
Collapse
Affiliation(s)
- Elizabeth Lee Lewandrowski
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - John A Branda
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Kent Lewandrowski
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sarah Turbett
- Department of Pathology, Division of Clinical Laboratories and Molecular Medicine, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
13
|
Lemieux JE, Huang W, Hill N, Cerar T, Freimark L, Hernandez S, Luban M, Maraspin V, Bogovic P, Ogrinc K, Ruzic-Sabljic E, Lapierre P, Lasek-Nesselquist E, Singh N, Iyer R, Liveris D, Reed KD, Leong JM, Branda JA, Steere AC, Wormser GP, Strle F, Sabeti PC, Schwartz I, Strle K. Whole genome sequencing of Borrelia burgdorferi isolates reveals linked clusters of plasmid-borne accessory genome elements associated with virulence. bioRxiv 2023:2023.02.26.530159. [PMID: 36909473 PMCID: PMC10002713 DOI: 10.1101/2023.02.26.530159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Lyme disease is the most common vector-borne disease in North America and Europe. The clinical manifestations of Lyme disease vary based on the genospecies of the infecting Borrelia burgdorferi spirochete, but the microbial genetic elements underlying these associations are not known. Here, we report the whole genome sequence (WGS) and analysis of 299 patient-derived B. burgdorferi sensu stricto ( Bbss ) isolates from patients in the Eastern and Midwestern US and Central Europe. We develop a WGS-based classification of Bbss isolates, confirm and extend the findings of previous single- and multi-locus typing systems, define the plasmid profiles of human-infectious Bbss isolates, annotate the core and strain-variable surface lipoproteome, and identify loci associated with disseminated infection. A core genome consisting of ∼800 open reading frames and a core set of plasmids consisting of lp17, lp25, lp36, lp28-3, lp28-4, lp54, and cp26 are found in nearly all isolates. Strain-variable (accessory) plasmids and genes correlate strongly with phylogeny. Using genetic association study methods, we identify an accessory genome signature associated with dissemination and define the individual plasmids and genes that make up this signature. Strains within the RST1/WGS A subgroup, particularly a subset marked by the OspC type A genotype, are associated with increased rates of dissemination. OspC type A strains possess a unique constellation of strongly linked genetic changes including the presence of lp56 and lp28-1 plasmids and a cluster of genes that may contribute to their enhanced virulence compared to other genotypes. The patterns of OspC type A strains typify a broader paradigm across Bbss isolates, in which genetic structure is defined by correlated groups of strain-variable genes located predominantly on plasmids, particularly for expression of surface-exposed lipoproteins. These clusters of genes are inherited in blocks through strain-specific patterns of plasmid occupancy and are associated with the probability of invasive infection.
Collapse
Affiliation(s)
- Jacob E Lemieux
- Massachusetts General Hospital, Harvard Medical School
- Broad Institute of MIT and Harvard
| | - Weihua Huang
- New York Medical College
- East Carolina University
| | - Nathan Hill
- Massachusetts General Hospital, Harvard Medical School
- Broad Institute of MIT and Harvard
| | | | | | | | - Matteo Luban
- Massachusetts General Hospital, Harvard Medical School
- Broad Institute of MIT and Harvard
| | | | | | | | | | | | | | | | | | | | | | - John M Leong
- Tufts University, Department of Molecular Biology and Microbiology
| | - John A Branda
- Massachusetts General Hospital, Harvard Medical School
| | | | | | | | - Pardis C Sabeti
- Massachusetts General Hospital, Harvard Medical School
- Broad Institute of MIT and Harvard
- Harvard University
- Harvard T.H.Chan School of Public Health
| | | | - Klemen Strle
- Massachusetts General Hospital, Harvard Medical School
- Wadsworth Center
| |
Collapse
|
14
|
Holbrook NR, Klontz EH, Adams GC, Schnittman SR, Issa NC, Bond SA, Branda JA, Lemieux JE. Babesia microti variant with multiple resistance mutations detected in an immunocompromised patient receiving atovaquone prophylaxis. Open Forum Infect Dis 2023; 10:ofad097. [PMID: 36968958 PMCID: PMC10034591 DOI: 10.1093/ofid/ofad097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Abstract
We report Babesia microti genomic sequences with multiple mutations in the atovaquone-target region of cytochrome b, including a newly identified Y272S mutation, plus one mutation of undetermined significance in the azithromycin-associated ribosomal protein L4. The parasite was sequenced from an immunocompromised patient on prophylactic atovaquone for Pneumocystis pneumonia prior to diagnosis of babesiosis.
Collapse
Affiliation(s)
- Nolan R Holbrook
- Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts , USA
- Infectious Diseases Division, Massachusetts General Hospital , Boston, Massachusetts , USA
| | - Erik H Klontz
- Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts , USA
| | - Gordon C Adams
- Infectious Diseases Division, Massachusetts General Hospital , Boston, Massachusetts , USA
| | - Samuel R Schnittman
- Division of Infectious Diseases, Brigham and Women’s Hospital , Boston, Massachusetts , USA
| | - Nicolas C Issa
- Division of Infectious Diseases, Brigham and Women’s Hospital , Boston, Massachusetts , USA
| | - Sheila A Bond
- Division of Infectious Diseases, Brigham and Women’s Hospital , Boston, Massachusetts , USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital , Boston, Massachusetts , USA
| | - Jacob E Lemieux
- Infectious Diseases Division, Massachusetts General Hospital , Boston, Massachusetts , USA
| |
Collapse
|
15
|
Ahmed S, van Zalm P, Rudmann EA, Leone M, Keller K, Branda JA, Steen J, Mukerji SS, Steen H. Using CSF Proteomics to Investigate Herpesvirus Infections of the Central Nervous System. Viruses 2022; 14:2757. [PMID: 36560759 PMCID: PMC9780940 DOI: 10.3390/v14122757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/04/2022] [Indexed: 12/14/2022] Open
Abstract
Herpesviruses have complex mechanisms enabling infection of the human CNS and evasion of the immune system, allowing for indefinite latency in the host. Herpesvirus infections can cause severe complications of the central nervous system (CNS). Here, we provide a novel characterization of cerebrospinal fluid (CSF) proteomes from patients with meningitis or encephalitis caused by human herpes simplex virus 1 (HSV-1), which is the most prevalent human herpesvirus associated with the most severe morbidity. The CSF proteome was compared with those from patients with meningitis or encephalitis due to human herpes simplex virus 2 (HSV-2) or varicella-zoster virus (VZV, also known as human herpesvirus 3) infections. Virus-specific differences in CSF proteomes, most notably elevated 14-3-3 family proteins and calprotectin (i.e., S100-A8 and S100-A9), were observed in HSV-1 compared to HSV-2 and VZV samples, while metabolic pathways related to cellular and small molecule metabolism were downregulated in HSV-1 infection. Our analyses show the feasibility of developing CNS proteomic signatures of the host response in alpha herpes infections, which is paramount for targeted studies investigating the pathophysiology driving virus-associated neurological disorders, developing biomarkers of morbidity, and generating personalized therapeutic strategies.
Collapse
Affiliation(s)
- Saima Ahmed
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Patrick van Zalm
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Emily A. Rudmann
- Neuroimmunology and Neuro-Infectious Diseases Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael Leone
- Neuroimmunology and Neuro-Infectious Diseases Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Kiana Keller
- Neuroimmunology and Neuro-Infectious Diseases Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Judith Steen
- F.M. Kirby Neurobiology Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Shibani S. Mukerji
- Neuroimmunology and Neuro-Infectious Diseases Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Hanno Steen
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Precision Vaccines Program and Neurobiology Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
16
|
Torous VF, Branda JA. Fun with fungi: a comprehensive review of common fungal organisms encountered in cytology. J Am Soc Cytopathol 2022; 12:153-169. [PMID: 36564314 DOI: 10.1016/j.jasc.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
The ability to detect and diagnose infection is essential in the practice of cytopathology. The identification of suppurative or granulomatous inflammation should prompt careful evaluation for infection. Many of the most commonly encountered fungal organisms demonstrate characteristic microscopic appearances that allow accurate identification even with routine cytology stains, particularly when considered in the context of clinical factors such as geographic location, social history, patient immune status, and symptoms. Given the vital role cytopathologists play in the accurate diagnosis or presumptive identification of infections, this review explores the epidemiology, clinical manifestations, and morphologic features of common fungal pathogens in addition to their differential diagnoses and ancillary testing methods.
Collapse
Affiliation(s)
- Vanda F Torous
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
17
|
Villalba JA, Hilburn CF, Garlin MA, Elliott GA, Li Y, Kunitoki K, Poli S, Alba GA, Madrigal E, Taso M, Price MC, Aviles AJ, Araujo-Medina M, Bonanno L, Boyraz B, Champion SN, Harris CK, Helland TL, Hutchison B, Jobbagy S, Marshall MS, Shepherd DJ, Barth JL, Hung YP, Ly A, Hariri LP, Turbett SE, Pierce VM, Branda JA, Rosenberg ES, Mendez-Pena J, Chebib I, Rosales IA, Smith RN, Miller MA, Rosas IO, Hardin CC, Baden LR, Medoff BD, Colvin RB, Little BP, Stone JR, Mino-Kenudson M, Shih AR. Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2022; 206:857-873. [PMID: 35671465 PMCID: PMC9799276 DOI: 10.1164/rccm.202109-2150oc] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. Methods: This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia (n = 20) and with respiratory failure and histologic DAD (n = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (CVasc) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. Measurements and Main Results: In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated (P = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes (P = 0.043), thromboemboli (P = 0.0038), pulmonary infarcts (P = 0.047), and perivascular inflammation (P < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall CVasc range (P = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.
Collapse
Affiliation(s)
- Julian A. Villalba
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Caroline F. Hilburn
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michelle A. Garlin
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts;,Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | | | - Yijia Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Keiko Kunitoki
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts;,Department of Psychiatry
| | - Sergio Poli
- Department of Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - George A. Alba
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Emilio Madrigal
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Manuel Taso
- Division of MRI Research, Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Melissa C. Price
- Division of Thoracic Imaging and Intervention, Department of Radiology
| | | | | | - Liana Bonanno
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Baris Boyraz
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Samantha N. Champion
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,C. S. Kubik Laboratory for Neuropathology, Department of Pathology, Massachusetts General Hospital Charlestown HealthCare Center, Charlestown, Massachusetts;,Miami-Dade County Medical Examiner Department, Miami, Florida
| | - Cynthia K. Harris
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Timothy L. Helland
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Bailey Hutchison
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Soma Jobbagy
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Michael S. Marshall
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Daniel J. Shepherd
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | | | - Yin P. Hung
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Amy Ly
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Lida P. Hariri
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Sarah E. Turbett
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Virginia M. Pierce
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Pediatric Infectious Disease Unit, MassGeneral Hospital for Children, Boston, Massachusetts
| | - John A. Branda
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Eric S. Rosenberg
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Ivan Chebib
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Ivy A. Rosales
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Rex N. Smith
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Miles A. Miller
- Center for Systems Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ivan O. Rosas
- Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Charles C. Hardin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Lindsey R. Baden
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Medoff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Department of Medicine
| | - Robert B. Colvin
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts;,Immunopathology Research Laboratory, and
| | - Brent P. Little
- Division of Thoracic Imaging and Intervention, Department of Radiology,,Division of Cardiothoracic Imaging, Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida
| | - James R. Stone
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Mari Mino-Kenudson
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| | - Angela R. Shih
- James Homer Wright Pathology Laboratories,,Department of Pathology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
18
|
Restrepo D, Haramati A, McCluskey SM, Branda JA. Case 22-2022: A 34-Year-Old Woman with Cavitary Lung Lesions. N Engl J Med 2022; 387:261-269. [PMID: 35857663 DOI: 10.1056/nejmcpc2201238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel Restrepo
- From the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - Adina Haramati
- From the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - Suzanne M McCluskey
- From the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - John A Branda
- From the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Medicine (D.R., S.M.M.), Radiology (A.H.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| |
Collapse
|
19
|
Halperin JJ, Eikeland R, Branda JA, Dersch R. Lyme neuroborreliosis: known knowns, known unknowns. Brain 2022; 145:2635-2647. [PMID: 35848861 DOI: 10.1093/brain/awac206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Lyme borreliosis affects the nervous system in three principal ways-mononuclear cell meningitis, cranial neuropathies and radiculoneuropathies-the last a broad term encompassing painful radiculopathy, unifocal and multifocal peripheral nerve involvement. Diagnostic tools have been significantly refined-including improved peripheral blood and CSF serodiagnostics-and much has been learned about the interactions between the causative pathogen and the nervous system. Despite these advances in our understanding of this disease, a broad range of other disorders continue to be misattributed to nervous system Lyme borreliosis, supported by, at best, limited evidence. These misattributions often reflect limited understanding not only of Lyme neuroborreliosis but also of what constitutes nervous system disease generally. Fortunately, a large body of evidence now exists to clarify many of these issues, establishing a clear basis for diagnosing nervous system involvement in this infection and, based on well performed studies, clarifying which clinical disorders are associated with Lyme neuroborreliosis, which with non-neurologic Lyme borreliosis, and which with neither.
Collapse
Affiliation(s)
- John J Halperin
- Department of Neurosciences, Overlook Medical Center, 99 Beauvoir Ave., Summit, NJ 07901, USA.,Department of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA.,Department of Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Randi Eikeland
- National Advisory on Tick-borne Diseases, Sørlandet Hospital Trust, Egvsveien 100, 4615 Kristiansand, Norway.,Faculty of Health and Sport Sciences, University of Agder, 4879 Grimstad, Norway
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA.,Department of Pathology, Harvard Medical School, Boston, MA 02114, USA
| | - Rick Dersch
- Clinic of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| |
Collapse
|
20
|
Sfeir MM, Meece JK, Theel ES, Granger D, Fritsche TR, Steere AC, Branda JA. Multicenter Clinical Evaluation of Modified Two-Tiered Testing Algorithms for Lyme Disease Using Zeus Scientific Commercial Assays. J Clin Microbiol 2022; 60:e0252821. [PMID: 35418241 PMCID: PMC9116174 DOI: 10.1128/jcm.02528-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/28/2022] [Indexed: 11/20/2022] Open
Abstract
Modified two-tiered testing (MTTT) algorithms for Lyme disease (LD), which involve the sequential use of orthogonal enzyme immunoassays (EIAs) without immunoblotting, are acceptable alternatives to standard two-tiered testing (STTT; EIA followed by immunoblots) provided the EIAs have been FDA-cleared for this intended use. We evaluated four Zeus Scientific LD EIAs used in two distinct MTTT algorithms for FDA review. MTTT 1 used a VlsE1/pepC10 polyvalent EIA followed by a whole-cell sonicate (WCS) polyvalent EIA. MTTT 2 used the same first-tier EIA followed by separate IgM and IgG WCS EIAs. In a retrospective phase, we compared each MTTT algorithm to STTT using archived samples from LD patients or control subjects. In a prospective phase, we used the same algorithms to analyze consecutive excess samples submitted for routine LD serology to three clinical laboratories. For the retrospective phase, MTTTs 1 and 2 were more sensitive (56% and 74%) than STTT (41%; P ≤ 0.03) among 61 patients with acute erythema migrans (EM). In LD patients with neuroborreliosis, carditis, or arthritis (n = 75), sensitivity was comparable between algorithms (96 to 100%; P = 1.0). Among 190 control subjects without past LD, all algorithms were highly and comparably specific (≥99%, P = 0.48). For the prospective phase, (n = 2,932), positive percent-agreement (PPA), negative percent-agreement (NPA), and overall agreement of MTTT 1 with STTT were 93%, 97.7% and 97.4% (kappa 0.80). MTTT 2 yielded higher PPA (98%) but lower NPA (96.1%) and overall agreement (96.2%, kappa 0.74; all P < 0.05). Compared with STTT, both MTTT algorithms provided increased sensitivity in EM patients, comparable sensitivity in later disease and non-inferior specificity.
Collapse
Affiliation(s)
| | | | - Elitza S. Theel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dane Granger
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Allen C. Steere
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John A. Branda
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
21
|
Welch NL, Zhu M, Hua C, Weller J, Mirhashemi ME, Nguyen TG, Mantena S, Bauer MR, Shaw BM, Ackerman CM, Thakku SG, Tse MW, Kehe J, Uwera MM, Eversley JS, Bielwaski DA, McGrath G, Braidt J, Johnson J, Cerrato F, Moreno GK, Krasilnikova LA, Petros BA, Gionet GL, King E, Huard RC, Jalbert SK, Cleary ML, Fitzgerald NA, Gabriel SB, Gallagher GR, Smole SC, Madoff LC, Brown CM, Keller MW, Wilson MM, Kirby MK, Barnes JR, Park DJ, Siddle KJ, Happi CT, Hung DT, Springer M, MacInnis BL, Lemieux JE, Rosenberg E, Branda JA, Blainey PC, Sabeti PC, Myhrvold C. Multiplexed CRISPR-based microfluidic platform for clinical testing of respiratory viruses and identification of SARS-CoV-2 variants. Nat Med 2022; 28:1083-1094. [PMID: 35130561 PMCID: PMC9117129 DOI: 10.1038/s41591-022-01734-1] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/03/2022] [Indexed: 11/23/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has demonstrated a clear need for high-throughput, multiplexed and sensitive assays for detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory viruses and their emerging variants. Here, we present a cost-effective virus and variant detection platform, called microfluidic Combinatorial Arrayed Reactions for Multiplexed Evaluation of Nucleic acids (mCARMEN), which combines CRISPR-based diagnostics and microfluidics with a streamlined workflow for clinical use. We developed the mCARMEN respiratory virus panel to test for up to 21 viruses, including SARS-CoV-2, other coronaviruses and both influenza strains, and demonstrated its diagnostic-grade performance on 525 patient specimens in an academic setting and 166 specimens in a clinical setting. We further developed an mCARMEN panel to enable the identification of 6 SARS-CoV-2 variant lineages, including Delta and Omicron, and evaluated it on 2,088 patient specimens with near-perfect concordance to sequencing-based variant classification. Lastly, we implemented a combined Cas13 and Cas12 approach that enables quantitative measurement of SARS-CoV-2 and influenza A viral copies in samples. The mCARMEN platform enables high-throughput surveillance of multiple viruses and variants simultaneously, enabling rapid detection of SARS-CoV-2 variants.
Collapse
Affiliation(s)
- Nicole L Welch
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Harvard Program in Virology, Division of Medical Sciences, Harvard Medical School, Boston, MA, USA.
| | - Meilin Zhu
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Catherine Hua
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juliane Weller
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | | | - Tien G Nguyen
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Matthew R Bauer
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA, USA
| | - Bennett M Shaw
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Cheri M Ackerman
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Sri Gowtham Thakku
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Megan W Tse
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jared Kehe
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Jacqueline S Eversley
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Derek A Bielwaski
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Graham McGrath
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph Braidt
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Gage K Moreno
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lydia A Krasilnikova
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - Brittany A Petros
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Cambridge, MA, USA
- Harvard/Massachusetts Institute of Technology MD-PhD Program, Harvard Medical School, Boston, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | | | - Ewa King
- State Health Laboratories, Rhode Island Department of Health, Providence, RI, USA
| | - Richard C Huard
- State Health Laboratories, Rhode Island Department of Health, Providence, RI, USA
| | | | - Michael L Cleary
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Sandra C Smole
- Massachusetts Department of Public Health, Boston, MA, USA
| | | | | | - Matthew W Keller
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Malania M Wilson
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Marie K Kirby
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John R Barnes
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Daniel J Park
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Katherine J Siddle
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA
| | - Christian T Happi
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- African Centre of Excellence for Genomics of Infectious Diseases, Redeemer's University, Ede, Nigeria
- Department of Biological Sciences, College of Natural Sciences, Redeemer's University, Ede, Nigeria
| | - Deborah T Hung
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Molecular Biology Department and Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Springer
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Bronwyn L MacInnis
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Jacob E Lemieux
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Rosenberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul C Blainey
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research at Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Pardis C Sabeti
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA, USA.
- Department of Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
- Koch Institute for Integrative Cancer Research at Massachusetts Institute of Technology, Cambridge, MA, USA.
- Howard Hughes Medical Institute, Chevy Chase, MD, USA.
| | - Cameron Myhrvold
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA.
| |
Collapse
|
22
|
Tolan NV, Sherman AC, Zhou G, Nabel KG, Desjardins M, Melanson S, Kanjilal S, Moheed S, Kupelian J, Kaufman RM, Ryan ET, LaRocque RC, Branda JA, Dighe AS, Abraham J, Baden LR, Charles RC, Turbett SE. The Effect of Vaccine Type and SARS-CoV-2 Lineage on Commercial SARS-CoV-2 Serologic and Pseudotype Neutralization Assays in mRNA Vaccine Recipients. Microbiol Spectr 2022; 10:e0021122. [PMID: 35311584 PMCID: PMC9045317 DOI: 10.1128/spectrum.00211-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 02/20/2022] [Indexed: 12/24/2022] Open
Abstract
The use of anti-spike (S) serologic assays as surrogate measurements of SARS-CoV-2 vaccine induced immunity will be an important clinical and epidemiological tool. The characteristics of a commercially available anti-S antibody assay (Roche Elecsys anti-SARS-CoV-2 S) were evaluated in a cohort of vaccine recipients. Levels were correlated with pseudotype neutralizing antibodies (NAb) across SARS-CoV-2 variants. We recruited adults receiving a two-dose series of mRNA-1273 or BNT162b2 and collected serum at scheduled intervals up to 8 months post-first vaccination. Anti-S and NAb levels were measured, and correlation was evaluated by (i) vaccine type and (ii) SARS-CoV-2 variant (wild-type, Alpha, Beta, Gamma, and three constructs Day 146*, Day 152*, and RBM-2). Forty-six mRNA vaccine recipients were enrolled. mRNA-1273 vaccine recipients had higher peak anti-S and NAb levels compared with BNT162b2 (P < 0.001 for anti-S levels; P < 0.05 for NAb levels). When anti-S and NAb levels were compared, there was good correlation (all r values ≥ 0.85) in both BNT162b2 and mRNA-1273 vaccine recipients across all evaluated variants; however, these correlations were nonlinear in nature. Lower correlation was identified between anti-S and NAb for the Beta variant (r = 0.88) compared with the wild-type (WT) strain (r = 0.94). Finally, the degree of neutralizing activity at any given anti-S level was lower for each variant compared with that of the WT strain, (P < 0.001). Although the Roche anti-S assay correlates well with NAb levels, this association is affected by vaccine type and SARS-CoV-2 variant. These variables must be considered when interpreting anti-S levels. IMPORTANCE We evaluated anti-spike antibody concentrations in healthy mRNA vaccinated individuals and compared these concentrations to values obtained from pseudotype neutralization assays targeting SARS-CoV-2 variants of concern to determine how well anti-spike antibodies correlate with neutralizing titers, which have been used as a marker of immunity from COVID-19 infection. We found high peak anti-spike concentrations in these individuals, with significantly higher levels seen in mRNA-1273 vaccine recipients. When we compared anti-spike and pseudotype neuralization titers, we identified good correlation; however, this correlation was affected by both vaccine type and variant, illustrating the difficulty of applying a "one size fits all" approach to anti-spike result interpretation. Our results support CDC recommendations to discourage anti-spike antibody testing to assess for immunity after vaccination and cautions providers in their interpretations of these results as a surrogate of protection in COVID-vaccinated individuals.
Collapse
Affiliation(s)
- Nicole V. Tolan
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Amy C. Sherman
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Guohai Zhou
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Michaël Desjardins
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Stacy Melanson
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjat Kanjilal
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Serina Moheed
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John Kupelian
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Richard M. Kaufman
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T. Ryan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Regina C. LaRocque
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Anand S. Dighe
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Abraham
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lindsey R. Baden
- Department of Medicine, Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Richelle C. Charles
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah E. Turbett
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Lantos PM, Balamuth F, Neville D, Garro AC, Levas MN, Bennett J, Thompson AD, Kharbanda AB, Branda JA, Nigrovic LE. Two-Tier Lyme Disease Serology in Children with Previous Lyme Disease. Vector Borne Zoonotic Dis 2021; 21:839-842. [PMID: 34610255 DOI: 10.1089/vbz.2021.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: A history of Lyme disease can complicate the interpretation of Lyme disease serology in acutely symptomatic patients. Materials and Methods: We prospectively enrolled children undergoing evaluation for Lyme disease in the emergency department of one of eight participating Pedi Lyme Net centers. We selected symptomatic children with a Lyme disease history (definite, probable, or none) as well as an available research biosample. We defined a Lyme disease case with either an erythema migrans (EM) lesion or positive two-tier serology with compatible symptoms. Using a generalized estimating equation, we examined the relationship between time from previous Lyme disease diagnosis and current Lyme disease after adjustment for patient demographics and symptoms as well as clustering by center. Results: Of 2501 prospectively enrolled study patients, 126 (5.0%) reported a history of definite or probable Lyme disease. Of these children with previous Lyme disease, 47 met diagnostic criteria for Lyme disease at the time of enrollment (37.3%; 95% confidence interval [CI] 29.1-45.7%); 2 had an EM lesion, and 45 had positive two-tier Lyme disease serology. Over time from the previous Lyme disease diagnosis, the less likely the patient met diagnostic criteria for Lyme disease (adjusted odds ratio 0.62 per time period; 95% CI 0.46-0.84). Conclusions: For children with a history of Lyme disease before enrollment, one-third met the diagnostic criteria for acute Lyme disease with a declining rate over time from previous Lyme disease diagnosis. Novel Lyme disease diagnostics are needed to help distinguish acute from previous Lyme disease.
Collapse
Affiliation(s)
- Paul M Lantos
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Frances Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Desiree Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aris C Garro
- Department of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Michael N Levas
- Division of Emergency Medicine, Milwaukee Children's Hospital, Milwaukee, Wisconsin, USA
| | - Jonathan Bennett
- Division of Emergency Medicine, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Amy D Thompson
- Division of Emergency Medicine, A.I. Dupont Children's Hospital, Wilmington, Delaware, USA
| | - Anupam B Kharbanda
- Department of Pediatrics, Children's Minnesota, Minneapolis, Minnesota, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
24
|
Branda JA, Lemieux JE, Blair L, Ahmed AA, Hong DK, Bercovici S, Blauwkamp TA, Hollemon D, Ho C, Strle K, Damle NS, Lepore TJ, Pollock NR. Detection of Borrelia burgdorferi Cell-free DNA in Human Plasma Samples for Improved Diagnosis of Early Lyme Borreliosis. Clin Infect Dis 2021; 73:e2355-e2361. [PMID: 32584965 PMCID: PMC8492203 DOI: 10.1093/cid/ciaa858] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/22/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Laboratory confirmation of early Lyme borreliosis (LB) is challenging. Serology is insensitive during the first days to weeks of infection, and blood polymerase chain reaction (PCR) offers similarly poor performance. Here, we demonstrate that detection of Borrelia burgdorferi (B.b.) cell-free DNA (cfDNA) in plasma can improve diagnosis of early LB. METHODS B.b. detection in plasma samples using unbiased metagenomic cfDNA sequencing performed by a commercial laboratory (Karius Inc) was compared with serology and blood PCR in 40 patients with physician-diagnosed erythema migrans (EM), 28 of whom were confirmed to have LB by skin biopsy culture (n = 18), seroconversion (n = 2), or both (n = 8). B.b. sequence analysis was performed using investigational detection thresholds, different from Karius' clinical test. RESULTS B.b. cfDNA was detected in 18 of 28 patients (64%) with laboratory-confirmed EM. In comparison, sensitivity of acute-phase serology using modified 2-tiered testing (MTTT) was 50% (P = .45); sensitivity of blood PCR was 7% (P = .0002). Combining B.b. cfDNA detection and MTTT increased diagnostic sensitivity to 86%, significantly higher than either approach alone (P ≤ .04). B.b. cfDNA sequences matched precisely with strain-specific sequence generated from the same individual's cultured B.b. isolate. B.b. cfDNA was not observed at any level in plasma from 684 asymptomatic ambulatory individuals. Among 3000 hospitalized patients tested as part of clinical care, B.b. cfDNA was detected in only 2 individuals, both of whom had clinical presentations consistent with LB. CONCLUSIONS This is the first report of B.b. cfDNA detection in early LB and a demonstration of potential diagnostic utility. The combination of B.b. cfDNA detection and acute-phase MTTT improves clinical sensitivity for diagnosis of early LB.
Collapse
Affiliation(s)
- John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob E Lemieux
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Lily Blair
- Karius Inc, Redwood City, California, USA
| | | | | | | | | | | | - Carine Ho
- Karius Inc, Redwood City, California, USA
| | - Klemen Strle
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nitin S Damle
- South County Internal Medicine Inc, Wakefield, Rhode Island, USA
| | | | - Nira R Pollock
- Department of Laboratory Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Dixon DM, Branda JA, Clark SH, Dumler JS, Horowitz HW, Perdue SS, Pritt BS, Sexton DJ, Storch GA, Walker DH. Ehrlichiosis and anaplasmosis subcommittee report to the Tick-borne Disease Working Group. Ticks Tick Borne Dis 2021; 12:101823. [PMID: 34517150 DOI: 10.1016/j.ttbdis.2021.101823] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/18/2021] [Accepted: 08/29/2021] [Indexed: 10/20/2022]
Abstract
Ehrlichioses and anaplasmosis have undergone dramatic increases in incidence, and the geographic ranges of their occurrence and vectors have also expanded. There is marked underreporting of these diseases owing to deficient physician awareness and knowledge of the illnesses as well as limited access to appropriate diagnostic tests. Human monocytic ehrlichiosis and anaplasmosis are life threatening diseases with estimated case fatality rates of 2.7 and 0.3%, respectively. However, knowledge of their full range of signs and symptoms is incomplete, and the incidence of subclinical infections is unknown. Currently available laboratory diagnostic methods are poorly utilized, and with the exception of nucleic acid amplification tests are not useful for diagnosis during the acute stage of illness when timely treatment is needed. The Ehrlichiosis and Anaplasmosis Subcommittee of the Tick-Borne Disease Working Group recommended active clinical surveillance to determine the true incidence, full clinical spectrum, and risk factors for severe illness, as well as standardized surveillance of ticks for these pathogens, and enhanced education of primary medical caregivers and the public regarding these diseases. The subcommittee identified the needs to develop sensitive, specific acute stage diagnostic tests for local clinical laboratories and point-of-care testing, to develop approaches for utilizing electronic medical records, data mining, and artificial intelligence for assisting early diagnosis and treatment, and to develop adjunctive therapies for severe disease.
Collapse
Affiliation(s)
| | - John A Branda
- Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Boston, MA 02114, United States.
| | - Stephen H Clark
- University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032, United States
| | - J Stephen Dumler
- Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Joint Pathology Center, 4301 Jones Bridge Road, Building B, Room 3152, Bethesda, MD 20814, United States.
| | - Harold W Horowitz
- Weill Cornell Medicine, 1300 York Avenue, New York, NY 10065, United States.
| | | | - Bobbi S Pritt
- Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, United States.
| | - Daniel J Sexton
- Duke University Medical Center, Durham, NC 27710, United States.
| | - Gregory A Storch
- Washington University School of Medicine, 425 South Euclid Avenue, St. Louis, MO 63110, United States.
| | - David H Walker
- The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555-0609, United States.
| |
Collapse
|
26
|
Anahtar MN, Shaw BM, Slater D, Byrne EH, Botti-Lodovico Y, Adams G, Schaffner SF, Eversley J, McGrath GEG, Gogakos T, Lennerz J, Marble HD, Ritterhouse LL, Batten JM, Georgantas NZ, Pellerin R, Signorelli S, Thierauf J, Kemball M, Happi C, Grant DS, Ndiaye D, Siddle KJ, Mehta SB, Harris JB, Ryan ET, Pierce VM, LaRocque RC, Lemieux JE, Sabeti PC, Rosenberg ES, Branda JA, Turbett SE. Development of a qualitative real-time RT-PCR assay for the detection of SARS-CoV-2: a guide and case study in setting up an emergency-use, laboratory-developed molecular microbiological assay. J Clin Pathol 2021; 74:496-503. [PMID: 34049977 PMCID: PMC8311084 DOI: 10.1136/jclinpath-2020-207128] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/20/2021] [Accepted: 01/30/2021] [Indexed: 12/31/2022]
Abstract
Developing and deploying new diagnostic tests are difficult, but the need to do so in response to a rapidly emerging pandemic such as COVID-19 is crucially important. During a pandemic, laboratories play a key role in helping healthcare providers and public health authorities detect active infection, a task most commonly achieved using nucleic acid-based assays. While the landscape of diagnostics is rapidly evolving, PCR remains the gold-standard of nucleic acid-based diagnostic assays, in part due to its reliability, flexibility and wide deployment. To address a critical local shortage of testing capacity persisting during the COVID-19 outbreak, our hospital set up a molecular-based laboratory developed test (LDT) to accurately and safely diagnose SARS-CoV-2. We describe here the process of developing an emergency-use LDT, in the hope that our experience will be useful to other laboratories in future outbreaks and will help to lower barriers to establishing fast and accurate diagnostic testing in crisis conditions.
Collapse
Affiliation(s)
- Melis N Anahtar
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bennett M Shaw
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Damien Slater
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth H Byrne
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
| | - Yolanda Botti-Lodovico
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA
| | - Gordon Adams
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stephen F Schaffner
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Center for Systems Biology, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
| | - Jacqueline Eversley
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Graham E G McGrath
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tasos Gogakos
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jochen Lennerz
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hetal Desai Marble
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren L Ritterhouse
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julie M Batten
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - N Zeke Georgantas
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rebecca Pellerin
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sylvia Signorelli
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Thierauf
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Otorhinolaryngology, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Molly Kemball
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Center for Systems Biology, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
| | - Christian Happi
- Department of Biological Sciences, Redeemer's University, Ede, Osun, Nigeria.,African Center of Excellence for Genomics of Infectious Diseases, Redeemer's University, Ede, Osun, Nigeria
| | - Donald S Grant
- Viral Hemorrhagic Fever Program, Kenema Government Hospital, Kenema, Sierra Leone.,College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Daouda Ndiaye
- African Center of Excellence for Genomics of Infectious Diseases, Redeemer's University, Ede, Osun, Nigeria.,Department of Mycology and Pharmacology, Universite Cheikh Anta Diop, Dakar, Senegal
| | - Katherine J Siddle
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Center for Systems Biology, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
| | - Samar B Mehta
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA.,Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason B Harris
- Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Edward T Ryan
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Virginia M Pierce
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Massachusetts, USA
| | - Regina C LaRocque
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacob E Lemieux
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA .,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pardis C Sabeti
- Infectious Disease and Microbiome Program, Eli and Edythe L. Broad Institute of Harvard and MIT, Cambridge, Massachusetts, USA .,Center for Systems Biology, Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA.,Immunology and Infectious Disease, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Howard Hughes Medical Institute, Chevy Chase, Maryland, USA
| | - Eric S Rosenberg
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John A Branda
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah E Turbett
- Department of Pathology and Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA .,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
27
|
Mehta D, Hofacker SA, Villalba JA, Duncan LM, Branda JA, Cañete-Gibas C, Wiederhold N, Moran J, Fathi AT, Chen ST, Cervantes J, Hammond SP. First Reported Case of Invasive Cutaneous Penicillium cluniae Infection in a Patient With Acute Myelogenous Leukemia: A Case Report and Literature Review. Open Forum Infect Dis 2021; 8:ofab265. [PMID: 34258314 PMCID: PMC8271139 DOI: 10.1093/ofid/ofab265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
Certain Penicillium species are emerging opportunistic pathogens. While these can be common causes of airborne contamination of clinical cultures, an increasing number of reports describe clinically significant disease in the immunocompromised population, particularly in patients with hematologic malignancy. The typical site of infection is respiratory, but disseminated infection is also reported with some frequency. Therefore, culture growth of Penicillium in respiratory and other clinical samples from immunocompromised patients requires thorough investigation with clinical correlation. Here we report a case of angioinvasive Penicillium cluniae infection of the right shin in a patient with acute myeloid leukemia and review reported cases of invasive Penicillium infection (excluding Talaromyces marneffei) in hematologic malignancy patients to characterize the emerging pathogen in this vulnerable population.
Collapse
Affiliation(s)
- Devanshi Mehta
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Samuel A Hofacker
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julian A Villalba
- Pathology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lyn M Duncan
- Pathology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John A Branda
- Pathology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Connie Cañete-Gibas
- Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Nathan Wiederhold
- Fungus Testing Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Jenna Moran
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amir T Fathi
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jessica Cervantes
- Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah P Hammond
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
28
|
Egbuonu K, Hyle EP, Hurtado RM, Alba GA, Zachary KC, Branda JA, Hibbert KA, Hooper DC, Shenoy ES, Turbett SE, Dugdale CM. Yield of Severe Acute Respiratory Syndrome Coronavirus 2 Lower Respiratory Tract Testing After a Negative Nasopharyngeal Test Among Hospitalized Persons Under Investigation for Coronavirus Disease 2019. Open Forum Infect Dis 2021; 8:ofab257. [PMID: 34113690 PMCID: PMC8186245 DOI: 10.1093/ofid/ofab257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/14/2021] [Indexed: 12/18/2022] Open
Abstract
Among hospitalized persons under investigation for coronavirus disease 2019 (COVID-19), more repeated severe acute respiratory syndrome coronavirus 2 nucleic acid amplification tests (NAATs) after a negative NAAT were positive from lower than from upper respiratory tract specimens (1.9% vs 1.0%, P = .033). Lower respiratory testing should be prioritized among patients displaying respiratory symptoms with moderate-to-high suspicion for COVID-19 after 1 negative upper respiratory NAAT.
Collapse
Affiliation(s)
| | - Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Rocio M Hurtado
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Global Health Committee, Boston, Massachusetts, USA
| | - George A Alba
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kimon C Zachary
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John A Branda
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn A Hibbert
- Harvard Medical School, Boston, Massachusetts, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David C Hooper
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erica S Shenoy
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caitlin M Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
29
|
Krause PJ, Auwaerter PG, Bannuru RR, Branda JA, Falck-Ytter YT, Lantos PM, Lavergne V, Meissner HC, Osani MC, Rips JG, Sood SK, Vannier E, Vaysbrot EE, Wormser GP. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis 2021; 72:185-189. [PMID: 33501959 DOI: 10.1093/cid/ciab050] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/13/2022] Open
Abstract
The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis. The diagnosis and treatment of co-infection with babesiosis and Lyme disease will be addressed in a separate Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) guideline [1]. Recommendations for the diagnosis and treatment of human granulocytic anaplasmosis can be found in the recent rickettsial disease guideline developed by the Centers for Disease Control and Prevention [2]. The target audience for the babesiosis guideline includes primary care physicians and specialists caring for this condition, such as infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.
Collapse
Affiliation(s)
- Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yngve T Falck-Ytter
- Case Western Reserve University and VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Valéry Lavergne
- Research Center CIUSSS NIM, University of Montreal, Quebec, Canada
| | - H Cody Meissner
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Mikala C Osani
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Sunil K Sood
- Zucker School of Medicine and Cohen Children's Medical Center, Northwell Health, New York, USA
| | - Edouard Vannier
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Elizaveta E Vaysbrot
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
30
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| |
Collapse
|
31
|
Krause PJ, Auwaerter PG, Bannuru RR, Branda JA, Falck-Ytter YT, Lantos PM, Lavergne V, Meissner HC, Osani MC, Rips JG, Sood SK, Vannier E, Vaysbrot EE, Wormser GP. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA): 2020 Guideline on Diagnosis and Management of Babesiosis. Clin Infect Dis 2021; 72:e49-e64. [PMID: 33252652 DOI: 10.1093/cid/ciaa1216] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/12/2022] Open
Abstract
The purpose of this guideline is to provide evidence-based guidance for the most effective strategies for the diagnosis and management of babesiosis. The diagnosis and treatment of co-infection with babesiosis and Lyme disease will be addressed in a separate Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) guideline [1]. Recommendations for the diagnosis and treatment of human granulocytic anaplasmosis can be found in the recent rickettsial disease guideline developed by the Centers for Disease Control and Prevention [2]. The target audience for the babesiosis guideline includes primary care physicians and specialists caring for this condition, such as infectious diseases specialists, emergency physicians, intensivists, internists, pediatricians, hematologists, and transfusion medicine specialists.
Collapse
Affiliation(s)
- Peter J Krause
- Yale School of Public Health and Yale School of Medicine, New Haven, Connecticut, USA
| | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yngve T Falck-Ytter
- Case Western Reserve University and VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | - Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Valéry Lavergne
- Research Center CIUSSS NIM, University of Montreal, Quebec, Canada
| | - H Cody Meissner
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Mikala C Osani
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Sunil K Sood
- Zucker School of Medicine and Cohen Children's Medical Center, Northwell Health, New York, USA
| | - Edouard Vannier
- Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Elizaveta E Vaysbrot
- Center for Treatment Comparison and Integrative Analysis (CTCIA), Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
32
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:1-8. [PMID: 33483734 DOI: 10.1093/cid/ciab049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 11/14/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
| |
Collapse
|
33
|
Muldur S, Ellett F, Marand AL, Marvil C, Branda JA, LeMieux JE, Raff AB, Strle K, Irimia D. Microfluidic Assays for Probing Neutrophil-Borrelia Interactions in Blood During Lyme Disease. Cells Tissues Organs 2021; 211:313-323. [PMID: 33735890 PMCID: PMC8448788 DOI: 10.1159/000513118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/16/2020] [Indexed: 01/03/2023] Open
Abstract
Human neutrophils are highly sensitive to the presence of Borrelia burgdorferi (Bb), the agent of Lyme disease (LD), in tissues. Although Bb is also found in the blood of LD patients, far less is known about how neutrophils respond to Bb in the presence of blood. In this study, we employed microfluidic tools to probe the interaction between human neutrophils and Bb and measured the activation of human neutrophils in blood samples from patients. We found that neutrophils migrate vigorously toward Bb in the presence of serum, and this process was complement-dependent. Preventing complement factor 5 cleavage or blocking complement receptors decreased neutrophil's ability to interact with Bb. We also found that spiking Bb directly into the blood from healthy donors induced spontaneous neutrophil motility. This response to Bb was also complement-dependent. Preventing complement factor 5 cleavage decreased spontaneous neutrophil motility in Bb-spiked blood. Moreover, we found that neutrophils in blood samples from acute LD patients displayed spontaneous motility patterns similar to those observed in Bb-spiked samples. Neutrophil motility was more robust in blood samples from LD patients than that measured in healthy and ill controls, validating the utility of the microfluidic assay for the study of neutrophil-Bb interactions in the presence of blood.
Collapse
Affiliation(s)
- Sinan Muldur
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Burns Hospital, Boston, Massachusetts, USA
| | - Felix Ellett
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Burns Hospital, Boston, Massachusetts, USA
| | - Anika L Marand
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Burns Hospital, Boston, Massachusetts, USA
| | - Charles Marvil
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Emory Medical School, Atlanta, Georgia, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob E LeMieux
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam B Raff
- Wellman Center for Photomedicine, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Beth Israel Lahey Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Klemen Strle
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Irimia
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Shriners Burns Hospital, Boston, Massachusetts, USA,
| |
Collapse
|
34
|
Lemieux JE, Siddle KJ, Shaw BM, Loreth C, Schaffner SF, Gladden-Young A, Adams G, Fink T, Tomkins-Tinch CH, Krasilnikova LA, DeRuff KC, Rudy M, Bauer MR, Lagerborg KA, Normandin E, Chapman SB, Reilly SK, Anahtar MN, Lin AE, Carter A, Myhrvold C, Kemball ME, Chaluvadi S, Cusick C, Flowers K, Neumann A, Cerrato F, Farhat M, Slater D, Harris JB, Branda JA, Hooper D, Gaeta JM, Baggett TP, O'Connell J, Gnirke A, Lieberman TD, Philippakis A, Burns M, Brown CM, Luban J, Ryan ET, Turbett SE, LaRocque RC, Hanage WP, Gallagher GR, Madoff LC, Smole S, Pierce VM, Rosenberg E, Sabeti PC, Park DJ, MacInnis BL. Phylogenetic analysis of SARS-CoV-2 in Boston highlights the impact of superspreading events. Science 2021; 371:eabe3261. [PMID: 33303686 PMCID: PMC7857412 DOI: 10.1126/science.abe3261] [Citation(s) in RCA: 165] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/07/2020] [Indexed: 12/20/2022]
Abstract
Analysis of 772 complete severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) genomes from early in the Boston-area epidemic revealed numerous introductions of the virus, a small number of which led to most cases. The data revealed two superspreading events. One, in a skilled nursing facility, led to rapid transmission and significant mortality in this vulnerable population but little broader spread, whereas other introductions into the facility had little effect. The second, at an international business conference, produced sustained community transmission and was exported, resulting in extensive regional, national, and international spread. The two events also differed substantially in the genetic variation they generated, suggesting varying transmission dynamics in superspreading events. Our results show how genomic epidemiology can help to understand the link between individual clusters and wider community spread.
Collapse
Affiliation(s)
- Jacob E Lemieux
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA.
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Katherine J Siddle
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Bennett M Shaw
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Loreth
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Stephen F Schaffner
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Gordon Adams
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Timelia Fink
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Christopher H Tomkins-Tinch
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Lydia A Krasilnikova
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Katherine C DeRuff
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Melissa Rudy
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Matthew R Bauer
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Harvard Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Kim A Lagerborg
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Harvard Program in Biological and Biomedical Sciences, Harvard Medical School, Boston, MA 02115, USA
| | - Erica Normandin
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Sinéad B Chapman
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Steven K Reilly
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Melis N Anahtar
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Aaron E Lin
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Amber Carter
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Cameron Myhrvold
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
| | - Molly E Kemball
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Department of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - Sushma Chaluvadi
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Caroline Cusick
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Katelyn Flowers
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Anna Neumann
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Felecia Cerrato
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Maha Farhat
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Damien Slater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Jason B Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - David Hooper
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Jessie M Gaeta
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
- Section of General Internal Medicine, Boston University Medical Center, Boston, MA, USA
| | - Travis P Baggett
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - James O'Connell
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Andreas Gnirke
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Tami D Lieberman
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Anthony Philippakis
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Meagan Burns
- Massachusetts Department of Public Health, Boston, MA, USA
| | | | - Jeremy Luban
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA
- Massachusetts Consortium on Pathogen Readiness, Boston, MA 02115, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Regina C LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - William P Hanage
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA
| | | | - Lawrence C Madoff
- Massachusetts Department of Public Health, Boston, MA, USA
- University of Massachusetts Medical School, Infectious Diseases and Immunology, Worcester, MA 01655, USA
| | - Sandra Smole
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Virginia M Pierce
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Pediatric Infectious Disease Unit, Massachusetts General Hospital for Children, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Eric Rosenberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Pardis C Sabeti
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA.
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Massachusetts Consortium on Pathogen Readiness, Boston, MA 02115, USA
- Howard Hughes Medical Institute, 4000 Jones Bridge Rd, Chevy Chase, MD 20815, USA
| | - Daniel J Park
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA
| | - Bronwyn L MacInnis
- Broad Institute of Harvard and MIT, 415 Main Street, Cambridge, MA 02142, USA.
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Massachusetts Consortium on Pathogen Readiness, Boston, MA 02115, USA
| |
Collapse
|
35
|
Anahtar MN, McGrath GEG, Rabe BA, Tanner NA, White BA, Lennerz JKM, Branda JA, Cepko CL, Rosenberg ES. Clinical Assessment and Validation of a Rapid and Sensitive SARS-CoV-2 Test Using Reverse Transcription Loop-Mediated Isothermal Amplification Without the Need for RNA Extraction. Open Forum Infect Dis 2021; 8:ofaa631. [PMID: 34853795 PMCID: PMC7798487 DOI: 10.1093/ofid/ofaa631] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Amid the enduring pandemic, there is an urgent need for expanded access to rapid, sensitive, and inexpensive coronavirus disease 2019 (COVID-19) testing worldwide without specialized equipment. We developed a simple test that uses colorimetric reverse transcription loop-mediated isothermal amplification (RT-LAMP) to detect severe acute resrpiratory syndrome coronavirus 2 (SARS-CoV-2) in 40 minutes from sample collection to result. METHODS We tested 135 nasopharyngeal specimens from patients evaluated for COVID-19 infection at Massachusetts General Hospital. Specimens were either added directly to RT-LAMP reactions, inactivated by a combined chemical and heat treatment step, or inactivated then purified with a silica particle-based concentration method. Amplification was performed with 2 SARS-CoV-2-specific primer sets and an internal specimen control; the resulting color change was visually interpreted. RESULTS Direct RT-LAMP testing of unprocessed specimens could only reliably detect samples with abundant SARS-CoV-2 (>3 000 000 copies/mL), with sensitivities of 50% (95% CI, 28%-72%) and 59% (95% CI, 43%-73%) in samples collected in universal transport medium and saline, respectively, compared with quantitative polymerase chain reaction (qPCR). Adding an upfront RNase inactivation step markedly improved the limit of detection to at least 25 000 copies/mL, with 87.5% (95% CI, 72%-95%) sensitivity and 100% specificity (95% CI, 87%-100%). Using both inactivation and purification increased the assay sensitivity by 10-fold, achieving a limit of detection comparable to commercial real-time PCR-based diagnostics. CONCLUSIONS By incorporating a fast and inexpensive sample preparation step, RT-LAMP accurately detects SARS-CoV-2 with limited equipment for about US$6 per sample, making this a potentially ideal assay to increase testing capacity, especially in resource-limited settings.
Collapse
Affiliation(s)
- Melis N Anahtar
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Graham E G McGrath
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian A Rabe
- Department of Genetics, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Benjamin A White
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jochen K M Lennerz
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Constance L Cepko
- Department of Genetics, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts, USA
- Howard Hughes Medical Institute, Chevy Chase, Maryland, USA
| | - Eric S Rosenberg
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
36
|
Garcia-Beltran WF, Lam EC, Astudillo MG, Yang D, Miller TE, Feldman J, Hauser BM, Caradonna TM, Clayton KL, Nitido AD, Murali MR, Alter G, Charles RC, Dighe A, Branda JA, Lennerz JK, Lingwood D, Schmidt AG, Iafrate AJ, Balazs AB. COVID-19-neutralizing antibodies predict disease severity and survival. Cell 2021; 184:476-488.e11. [PMID: 33412089 PMCID: PMC7837114 DOI: 10.1016/j.cell.2020.12.015] [Citation(s) in RCA: 463] [Impact Index Per Article: 154.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 12/26/2022]
Abstract
Coronavirus disease 2019 (COVID-19) exhibits variable symptom severity ranging from asymptomatic to life-threatening, yet the relationship between severity and the humoral immune response is poorly understood. We examined antibody responses in 113 COVID-19 patients and found that severe cases resulting in intubation or death exhibited increased inflammatory markers, lymphopenia, pro-inflammatory cytokines, and high anti-receptor binding domain (RBD) antibody levels. Although anti-RBD immunoglobulin G (IgG) levels generally correlated with neutralization titer, quantitation of neutralization potency revealed that high potency was a predictor of survival. In addition to neutralization of wild-type SARS-CoV-2, patient sera were also able to neutralize the recently emerged SARS-CoV-2 mutant D614G, suggesting cross-protection from reinfection by either strain. However, SARS-CoV-2 sera generally lacked cross-neutralization to a highly homologous pre-emergent bat coronavirus, WIV1-CoV, which has not yet crossed the species barrier. These results highlight the importance of neutralizing humoral immunity on disease progression and the need to develop broadly protective interventions to prevent future coronavirus pandemics.
Collapse
Affiliation(s)
| | - Evan C Lam
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Michael G Astudillo
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Diane Yang
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Tyler E Miller
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jared Feldman
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Blake M Hauser
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | | | - Kiera L Clayton
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Adam D Nitido
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Mandakolathur R Murali
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Richelle C Charles
- Infectious Disease Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Anand Dighe
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Daniel Lingwood
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - Aaron G Schmidt
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA 02139, USA
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital, Boston, MA 02114, USA
| | | |
Collapse
|
37
|
Turbett SE, Anahtar MN, Pattanayak V, Azar MM, Coffey KC, Eng G, Rudolf JW, Lewandrowski KB, Baron J, Rosenberg ES, Branda JA. Use of Routine Complete Blood Count Results to Rule Out Anaplasmosis Without the Need for Specific Diagnostic Testing. Clin Infect Dis 2021; 70:1215-1221. [PMID: 31044232 DOI: 10.1093/cid/ciz346] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Anaplasmosis presents with fever, headache, and laboratory abnormalities including leukopenia and thrombocytopenia. Polymerase chain reaction (PCR) is the preferred diagnostic but is overutilized. We determined if routine laboratory tests could exclude anaplasmosis, improving PCR utilization. METHODS Anaplasma PCR results from a 3-year period, with associated complete blood count (CBC) and liver function test results, were retrospectively reviewed. PCR rejection criteria, based on white blood cell (WBC) and platelet (PLT) counts, were developed and prospectively applied in a mock stewardship program. If rejection criteria were met, a committee mock-refused PCR unless the patient was clinically unstable or immunocompromised. RESULTS WBC and PLT counts were the most actionable routine tests for excluding anaplasmosis. Retrospective review demonstrated that rejection criteria of WBC ≥11 000 cells/µL or PLT ≥300 000 cells/µL would have led to PCR refusal in 428 of 1685 true-negative cases (25%) and 3 of 66 true-positive cases (5%) involving clinically unstable or immunocompromised patients. In the prospective phase, 155 of 663 PCR requests (23%) met rejection criteria and were reviewed by committee, which endorsed refusal in 110 of 155 cases (71%) and approval in 45 (29%), based on clinical criteria. PCR was negative in all 45 committee-approved cases. Only 1 of 110 mock-refused requests yielded a positive PCR result; this patient was already receiving doxycycline at the time of testing. CONCLUSIONS A CBC-based stewardship algorithm would reduce unnecessary Anaplasma PCR testing, without missing active cases. Although the prospectively evaluated screening approach involved medical record review, this was unnecessary to prevent errors and could be replaced by a rejection comment specifying clinical situations that might warrant overriding the algorithm.
Collapse
Affiliation(s)
- Sarah E Turbett
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston.,Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Melis N Anahtar
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Vikram Pattanayak
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Marwan M Azar
- Department of Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - K C Coffey
- Department of Section of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - George Eng
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Joseph W Rudolf
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis
| | - Kent B Lewandrowski
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Jason Baron
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Eric S Rosenberg
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston
| |
Collapse
|
38
|
Dugdale CM, Anahtar MN, Chiosi JJ, Lazarus JE, McCluskey SM, Ciaranello AL, Gogakos T, Little BP, Branda JA, Shenoy ES, Walensky RP, Zachary KC, Hooper DC, Turbett SE, Hyle EP. Clinical, Laboratory, and Radiologic Characteristics of Patients With Initial False-Negative Severe Acute Respiratory Syndrome Coronavirus 2 Nucleic Acid Amplification Test Results. Open Forum Infect Dis 2021; 8:ofaa559. [PMID: 34164560 PMCID: PMC7717411 DOI: 10.1093/ofid/ofaa559] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/10/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Concerns about false-negative (FN) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid amplification tests (NAATs) have prompted recommendations for repeat testing if suspicion for coronavirus disease 2019 (COVID-19) infection is moderate to high. However, the frequency of FNs and patient characteristics associated with FNs are poorly understood. METHODS We retrospectively reviewed test results from 15 011 adults who underwent ≥1 SARS-CoV-2 NAATs; 2699 had an initial negative NAAT and repeat testing. We defined FNs as ≥1 negative NAATs followed by a positive NAAT within 14 days during the same episode of illness. We stratified subjects with FNs by duration of symptoms before the initial FN test (≤5 days versus >5 days) and examined their clinical, radiologic, and laboratory characteristics. RESULTS Sixty of 2699 subjects (2.2%) had a FN result during the study period. The weekly frequency of FNs among subjects with repeat testing peaked at 4.4%, coinciding with peak NAAT positivity (38%). Most subjects with FNs had symptoms (52 of 60; 87%) and chest radiography (19 of 32; 59%) consistent with COVID-19. Of the FN NAATs, 18 of 60 (30%) were performed early (ie, ≤1 day of symptom onset), and 18 of 60 (30%) were performed late (ie, >7 days after symptom onset) in disease. Among 17 subjects with 2 consecutive FNs on NP NAATs, 9 (53%) provided lower respiratory tract (LRT) specimens for testing, all of which were positive. CONCLUSIONS Our findings support repeated NAATs among symptomatic patients, particularly during periods of higher COVID-19 incidence. The LRT testing should be prioritized to increase yield among patients with high clinical suspicion for COVID-19.
Collapse
Affiliation(s)
- Caitlin M Dugdale
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Melis N Anahtar
- Department of Pathology, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - John J Chiosi
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob E Lazarus
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne M McCluskey
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Andrea L Ciaranello
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tasos Gogakos
- Department of Pathology, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Brent P Little
- Department of Radiology, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - John A Branda
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Erica S Shenoy
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control Unit, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kimon C Zachary
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control Unit, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - David C Hooper
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Infection Control Unit, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston,
Massachusetts, USA
| | - Emily P Hyle
- Medical Practice Evaluation Center, Department of Medicine, Massachusetts
General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Massachusetts General
Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
39
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Neurology 2020; 96:262-273. [PMID: 33257476 DOI: 10.1212/wnl.0000000000011151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/05/2020] [Indexed: 11/15/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
Collapse
Affiliation(s)
- Paul M Lantos
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla.
| | - Jeffrey Rumbaugh
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Linda K Bockenstedt
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Yngve T Falck-Ytter
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Maria E Aguero-Rosenfeld
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Paul G Auwaerter
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Kelly Baldwin
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Raveendhara R Bannuru
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Kiran K Belani
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - William R Bowie
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - John A Branda
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - David B Clifford
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Francis J DiMario
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - John J Halperin
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Peter J Krause
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Valery Lavergne
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Matthew H Liang
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - H Cody Meissner
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lise E Nigrovic
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - James Jay J Nocton
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Mikala C Osani
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Amy A Pruitt
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Jane Rips
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lynda E Rosenfeld
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Margot L Savoy
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Sunil K Sood
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Allen C Steere
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Franc Strle
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Robert Sundel
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Jean Tsao
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Elizaveta E Vaysbrot
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Gary P Wormser
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| | - Lawrence S Zemel
- From the Duke University School of Medicine (P.M.L.), Durham, NC; Pathway Neurology (J. Rumbaugh), Tampa, FL; Yale University (L.K.B., L.E.R.), New Haven, CT; Case Western Reserve University, VA Northeast Ohio Healthcare System (Y.T.F.-Y.), Cleveland; New York University School of Medicine (M.E.A.-R.), New York; Johns Hopkins University School of Medicine (P.G.A.), Baltimore, MD; Geisinger Medical Center (K.B.), Danville, PA; Tufts Medical Center (R.R.B., H.C.M., M.C.O., E.E.V.), Boston, MA; Childrens Hospital and Clinical of Minnesota (K.K.B.), Minneapolis; University of British Columbia (W.R.B.), Vancouver Canada; Massachusetts General Hospital (J.A.B., A.C.S.), Boston; Washington University School of Medicine (D.B.C.), St. Louis, Missouri; Connecticut Children's Medical Center (F.J.D.M., L.S.Z.), Hartford, CT; Atlantic Health System (J.J.H.), Summit, NJ; Yale School of Public Health (P.J.K.), New Haven, CT; University of Montreal (V.L.), Quebec, Canada; Brigham and Women's Hospital (M.H.L.), Boston, MA; Boston Children's Hospital (L.E.N., R.S.), Massachusetts; Medical College of Wisconsin (J.(J.)J.N.), Waowatosa; University of Pennsylvania (A.A.P.), Philadelphia; Consumer Representative (J. Rips), Omaha, NE; Temple University (M.L.S.), Philadelphia, PA; Northwell Health (S.K.S.), New York, NY; University Medical Centre Ljubljana (F.S.), Slovenia; Michigan State University (J.T.), East Lansing; and New York Medical College (G.P.W.), Valhalla
| |
Collapse
|
40
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Cody Meissner H, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Care Res (Hoboken) 2020; 73:1-9. [PMID: 33251700 DOI: 10.1002/acr.24495] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 06/04/2020] [Accepted: 10/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Kiran K Belani
- Children's Hospital and Clinics of Minnesota, Minneapolis
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jane Rips
- Consumer Representative, Omaha, Nebraska
| | | | | | | | | | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Jean Tsao
- Michigan State University, East Lansing
| | | | | | | |
Collapse
|
41
|
Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Cody Meissner H, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Rheumatol 2020; 73:12-20. [PMID: 33251716 DOI: 10.1002/art.41562] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 06/04/2020] [Accepted: 10/16/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Kiran K Belani
- Children's Hospital and Clinics of Minnesota, Minneapolis
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jane Rips
- Consumer Representative, Omaha, Nebraska
| | | | | | | | | | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Jean Tsao
- Michigan State University, East Lansing
| | | | | | | |
Collapse
|
42
|
Nigrovic LE, Neville DN, Balamuth F, Levas MN, Bennett JE, Kharbanda AB, Thompson AD, Branda JA, Garro AC. Pediatric Lyme Disease Biobank, United States, 2015-2020. Emerg Infect Dis 2020; 26:3099-3101. [PMID: 33219811 PMCID: PMC7706969 DOI: 10.3201/eid2612.200920] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
In 2015, we founded Pedi Lyme Net, a pediatric Lyme disease research network comprising 8 emergency departments in the United States. Of 2,497 children evaluated at 1 of these sites for Lyme disease, 515 (20.6%) were infected. This network is a unique resource for evaluating new approaches for diagnosing Lyme disease in children.
Collapse
|
43
|
Garcia-Beltran WF, Lam EC, Astudillo MG, Yang D, Miller TE, Feldman J, Hauser BM, Caradonna TM, Clayton KL, Nitido AD, Murali MR, Alter G, Charles RC, Dighe A, Branda JA, Lennerz JK, Lingwood D, Schmidt AG, Iafrate AJ, Balazs AB. COVID-19 neutralizing antibodies predict disease severity and survival. medRxiv 2020:2020.10.15.20213512. [PMID: 33106822 PMCID: PMC7587842 DOI: 10.1101/2020.10.15.20213512] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
COVID-19 exhibits variable symptom severity ranging from asymptomatic to life-threatening, yet the relationship between severity and the humoral immune response is poorly understood. We examined antibody responses in 113 COVID-19 patients and found that severe cases resulting in intubation or death exhibited increased inflammatory markers, lymphopenia, and high anti-RBD antibody levels. While anti-RBD IgG levels generally correlated with neutralization titer, quantitation of neutralization potency revealed that high potency was a predictor of survival. In addition to neutralization of wild-type SARS-CoV-2, patient sera were also able to neutralize the recently emerged SARS-CoV-2 mutant D614G, suggesting protection from reinfection by this strain. However, SARS-CoV-2 sera was unable to cross-neutralize a highly-homologous pre-emergent bat coronavirus, WIV1-CoV, that has not yet crossed the species barrier. These results highlight the importance of neutralizing humoral immunity on disease progression and the need to develop broadly protective interventions to prevent future coronavirus pandemics.
Collapse
Affiliation(s)
| | - Evan C. Lam
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA
| | | | - Diane Yang
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Tyler E. Miller
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Jared Feldman
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA
| | | | | | | | | | - Mandakolathur R. Murali
- Department of Pathology, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Massachusetts General, Hospital, Boston, MA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA
| | | | - Anand Dighe
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | | | | | | | - A. John Iafrate
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | | |
Collapse
|
44
|
Affiliation(s)
- Shibani S Mukerji
- From the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - Kevin L Ard
- From the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - Pamela W Schaefer
- From the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| | - John A Branda
- From the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Massachusetts General Hospital, and the Departments of Neurology (S.S.M.), Medicine (K.L.A.), Radiology (P.W.S.), and Pathology (J.A.B.), Harvard Medical School - both in Boston
| |
Collapse
|
45
|
Iyer AS, Jones FK, Nodoushani A, Kelly M, Becker M, Slater D, Mills R, Teng E, Kamruzzaman M, Garcia-Beltran WF, Astudillo M, Yang D, Miller TE, Oliver E, Fischinger S, Atyeo C, Iafrate AJ, Calderwood SB, Lauer SA, Yu J, Li Z, Feldman J, Hauser BM, Caradonna TM, Branda JA, Turbett SE, LaRocque RC, Mellon G, Barouch DH, Schmidt AG, Azman AS, Alter G, Ryan ET, Harris JB, Charles RC. Persistence and decay of human antibody responses to the receptor binding domain of SARS-CoV-2 spike protein in COVID-19 patients. Sci Immunol 2020; 5:eabe0367. [PMID: 33033172 PMCID: PMC7857394 DOI: 10.1126/sciimmunol.abe0367] [Citation(s) in RCA: 435] [Impact Index Per Article: 108.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
We measured plasma and/or serum antibody responses to the receptor-binding domain (RBD) of the spike (S) protein of SARS-CoV-2 in 343 North American patients infected with SARS-CoV-2 (of which 93% required hospitalization) up to 122 days after symptom onset and compared them to responses in 1548 individuals whose blood samples were obtained prior to the pandemic. After setting seropositivity thresholds for perfect specificity (100%), we estimated sensitivities of 95% for IgG, 90% for IgA, and 81% for IgM for detecting infected individuals between 15 and 28 days after symptom onset. While the median time to seroconversion was nearly 12 days across all three isotypes tested, IgA and IgM antibodies against RBD were short-lived with median times to seroreversion of 71 and 49 days after symptom onset. In contrast, anti-RBD IgG responses decayed slowly through 90 days with only 3 seropositive individuals seroreverting within this time period. IgG antibodies to SARS-CoV-2 RBD were strongly correlated with anti-S neutralizing antibody titers, which demonstrated little to no decrease over 75 days since symptom onset. We observed no cross-reactivity of the SARS-CoV-2 RBD-targeted antibodies with other widely circulating coronaviruses (HKU1, 229 E, OC43, NL63). These data suggest that RBD-targeted antibodies are excellent markers of previous and recent infection, that differential isotype measurements can help distinguish between recent and older infections, and that IgG responses persist over the first few months after infection and are highly correlated with neutralizing antibodies.
Collapse
Affiliation(s)
- Anita S Iyer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Forrest K Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ariana Nodoushani
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Meagan Kelly
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Margaret Becker
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Damien Slater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel Mills
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Teng
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammad Kamruzzaman
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | | | - Michael Astudillo
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Diane Yang
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Tyler E Miller
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Oliver
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | | | - Caroline Atyeo
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - A John Iafrate
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen B Calderwood
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Stephen A Lauer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jingyou Yu
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhenfeng Li
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jared Feldman
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Blake M Hauser
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | | | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah E Turbett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Regina C LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Guillaume Mellon
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Dan H Barouch
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aaron G Schmidt
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Andrew S Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jason B Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richelle C Charles
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
46
|
Miller TE, Garcia Beltran WF, Bard AZ, Gogakos T, Anahtar MN, Astudillo MG, Yang D, Thierauf J, Fisch AS, Mahowald GK, Fitzpatrick MJ, Nardi V, Feldman J, Hauser BM, Caradonna TM, Marble HD, Ritterhouse LL, Turbett SE, Batten J, Georgantas NZ, Alter G, Schmidt AG, Harris JB, Gelfand JA, Poznansky MC, Bernstein BE, Louis DN, Dighe A, Charles RC, Ryan ET, Branda JA, Pierce VM, Murali MR, Iafrate AJ, Rosenberg ES, Lennerz JK. Clinical sensitivity and interpretation of PCR and serological COVID-19 diagnostics for patients presenting to the hospital. FASEB J 2020; 34:13877-13884. [PMID: 32856766 PMCID: PMC7461169 DOI: 10.1096/fj.202001700rr] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 12/15/2022]
Abstract
The diagnosis of COVID-19 requires integration of clinical and laboratory data. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnostic assays play a central role in diagnosis and have fixed technical performance metrics. Interpretation becomes challenging because the clinical sensitivity changes as the virus clears and the immune response emerges. Our goal was to examine the clinical sensitivity of two most common SARS-CoV-2 diagnostic test modalities, polymerase chain reaction (PCR) and serology, over the disease course to provide insight into their clinical interpretation in patients presenting to the hospital. We conducted a single-center, retrospective study. To derive clinical sensitivity of PCR, we identified 209 PCR-positive SARS-CoV-2 patients with multiple PCR test results (624 total PCR tests) and calculated daily sensitivity from date of symptom onset or first positive test. Clinical sensitivity of PCR decreased with days post symptom onset with >90% clinical sensitivity during the first 5 days after symptom onset, 70%-71% from Days 9 to 11, and 30% at Day 21. To calculate daily clinical sensitivity by serology, we utilized 157 PCR-positive patients with a total of 197 specimens tested by enzyme-linked immunosorbent assay for IgM, IgG, and IgA anti-SARS-CoV-2 antibodies. In contrast to PCR, serological sensitivity increased with days post symptom onset with >50% of patients seropositive by at least one antibody isotype after Day 7, >80% after Day 12, and 100% by Day 21. Taken together, PCR and serology are complimentary modalities that require time-dependent interpretation. Superimposition of sensitivities over time indicate that serology can function as a reliable diagnostic aid indicating recent or prior infection.
Collapse
Affiliation(s)
- Tyler E. Miller
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | | | - Adam Z. Bard
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Tasos Gogakos
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Melis N. Anahtar
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | | | - Diane Yang
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Julia Thierauf
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Adam S. Fisch
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Grace K. Mahowald
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Megan J. Fitzpatrick
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Valentina Nardi
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Jared Feldman
- Ragon Institute of MGH, MIT, and HarvardCambridgeMAUSA
| | | | | | - Hetal D. Marble
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Lauren L. Ritterhouse
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Sara E. Turbett
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Julie Batten
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | | | - Galit Alter
- Ragon Institute of MGH, MIT, and HarvardCambridgeMAUSA
| | | | - Jason B. Harris
- Division of Infectious DiseasesDepartment of PediatricsMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Jeffrey A. Gelfand
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Mark C. Poznansky
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Bradley E. Bernstein
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - David N. Louis
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Anand Dighe
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Richelle C. Charles
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Edward T. Ryan
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - John A. Branda
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Virginia M. Pierce
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
- Division of Infectious DiseasesDepartment of PediatricsMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Mandakolathur R. Murali
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
- Division of Allergy and ImmunologyDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - A. John Iafrate
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Eric S. Rosenberg
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
- Division of Infectious DiseasesDepartment of MedicineMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| | - Jochen K. Lennerz
- Department of PathologyMassachusetts General Hospital/Harvard Medical SchoolBostonMAUSA
| |
Collapse
|
47
|
Conklin J, Frosch MP, Mukerji S, Rapalino O, Maher M, Schaefer PW, Lev MH, Gonzalez RG, Das S, Champion SN, Magdamo C, Sen P, Harrold GK, Alabsi H, Normandin E, Shaw B, Lemieux J, Sabeti P, Branda JA, Brown EN, Westover MB, Huang SY, Edlow BL. Cerebral Microvascular Injury in Severe COVID-19. medRxiv 2020. [PMID: 32743599 DOI: 10.1101/2020.07.21.20159376] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
IMPORTANCE Microvascular lesions are common in patients with severe COVID-19. Radiologic-pathologic correlation in one case suggests a combination of microvascular hemorrhagic and ischemic lesions that may reflect an underlying hypoxic mechanism of injury, which requires validation in larger studies. OBJECTIVE To determine the incidence, distribution, and clinical and histopathologic correlates of microvascular lesions in patients with severe COVID-19. DESIGN Observational, retrospective cohort study: March to May 2020. SETTING Single academic medical center. PARTICIPANTS Consecutive patients (16) admitted to the intensive care unit with severe COVID-19, undergoing brain MRI for evaluation of coma or focal neurologic deficits. EXPOSURES Not applicable. MAIN OUTCOME AND MEASURES Hypointense microvascular lesions identified by a prototype ultrafast high-resolution susceptibility-weighted imaging (SWI) MRI sequence, counted by two neuroradiologists and categorized by neuroanatomic location. Clinical and laboratory data (most recent measurements before brain MRI). Brain autopsy and cerebrospinal fluid PCR for SARS-CoV 2 in one patient who died from severe COVID-19. RESULTS Eleven of 16 patients (69%) had punctate and linear SWI lesions in the subcortical and deep white matter, and eight patients (50%) had >10 SWI lesions. In 4/16 patients (25%), lesions involved the corpus callosum. Brain autopsy in one patient revealed that SWI lesions corresponded to widespread microvascular injury, characterized by perivascular and parenchymal petechial hemorrhages and microscopic ischemic lesions. CONCLUSIONS AND RELEVANCE SWI lesions are common in patients with neurological manifestations of severe COVID-19 (coma and focal neurologic deficits). The distribution of lesions is similar to that seen in patients with hypoxic respiratory failure, sepsis, and disseminated intravascular coagulation. Collectively, these radiologic and histopathologic findings suggest that patients with severe COVID-19 are at risk for multifocal microvascular hemorrhagic and ischemic lesions in the subcortical and deep white matter.
Collapse
|
48
|
Iyer AS, Jones FK, Nodoushani A, Kelly M, Becker M, Slater D, Mills R, Teng E, Kamruzzaman M, Garcia-Beltran WF, Astudillo M, Yang D, Miller TE, Oliver E, Fischinger S, Atyeo C, Iafrate AJ, Calderwood SB, Lauer SA, Yu J, Li Z, Feldman J, Hauser BM, Caradonna TM, Branda JA, Turbett SE, LaRocque RC, Mellon G, Barouch DH, Schmidt AG, Azman AS, Alter G, Ryan ET, Harris JB, Charles RC. Dynamics and significance of the antibody response to SARS-CoV-2 infection. medRxiv 2020:2020.07.18.20155374. [PMID: 32743600 PMCID: PMC7386524 DOI: 10.1101/2020.07.18.20155374] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Characterizing the humoral immune response to SARS-CoV-2 and developing accurate serologic assays are needed for diagnostic purposes and estimating population-level seroprevalence. METHODS We measured the kinetics of early antibody responses to the receptor-binding domain (RBD) of the spike (S) protein of SARS-CoV-2 in a cohort of 259 symptomatic North American patients infected with SARS-CoV-2 (up to 75 days after symptom onset) compared to antibody levels in 1548 individuals whose blood samples were obtained prior to the pandemic. RESULTS Between 14-28 days from onset of symptoms, IgG, IgA, or IgM antibody responses to RBD were all accurate in identifying recently infected individuals, with 100% specificity and a sensitivity of 97%, 91%, and 81% respectively. Although the estimated median time to becoming seropositive was similar across isotypes, IgA and IgM antibodies against RBD were short-lived with most individuals estimated to become seronegative again by 51 and 47 days after symptom onset, respectively. IgG antibodies against RBD lasted longer and persisted through 75 days post-symptoms. IgG antibodies to SARS-CoV-2 RBD were highly correlated with neutralizing antibodies targeting the S protein. No cross-reactivity of the SARS-CoV-2 RBD-targeted antibodies was observed with several known circulating coronaviruses, HKU1, OC 229 E, OC43, and NL63. CONCLUSIONS Among symptomatic SARS-CoV-2 cases, RBD-targeted antibodies can be indicative of previous and recent infection. IgG antibodies are correlated with neutralizing antibodies and are possibly a correlate of protective immunity.
Collapse
Affiliation(s)
- Anita S. Iyer
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Forrest K. Jones
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ariana Nodoushani
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Meagan Kelly
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Margaret Becker
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Damien Slater
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel Mills
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Teng
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammad Kamruzzaman
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | | | - Michael Astudillo
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Diane Yang
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Tyler E. Miller
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth Oliver
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | | | - Caroline Atyeo
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - A. John Iafrate
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen B. Calderwood
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Stephen A. Lauer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jingyou Yu
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhenfeng Li
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jared Feldman
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Blake M. Hauser
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | | | - John A. Branda
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah E. Turbett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Regina C. LaRocque
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Guillaume Mellon
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Dan H. Barouch
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Aaron G. Schmidt
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Andrew S. Azman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Galit Alter
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jason B. Harris
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richelle C. Charles
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
49
|
Lazarus JE, Branda JA, Gandhi RG, Barshak MB, Zachary KC, Barczak AK. Disseminated Intravascular Infection Caused by Paecilomyces variotii: Case Report and Review of the Literature. Open Forum Infect Dis 2020; 7:ofaa166. [PMID: 32617367 PMCID: PMC7314584 DOI: 10.1093/ofid/ofaa166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/07/2020] [Indexed: 11/14/2022] Open
Abstract
Paecilomyces variotii is a ubiquitous environmental saprophyte with worldwide distribution. Commonly found in soil and decomposing organic material [1, 2], P. variotii can also be isolated from drinking water [3] and indoor and outdoor air [4-6]. In immunocompetent hosts, P. variotii has been reported as a cause of locally invasive disease including prosthetic valve endocarditis [7, 8], endophthalmitis [9, 10], rhinosinusitis [11, 12], and dialysis-associated peritonitis [13, 14]. In contrast, disseminated infections are more commonly reported in immunocompromised patients, including those with chronic granulomatous disease [15], solid malignancy [16], acute leukemia [17], lymphoma [18], multiple myeloma [19], and after stem cell transplant for myelodysplasia [20]. In 1 case series examining invasive infections by non-Aspergillus molds, P. variotii was the most common cause after Fusarium spp. [21]. Here, we present the case of an immunocompetent patient with extensive intravascular infection involving prosthetic material. We describe successful induction therapy with combination antifungals and extended suppression with posaconazole with clinical quiescence and eventual normalization of serum fungal biomarkers.
Collapse
Affiliation(s)
- Jacob E Lazarus
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ronak G Gandhi
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Miriam B Barshak
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kimon C Zachary
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Amy K Barczak
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- The Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| |
Collapse
|
50
|
Maulden AB, Garro AC, Balamuth F, Levas MN, Bennett JE, Neville DN, Branda JA, Nigrovic LE. Two-Tier Lyme Disease Serology Test Results Can Vary According to the Specific First-Tier Test Used. J Pediatric Infect Dis Soc 2020; 9:128-133. [PMID: 30793167 DOI: 10.1093/jpids/piy133] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/19/2018] [Accepted: 11/29/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Variability in 2-tier Lyme disease test results according to the specific first-tier enzyme immunoassay (EIA) in children has not been examined rigorously. In this study, we compared paired results of clinical 2-tier Lyme disease tests to those of the C6 peptide EIA followed by supplemental immunoblotting (C6 2-tier test). METHODS We performed a prospective cohort study of children aged ≥1 to ≤21 years who were undergoing evaluation for Lyme disease in the emergency department at 1 of 6 centers located in regions in which Lyme disease is endemic. The clinical first-tier test and a C6 EIA were performed on the same serum sample with supplemental immunoblotting if the first-tier test result was either positive or equivocal. We compared the results of the paired clinical and C6 2-tier Lyme disease test results using the McNemar test. RESULTS Of the 1714 children enrolled, we collected a research serum sample from 1584 (92.4%). The clinical 2-tier EIA result was positive in 316 (19.9%) children, and the C6 2-tier test result was positive or equivocal in 295 (18.6%) children. The clinical and C6 2-tier test results disagreed more often than they would have by chance alone (P = .002). Of the 39 children with either a positive clinical or C6 2-tier test result alone, 2 children had an erythema migrans (EM) lesion, and 29 had symptoms compatible with early disseminated Lyme disease. CONCLUSIONS Two-tier Lyme disease test results differed for a substantial number of children on the basis of the specific first-tier test used. In children for whom there is a high clinical suspicion for Lyme disease and who have an initially negative test result, clinicians should consider retesting for Lyme disease.
Collapse
Affiliation(s)
- Alexandra B Maulden
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Aris C Garro
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, Rhode Island
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Michael N Levas
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan E Bennett
- Division of Emergency Medicine, A. I. Dupont Hospital for Children, Sidney Kimmel Medical College Thomas Jefferson University, Wilmington, Delaware
| | - Desiree N Neville
- Division of Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| |
Collapse
|