Two phenotypes of chronic recurrent multifocal osteomyelitis with different patterns of bone involvement

INTRODUCTION

Chronic Recurrent Multifocal Osteomyelitis (CRMO) is an autoinflammatory bone disorder with predominantly paediatric onset. Children present with multifocal osteolytic lesions accompanied by bone pain and soft tissue swelling. Patients often exhibit extraosseous co-morbidities such as psoriasis, inflammatory bowel disease, and arthritis.

OBJECTIVES

Comparison of children with two different phenotypes of CRMO defined by presence or absence of extraosseous co-morbidities.

METHODS

Children diagnosed with CRMO at the Motol University Hospital between 2010 and 2020 were retrospectively reviewed, and according to the absence or presence of extraosseous manifestations divided into two cohorts - bone limited CRMO and complex CRMO. The two groups were compared in terms of demographic data, age at disease onset, number and site of bone lesions, laboratory biomarker values, and need of escalation to a second-line therapy.

RESULTS

Thirty-seven children (30 female, 7 male) with confirmed CRMO were included in the analysis. The mean age at disease onset was 10 years. All but 3 patients presented with multifocal disease. Twenty-three children (62%) had at least one extraosseous manifestation (13 sacroiliitis, 8 inflammatory bowel disease, 6 skin disease [acne, pustulosis, or psoriasis], 7 arthritis). Complex CRMO was associated with a significantly higher ESR rate (p = 0.0064) and CRP level (p = 0.018). The groups did not differ in number of foci or in age at disease onset. Bone lesion distribution differed between the two groups with significantly more frequent involvement of clavicle (p = 0.011) and pelvis (p = 0.038) in patients with complex CRMO. Children with complex CRMO more often needed escalation of therapy to DMARDs and biologic agents.

CONCLUSION

Our data suggest that CRMO affecting solely the skeleton has milder course compared to complex CRMO with extraskeletal features. Further studies are needed to explore the clinical as well as the patient reported outcomes and promote individually tailored therapeutic strategies in both CRMO phenotypes.

Current treatment options for monogenic periodic fever syndromes - the role of interleukin 1 inhibitors

Monogenic periodic fever syndromes are heterogeneous group of autoinflammatory diseases including distinct syndromes, such as cryopyrin-associated periodic syndrome (CAPS), tumor necrosis factor alpha receptor-associated periodic syndrome (TRAPS), mevalonate kinase deficiency/hyper IgD syndrome (MKD/HIDS), and familial Mediterranean fever (FMF). Individual diseases differ in pathogenesis, clinical manifestations, and severity. However, cytokines from the interleukin 1 (IL-1) family play a key role in all of them. Inhibition of these cytokines, especially IL-1, thus plays a crucial role in their treatment. At present, we have a wide range of drugs that differ in structure, mechanism of action, efficacy, and spectrum of side effects. The most available are anakinra, canakinumab and rilonacept. Moreover, several clinical trials are currently underway with other very promising drugs, such as gevokizumab, tadekinig alfa or tranilast. In the following review, we provide a new perspective on the efficacy and safety of IL-1 inhibitors that have provided the novel results coming from recently published clinical trials.

Clinical effectiveness and safety of intra-articular injection of HYALGO in the management of knee osteoarthritis symptoms: A multicenter prospective study

BACKGROUND

The reduced concentration of hyaluronic acid in the synovial fluid, leading to impairment of joint function and painful symptomatology during knee osteoarthritis (OA), can be restored by using injectable formulations of hyaluronic acid (HA) and chondroitin sulfate (CS), variable for relative composition, HA/CS molecular modifications, and injection protocols. The present study aims to assess the safety and performance of the intra-articular (IA) viscosupplementing agent HYALGO, a formulation combining 40 mg/mL HA (>1700 kDa) and 40 mg/mL CS, in the treatment of patients suffering from knee OA.

METHODS

74 patients affected by knee lesions classified as grade II and III according to Kellgren and Lawrence classification were prospectively recruited and treated with three HYALGO injections (2 mL) given one week apart. Visual analogue scale (VAS) pain changes were monitored at each injection and over-time at 6, 14, and 26 weeks of follow-up. Secondary endpoints were: Western Ontario McMaster University Osteoarthritis index (WOMAC), Patient's Global Assessment (PGA) score, Clinical Observer Global Assessment (COGA) score, Outcome Measures in Rheumatology Committee (OMERACT) and Osteoarthritis Research Society International (OARSI) responders rates. Patients were also assessed for changes in their ultrasound joint scores according to the criteria of the OMERACT US Task Force Group.

RESULTS

Pain reduction was statistically significant starting from the first IA injection. Mean pain reduction from baseline to week 26 was -90.6%. At 26 weeks, WOMAC Pain was reduced by -62.7%, WOMAC Stiffness by -47.2%, WOMAC Physical Function by -54.1%; Total WOMAC by -53.8%. The VAS PGA change from baseline was -48.0 [mm] and VAS COGA -41.0 [mm]. Responders at week 26 were 78.4%. Ultrasound parameters (joint effusion, synovial thickness, and popliteal cysts) improved or remained stable from baseline to week 6.

CONCLUSIONS

Three injections of HYALGO were safe and effective to manage symptomatic knee OA, with a beneficial effect that increased progressively over time, peaking 6 months after injection.

Association between clinical specialty setting and disease management in patients with psoriatic arthritis: results from LOOP, a cross-sectional, multi-country, observational study

BACKGROUND

Psoriatic arthritis (PsA) is a chronic and debilitating disease that can be managed by different clinical specialists.

OBJECTIVES

The objective of the LOOP study was to evaluate the impact of clinical specialty setting on the time to diagnosis and treatment of patients with PsA. Clinical disease activity and disease burden were also compared between clinical settings.

METHODS

LOOP was a cross-sectional, multicentre, observational study conducted in 17 countries in Western and Eastern Europe, the Middle East, Latin America and Asia. Adult patients (≥18 years) with a suspected or established diagnosis of PsA who were routinely visiting a rheumatologist, dermatologist or non-rheumatology/non-dermatology physician were enrolled. All patients were assessed by both a rheumatologist and a dermatologist.

RESULTS

Of 1483 enrolled patients, a total of 1273 had a confirmed diagnosis of PsA. There was no significant difference in the median time from onset of inflammatory musculoskeletal symptoms to PsA diagnosis between patients enrolled by rheumatologists and dermatologists (6.0 vs. 3.9 months). However, the median time from diagnosis to first treatment with a conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) was significantly shorter in the rheumatology setting compared with the dermatology setting (0 vs. 2.0 months; P < 0.001). In addition, disease activity was significantly higher in the dermatology setting compared with the rheumatology setting.

CONCLUSIONS

Differences in the management and clinical status of patients with PsA were observed between the rheumatology and dermatology settings. Importantly, median time from diagnosis to first csDMARD was significantly shorter in the rheumatology setting, and patients in the dermatology setting had higher disease activity. These data show the importance of improved collaboration between rheumatologists and dermatologists.

The identification and management of interstitial lung disease in systemic sclerosis: evidence-based European consensus statements

BACKGROUND

Systemic sclerosis-associated interstitial lung disease (ILD) carries a high mortality risk; expert guidance is required to aid early recognition and treatment. We aimed to develop the first expert consensus and define an algorithm for the identification and management of the condition through application of well established methods.

METHODS

Evidence-based consensus statements for systemic sclerosis-associated ILD management were established for six domains (ie, risk factors, screening, diagnosis and severity assessment, treatment initiation and options, disease progression, and treatment escalation) using a modified Delphi process based on a systematic literature analysis. A panel of 27 Europe-based pulmonologists, rheumatologists, and internists with expertise in systemic sclerosis-associated ILD participated in three rounds of online surveys, a face-to-face discussion, and a WebEx meeting, followed by two supplemental Delphi rounds, to establish consensus and define a management algorithm. Consensus was considered achieved if at least 80% of panellists indicated agreement or disagreement.

FINDINGS

Between July 1, 2018, and Aug 27, 2019, consensus agreement was reached for 52 primary statements and six supplemental statements across six domains of management, and an algorithm was defined for clinical practice use. The agreed statements most important for clinical use included: all patients with systemic sclerosis should be screened for systemic sclerosis-associated ILD using high-resolution CT; high-resolution CT is the primary tool for diagnosing ILD in systemic sclerosis; pulmonary function tests support screening and diagnosis; systemic sclerosis-associated ILD severity should be measured with more than one indicator; it is appropriate to treat all severe cases; no pharmacological treatment is an option for some patients; follow-up assessments enable identification of disease progression; progression pace, alongside disease severity, drives decisions to escalate treatment.

INTERPRETATION

Through a robust modified Delphi process developed by a diverse panel of experts, the first evidence-based consensus statements were established on guidance for the identification and medical management of systemic sclerosis-associated ILD.

FUNDING

An unrestricted grant from Boehringer Ingelheim International.

[Granulomatosis with polyangiitis manifested as diabetes insipidus]

The case report shows a surprising presentation of pulmonary granulomatosis with polyangiitis (GPA) through symptoms of diabetes insipidus (DI) with granulomatous infiltration of the pituitary gland. The pituitary hormonal dysfunction as a result of granulomatosis of the pituitary gland is rare. Several studies have demonstrated that the incidence of the pituitary dysfunction reaches approx. 1 % of the patients with GPA. However it is mostly presented in patients with the disease already diagnosed. The patient described by us had no clinical expressions of GPA in the respiratory tract. He presented with polyuria and polydipsia. It was not until a more detailed examination of these symptoms was performed that a focal lung disease was detected and diagnosed as GPA.

KEY WORDS

diabetes insipidus - granulomatosis with polyangiitis - granulomatous infiltration of the pituitary gland - pituitary hormonal dysfunction.

[Rapid identification of ESBL--positive clinical samples using real-time PCR method]

OBJECTIVES

A new method has been developed for detecting genes determining the extended-spectrum beta-lactamase (ESBL) phenotype directly from patients' clinical material. The method enables detection of the bla(CTX-M) gene encoding CTX-M beta-lactamases and the bla(SHV) gene variants with real-time PCR technology using locked nucleic acid oligonucleotides.

MATERIAL AND METHODS

In this pilot study, tracheal aspirates obtained from patients with mechanical ventilation hospitalized at Department of Anaesthesiology and Resuscitation of the University Hospital in Olomouc between 1st March and 30th December 2010 period were tested. Each sample was identified with standard microbiological procedures including phenotypic determination of ESBL-positive enterobacteria. At the same time, each sample was analyzed for the presence of nucleic acids (DNA) which encode CTX-M and SHV ESBL using real-time PCR.

RESULTS

150 samples of tracheal aspirates from 71 patients were included into testing. In the set, 13 (8.7%) ESBL-positive samples were identified by culture methods while 27 (18 %) positive samples were identified by the real-time PCR method. Of the 27 PCR-positive samples, 24 were positive for the bla(CTX) gene; in 2 samples, the ESBL bla(SHV) gene was detected, and both genes were present in 1 sample. All culture-positive samples were also PCR-positive for the presence of bla(CTX) and/or bla(SHV) sequences.

CONCLUSIONS

The new real-time PCR assay is likely to shorten the time for detection of enterobacteria producing SHV and CTX-M beta-lactamases from 48 to 6 hours. It enables ESBL-positive enterobacteria determination in tracheal aspirates of patients suffered from life-threatening nosocomial pneumonia where the early introduction of adequate antimicrobial treatment plays the important role.

Vaccination with dendritic cells loaded with tumor apoptotic bodies (Apo-DC) in patients with chronic lymphocytic leukemia: effects of various adjuvants and definition of immune response criteria

We previously demonstrated that autologous dendritic cells that have endocytosed apoptotic bodies of chronic lymphocytic leukemia (CLL) cells (Apo-DC) can stimulate antileukemic T cell responses in vitro. In this phase I study, we vaccinated 15 asymptomatic CLL patients at five time points with Apo-DC administered intradermally either alone (cohort I), or in combination with subcutaneous granulocyte-macrophage-colony-stimulating-factor (GM-CSF) (cohort II) or with GM-CSF and intravenous low-dose cyclophosphamide (cohort III). Aim of the study was to evaluate the safety and immunogenicity of Apo-DC alone or in combination with GM-CSF and low-dose cyclophosphamide in CLL patients. All patients completed the vaccination schedule without dose-limiting toxicity. No objective clinical responses were seen. Vaccine-induced leukemia-specific immune responses were evaluated by IFN-γ ELISpot and proliferation assays over a 52 weeks observation period and immune response criteria were defined. According to these criteria, 10/15 patients were defined as immune responders. The frequency of immune-responding patients was higher in cohorts II (3/5) and III (5/5) than in cohort I (2/5). In order to further characterize the induced immune response, estimation of secreted cytokines and CD107-degranulation assay were performed. Clustering of T and CLL cells was observed in CD107-degranulation assay and visualized by confocal microscopy. Additionally, assessment of regulatory T cells (T(regs)) revealed their significantly lower frequencies in immune responders versus non-responders (P < 0.0001). Cyclophosphamide did not reduce T(regs) frequency. In conclusion, vaccination with Apo-DC + GM-CSF and cyclophosphamide was safe and elicited anti-CLL immune responses that correlated inversely with T(regs) levels. Lack of clinical responses highlights the necessity to develop more potent vaccine strategies in B cell malignancies.

Expansion of T helper type 17 lymphocytes in patients with chronic granulomatous disease

Hyper-immunoglobulin (Ig)E syndrome (HIES) is a primary immunodeficiency associated with mutations in STAT3 resulting in impaired development of T helper type 17 (Th17) lymphocytes. HIES patients with a reduced frequency of Th17 cells present with infections caused by Staphylococcus aureus and/or Candida strains. The same spectrum of pathogens is present in patients with chronic granulomatous disease (CGD).We analysed the characteristics of the Th17 compartment in HIES and CGD. HIES patients showed very low numbers of Th17 cells. By contrast, the frequency of Th17 cells and production of Th17-derived cytokines was significantly higher among CGD patients when compared to both control samples and HIES. Naive CD4(+) cells in CGD patients had a normal capacity to differentiate into IL-17-producing cells and the numbers of Th17 cells in the CGD patients normalized following successful bone marrow transplantation. Our findings complement recent data on the importance of Th17 cells for elimination of infections with C. albicans and S. aureus.

[The use of molecular genetics techniques in clinical microbiology--final report from the workshop of the Molecular Microbiology Working Group TIDE]

In the last decade, there has been a rapid development in the use of molecular genetics methods in clinical microbiology. Novel technologies bring new knowledge and approaches to various disciplines of microbiology--taxonomy, identification of microbes, clinical diagnosis, epidemiology of infectious diseases and antibiotic resistance. This article summarizes the conclusions from the workshop of the Molecular Microbiology Working Group TIDE held during the Second Annual Meeting of the Society for Medical Microbiology of the J. E. Purkyne Czech Medical Association.

[Fragile X-associated tremor/ataxia syndrome]

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a recently characterized adult onset neurodegenerative disorder affecting both male and female (male>female) carriers of premutation CGG repeat expansions of the FMR1 gene. Onset typically occurs after the age of 50 years with a lifetime risk of FXTAS in males of about 1 in 3,000-6,000. Core features include progressive gait ataxia and cerebellar tremor with associated features of cognitive deficits, peripheral neuropathy and dysautonomia. The diagnosis of FXTAS is established based on clinical presentation, cerebral imaging and genetic testing. Due to the still low level of awareness of FXTAS and its variable clinical picture FXTAS is substantially underdiagnosed. However, confirming the diagnosis is essential for genetic counseling of the patients as the offspring are at risk for fragile X syndrome, premature ovarian insufficiency (POI) or FXTAS. Furthermore, many features of FXTAS can be treated symptomatically.

Kinetics of dendritic cells reconstitution and costimulatory molecules expression after myeloablative allogeneic haematopoetic stem cell transplantation: implications for the development of acute graft-versus host disease

Allogeneic hematopoetic stem cell transplantation (HSCT) represents a unique opportunity to monitor the kinetics of reconstitution of dendritic cells (DCs) and their dynamics in distinct pathologies. We analyzed DCs reconstitution after myeloablative HSCT. We separately analyzed patients with acute GVHD. DCs were monitored from the earliest phase of hematopoetic reconstitution until day +365. Both myeloid DCs and plasmacytoid DCs appeared at earliest stages after engraftment and relative numbers within white blood cells compartment peaked between days 19-25 after HSCT. Their proportion then gradually declined and absolute numbers of both DC subsets remained lower than in controls during the whole follow-up. Patients with acute GVHD had significantly lower numbers of circulating DCs. Decrease in DC counts preceded onset of clinical symptoms by at least 24 h and was independent of corticosteroids administration. This study reveals quantification of plasmacytoid and myeloid DCs as a potential biomarker for the prediction of acute GVHD development.

Impaired Toll-like receptor 8–mediated IL-6 and TNF-α production in antigen-presenting cells from patients with X-linked agammaglobulinemia

The critical role of Bruton tyrosine kinase (Btk) in B cells has been documented by the block of B-cell development in X-linked agammaglobulinemia (XLA). Less is known about Btk function in myeloid cells. Several pieces of evidence indicate that Btk is a component of Toll-like receptor (TLR) signaling. We analyzed whether Btk deficiency in XLA is associated with an impaired dendritic cell (DC) compartment or defective TLR signaling. We analyzed the expression of TLRs 1 to 9 on myeloid DCs generated from XLA patients and evaluated their response to activation by specific TLR agonists. We show that XLA patients have normal numbers of circulating DCs. Btk-deficient DCs have no defect in response to stimulation of TLRs 1/2, 2/6, 3, 4, and 5 but display a profound impairment of IL-6 and TNF-α production in response to stimulation by TLR-8 cognate agonist, ssRNA. These findings may provide an explanation for the susceptibility to enteroviral infections in XLA patients.

Presence of Borrelia burgdorferi sensu lato in mites parasitizing small rodents

Ticks (especially those in the family Ixodidae) are the primary vectors of the infectious agent Borrelia burgdorferi sensu lato, which causes Lyme disease. To determine the potential role of mites as vectors of B. burgdorferi sensu lato, mites were collected from wild rodents in the Bazantula region of North Moravia (Czech Republic). These samples were examined for the presence of Borreliae by using DFM and PCR methods. Mites positive for the presence of DNA of B. burgdorferi sensu lato were determined as members of the families Haemogamasidae and Parasitidae. One sample from a mite of genus Haemogamasus was successfully isolated, and the specimen was confirmed as B. afzelii by using PCR-RFLP and by gradient SDS-PAGE. This suggests the possible participation of gamasid mites in borrelial circulation in nature and also points to the utility of further such studies to identify potential vectors (other than ticks) of the spirochete.

Leigh syndrome caused by mutations in the flavoprotein (Fp) subunit of succinate dehydrogenase (SDHA)

Detailed clinical, neuroradiological, histological, biochemical, and genetic investigations were undertaken in a child suffering from Leigh syndrome. The clinical symptoms started at age five months and led to a severe progressive neurodegenerative disorder causing epilepsy, psychomotor retardation, and tetraspasticity. Biochemical measurement of skeletal muscle showed a severe decrease in mitochondrial complex II. Sequencing of SDHA revealed compound heterozygosity for a nonsense mutation in exon 4 (W119X) and a missense mutation in exon 3 (A83V), both absent in normal controls. In six additional patients--five with Leigh or Leigh-like syndrome and one with neuropathy and ataxia associated with isolated deficiency of complex II--mutations in SDHA were not detected, indicating genetic heterogeneity.

Mutations in mtDNA-encoded cytochrome c oxidase subunit genes causing isolated myopathy or severe encephalomyopathy

We report on clinical, histological and genetic findings in two patients carrying novel heteroplasmic mutations in the mitochondrial cytochrome c oxidase subunit genes COII and COIII. The first patient, a 35 year-old man had a multisystemic disease, with clinical symptoms of bilateral cataract, sensori-neural hearing loss, myopathy, ataxia, cardiac arrhythmia, depression and short stature and carried a 7970 G>T (E129X) nonsense mutation in COII. A sudden episode of metabolic encephalopathy caused by extremely high blood lactate lead to coma. The second patient developed exercise intolerance and rhabdomyolysis at age 22 years. A heteroplasmic missense mutation 9789 T>C (S195P) was found in skeletal muscle, but not in blood and myoblasts pointing to a sporadic mutation. Our report of two patients with isolated COX deficiency and new mutations in COX subunit genes may help to draw more attention to this type of mtDNA defects and provide new aspects for counselling affected families.

Congenital cataract, muscular hypotonia, developmental delay and sensorineural hearing loss associated with a defect in copper metabolism

Deficiencies of different proteins involved in copper metabolism have been reported to cause human diseases. Well-known syndromes, for example, are Menkes and Wilson diseases. Here we report a patient presenting with congenital cataract, severe muscular hypotonia, developmental delay, sensorineural hearing loss and cytochrome-c oxidase deficiency with repeatedly low copper and ceruloplasmin levels. These findings were suggestive of a copper metabolism disorder. In support of this, the patient's fibroblasts showed an increased copper uptake with normal retention. Detailed follow-up examinations were performed. Immunoblotting for several proteins including ATP7A (MNK or Menkes protein), ATP7B (Wilson protein) and SOD1 showed normal results, implying a copper metabolism defect other than Wilson or Menkes disease. Sequence analysis of ATOX1 and genes coding for proteins that are known to play a role in the mitochondrial copper metabolism (COI-III, SCO1, SCO2, COX11, COX17, COX19) revealed no mutations. Additional disease genes that have been associated with cytochrome-c oxidase deficiency were negative for mutations as well. As beneficial effects of copper histidinate supplementation have been reported in selected disorders of copper metabolism presenting with low serum copper and ceruloplasmin levels, we initiated a copper histidinate supplementation. Remarkable improvement of clinical symptoms was observed, with complete restoration of cytochrome-c oxidase activity in skeletal muscle.

[Glucocorticoids and their effect on dendritic cell function]

BACKGROUND

Dendritic cells represent the most effective antigen presenting cells and they are the only cell type capable of initiating the primary immune response. They use several sets of germ-line encoded receptors to differentiate between self and non-self and to detect the presence of danger signals. Danger signals are mainly represented by microbial pathogens but it can be also a necrotic or malignant cell. At various stages of their lifecycle dendritic cells play a key role in maintaining the peripheral tolerance towards self-antigens and in the initiation of an effective immune response. Glucocorticoids have been widely used in the treatment of autoimmune or inflammatory disorders and their immunosuppressive effect has been mainly attributed to the inhibition of lymphocytes functions.

METHODS AND RESULTS

In this study, we discuss the effects of glucocorticoids on in vitro generated myeloid dendritic cells and on peripheral blood myeloid and plasmacytoid dendritic cells subsets.

CONCLUSIONS

Experimental results point to the profound suppressive effect of glucocorticoids on the antigen presenting functions of dendritic cells and to contribute to better understanding of glucocorticoids-mediated immunosuppressive effect.

Two families with autosomal dominant progressive external ophthalmoplegia

OBJECTIVES

We report here the clinical and genetic features of two new families with autosomal dominant progressive external ophthalmoplegia (adPEO).

PATIENTS AND METHODS

The examination of index patients included a detailed clinical characterisation, histological analysis of muscle biopsy specimens, and genetic testing of mitochondrial and nuclear DNA extracted from muscle and leucocytes.

RESULTS

Index patients in both families presented with PEO and developed other clinical disease manifestations, such as myopathy and cardiomyopathy (patient 1) and axonal neuropathy, diabetes mellitus, hearing loss, and myopathy (patient 2), later in the course of illness. Both patients had ragged red fibres on muscle histology. Southern blot of mtDNA from muscle of patient 2 showed multiple deletions. In this case, a novel heterozygous missense mutation F485L was identified in the nuclear encoded putative mitochondrial helicase Twinkle. The mutation co-segregated with the clinical phenotype in the family and was not detected in 150 control chromosomes. In the other index patient, sequencing of ANT1, C10orf2 (encoding for Twinkle), and POLG1 did not reveal pathogenic mutations.

CONCLUSIONS

Our cases illustrate the clinical variability of adPEO, add a novel pathogenic mutation in Twinkle (F485L) to the growing list of genetic abnormalities in adPEO, and reinforce the relevance of other yet unidentified genes in mtDNA maintenance and pathogenesis of adPEO.

A combined AFLP-multiplex PCR assay for molecular typing of Escherichia coli strains using variable bacterial interspersed mosaic elements

The original method for molecular typing of E. coli strains was developed using the polymorphism in chromosomal sequences of bacterial interspersed mosaic elements (BIMEs) detected by multiplex PCR and analysed by AFLP assay. The applicability of the method in the epidemiology of E. coli was tested on a group of 524 strains of human and veterinary origin. In the studied group 18 different genotypes were detected. Significant differences were found in the frequencies of the genotypes among various groups of strains, suggesting the method could be a promising tool in the epidemiology of E. coli.

PCR-RFLP detection and species identification of fungal pathogens in patients with febrile neutropenia

OBJECTIVE

To assess the usefulness of polymerase chain reaction (PCR) assays in the diagnosis of fungal infections in immunocompromised patients.

METHODS

A rapid and sensitive PCR-based assay for the detection and identification of fungal pathogens was designed and applicability of this method was investigated in a group of children with cancer and febrile neutropenia (FN).

RESULTS

The ITS2 sequences and adjacent regions of 40 fungal pathogens were analyzed and primers for detection of all analyzed fungal species were designed. Amplification product length polymorphism (APLP) and restriction fragment length polymorphism (RFLP) generated genus- or species-specific patterns. The sensitivity of the method was approximately three cells of Candida albicans per 1 mL of blood. The results were available within 8 h after sample collection. The method was tested on 53 blood samples and one lung biopsy sample from 24 children with cancer and febrile neutropenia (FN). The PCR assay detected fungal DNA in 25 clinical samples from ten patients. Blood cultures were positive in only five samples, while another two blood-culture negative patients had positive cultures from throat swabs. The remaining 14 patients were both culture- and PCR-negative. Culture-isolated strains matched completely those obtained by PCR-APLP-RFLP identification. The identity of fungal species was confirmed by direct sequencing of amplified products.

CONCLUSION

Our results suggest that PCR-APLP-RFLP assays can be useful in the diagnosis of fungal infections in immunocompromised patients.

Application of the optical waveguide lightmode spectroscopy to monitor lipid bilayer phase transition

An instrument for optical waveguide lightmode spectroscopy (OWLS) was designed and developed for measurements at different and controlled temperatures in a range of 15 degrees C around room temperature. The instrument allows to scan the waveguide modes at different wavelengths on the same optical chip using different lasers. This instrument was used to monitor DMPC lipid bilayer main phase transition around the critical temperature. The main problem in these experiments is that the OWLS measurements do not give enough information about an optically anisotropic system like a lipid bilayer. Experimental OWLS data at two different wavelengths can however approximately solve the problem. The temperature dependence of the thickness and the refractive indices (ordinary and extraordinary) for the lipid bilayer around the phase transition is presented. (A theoretical derivation of the extraordinary refractive index is given in.)

Molecular diagnosis of culture negative infective endocarditis: clinical validation in a group of surgically treated patients

OBJECTIVE

To assess the clinical validity of polymerase chain reaction (PCR) based molecular methods in the microbiological diagnosis of culture negative infective endocarditis in a group of surgically treated patients.

DESIGN

Retrospective case-control study.

SETTING

Reference cardiovascular surgical centre. PATIENTS AND SAMPLES: 15 culture negative patients with infective endocarditis classified according to Duke criteria, with 17 heart valve samples; 13 age and sex matched control patients without infective endocarditis, with 13 valve samples.

INTERVENTIONS

Medical records were reviewed and clinical, demographic, and microbiological data collected, including results of molecular detection of bacteria and fungi from valve samples. The clinical validity of molecular diagnosis was assessed, along with the sensitivity and speed of the systems.

RESULTS

In the study group, 14 patients were PCR positive (93%). Organisms detected were streptococci (3), staphylococci (2), enterobacter (1), Tropheryma whippelii (1), Borrelia burgdorferi (1), Candida albicans (1), and Aspergillus species (2). Three cases were positive on universal bacterial detection but the pathogen could not be identified because of contaminating background. One case was negative. All but two positive cases showed clinical correlations. These two cases had no symptoms of infective endocarditis but there was agreement with the surgical findings. All control cases were PCR negative. Results were available within eight hours, and if sequencing was necessary, within 48 hours.

CONCLUSIONS

PCR based molecular detection of pathogens in valve samples from surgically treated culture negative infective endocarditis patients is fast, sensitive, and reliable. The technology, combined with thorough validation and clinical interpretation, may be a promising tool for routine testing of infective endocarditis.

[Molecular diagnosis of infections]

Molecular diagnostics (detection of nucleic acids by molecular genetics techniques) become more valuable in clinical diagnosis of disease. Apart from the already long-time used genetic techniques for detection of congenital anomalies, current use of molecular techniques includes detection of microbial pathogens. The character of these techniques increases the possibility of achieving diagnosis in cases where classical cultivation is not possible, is not reliable or is not fast enough. As with every new approach, molecular diagnostics have faced encountered reactions from the scientific community. Some scientists tend to overestimate the value of molecular diagnostic techniques, while sceptics, sometimes influenced by a biased or incomplete knowledge of the technology, think it is of little value. In this work, on the basis of literature and our own data from more than 5 years of experience with these methods, we have assessed the pros and cons of the use of molecular diagnostics of infectious diseases in the light of their potential use in clinical practice.

[TT virus infection in liver transplant recipients with cryptogennic cirrhosis]

The possible causative role of novel TT virus in liver diseases has been intensively studied in regarding its hepatotrophy, ability to cause persistent infection and worldwide prevalence. The aim of this study was to estimate the prevalence as well as the clinical importance of TTV in a normal healthy population group in the Czech Republic and in a group of liver transplant recipients diagnosed with cryptogenic cirrhosis. Polymerase chain reaction (PCR) detected the DNA of TT virus in 68% (13/19) of samples isolated from peripheral blood leukocytes and in 21% (4/19) of plasma samples in the liver transplant group. The viral DNA was detected only in 11.8% (4/34) of leukocytes and in no plasma sample from the healthy population control group. All patients included in this study had good liver function and had no complications during the postoperative period. The prevalence of TTV DNA detection in healthy control group in Czech republic is similar to the rates reported in European and North American countries. Significant difference was proved between the prevalences of TTV in the groups of healthy controls and liver transplant recipients with cryptogenic cirrhosis. However, no association of TTV infection with possible postoperative complications could be found.

The effect of UV irradiation on uracil thin layer measured by optical waveguide lightmode spectroscopy

The polycrystalline uracil thin-layer dosimeter is a well-established method to monitor the biological effects of the environmental ultraviolet (UV) radiation. It is based on the optical density (OD) decrease of the uracil layer in the UV absorption band due to photodimerization of the crystal caused by UV irradiation. In the present study, we report measurements made with optical waveguide lightmode spectroscopy (OWLS) to characterize the changes in the optogeometrical parameters of the uracil layer caused by an artificial UV source. It is shown that UV irradiation causes a decrease in the refractive index and an increase of the optical anisotropy. The determined kinetic parameters of the UV dose-sensor response curves correlate well with results of OD measurements, but the sensitivity of OWLS is about ten times higher. The results show that OWLS is capable of analyzing the UV response of the uracil layer and opens the way for dosimetrical applications.

The possible role of human cytomegalovirus (HCMV) in the origin of atherosclerosis

BACKGROUND

The biological properties of some herpesviruses such as the ability of latent persistency in the host cells and the presence of viral DNA in atherosclerotic lesions, suggest the possible role of herpesviruses in the development of atherosclerosis. Although many authors proved the presence of viral DNA in arterial wall tissue, the role of herpesviruses in the origin and progress of atherogenesis still remains unclear.

OBJECTIVES

The aim of this study was to confirm the presence of viral DNA in arterial wall and to associate the presence of these viruses with the development of atherosclerosis in patients with ischemic heart disease (IHD).

STUDY DESIGN

A possible role of HCMV, EBV and HHV6 in the development of atherosclerosis was tested in 244 IHD patients and 87 coronarographically negative controls. The presence of viral DNA in aortic and venous walls, as well as in a peripheral blood samples was tested by the use of polymerase chain reaction (PCR) accompanied by, immunological tests for anti-virus antibodies IgM and IgG types for all experimental groups.

RESULTS

The genomic DNA of HCMV was found in 76 and 59%, DNA of EBV in 59 and 50%, and DNA of HHV6 in 0.08 and 0.0%, of arterial walls of IHD patients and non-ischemic control group, respectively. No viral DNA was found in venous samples. Significant association (P < 0.01) has been proved between CMV infection and IHD.

CONCLUSIONS

Our results suggest that HCMV and EBV can be found in the arterial wall, so that the arterial wall could be a potential site of persistency of those viruses. We also proved a significant association between the presence of HCMV DNA in aortic walls and atherosclerosis. Despite of the high genetic and biological similarity between CMV and HHV6 no substantial role of HHV6 in atherosclerosis has been proved.

A common mutation (epsilon1267delG) in congenital myasthenic patients of Gypsy ethnic origin

OBJECTIVE

Mutation analysis of the acetylcholine receptor (AChR) epsilon subunit gene in patients with sporadic or autosomal recessive congenital myasthenic syndromes (CMS).

BACKGROUND

The nicotinic AChR of skeletal muscle is a neurotransmitter-gated ion channel that mediates synaptic transmission at the vertebrate neuromuscular junction. Mutations in its gene may cause congenital myasthenic syndromes. A recently described mutation in exon 12 of the AChR epsilon subunit (epsilon1267delG) disrupts the cytoplasmic loop and the fourth transmembrane region (M4) of the AChR epsilon subunit.

METHODS

Forty-three CMS patients from 35 nonrelated families were clinically classified as sporadic cases of CMS (group III according to European Neuromuscular Centre consensus) and were analyzed for epsilon1267delG by PCR amplification and sequence analysis.

RESULTS

The authors report the complete genomic sequence and organization of the gene coding for the epsilon subunit of the human AChR (accession number AF105999). Homozygous epsilon1267delG was identified in 13 CMS patients from 11 independent families. All epsilon1267delG families were of Gypsy or southeastern European origin. Genotype analysis indicated that they derive from a common ancestor (founder) causing CMS in the southeastern European Gypsy population. Phenotype analysis revealed a uniform pattern of clinical features including bilateral ptosis and mild to moderate fatigable weakness of ocular, facial, bulbar, and limb muscles.

CONCLUSIONS

The mutation epsilon1267delG might be frequent in European congenital myasthenic syndrome patients of Gypsy ethnic origin. In general, patients (epsilon1267delG) were characterized by the onset of symptoms in early infancy, the presence of ophthalmoparesis, positive response to anticholinesterase treatment, and the benign natural course of the disease.

Human herpesvirus-6 infection in children with cancer

Pediatric cancer patients treated with multimodal therapy are at a great risk of opportunistic infections or reactivation of latent infections. Human herpesvirus-6 (HHV-6) can serve as an example of such infection, with high seroprevalence in population. In 66 children with cancer and in 45 healthy controls, age matched, the presence of DNA HHV-6 was examined in peripheral blood by the polymerase chain reaction method. HHV-6 serology was also performed. No difference has been found between patients at the time of cancer diagnosis and the group of healthy children in the presence of DNA HHV-6 in blood, 17.4 and 15.6%, respectively. During cytotoxic chemotherapy the presence of HHV-6 in peripheral blood raised to 37.1% in patients with fever. Other parameters and symptoms such as febrile neutropenia, lymphopenia, exanthem, hepatopathy, lymphadenopathy, enteritis, bone marrow aplasia, pneumonitis, and encephalitis were examined in both the HHV-6 positive and HHV-6 negative groups of pediatric cancer patients. Statistically significant differences (p < .05) were found in case of lymphopenia, exanthem, and hepatopathy. In 4 out of 66 patients (6.1%) severe HHV-6 infection has been found: in 3 patients during cytotoxic chemotherapy and in 1 at the time of cancer diagnosis. Reactivation of HHV-6 infection in pediatric cancer patients under treatment with cytotoxic chemotherapy is frequent and can lead to severe complications as described in patients after bone marrow or organ transplantation.

[Polymerase chain reaction in diagnosis of infection of total knee replacement.]

Polymerase chain reaction allows a direct detection of DNA of bacterial pathogens in synovial fluid. With the help of artificially synthetized nucleotides, the so called primers, and in the presence of DNA polymerase enzyme it is possible to produce a great number of copies of the DNA being investigated and subsequently detect them. Authors used this method in 32 symptomatic knees after TKR (P.F.C. cemented type - Johnson and Johnson). Group I (pyogenic infection) comprised 14 patients. Their clinical condition required operation - extraction of TKR, debridement, spacer, lavage. All of them were PCR positive. Only 6 patients had a positive bacteriological cultivation, 8 of them were bacteriologically negative. Group II (synovialitis) included 18 patients. All of them had a negative bacteriological cultivation. Group II.a showed a slightly positive PCR reaction (mitigated infection, detection of DNA microbes incapable of reproduction). After the treatment by antibiotics the patients were without complaints. Group IIb included patients who were all PCR negative. Their case was non-bacterial irritation of synovial membrane. They had a good response to non-steroid antiflogistics. The sensitivity of PCR method is 100%, it can detect also microbes in patients treated by antibiotics. PCR method is fast providing results within 24 hours. It reliably detects the presence of bacteria in the punctate, it specifies diagnosis and contributes to the distinguishing between pyogenic infection from non-bacterial synovialitis. Key words: total knee replacement, infection.

[Use of genetic methods in the detection of pathogens in complications of extensive surgical procedures]

The method of the polymerase chain reaction (PCR) is used in the detection of septic conditions and monitoring of infectious agents in asymptomatic patients after organ transplantations and extensive cardiosurgical operations. The method allows semiquantitative and quantitative detection of bacteria, micromycetes and viruses and from the systematic quantitative follow-up of pathogen levels it is possible to draw conclusions on the prognosis of the patients condition or the success of the therapeutic procedure. The author demonstrates on practical examples of examined patients the possibilities of the method as compared with hitherto used ones. As examples two patients are quoted after surgery of a valve on account of bacterial endocarditis and three patients after transplantation of life important organs where the presence if cytomegalovirus was detected.

The polyvalent staphylococcal phage phi 812: its host-range mutants and related phages

Ninety-five percent of 782 culture collection strains, as well as hospital strains of Staphylococcus aureus subsp. aureus of different provenance and 43% of 89 culture collection strains of different coagulase-negative species of the genus Staphylococcus, were found to be sensitive to the polyvalent phage phi 812 or to at least one of its host-range mutants or to the polyvalent phages SK311, phi 131, and U16. Thus sensitivity to the polyvalent staphylococcal phages seems to be one of the common features of S. aureus subsp. aureus strains. The adsorption kinetics and one-step growth characteristics of the phages phi 812 and SK311 were estimated. Restriction genomic maps of the phages phi 812 (146.5 kb) and SK311 (141.1 kb) were constructed by use of the restriction endonucleases AvaII, PstI, KpnI, SacI, SmaI, and XhoI. The host-range mutations of the phage phi 812 were localized on this map. Comparison of restriction patterns of the phages phi 812 and SK311 with those of the polyvalent phages U16 and phi 131 suggests that all these phages are closely related. Their genomes differ from each other mostly by some deletions, insertions (1-3 kb), or inversions. Evidence was given that the phage phi 812 together with SK311, phi 131, and U16 belongs in the phage species Twort, the description of which is substantially supplemented with the data on the phage phi 812 reported in this paper.

[Detection of DNA specific for Mycobacterium tuberculosis in archeological material using the polymerase chain reaction]

The paleopathological diagnosis of bone tuberculosis in archeological findings may be confirmed by the polymerase chain reaction (PCR). If the M. tuberculosis-specific DNA fragment is amplified, then the presence of this microorganism in the sample is demonstrated. The pilot study presented investigated whether our molecular biology laboratory can collaborate with anthropologists in paleopathological analyses and to verify the use of the commercial diagnostic kit Cleanmix (Talent, Italy), for DNA isolation from archeological samples. The results were compared with the conclusions of anthropologists. Successful amplification of specific DNA fragments was achieved in a specimen from the period of the 13th to 15th century. The specimen consists of four thoracic vertebrae modified by osseous tuberculosis (gibbus). The PCR result was also positive in a five-year-old femur sample of a patient with chronic pulmonary tuberculosis. All other specimens of various ages but without macroscopic symptoms of osseous tuberculosis, were PCR negative. These results suggest that it is possible to detect former infections with pathogenic microorganisms in archeological bones find.

Newly discovered stereochemical requirements in the side-chain conformation of delta opioid agonists for recognizing opioid delta receptors

Topographic design of peptide ligands using specialized topographically constrained amino acids can provide new insights into the stereochemical requirements for delta opioid receptors. A highly constrained tyrosine derivative, (2S,3S)-beta-methyl-2',6'-dimethyltyrosine [(2S,3S)-TMT], was prepared by asymmetric synthesis and incorporated in [D-Pen2,D-Pen5] enkephalin (delta 1) and Deltorphin I (delta 2). The results of binding assays and bioassays showed that the two analogues (3 and 4) acted very differently at delta opioid receptors. Further pharmacological evaluations suggested that they actually interact primarily with the delta 1 and delta 2 receptor subtypes, respectively. These results, and conformational studies using NMR and computer-assisted modeling, provided insights into the different stereochemical requirements for these two delta opioid ligands to recognize the delta opioid receptor and its subtypes.

[Repeated yearly BCG treatment in superficial bladder cancer]

The authors report on experiences of treatment for superficial bladder cancer with BCG have achieved during three years. To achieve a permanent recidive prophylaxis the 6 weeks long course was repeated yearly. During the 37-12 months follow up a tumor recurrence have been observed in 10 of 49 patients (20.4%). There have not been seen any serious side-effects requering the interruption of the course or requering any antituberculotica. On the basis of their results and the torelable side-effects they recommend the local BCG treatment as a favourable possibility in prevention of bladder tumor recurrence.