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Wang LJ, Li KC, Qian SY, Gao HM, Liu J, Li Z, Jia XL, Fan CN, Wang Q. [Clinical characteristics and prognosis of 8 cases of severe infant botulism]. Zhonghua Er Ke Za Zhi 2024; 62:218-222. [PMID: 38378282 DOI: 10.3760/cma.j.cn112140-20230908-00169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Objective: To summarize the clinical characteristics and prognosis of severe infant botulism and evaluate the therapeutic effect of botulinum antitoxin in the pediatric intensive care unit (PICU). Methods: The clinical data of 8 cases diagnosed with infantile botulism were retrospectively analyzed in the PICU of Beijing Children's Hospital from October 2019 to August 2023. Data of basic demographic information, clinical manifestations, laboratory tests, treatment and prognosis of each child were collected and analyzed using descriptive statistical methods. Results: Eight laboratory-confirmed cases of infant botulism were included in this study, all of which were male infants with an age of 6.0 (3.3,6.8) months. Three of the children were from Inner Mongolia Autonomous Region, 2 of them were from Hebei, and the other 3 were from Beijing, Shandong and Xinjiang Uyghur Autonomous Region, respectively. All the patients were previously healthy. In 4 of these cases, the possible cause was the ingestion of either honey and its products or sealed pickled food by the mother or child before the onset of the disease. The first symptom was poor milk intake (4 cases), followed by shallow shortness of breath (7 cases), limb weakness (7 cases) and so on. The typical signs were bilateral dilated pupils (8 cases) and decreased limb muscle strength (8 cases). The main subtype was type B (7 cases), and only 1 case was classified as type A. Six of the children were treated with antitoxin therapy for a duration of 24 (19, 49) d. Seven of them had invasive mechanical ventilation. All the patients survived upon discharge with a follow-up period of 29 d to 3 years and 8 months. Six patients had fully recovered, and 2 recently discharged patients were gradually recovering. Conclusions: For infants with suspected contact or ingestion of botulinum and presented with bilateral pupillary paralysis, muscle weakness and clear consciousness, the stool should be collected for diagnostic testing using a mouse bioassay as soon as possible. Type B was the most common type. The antitoxin treatment was effectiveness and the prognosis was well.
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Affiliation(s)
- L J Wang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - K C Li
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - S Y Qian
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - H M Gao
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - J Liu
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Z Li
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - X L Jia
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - C N Fan
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
| | - Q Wang
- Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing 100045, China
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Gal Y, Sapoznikov A, Lazar S, Shoseyov D, Aftalion M, Gutman H, Evgy Y, Gez R, Nevo R, Falach R. Long-Term Pulmonary Damage in Surviving Antitoxin-Treated Mice following a Lethal Ricin Intoxication. Toxins (Basel) 2024; 16:103. [PMID: 38393180 PMCID: PMC10892648 DOI: 10.3390/toxins16020103] [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: 12/13/2023] [Revised: 01/30/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
Ricin, a highly potent plant-derived toxin, is considered a potential bioterrorism weapon due to its pronounced toxicity, high availability, and ease of preparation. Acute damage following pulmonary ricinosis is characterized by local cytokine storm, massive neutrophil infiltration, and edema formation, resulting in respiratory insufficiency and death. A designated equine polyclonal antibody-based (antitoxin) treatment was developed in our laboratory and proved efficacious in alleviating lung injury and increasing survival rates. Although short-term pathogenesis was thoroughly characterized in antitoxin-treated mice, the long-term damage in surviving mice was never determined. In this study, long-term consequences of ricin intoxication were evaluated 30 days post-exposure in mice that survived antitoxin treatment. Significant pulmonary sequelae were demonstrated in surviving antitoxin-treated mice, as reflected by prominent histopathological changes, moderate fibrosis, increased lung hyperpermeability, and decreased lung compliance. The presented data highlight, for the first time to our knowledge, the possibility of long-term damage development in mice that survived lethal-dose pulmonary exposure to ricin due to antitoxin treatment.
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Affiliation(s)
- Yoav Gal
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Anita Sapoznikov
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Shlomi Lazar
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - David Shoseyov
- Pediatric Pulmonology Unit, Hadassah Medical Center, Jerusalem P.O. Box 12000, Israel;
| | - Moshe Aftalion
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Hila Gutman
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - Yentl Evgy
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
| | - Rellie Gez
- Department of Pharmacology, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (S.L.); (H.G.); (R.G.)
| | - Reinat Nevo
- Department of Biomolecular Sciences, Weizmann Institute of Science, Herzel 234, Rehovot P.O. Box 26, Israel;
| | - Reut Falach
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 74100, Israel; (A.S.); (M.A.); (Y.E.)
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Beliveau M, Rubets I, Bojan D, Hall C, Toth D, Kodihalli S, Kammanadiminti S. Animal-to-Human Dose Translation of ANTHRASIL for Treatment of Inhalational Anthrax in Healthy Adults, Obese Adults, and Pediatric Subjects. Clin Pharmacol Ther 2024; 115:248-255. [PMID: 38082506 DOI: 10.1002/cpt.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/24/2023] [Accepted: 10/25/2023] [Indexed: 01/23/2024]
Abstract
Anthrax Immune Globulin Intravenous (AIGIV [ANTHRASIL]), was developed for the treatment of toxemia associated with inhalational anthrax. It is a plasma product collected from individuals vaccinated with anthrax vaccine and contains antitoxin IgG antibodies against Bacillus anthracis protective antigen. A pharmacokinetic (PK) and exposure-response model was constructed to assess the PKs of AIGIV in anthrax-free and anthrax-exposed rabbits, non-human primates and anthrax-free humans, as well as the relationship between AIGIV exposure and survival from anthrax, based on available preclinical/clinical studies. The potential effect of anthrax on the PKs of AIGIV was evaluated and estimates of survival odds following administration of AIGIV protective doses with and without antibiotic co-treatment were established. As the developed PK model can simulate exposure of AIGIV in any species for any dosing scenario, the relationship between the predicted area under the concentration curve of AIGIV in humans and the probability of survival observed in preclinical studies was explored. Based on the simulation results, the intravenous administration of 420 U (units of potency as measured by validated Toxin Neutralization Assay) of AIGIV is expected to result in a > 80% probability of survival in more than 90% of the human population. Additional simulations suggest that exposure levels were similar in healthy and obese humans, and exposure in pediatrics is expected to be up to approximately seven-fold higher than in healthy adults, allowing for doses in pediatric populations that ranged from one to seven vials. Overall, the optimal human dose was justified based on the PK/pharmacodynamic (PD) properties of AIGIV in animals and model-based translation of PK/PD to predict human exposure and efficacy.
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Affiliation(s)
- Martin Beliveau
- Integrated Drug Development, Certara, Montreal, Quebec, Canada
| | - Igor Rubets
- Integrated Drug Development, Certara, Montreal, Quebec, Canada
| | - Drobic Bojan
- Emergent BioSolutions Inc., Winnipeg, Manitoba, Canada
| | | | - Derek Toth
- Emergent BioSolutions Inc., Winnipeg, Manitoba, Canada
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Bower WA, Yu Y, Person MK, Parker CM, Kennedy JL, Sue D, Hesse EM, Cook R, Bradley J, Bulitta JB, Karchmer AW, Ward RM, Cato SG, Stephens KC, Hendricks KA. CDC Guidelines for the Prevention and Treatment of Anthrax, 2023. MMWR Recomm Rep 2023; 72:1-47. [PMID: 37963097 PMCID: PMC10651316 DOI: 10.15585/mmwr.rr7206a1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
This report updates previous CDC guidelines and recommendations on preferred prevention and treatment regimens regarding naturally occurring anthrax. Also provided are a wide range of alternative regimens to first-line antimicrobial drugs for use if patients have contraindications or intolerances or after a wide-area aerosol release of Bacillus anthracis spores if resources become limited or a multidrug-resistant B. anthracis strain is used (Hendricks KA, Wright ME, Shadomy SV, et al.; Workgroup on Anthrax Clinical Guidelines. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20:e130687; Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013;122:885-900; Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014;133:e1411-36). Specifically, this report updates antimicrobial drug and antitoxin use for both postexposure prophylaxis (PEP) and treatment from these previous guidelines best practices and is based on systematic reviews of the literature regarding 1) in vitro antimicrobial drug activity against B. anthracis; 2) in vivo antimicrobial drug efficacy for PEP and treatment; 3) in vivo and human antitoxin efficacy for PEP, treatment, or both; and 4) human survival after antimicrobial drug PEP and treatment of localized anthrax, systemic anthrax, and anthrax meningitis. Changes from previous CDC guidelines and recommendations include an expanded list of alternative antimicrobial drugs to use when first-line antimicrobial drugs are contraindicated or not tolerated or after a bioterrorism event when first-line antimicrobial drugs are depleted or ineffective against a genetically engineered resistant B. anthracis strain. In addition, these updated guidelines include new recommendations regarding special considerations for the diagnosis and treatment of anthrax meningitis, including comorbid, social, and clinical predictors of anthrax meningitis. The previously published CDC guidelines and recommendations described potentially beneficial critical care measures and clinical assessment tools and procedures for persons with anthrax, which have not changed and are not addressed in this update. In addition, no changes were made to the Advisory Committee on Immunization Practices recommendations for use of anthrax vaccine (Bower WA, Schiffer J, Atmar RL, et al. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices, 2019. MMWR Recomm Rep 2019;68[No. RR-4]:1-14). The updated guidelines in this report can be used by health care providers to prevent and treat anthrax and guide emergency preparedness officials and planners as they develop and update plans for a wide-area aerosol release of B. anthracis.
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Abstract
OBJECTIVE Botulinum toxin type A is widely used for the treatment of spasticity, focal dystonia, hemifacial spasm, hyperhidrosis, strabismus, chronic migraine, and also cosmetic purposes. Therapeutic use is commonly effective and safe. However, if toxin enters the vascular space and gets through to peripheral cholinergic nerve terminals, it may lead to iatrogenic botulism. METHOD We presented a patient who is diagnosed as iatrogenic botulism and treated with antitoxin at the 15th day of the exposure. RESULTS After the antitoxin administration, dramatical response to the treatment was observed. CONCLUSIONS In this report, we want to evaluate a new case of iatrogenic botulism and emphasize the importance of antitoxin administration regardless the timing of the exposure for patients with progressing paralysis.
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Affiliation(s)
- Ozge Gonul Oner
- Sancaktepe Sehit Prof Dr Ilhan Varank Training and Research Hospital, Sancaktepe, İstanbul
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Abstract
BACKGROUND The deliberate use of Bacillus anthracis spores is believed by the US government to be a high bioweapons threat. The first line of defense following potential exposure to B. anthracis spores would be postexposure prophylaxis with antimicrobials that have activity against B. anthracis. Additional therapies to address the effects of toxins may be needed in systemically ill individuals. Over the last 2 decades, the United States government (USG) collaborated with the private sector to develop, test, and stockpile 3 antitoxins: anthrax immunoglobulin intravenous (AIGIV), raxibacumab, and obiltoxaximab. All 3 products target protective antigen, a protein factor common to the 2 exotoxins released by B. anthracis, and hamper or block the toxins' effects and prevent or reduce pathogenesis. These antitoxins were approved for licensure by the United States Food and Drug Administration based on animal efficacy studies compared to placebo. METHODS We describe USG-sponsored pre- and postlicensure studies that compared efficacy of 3 antitoxins in a New Zealand White rabbit model of inhalation anthrax; survival following a lethal aerosolized dose of B. anthracis spores was the key measure of effectiveness. To model therapeutic intervention, intravenous treatments were started following onset of antigenemia. RESULTS In pre- and postlicensure studies, all 3 antitoxins were superior to placebo; in the postlicensure study, raxibacumab and obiltoxaximab were superior to AIGIV, but neither was superior to the other. CONCLUSIONS These data illustrate the relative therapeutic benefit of the 3 antitoxins and provide a rationale to prioritize their deployment.
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Affiliation(s)
- Raymond M Slay
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Rachel Cook
- Oak Ridge Institute for Science and Education, CDC Fellowship Program, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Hendricks
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Boucher
- Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority, Washington, District of Columbia, USA
| | - Michael Merchlinsky
- Office of the Assistant Secretary for Preparedness and Response, Biomedical Advanced Research and Development Authority, Washington, District of Columbia, USA
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Person MK, Cook R, Bradley JS, Hupert N, Bower WA, Hendricks K. Systematic Review of Hospital Treatment Outcomes for Naturally Acquired and Bioterrorism-Related Anthrax, 1880-2018. Clin Infect Dis 2022; 75:S392-S401. [PMID: 36251553 PMCID: PMC9649424 DOI: 10.1093/cid/ciac536] [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] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Bacillus anthracis can cause anthrax and is a potential bioterrorism agent. The 2014 Centers for Disease Control and Prevention recommendations for medical countermeasures against anthrax were based on in vitro data and expert opinion. However, a century of previously uncompiled observational human data that often includes treatment and outcomes is available in the literature for analysis. METHODS We reviewed treatment outcomes for patients hospitalized with anthrax. We stratified patients by meningitis status, route of infection, and systemic criteria, then analyzed survival by treatment type, including antimicrobials, antitoxin/antiserum, and steroids. Using logistic regression, we calculated odds ratios and 95% confidence intervals to compare survival between treatments. We also calculated hospital length of stay. Finally, we evaluated antimicrobial postexposure prophylaxis (PEPAbx) using data from a 1970 Russian-language article. RESULTS We identified 965 anthrax patients reported from 1880 through 2018. After exclusions, 605 remained: 430 adults, 145 children, and 30 missing age. Survival was low for untreated patients and meningitis patients, regardless of treatment. Most patients with localized cutaneous or nonmeningitis systemic anthrax survived with 1 or more antimicrobials; patients with inhalation anthrax without meningitis fared better with at least 2. Bactericidal antimicrobials were effective for systemic anthrax; addition of a protein synthesis inhibitor(s) (PSI) to a bactericidal antimicrobial(s) did not improve survival. Likewise, addition of antitoxin/antiserum to antimicrobials did not improve survival. Mannitol improved survival for meningitis patients, but steroids did not. PEPAbx reduced risk of anthrax following exposure to B. anthracis. CONCLUSIONS Combination therapy appeared to be superior to monotherapy for inhalation anthrax without meningitis. For anthrax meningitis, neither monotherapy nor combination therapy were particularly effective; however, numbers were small. For localized cutaneous anthrax, monotherapy was sufficient. For B. anthracis exposures, PEPAbx was effective.
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Affiliation(s)
- Marissa K Person
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel Cook
- Oak Ridge Institute for Science and Education, CDC Fellowship Program, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, USA
| | - John S Bradley
- Division of Infectious Diseases, Rady Children’s Hospital San Diego and the University of California San Diego School of Medicine, San Diego, California, USA
| | - Nathaniel Hupert
- Departments of Population Health Sciences and of Medicine, Weill Cornell Medicine (Cornell University) and New York-Presbyterian Hospital, New York, New York, USA
| | - William A Bower
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Katherine Hendricks
- Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Van Hao N, Loan HT, Yen LM, Kestelyn E, Hong DD, Thuy DB, Nguyen NT, Duong HTH, Thuy TTD, Nhat PTH, Khanh PNQ, Dung NTP, Phu NH, Phong NT, Lieu PT, Tuyen PT, Hanh BTB, Nghia HDT, Oanh PKN, Tho PV, Tan Thanh T, Turner HC, van Doorn HR, Van Tan L, Wyncoll D, Day NP, Geskus RB, Thwaites GE, Van Vinh Chau N, Thwaites CL. Human versus equine intramuscular antitoxin, with or without human intrathecal antitoxin, for the treatment of adults with tetanus: a 2 × 2 factorial randomised controlled trial. The Lancet Global Health 2022; 10:e862-e872. [PMID: 35561721 PMCID: PMC9115864 DOI: 10.1016/s2214-109x(22)00117-6] [Citation(s) in RCA: 6] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/11/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background Intramuscular antitoxin is recommended in tetanus treatment, but there are few data comparing human and equine preparations. Tetanus toxin acts within the CNS, where there is limited penetration of peripherally administered antitoxin; thus, intrathecal antitoxin administration might improve clinical outcomes compared with intramuscular injection. Methods In a 2 × 2 factorial trial, all patients aged 16 years or older with a clinical diagnosis of generalised tetanus admitted to the intensive care unit of the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, were eligible for study entry. Participants were randomly assigned first to 3000 IU human or 21 000 U equine intramuscular antitoxin, then to either 500 IU intrathecal human antitoxin or sham procedure. Interventions were delivered by independent clinicians, with attending clinicians and study staff masked to treatment allocations. The primary outcome was requirement for mechanical ventilation. The analysis was done in the intention-to-treat population. The study is registered at ClinicalTrials.gov, NCT02999815; recruitment is completed. Findings 272 adults were randomly assigned to interventions between Jan 8, 2017, and Sept 29, 2019, and followed up until May, 2020. In the intrathecal allocation, 136 individuals were randomly assigned to sham procedure and 136 to antitoxin; in the intramuscular allocation, 109 individuals were randomly assigned to equine antitoxin and 109 to human antitoxin. 54 patients received antitoxin at a previous hospital, excluding them from the intramuscular antitoxin groups. Mechanical ventilation was given to 56 (43%) of 130 patients allocated to intrathecal antitoxin and 65 (50%) of 131 allocated to sham procedure (relative risk [RR] 0·87, 95% CI 0·66–1·13; p=0·29). For the intramuscular allocation, 48 (45%) of 107 patients allocated to human antitoxin received mechanical ventilation compared with 48 (44%) of 108 patients allocated to equine antitoxin (RR 1·01, 95% CI 0·75–1·36, p=0·95). No clinically relevant difference in adverse events was reported. 22 (16%) of 136 individuals allocated to the intrathecal group and 22 (11%) of 136 allocated to the sham procedure experienced adverse events related or possibly related to the intervention. 16 (15%) of 108 individuals allocated to equine intramuscular antitoxin and 17 (16%) of 109 allocated to human antitoxin experienced adverse events related or possibly related to the intervention. There were no intervention-related deaths. Interpretation We found no advantage of intramuscular human antitoxin over intramuscular equine antitoxin in tetanus treatment. Intrathecal antitoxin administration was safe, but did not provide overall benefit in addition to intramuscular antitoxin administration. Funding The Wellcome Trust.
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Affiliation(s)
- Nguyen Van Hao
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Huynh Thi Loan
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Lam Minh Yen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Duc Du Hong
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | | | | | - Phung Tran Huy Nhat
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Phan Nguyen Quoc Khanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Phuong Dung
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nguyen Hoan Phu
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Pham Thi Lieu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Pham Thi Tuyen
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Bui Thi Bich Hanh
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Ho Dang Trung Nghia
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | | | - Phan Vinh Tho
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran Tan Thanh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Hugo C Turner
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, UK
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | - Le Van Tan
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nicholas Pj Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK
| | | | - C Louise Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine Research Building, University of Oxford, Oxford, UK.
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Vazquez-Cintron E, Machamer J, Ondeck C, Pagarigan K, Winner B, Bodner P, Kelly K, Pennington MR, McNutt P. Symptomatic treatment of botulism with a clinically approved small molecule. JCI Insight 2020; 5:132891. [PMID: 31996484 DOI: 10.1172/jci.insight.132891] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022] Open
Abstract
Botulinum neurotoxins (BoNTs) are potent neuroparalytic toxins that cause mortality through respiratory paralysis. The approved medical countermeasure for BoNT poisoning is infusion of antitoxin immunoglobulins. However, antitoxins have poor therapeutic efficacy in symptomatic patients; thus, there is an urgent need for treatments that reduce the need for artificial ventilation. We report that the US Food and Drug Administration-approved potassium channel blocker 3,4-diaminopyridine (3,4-DAP) reverses respiratory depression and neuromuscular weakness in murine models of acute and chronic botulism. In ex vivo studies, 3,4-DAP restored end-plate potentials and twitch contractions of diaphragms isolated from mice at terminal stages of BoNT serotype A (BoNT/A) botulism. In vivo, human-equivalent doses of 3,4-DAP reversed signs of severe respiratory depression and restored mobility in BoNT/A-intoxicated mice at terminal stages of respiratory collapse. Multiple-dosing administration of 3,4-DAP improved respiration and extended survival at up to 5 LD50 BoNT/A. Finally, 3,4-DAP reduced gastrocnemius muscle paralysis and reversed respiratory depression in sublethal models of serotype A-, B-, and E-induced botulism. These findings make a compelling argument for repurposing 3,4-DAP to symptomatically treat symptoms of muscle paralysis caused by botulism, independent of serotype. Furthermore, they suggest that 3,4-DAP is effective for a range of botulism symptoms at clinically relevant time points.
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Dela Cruz M, Miloradovich JE, Mostafa A, McKeever R, Vearrier D. Type B botulism in a Korean couple after eating homemade doenjang. Clin Toxicol (Phila) 2019; 57:223-224. [PMID: 30451029 DOI: 10.1080/15563650.2018.1530779] [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] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Maricel Dela Cruz
- a Department of Emergency Medicine , Drexel University College of Medicine , Philadelphia , PA , USA
| | - Jane E Miloradovich
- b Philadelphia Poison Control Center, The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Ahmed Mostafa
- c Department of Emergency Medicine , Drexel University College of Medicine , Philadelphia , PA , USA
| | - Rita McKeever
- c Department of Emergency Medicine , Drexel University College of Medicine , Philadelphia , PA , USA
| | - David Vearrier
- c Department of Emergency Medicine , Drexel University College of Medicine , Philadelphia , PA , USA
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11
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Obiltoxaximab (Anthim) for inhalation anthrax. Med Lett Drugs Ther 2018; 60:150-1. [PMID: 30383733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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12
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Cui X, Nolen LD, Sun J, Booth M, Donaldson L, Quinn CP, Boyer AE, Hendricks K, Shadomy S, Bothma P, Judd O, McConnell P, Bower WA, Eichacker PQ. Analysis of Anthrax Immune Globulin Intravenous with Antimicrobial Treatment in Injection Drug Users, Scotland, 2009-2010. Emerg Infect Dis 2018; 23:56-65. [PMID: 27983504 PMCID: PMC5176236 DOI: 10.3201/eid2301.160608] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We studied anthrax immune globulin intravenous (AIG-IV) use from a 2009-2010 outbreak of Bacillus anthracis soft tissue infection in injection drug users in Scotland, UK, and we compared findings from 15 AIG-IV recipients with findings from 28 nonrecipients. Death rates did not differ significantly between recipients and nonrecipients (33% vs. 21%). However, whereas only 8 (27%) of 30 patients at low risk for death (admission sequential organ failure assessment score of 0-5) received AIG-IV, 7 (54%) of the 13 patients at high risk for death (sequential organ failure assessment score of 6-11) received treatment. AIG-IV recipients had surgery more often and, among survivors, had longer hospital stays than did nonrecipients. AIG-IV recipients were sicker than nonrecipients. This difference and the small number of higher risk patients confound assessment of AIG-IV effectiveness in this outbreak.
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13
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Gal Y, Mazor O, Falach R, Sapoznikov A, Kronman C, Sabo T. Treatments for Pulmonary Ricin Intoxication: Current Aspects and Future Prospects. Toxins (Basel) 2017; 9:toxins9100311. [PMID: 28972558 PMCID: PMC5666358 DOI: 10.3390/toxins9100311] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 09/26/2017] [Accepted: 09/29/2017] [Indexed: 12/13/2022] Open
Abstract
Ricin, a plant-derived toxin originating from the seeds of Ricinus communis (castor beans), is one of the most lethal toxins known, particularly if inhaled. Ricin is considered a potential biological threat agent due to its high availability and ease of production. The clinical manifestation of pulmonary ricin intoxication in animal models is closely related to acute respiratory distress syndrome (ARDS), which involves pulmonary proinflammatory cytokine upregulation, massive neutrophil infiltration and severe edema. Currently, the only post-exposure measure that is effective against pulmonary ricinosis at clinically relevant time-points following intoxication in pre-clinical studies is passive immunization with anti-ricin neutralizing antibodies. The efficacy of this antitoxin treatment depends on antibody affinity and the time of treatment initiation within a limited therapeutic time window. Small-molecule compounds that interfere directly with the toxin or inhibit its intracellular trafficking may also be beneficial against ricinosis. Another approach relies on the co-administration of antitoxin antibodies with immunomodulatory drugs, thereby neutralizing the toxin while attenuating lung injury. Immunomodulators and other pharmacological-based treatment options should be tailored according to the particular pathogenesis pathways of pulmonary ricinosis. This review focuses on the current treatment options for pulmonary ricin intoxication using anti-ricin antibodies, disease-modifying countermeasures, anti-ricin small molecules and their various combinations.
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Affiliation(s)
- Yoav Gal
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
| | - Ohad Mazor
- Department of Infectious Diseases, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
| | - Reut Falach
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
| | - Anita Sapoznikov
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
| | - Chanoch Kronman
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
| | - Tamar Sabo
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological Research, Ness-Ziona 76100, Israel.
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Xu W, Ohanjandian L, Sun J, Cui X, Suffredini D, Li Y, Welsh J, Eichacker PQ. A systematic review and meta-analysis of preclinical trials testing anti-toxin therapies for B. anthracis infection: A need for more robust study designs and results. PLoS One 2017; 12:e0182879. [PMID: 28797061 PMCID: PMC5552191 DOI: 10.1371/journal.pone.0182879] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [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: 04/01/2017] [Accepted: 07/26/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND B. anthracis anti-toxin agents are approved and included in the Strategic National Stockpile based primarily on animal infection trials. However, in the only anthrax outbreak an approved anti-toxin agent was administered in, survival did not differ comparing recipients and non-recipients, although recipients appeared sicker. OBJECTIVE Employ a systematic review and meta-analysis to investigate preclinical studies supporting anthrax anti-toxin agents. DATA SOURCE PubMed, EMBASE, and Scopus. STUDY ELIGIBILITY Compared survival with an anti-toxin agent versus control in B. anthracis challenged, antibiotic treated animals. STUDY METHODS Examine model and study design and the effect of anti-toxin agents on relative risk of death(95%CI) (RR). RESULTS From 9 studies, 29 experiments were analyzed which included 4 species (748 animals) and 5 agents; LFI, AIG, AVP-21D9, Raxibacumab, and ETI-204. Only five experiments were blinded and no experiment included the cardiopulmonary support sick B. anthracis patients receive. Only one agent in a single un-blinded experiment reduced RR significantly [0.45(0.22,0.940]. However, in six studies testing an agent in more than one experiment in the same species, agents had consistent survival effects across experiments [I2 = 0, p≥0.55 in five and I2 = 42%, p = 0.16 in one]. Within each species, agents had effects on the side of benefit; in one study testing AVP-21D9 in mice [0.11(0.01,1.82)] or guinea pigs [0.70(0.48,1.03)]; across eight rabbit studies testing LFI, Raxibacumab, AIG or ETI-204 [0.62(0.45,0.87); I2 = 17.4%, p = 0.29]; and across three monkey studies testing Raxibacumab, AIG or ETI-204 [0.66(0.34,1.27); I2 = 25.3%, p = 0.26]. Across all agents and species, agents decreased RR [0.64(0.52,0.79); I2 = 5.3%, p = 0.39]. LIMITATIONS Incidence of selective reporting not identifiable. CONCLUSIONS Although overall significant, individually anti-toxin agents had weak beneficial effects. Lack of study blinding and relevant clinical therapies further weakened studies. Although difficult, preclinical studies with more robust designs and results are warranted to justify the resources necessary to maintain anti-toxin agents in national stockpiles.
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Affiliation(s)
- Wanying Xu
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Lernik Ohanjandian
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Dante Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Yan Li
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Judith Welsh
- National Institutes of Health Library, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States of America
- * E-mail:
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15
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Abstract
OBJECTIVE To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015). DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.
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Affiliation(s)
- Allan Doctor
- Departments of Pediatrics (Critical Care Medicine) and Biochemistry, Washington University in Saint Louis
| | - Jerry Zimmerman
- Department of Pediatrics (Critical Care Medicine), University of Washington, Seattle, WA
| | - Michael Agus
- Department of Pediatrics (Critical Care Medicine), Harvard University, Boston, MA
| | - Surender Rajasekaran
- Department of Pediatrics (Critical Care Medicine), Michigan State University, Grand Rapids, MI
| | | | - James Fortenberry
- Department of Pediatrics (Critical Care Medicine), Emory University, Atlanta, GA
| | - Anne Zajicek
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, NICHD
| | - Katri Typpo
- Department of Pediatrics (Critical Care Medicine), University of Arizona, Phoenix, AZ
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Nagy CF, Mondick J, Serbina N, Casey LS, Carpenter SE, French J, Guttendorf R. Animal-to-Human Dose Translation of Obiltoxaximab for Treatment of Inhalational Anthrax Under the US FDA Animal Rule. Clin Transl Sci 2017; 10:12-19. [PMID: 27925405 PMCID: PMC5245108 DOI: 10.1111/cts.12433] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/07/2016] [Indexed: 12/14/2022] Open
Abstract
Obiltoxaximab, a monoclonal antibody against protective antigen (PA), is approved for treatment of inhalational anthrax under the US Food and Drug Administration's (FDA) Animal Rule. The human dose was selected and justified by comparing observed obiltoxaximab exposures in healthy and infected New Zealand White rabbits and cynomolgus macaques to observed exposures in healthy humans, to simulated exposures in healthy and infected humans, and to serum PA levels in infected animals. In humans, at 16 mg/kg intravenous, obiltoxaximab AUC was >2 times that in animals, while maximum serum concentrations were comparable to those in animals and were maintained in excess of the concentration required for PA neutralization in infected animals for 2-3 weeks. Obiltoxaximab 16 mg/kg in humans provided exposure beyond that of 16 mg/kg in animals, ensuring a sufficient duration of PA neutralization to allow for adaptive immunity development. Our approach to dose translation may be applicable to other agents being developed under the Animal Rule.
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Affiliation(s)
- CF Nagy
- Department of Clinical OperationsElusys Therapeutics, IncPine BrookNew JerseyUSA
| | - J Mondick
- Metrum Research Group LLCTariffvilleConnecticutUSA
| | - N Serbina
- Department of Research and Nonclinical Development, Elusys Therapeutics, IncPine BrookNew JerseyUSA
| | - LS Casey
- Department of Research and Nonclinical Development, Elusys Therapeutics, IncPine BrookNew JerseyUSA
| | - SE Carpenter
- Department of Research and Nonclinical Development, Elusys Therapeutics, IncPine BrookNew JerseyUSA
| | - J French
- Metrum Research Group LLCTariffvilleConnecticutUSA
| | - R Guttendorf
- Aclairo Pharmaceutical Development Group IncViennaVirginiaUSA
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Anniballi F, Chironna E, Astegiano S, Fiore A, Auricchio B, Buonincontro G, Corvonato M, Segala V, Mandarino G, De Medici D, Decastelli L. Foodborne botulism associated with home-preserved turnip tops in Italy. Ann Ist Super Sanita 2016; 51:60-1. [PMID: 25857385 DOI: 10.4415/ann_15_01_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In Italy, foodborne botulism is a rare disease mainly due to home-preserved food. In the case reported here, clinical diagnosis was performed on the basis of clinical signs and referred consumption of home-preserved turnip tops in oil. Definitive diagnosis was performed by detection of botulinum toxin in sera and neuro-toxigenic organisms in stools and leftover food. This case report highlights the need of a high medical awareness, prompt clinical diagnosis, and synergic collaboration among the health authorities for a correct management of botulism as well as disease containment.
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Abstract
BACKGROUND Bacillus anthracis, the causative agent of anthrax, is a spore forming and toxin producing rod-shaped bacterium that is classified as a category A bioterror agent. This pathogenic microbe can be transmitted to both animals and humans. Clinical presentation depends on the route of entry (direct contact, ingestion, injection or aerosolization) with symptoms ranging from isolated skin infections to more severe manifestations such as cardiac or pulmonary shock, meningitis, and death. To date, anthrax is treatable if antibiotics are administered promptly and continued for 60 days. However, if treatment is delayed or administered improperly, the patient's chances of survival are decreased drastically. In addition, antibiotics are ineffective against the harmful anthrax toxins and spores. Therefore, alternative therapeutics are essential. In this review article, we explore and discuss advances that have been made in anthrax therapy with a primary focus on alternative pre-approved and novel antibiotics as well as anti-toxin therapies. METHODS A literature search was conducted using the University of Manitoba search engine. Using this search engine allowed access to a greater variety of journals/articles that would have otherwise been restricted for general use. In order to be considered for discussion for this review, all articles must have been published later than 2009. RESULTS The alternative pre-approved antibiotics demonstrated high efficacy against B. anthracis both in vitro and in vivo. In addition, the safety profile and clinical pharmacology of these drugs were already known. Compounds that targeted underexploited bacterial processes (DNA replication, RNA synthesis, and cell division) were also very effective in combatting B. anthracis. In addition, these novel compounds prevented bacterial resistance. Targeting B. anthracis virulence, more specifically the anthrax toxins, increased the length of which treatment could be administered. CONCLUSIONS Several novel and pre-existing antibiotics, as well as toxin inhibitors, have shown increasing promise. A combination treatment that targets both bacterial growth and toxin production would be ideal and probably necessary for effectively combatting this armed bacterium.
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Affiliation(s)
- Breanne M. Head
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB R3E 0J9 Canada
| | - Ethan Rubinstein
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB R3E 0J9 Canada
| | - Adrienne F. A. Meyers
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB R3E 0J9 Canada
- National Laboratory for HIV Immunology, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, Winnipeg, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
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19
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Huang E, Pillai SK, Bower WA, Hendricks KA, Guarnizo JT, Hoyle JD, Gorman SE, Boyer AE, Quinn CP, Meaney-Delman D. Antitoxin Treatment of Inhalation Anthrax: A Systematic Review. Health Secur 2016; 13:365-77. [PMID: 26690378 DOI: 10.1089/hs.2015.0032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Concern about use of anthrax as a bioweapon prompted development of novel anthrax antitoxins for treatment. Clinical guidelines for the treatment of anthrax recommend antitoxin therapy in combination with intravenous antimicrobials; however, a large-scale or mass anthrax incident may exceed antitoxin availability and create a need for judicious antitoxin use. We conducted a systematic review of antitoxin treatment of inhalation anthrax in humans and experimental animals to inform antitoxin recommendations during a large-scale or mass anthrax incident. A comprehensive search of 11 databases and the FDA website was conducted to identify relevant animal studies and human reports: 28 animal studies and 3 human cases were identified. Antitoxin monotherapy at or shortly after symptom onset demonstrates increased survival compared to no treatment in animals. With early treatment, survival did not differ between antimicrobial monotherapy and antimicrobial-antitoxin therapy in nonhuman primates and rabbits. With delayed treatment, antitoxin-antimicrobial treatment increased rabbit survival. Among human cases, addition of antitoxin to combination antimicrobial treatment was associated with survival in 2 of the 3 cases treated. Despite the paucity of human data, limited animal data suggest that adjunctive antitoxin therapy may improve survival. Delayed treatment studies suggest improved survival with combined antitoxin-antimicrobial therapy, although a survival difference compared with antimicrobial therapy alone was not demonstrated statistically. In a mass anthrax incident with limited antitoxin supplies, antitoxin treatment of individuals who have not demonstrated a clinical benefit from antimicrobials, or those who present with more severe illness, may be warranted. Additional pathophysiology studies are needed, and a point-of-care assay correlating toxin levels with clinical status may provide important information to guide antitoxin use during a large-scale anthrax incident.
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Dixit R, Herz J, Dalton R, Booy R. Benefits of using heterologous polyclonal antibodies and potential applications to new and undertreated infectious pathogens. Vaccine 2016; 34:1152-61. [PMID: 26802604 PMCID: PMC7131169 DOI: 10.1016/j.vaccine.2016.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 01/06/2016] [Accepted: 01/08/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Passive immunotherapy using polyclonal antibodies (immunoglobulins) has been used for over a century in the treatment and post-exposure prophylaxis of various infections and toxins. Heterologous polyclonal antibodies are obtained from animals hyperimmunised with a pathogen or toxin. AIMS The aims of this review are to examine the history of animal polyclonal antibody therapy use, their development into safe and effective products and the potential application to humans for emerging and neglected infectious diseases. METHODS A literature search of OVID Medline and OVID Embase databases was undertaken to identify articles on the safety, efficacy and ongoing development of polyclonal antibodies. The search contained database-specific MeSH and EMTREE terms in combination with pertinent text-words: polyclonal antibodies and rare/neglected diseases, antivenins, immunoglobulins, serum sickness, anaphylaxis, drug safety, post marketing surveillance, rabies, human influenza, Dengue, West Nile, Nipah, Hendra, Marburg, MERS, Hemorrhagic Fever Virus, and Crimean-Congo. No language limits were applied. The final search was completed on 20.06.2015. Of 1960 articles, title searches excluded many irrelevant articles, yielding 303 articles read in full. Of these, 179 are referenced in this study. RESULTS Serum therapy was first used in the 1890s against diphtheria. Early preparation techniques yielded products contaminated with reactogenic animal proteins. The introduction of enzymatic digestion, and purification techniques substantially improved their safety profile. The removal of the Fc fragment of antibodies further reduces hypersensitivity reactions. Clinical studies have demonstrated the efficacy of polyclonal antibodies against various infections, toxins and venoms. Products are being developed against infections for which prophylactic and therapeutic options are currently limited, such as avian influenza, Ebola and other zoonotic viruses. CONCLUSIONS Polyclonal antibodies have been successfully applied to rabies, envenomation and intoxication. Polyclonal production provides an exciting opportunity to revolutionise the prognosis of both longstanding neglected tropical diseases as well as emerging infectious threats to humans.
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Affiliation(s)
- Rashmi Dixit
- The Children's Hospital, Westmead, Sydney, Australia.
| | | | | | - Robert Booy
- The Children's Hospital, Westmead, Sydney, Australia
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21
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Pillai SK, Huang E, Guarnizo JT, Hoyle JD, Katharios-Lanwermeyer S, Turski TK, Bower WA, Hendricks KA, Meaney-Delman D. Antimicrobial Treatment for Systemic Anthrax: Analysis of Cases from 1945 to 2014 Identified Through a Systematic Literature Review. Health Secur 2015; 13:355-64. [PMID: 26623698 DOI: 10.1089/hs.2015.0033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Systemic anthrax is associated with high mortality. Current national guidelines, developed for the individualized treatment of systemic anthrax, outline the use of combination intravenous antimicrobials for a minimum of 2 weeks, bactericidal and protein synthesis inhibitor antimicrobials for all cases of systemic anthrax, and at least 3 antimicrobials with good blood-brain barrier penetration for anthrax meningitis. However, in an anthrax mass casualty incident, large numbers of anthrax cases may create challenges in meeting antimicrobial needs. To further inform our understanding of the role of antimicrobials in treating systemic anthrax, a systematic review of the English-language literature was conducted to identify cases of systemic anthrax treated with antimicrobials for which a clinical outcome was recorded. A total of 149 cases of systemic anthrax were identified. Among the identified 59 cases of cutaneous anthrax, 33 were complicated by meningitis (76% mortality), while 26 simply had evidence of the systemic inflammatory response syndrome (4% mortality); 21 of 26 (81%) of this latter group received monotherapy. Subsequent analysis regarding combination antimicrobial therapy was restricted to the remaining 123 cases of more severe anthrax (overall 67% mortality). Recipients of combination bactericidal and protein synthesis inhibitor therapy had a 45% survival versus 28% in the absence of combination therapy (p = 0.07). For meningitis cases (n = 77), survival was greater for those receiving 3 or more antimicrobials over the course of treatment (3 of 4; 75%), compared to receipt of 1 or 2 antimicrobials (12 of 73; 16%) (p = 0.02). Median parenteral antimicrobial duration was 14 days. Combination bactericidal and protein synthesis inhibitor therapy may be appropriate in severe anthrax disease, particularly anthrax meningitis, in a mass casualty incident.
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22
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Targowski T, Płusa T. [Overall principles of treatment in case of toxicological threats]. Pol Merkur Lekarski 2015; 39:191-193. [PMID: 26449586] [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] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Toxins and venoms are silent weapons capable of killing people secretly. All around the world, there are a lot of such substances produced by bacteria, fungi, plants and animals. The threat to health and life, which are caused by toxins and venoms, meant that they are seen as a biological weapon. In the rescue proceedings with the victims the mechanism of toxin action is imported, because in some cases the antitoxins are known. However, in the most cases, the primary consideration is the symptomatic treatment. Conducted research on the usefulness of oxime and autofages in eliminating the effects of toxins are advanced, but not yet implemented into therapy. In each case the toxin action the victims must be evacuated to a safe location. It is also necessary to protect teams providing assistance in suitable protective clothing.
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Affiliation(s)
- Tomasz Targowski
- Military Medical Institute in Warsaw, Department of Internal Medicine, Pulmonology and Allergology, Central Clinical Hospital of the Ministry of National Defense
| | - Tadeusz Płusa
- Military Medical Institute in Warsaw, Department of Internal Medicine, Pulmonology and Allergology, Central Clinical Hospital of the Ministry of National Defense
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23
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Abstract
Type II (proteic) toxin–antitoxin (TA) operons are widely spread in bacteria and archaea. They are organized as operons in which, usually, the antitoxin gene precedes the cognate toxin gene. The antitoxin generally acts as a transcriptional self-repressor, whereas the toxin acts as a co-repressor, both proteins constituting a harmless complex. When bacteria encounter a stressful environment, TAs are triggered. The antitoxin protein is unstable and will be degraded by host proteases, releasing the free toxin to halt essential processes. The result is a cessation of cell growth or even death. Because of their ubiquity and the essential processes targeted, TAs have been proposed as good candidates for development of novel antimicrobials. We discuss here the possible druggability of TAs as antivirals and antibacterials, with focus on the potentials and the challenges that their use may find in the ‘real’ world. We present strategies to develop TAs as antibacterials in view of novel technologies, such as the use of very small molecules (fragments) as inhibitors of protein–protein interactions. Appropriate fragments could disrupt the T:A interfaces leading to the release of the targeted TA pair. Possible ways of delivery and formulation of Tas are also discussed. We consider various approaches to develop the toxins of the type II family as possible candidates to drug discovery; druggability of toxins-antitoxins could be possible as antivirals. As antibacterials, they might be considered as druggable but delivery and formulation may not be simple so far.
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Affiliation(s)
- Wai Ting Chan
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Ramiro de Maeztu, 9, 28006-Madrid, Spain
| | - Dolors Balsa
- Immunology & Vaccines, Laboratorios LETI, Gran Via de les Corts Catalanes 184. 08034-Barcelona, Spain
| | - Manuel Espinosa
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Ramiro de Maeztu, 9, 28006-Madrid, Spain
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Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT, Rubinstein E, Holty JEC, Messonnier NE, Smith TL, Pesik N, Treadwell TA, Bower WA. Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014; 20. [PMID: 24447897 PMCID: PMC3901462 DOI: 10.3201/eid2002.130687] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The Centers for Disease Control and Prevention convened panels of anthrax experts to review and update guidelines for anthrax postexposure prophylaxis and treatment. The panels included civilian and military anthrax experts and clinicians with experience treating anthrax patients. Specialties represented included internal medicine, pediatrics, obstetrics, infectious disease, emergency medicine, critical care, pulmonology, hematology, and nephrology. Panelists discussed recent patients with systemic anthrax; reviews of published, unpublished, and proprietary data regarding antimicrobial drugs and anthrax antitoxins; and critical care measures of potential benefit to patients with anthrax. This article updates antimicrobial postexposure prophylaxis and antimicrobial and antitoxin treatment options and describes potentially beneficial critical care measures for persons with anthrax, including clinical procedures for infected nonpregnant adults. Changes from previous guidelines include an expanded discussion of critical care and clinical procedures and additional antimicrobial choices, including preferred antimicrobial drug treatment for possible anthrax meningitis.
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25
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Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA, Messonnier NE, Jamieson DJ. Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women. Emerg Infect Dis 2014; 20. [PMID: 24457117 PMCID: PMC3901460 DOI: 10.3201/eid2002.130611] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Clinical recommendations for the prevention and treatment of anthrax among pregnant women are updated. In August 2012, the Centers for Disease Control and Prevention, in partnership with the Association of Maternal and Child Health Programs, convened a meeting of national subject matter experts to review key clinical elements of anthrax prevention and treatment for pregnant, postpartum, and lactating (P/PP/L) women. National experts in infectious disease, obstetrics, maternal fetal medicine, neonatology, pediatrics, and pharmacy attended the meeting, as did representatives from professional organizations and national, federal, state, and local agencies. The meeting addressed general principles of prevention and treatment for P/PP/L women, vaccines, antimicrobial prophylaxis and treatment, clinical considerations and critical care issues, antitoxin, delivery concerns, infection control measures, and communication. The purpose of this meeting summary is to provide updated clinical information to health care providers and public health professionals caring for P/PP/L women in the setting of a bioterrorist event involving anthrax.
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26
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Sako FB, Bangoura EF, Traoré FA, Soumah MM, Tounkara TM, Djessanglar R, Baldé H, Baldé O. [Scorpion envenomation treated in the Infectious and Tropical Diseases at the Donka National Hospital, Guinea]. ACTA ACUST UNITED AC 2014; 107:323-6. [PMID: 25158841 DOI: 10.1007/s13149-014-0385-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/26/2013] [Accepted: 06/17/2014] [Indexed: 11/25/2022]
Abstract
A retrospective descriptive study was conducted from 1(st) October 2010 to 30 November 2012 on the records of patients admitted for scorpion envenomation in the Department of Infectious and Tropical Diseases at the Donka National Hospital. The objective of this study is to describe the epidemiological profile and clinical characteristics of scorpion envenomation in Maritime Guinea, from scorpion stings recently covered in this service. We collected 75 cases of scorpion envenomation. The median age was 21.5 with interquartile 8 and 20 and sex ratio was 1.29. The upper limbs were involved in 55% of cases, followed by the lower limbs (35%), trunk (6%), head and neck (4%). We observed 63% of patients with local signs, 30% mild and general clinical signs of 7% severe systemic symptoms. All patients received an analgesic and a heterologous antitoxin, associated with an antibiotic (87% of patients), a corticosteroid (72%), diazepam (13%) and furosemide (34.6%). The incidence of scorpion envenomation is not negligible despite underreporting of cases, most often treated in traditional medicine.
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Affiliation(s)
- F B Sako
- Service des maladies infectieuses et tropicales de l'hôpital national Donka, Donka, République de Guinée,
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Stich N, Model N, Samstag A, Gruener CS, Wolf HM, Eibl MM. Toxic shock syndrome toxin-1-mediated toxicity inhibited by neutralizing antibodies late in the course of continual in vivo and in vitro exposure. Toxins (Basel) 2014; 6:1724-41. [PMID: 24887085 PMCID: PMC4073126 DOI: 10.3390/toxins6061724] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 05/07/2014] [Accepted: 05/20/2014] [Indexed: 02/05/2023] Open
Abstract
Toxic shock syndrome (TSS) results from the host's overwhelming inflammatory response and cytokine storm mainly due to superantigens (SAgs). There is no effective specific therapy. Application of immunoglobulins has been shown to improve the outcome of the disease and to neutralize SAgs both in vivo and in vitro. However, in most experiments that have been performed, antiserum was either pre-incubated with SAg, or both were applied simultaneously. To mirror more closely the clinical situation, we applied a multiple dose (over five days) lethal challenge in a rabbit model. Treatment with toxic shock syndrome toxin 1 (TSST-1) neutralizing antibody was fully protective, even when administered late in the course of the challenge. Kinetic studies on the effect of superantigen toxins are scarce. We performed in vitro kinetic studies by neutralizing the toxin with antibodies at well-defined time points. T-cell activation was determined by assessing T-cell proliferation (3H-thymidine incorporation), determination of IL-2 release in the cell supernatant (ELISA), and IL-2 gene activation (real-time PCR (RT-PCR)). Here we show that T-cell activation occurs continuously. The application of TSST-1 neutralizing antiserum reduced IL-2 and TNFα release into the cell supernatant, even if added at later time points. Interference with the prolonged stimulation of proinflammatory cytokines is likely to be in vivo relevant, as postexposure treatment protected rabbits against the multiple dose lethal SAg challenge. Our results shed new light on the treatment of TSS by specific antibodies even at late stages of exposure.
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MESH Headings
- Animals
- Antibodies, Neutralizing/pharmacology
- Antibodies, Neutralizing/therapeutic use
- Antitoxins/pharmacology
- Antitoxins/therapeutic use
- Bacterial Toxins/antagonists & inhibitors
- Bacterial Toxins/genetics
- Bacterial Toxins/metabolism
- Bacterial Toxins/toxicity
- Cell Proliferation/drug effects
- Cells, Cultured
- Disease Models, Animal
- Enterotoxins/antagonists & inhibitors
- Enterotoxins/genetics
- Enterotoxins/metabolism
- Enterotoxins/toxicity
- Female
- Gene Expression Regulation/drug effects
- Humans
- Interleukin-2/genetics
- Interleukin-2/metabolism
- Leukocytes, Mononuclear/cytology
- Leukocytes, Mononuclear/drug effects
- Leukocytes, Mononuclear/immunology
- Leukocytes, Mononuclear/metabolism
- Lymphocyte Activation/drug effects
- Male
- Mutant Proteins/antagonists & inhibitors
- Mutant Proteins/metabolism
- Mutant Proteins/toxicity
- Rabbits
- Recombinant Proteins/chemistry
- Recombinant Proteins/metabolism
- Recombinant Proteins/toxicity
- Shock, Septic/drug therapy
- Shock, Septic/etiology
- Shock, Septic/immunology
- Shock, Septic/metabolism
- Superantigens/genetics
- Superantigens/metabolism
- Superantigens/toxicity
- Survival Analysis
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Toxicokinetics
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
- Norbert Stich
- Biomedizinische ForschungsgmbH Lazarettgasse 19/2, Vienna A-1090, Austria.
| | - Nina Model
- Biomedizinische ForschungsgmbH Lazarettgasse 19/2, Vienna A-1090, Austria.
| | - Aysen Samstag
- Immunology Outpatient Clinic, Schwarzspanierstrasse 15, Vienna A-1090, Austria.
| | - Corina S Gruener
- Biomedizinische ForschungsgmbH Lazarettgasse 19/2, Vienna A-1090, Austria.
| | - Hermann M Wolf
- Immunology Outpatient Clinic, Schwarzspanierstrasse 15, Vienna A-1090, Austria.
| | - Martha M Eibl
- Biomedizinische ForschungsgmbH Lazarettgasse 19/2, Vienna A-1090, Austria.
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Chen K, Shu G, Peng X, Fang J, Cui H, Chen J, Wang F, Chen Z, Zuo Z, Deng J, Geng Y, Lai W. Protective role of sodium selenite on histopathological lesions, decreased T-cell subsets and increased apoptosis of thymus in broilers intoxicated with aflatoxin B₁. Food Chem Toxicol 2013; 59:446-54. [PMID: 23810797 DOI: 10.1016/j.fct.2013.06.032] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [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: 02/15/2013] [Revised: 06/16/2013] [Accepted: 06/18/2013] [Indexed: 01/15/2023]
Abstract
For evaluating the ability of selenium (Se) in counteracting the adverse effects of aflatoxin B₁ (AFB₁), two hundred 1-day-old male Avian broilers, divided into five groups, were fed with basal diet (control group), 0.3 mg/kg AFB₁ (AFB₁ group), 0.3 mg/kg AFB₁+0.2 mg/kg Se (+Se group I), 0.3mg/kg AFB₁+0.4 mg/kg Se (+Se group II) and 0.3mg/kg AFB₁+0.6 mg/kg Se (+Se group III), respectively. Compared with control group, the decreased relative weight of thymus and percentages of mature thymocytes, congestion in medulla and much debris in cortex of thymus, and the increased apoptotic thymocytes were observed in AFB1 group. However, supplied dietary sodium selenite could increase the relative weight of thymus and percentages of mature thymocytes, and alleviate histopathological lesions. Compared with AFB1 group, the percentages of apoptotic thymocytes detected by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling method and flow cytometry method in three +Se groups were decreased, the expression of Caspase-3 and Bax, through quantitative real-time PCR and immunohistochemical method, in three +Se groups were decreased, while the expression of Bcl-2 was increased. The results indicate that sodium selenite supplied in the diet, through a mechanism of apoptosis regulation, may ameliorated AFB₁-induced lesions of thymus and accordingly improve the impaired cellular immune function.
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Affiliation(s)
- Kejie Chen
- Key Laboratory of Animal Diseases and Environmental Hazards of Sichuan Province, College of Veterinary Medicine, Sichuan Agricultural University, Ya'an, Sichuan 625014, China
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Friedman M, Rasooly R. Review of the inhibition of biological activities of food-related selected toxins by natural compounds. Toxins (Basel) 2013; 5:743-75. [PMID: 23612750 PMCID: PMC3705290 DOI: 10.3390/toxins5040743] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 11/17/2022] Open
Abstract
There is a need to develop food-compatible conditions to alter the structures of fungal, bacterial, and plant toxins, thus transforming toxins to nontoxic molecules. The term 'chemical genetics' has been used to describe this approach. This overview attempts to survey and consolidate the widely scattered literature on the inhibition by natural compounds and plant extracts of the biological (toxicological) activity of the following food-related toxins: aflatoxin B1, fumonisins, and ochratoxin A produced by fungi; cholera toxin produced by Vibrio cholerae bacteria; Shiga toxins produced by E. coli bacteria; staphylococcal enterotoxins produced by Staphylococcus aureus bacteria; ricin produced by seeds of the castor plant Ricinus communis; and the glycoalkaloid α-chaconine synthesized in potato tubers and leaves. The reduction of biological activity has been achieved by one or more of the following approaches: inhibition of the release of the toxin into the environment, especially food; an alteration of the structural integrity of the toxin molecules; changes in the optimum microenvironment, especially pH, for toxin activity; and protection against adverse effects of the toxins in cells, animals, and humans (chemoprevention). The results show that food-compatible and safe compounds with anti-toxin properties can be used to reduce the toxic potential of these toxins. Practical applications and research needs are suggested that may further facilitate reducing the toxic burden of the diet. Researchers are challenged to (a) apply the available methods without adversely affecting the nutritional quality, safety, and sensory attributes of animal feed and human food and (b) educate food producers and processors and the public about available approaches to mitigating the undesirable effects of natural toxins that may present in the diet.
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Affiliation(s)
- Mendel Friedman
- Produce Safety and Microbiology Research Unit, Agricultural Research Service, USDA, Albany, CA 94710, USA
| | - Reuven Rasooly
- Foodborne Contaminants Research Unit, Agricultural Research Service, USDA, Albany, CA 94710, USA; E-Mail:
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Koo YS, Kim YS. Author’s response to letter to the editor. Clin Mol Hepatol 2013; 19:98. [PMID: 23720868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
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Hu WG, Yin J, Chau D, Negrych LM, Cherwonogrodzky JW. Humanization and characterization of an anti-ricin neutralization monoclonal antibody. PLoS One 2012; 7:e45595. [PMID: 23049820 PMCID: PMC3458913 DOI: 10.1371/journal.pone.0045595] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/21/2012] [Indexed: 01/02/2023] Open
Abstract
Ricin is regarded as a high terrorist risk for the public due to its high toxicity and ease of production. Currently, there is no therapeutic or vaccine available against ricin. D9, a murine monoclonal antibody developed previously in our laboratory, can strongly neutralize ricin and is therefore a good candidate for humanization. Humanization of D9 variable regions was achieved by a complementarity-determining region grafting approach. The humanized D9 (hD9) variable regions were further grafted onto human heavy and light chain constant regions to assemble the complete antibody gene. A foot-and-mouth-disease virus-derived 2A self-processing sequence was introduced between heavy and light chain DNA sequences to cleave the recombinant protein into a functional full-length antibody molecule from a single open reading frame driven by a single promoter in an adenoviral vector. After expression in mammalian cells and purification, the hD9 was demonstrated to have equimolar expression of the full-length antibody heavy and light chains. More importantly, the hD9 exhibited high affinity to ricin with KD of 1.63 nM, comparable to its parental murine D9 (2.55 nM). In a mouse model, intraperitoneal (i.p.) administration of hD9, at a low dose of 5 µg per mouse, 4 hours after the i.p. challenge with 5×LD50 ricin was found to rescue 100% of the mice. In addition, administered 6 hours post-challenge, hD9 could still rescue 50% of the mice. The hD9 has the potential to be used for prophylactic or therapeutic purposes against ricin poisoning.
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MESH Headings
- Adenoviridae/genetics
- Amino Acid Sequence
- Animals
- Antibodies, Monoclonal, Humanized/genetics
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibody Affinity
- Antitoxins/genetics
- Antitoxins/immunology
- Antitoxins/therapeutic use
- Chemical Warfare Agents/poisoning
- Complementarity Determining Regions/genetics
- Complementarity Determining Regions/immunology
- DNA, Viral/genetics
- DNA, Viral/metabolism
- Female
- Foot-and-Mouth Disease Virus/genetics
- Genetic Vectors
- Half-Life
- Humans
- Immunoglobulin Heavy Chains/genetics
- Immunoglobulin Heavy Chains/immunology
- Immunoglobulin Light Chains/genetics
- Immunoglobulin Light Chains/immunology
- Injections, Intraperitoneal
- Mice
- Models, Molecular
- Molecular Sequence Data
- Plant Poisoning/immunology
- Plant Poisoning/mortality
- Plant Poisoning/prevention & control
- Protein Engineering
- Ricin/poisoning
- Survival Rate
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Affiliation(s)
- Wei-Gang Hu
- Defence Research and Development Canada - Suffield, Medicine Hat, Alberta, Canada.
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Abstract
The development of an infection involves interplay between the host's immune system and the virulence of the infecting microorganism. The traditional treatment of an infection involves antimicrobial chemotherapy to kill the organism. The use of immunotherapies in infections includes treatment options that modulate the immune response and can lead to control of infections. These therapies are expected to become more important therapeutic options with the increase in infections due to multidrug-resistant organisms and the increasing number of immunocompromised patients.
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Affiliation(s)
- Vivek Kak
- Allegiance Health, 1100 East Michigan Avenue, #305, Jackson, MI 49201, USA.
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Mett V, Chichester JA, Stewart ML, Musiychuk K, Bi H, Reifsnyder CJ, Hull AK, Albrecht MT, Goldman S, Baillie LWJ, Yusibov V. A non-glycosylated, plant-produced human monoclonal antibody against anthrax protective antigen protects mice and non-human primates from B. anthracis spore challenge. Hum Vaccin 2011; 7 Suppl:183-90. [PMID: 21270531 DOI: 10.4161/hv.7.0.14586] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The health and economic burden of infectious diseases in general and bioterrorism in particular necessitate the development of medical countermeasures. One proven approach to reduce the disease burden and spread of pathogen is treatment with monoclonal antibodies (mAb). mAbs can prevent or reduce severity of the disease by variety of mechanisms, including neutralizing pathogen growth, limiting its spread from infected to adjacent cells, or by inhibiting biological activity of toxins, such as anthrax lethal toxin. Here, we report the production of glycosylated (pp-mAb (PA) ) and non-glycosylated (pp-mAb (PANG) ) versions of a plant-derived mAb directed against protective antigen (PA) of Bacillus anthracis in Nicotiana benthamiana plants using agroinfiltration. Both forms of the antibody were able to neutralize anthrax lethal toxin activity in vitro and protect mice against an intraperitoneal challenge with spores of B. anthracis Sterne strain. A single 180 µg intraperitoneal dose of pp-mAb (PA) or pp-mAb (PANG) provided 90% and 100% survival, respectively. When tested in non-human primates, pp-mAb (PANG) was demonstrated to be superior to pp-mAb (PA) in that it had a significantly longer terminal half-life and conferred 100% protection against a lethal dose of aerosolized anthrax spore challenge after a single 5 mg/kg intravenous dose compared to a 40% survival rate conferred by pp-mAb (PA) . This study demonstrates the potential of a plant-produced non-glycosylated antibody as a useful tool for the treatment of inhalation anthrax.
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MESH Headings
- Animals
- Anthrax/therapy
- Antibodies, Bacterial/genetics
- Antibodies, Bacterial/metabolism
- Antibodies, Bacterial/therapeutic use
- Antibodies, Monoclonal/genetics
- Antibodies, Monoclonal/metabolism
- Antibodies, Monoclonal/therapeutic use
- Antigens, Bacterial
- Antitoxins/genetics
- Antitoxins/metabolism
- Antitoxins/therapeutic use
- Bacterial Toxins/antagonists & inhibitors
- Disease Models, Animal
- Macaca fascicularis
- Male
- Mice
- Mice, Inbred BALB C
- Plants, Genetically Modified/genetics
- Primate Diseases/therapy
- Recombinant Proteins/genetics
- Recombinant Proteins/metabolism
- Recombinant Proteins/therapeutic use
- Rodent Diseases/therapy
- Survival Analysis
- Nicotiana/genetics
- Treatment Outcome
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Affiliation(s)
- Vadim Mett
- Fraunhofer USA Center for Molecular Biotechnology, Newark, DE, USA
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Safdar A. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med 2010; 362:1444-5; author reply 1445-6. [PMID: 20397289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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Lowy I, Molrine DC, Leav BA, Blair BM, Baxter R, Gerding DN, Nichol G, Thomas WD, Leney M, Sloan S, Hay CA, Ambrosino DM. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med 2010; 362:197-205. [PMID: 20089970 DOI: 10.1056/nejmoa0907635] [Citation(s) in RCA: 547] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND New therapies are needed to manage the increasing incidence, severity, and high rate of recurrence of Clostridium difficile infection. METHODS We performed a randomized, double-blind, placebo-controlled study of two neutralizing, fully human monoclonal antibodies against C. difficile toxins A (CDA1) and B (CDB1). The antibodies were administered together as a single infusion, each at a dose of 10 mg per kilogram of body weight, in patients with symptomatic C. difficile infection who were receiving either metronidazole or vancomycin. The primary outcome was laboratory-documented recurrence of infection during the 84 days after the administration of monoclonal antibodies or placebo. RESULTS Among the 200 patients who were enrolled (101 in the antibody group and 99 in the placebo group), the rate of recurrence of C. difficile infection was lower among patients treated with monoclonal antibodies (7% vs. 25%; 95% confidence interval, 7 to 29; P<0.001). The recurrence rates among patients with the epidemic BI/NAP1/027 strain were 8% for the antibody group and 32% for the placebo group (P=0.06); among patients with more than one previous episode of C. difficile infection, recurrence rates were 7% and 38%, respectively (P=0.006). The mean duration of the initial hospitalization for inpatients did not differ significantly between the antibody and placebo groups (9.5 and 9.4 days, respectively). At least one serious adverse event was reported by 18 patients in the antibody group and by 28 patients in the placebo group (P=0.09). CONCLUSIONS The addition of monoclonal antibodies against C. difficile toxins to antibiotic agents significantly reduced the recurrence of C. difficile infection. (ClinicalTrials.gov number, NCT00350298.)
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Cheng LW, Stanker LH, Henderson TD, Lou J, Marks JD. Antibody protection against botulinum neurotoxin intoxication in mice. Infect Immun 2009; 77:4305-13. [PMID: 19651864 PMCID: PMC2747958 DOI: 10.1128/iai.00405-09] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [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: 04/10/2009] [Revised: 05/21/2009] [Accepted: 07/25/2009] [Indexed: 11/20/2022] Open
Abstract
Adulteration of food or feed with any of the seven serotypes of botulinum neurotoxin (BoNT) is a potential bioterrorism concern. Currently, there is strong interest in the development of detection reagents, vaccines, therapeutics, and other countermeasures. A sensitive immunoassay for detecting BoNT serotype A (BoNT/A), based on monoclonal antibodies (MAbs) F1-2 and F1-40, has been developed and used in complex matrices. The epitope for F1-2 has been mapped to the heavy chain of BoNT/A, and the epitope of F1-40 has been mapped to the light chain. The ability of these MAbs to provide therapeutic protection against BoNT/A intoxication in mouse intravenous and oral intoxication models was tested. High dosages of individual MAbs protected mice well both pre- and postexposure to BoNT/A holotoxin. A combination therapy consisting of antibodies against both the light and heavy chains of the toxin, however, significantly increased protection, even at a lower MAb dosage. An in vitro peptide assay for measuring toxin activity showed that pretreatment of toxin with these MAbs did not block catalytic activity but instead blocked toxin entry into primary and cultured neuronal cells. The timing of antibody rescue in the mouse intoxication models revealed windows of opportunity for antibody therapeutic treatment that correlated well with the biologic half-life of the toxin in the serum. Knowledge of BoNT intoxication and antibody clearance in these mouse models and understanding of the pharmacokinetics of BoNT are invaluable for future development of antibodies and therapeutics against intoxication by BoNT.
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Affiliation(s)
- Luisa W Cheng
- Foodborne Contaminants Research Unit, Western Regional Research Center, USDA Agricultural Research Service, 800 Buchanan Street, Albany, CA 94710, USA.
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Roest HIJ, de Bruijn CM, Picavet MTJE, Prins B, Parmentier D, de Zwart GMAM, Dijkstra YE, van Zijderveld FG. [Two horses with neurological symptoms: could this be equine botulism?]. Tijdschr Diergeneeskd 2009; 134:790-795. [PMID: 19891336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Symptoms, diagnosis and therapy of equine botulism are discussed by the presentation of two detailed reports of horses with neurological symptoms and the results of laboratory investigations over the period 2003-2008 in the Netherlands. In addition a brief summary of the available literature is presented. Prevailing symptoms of botulism in horses include paralysis of the tongue, salvation, dysphagia and paresis and paralysis of the skeletal muscles, as well as signs of colic. Symptoms and prognosis vary with the amount of botulinum neurotoxin (BoNT) involved. For early clinical diagnosis of botulism thorough investigation of the facial nerves is important, for instance by the use of the 'Tongue Stress Test'. Laboratory results often remain negative, probably due to the sampling time, the high sensitivity of horses for botulinum neurotoxin or treatment with antitoxins. Most clinical cases in horses are caused by botulinum neurotoxin B (BoNT/B). For therapy to be successful antiserum needs to be administered in the earliest possible stage of the disease and this should be supported by symptomatic therapy. Botulism is a feed-related intoxication caused by either carcasses in the roughage or BoNT/B production after poor conservation of grass silage. This is the main source of botulism in horses due to the popularity of individually packed grass silage as feed for horses. As long as no vaccine is available in the Netherlands quality control of silage and haylage is strictly recommended in order to reduce the risk of botulism in horses.
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Affiliation(s)
- H I J Roest
- Divisie Bacteriologie en TSE'S, Centraal Veterinair Instituut van Wageningen UR, Lelystad, Nederland.
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Temperton N. Society of General Microbiology--2009 spring meeting. IDrugs 2009; 12:294-296. [PMID: 19431093] [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] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Nigel Temperton
- University College London, Wohl Virion Centre and Division of Infection and Immunity, 46 Cleveland Street, London W1T 4JF, UK.
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Que HF, Tang HJ, Xing J, Xiang HY, Chen W, Cheng YQ. [Venomous snake bite treated by Chinese integrative medicine: a report of 4 cases]. Zhong Xi Yi Jie He Xue Bao 2008; 6:1071-1073. [PMID: 18847547 DOI: 10.3736/jcim20081018] [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] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Hua-Fa Que
- Institute of Traditional Chinese Surgery, Longhua Hospital, Shanghai University of Tranditional Chinese Medicine, Shanghai 200032, China.
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Selinsky CL, Whitlow VD, Smith LR, Kaslow DC, Horton HM. Qualification and performance characteristics of a quantitative enzyme-linked immunosorbent assay for human lgG antibodies to anthrax lethal factor antigen. Biologicals 2006; 35:123-9. [PMID: 17071101 DOI: 10.1016/j.biologicals.2006.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [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: 03/14/2006] [Revised: 07/07/2006] [Accepted: 07/13/2006] [Indexed: 11/30/2022] Open
Abstract
The contribution of Bacillus anthracis lethal factor (LF)-specific immune responses to protection against anthrax disease in humans remains incompletely defined due, in part, to a paucity of qualified reagents and a lack of standardized serological assays. Toward this end, we have identified and characterized suitable positive quality control and standard reference sera and developed, optimized, and qualified an enzyme-linked immunosorbent assay (ELISA) to measure LF-binding IgG. Herein we describe the performance characteristics of this ELISA and propose criteria for its use in the detection and quantification of anti-LF IgG in human serum.
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Abstract
AIM Anthrax is caused by the bacterium Bacillus anthracis. Although primarily a disease of animals, it can also infect man, sometimes with fatal consequences. As a result of concerns over the illicit use of this organism, considerable effort is focussed on the development of therapies capable of conferring protection against anthrax. This brief review will describe the efforts being made to address these issues. METHODS AND RESULTS A review of the literature and the proceedings of the sixth international conference on anthrax, held in Santa Fe, USA in 2005 shows intense activity, but there has been as yet no real progress. While effective antibiotics, antitoxins and vaccines are available, concerns over their toxicity and the emergence of resistant strains have driven the development of second-generation products. The principal target for vaccine development is Protective Antigen (PA), the nontoxic cell-binding component of anthrax lethal toxin. While the recombinant products currently undergoing human clinical trials will offer considerable advantages in terms of reduced side effects and ease of production, they would still require multiple, needle-based dosing, and the inclusion of the adjuvant alum makes them expensive to administer and stockpile. To address these issues, researchers are developing vaccine formulations, which stimulate rapid protection following needle-free injection (nasal, oral or transcutaneous), and are stable at room temperature to facilitate stockpiling and mass vaccination programs. CONCLUSIONS An array of medical countermeasures targeting B. anthracis will become available over the next 5-10 years. SIGNIFICANCE AND IMPACT OF THE STUDY The huge investment of research dollars is expected to dramatically expand the knowledge base. A better understanding of basic issues, such as survival in nature and pathogenesis in humans, will facilitate the development of new modalities to eliminate the threat posed by this organism.
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Affiliation(s)
- L W J Baillie
- Biodefence Initiative, Medical Biotechnology Center, University of Maryland Biotechnology Institute, Baltimore, 21201, USA.
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44
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Mabry R, Rani M, Geiger R, Hubbard GB, Carrion R, Brasky K, Patterson JL, Georgiou G, Iverson BL. Passive protection against anthrax by using a high-affinity antitoxin antibody fragment lacking an Fc region. Infect Immun 2005; 73:8362-8. [PMID: 16299334 PMCID: PMC1307075 DOI: 10.1128/iai.73.12.8362-8368.2005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [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: 07/13/2005] [Revised: 08/16/2005] [Accepted: 09/04/2005] [Indexed: 11/20/2022] Open
Abstract
Passive immunization has been successfully employed for protection against bacterial and viral infections for over 100 years. Immunoglobulin Fc regions play a critical role in the clearance of bacterial pathogens by mediating antibody-dependent and complement-dependent cytotoxicity. Here we show that antibody fragments engineered to recognize the protective antigen component of the B. anthracis exotoxin with high affinity and conjugated to polyethylene glycol (PEG) for prolonged circulation half-life confer significant protection against inhalation anthrax despite their lack of Fc regions. The speed and lower manufacturing cost of bacterially expressed PEGylated antibody fragments could provide decisive advantages for anthrax prophylaxis. Importantly, our results suggest that PEGylated antibody fragments may represent a unique approach for mounting a rapid therapeutic response to emerging pathogen infections.
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Affiliation(s)
- Robert Mabry
- Department of Chemical Engineering and Biomedical Engineering, University of Texas at Austin, 1 University Station, Austin, TX 78712, USA
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45
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Abstract
Health care providers must understand the following regarding pathogens linked to bioterrorism: (1) the classification and qualities of possible biologic agents; (2) the natural history and management of biologic, chemical and radiologic injuries and exposures; (3) chemical agents that may be used and their properties; (4) different types of radiologic terrorism; (5) decontamination procedures; and (6) availability of antidotes and other therapeutics.
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Affiliation(s)
- David Markenson
- Division of Pediatric Critical Care, Department of Pediatrics, Flushing Hospital Medical Center, NY 11355, USA.
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46
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Abstract
Sepsis syndrome, a systemic response to infection, can beget devastating outcomes even in previously normal individuals. Recent research in septic patients has led to the discovery that early goal-directed resuscitation guided by continuous monitoring of mixed venous hemoglobin saturation, along with moderate doses of corticosteroids, can reduce mortality. An improved understanding of the complex interaction between the inflammatory and coagulant systems in sepsis pathophysiology has resulted in novel treatments, such as recombinant human activated protein C, which improves survival in patients with severe sepsis and a high risk of death. However, despite an increased understanding of the complex pathophysiology of this syndrome and the discovery of new, effective treatments, severe sepsis still results in significant morbidity and mortality. Consequently, investigations continue into additional therapeutic agents directed against novel targets. Following a review of recent advances in sepsis treatment, we briefly discuss a few of the new, promising therapeutic strategies currently being investigated.
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Affiliation(s)
- Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Center for Lung Research, Nashville, Tennessee 37232-2650, USA.
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47
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Abstract
Never before has there been such a strong possibility that biological agents might be used indiscriminately on civilian populations. This review focuses on the use of antitoxins - antibodies, receptor decoys, dominant-negative inhibitors of translocation, small-molecule inhibitors and substrate analogues - to counteract those biological weapons for which toxins are an important mechanism of disease pathogenesis.
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Affiliation(s)
- G Jonah A Rainey
- Infectious Disease Laboratory, The Salk Institute for Biological Studies, 10010 North Torrey Pines Road, La Jolla, California 92037-1099, USA
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48
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Abgueguen P, Delbos V, Chennebault JM, Fanello S, Brenet O, Alquier P, Granry JC, Pichard E. Nine Cases of Foodborne Botulism Type B in France and Literature Review. Eur J Clin Microbiol Infect Dis 2003; 22:749-52. [PMID: 14605938 DOI: 10.1007/s10096-003-1019-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Presented here is an outbreak of nine cases of type B botulism that occurred in France in 2000 followed by a review of the relevant literature. The outbreak resulted from the consumption of home-canned asparagus and required the intubation of six patients. Despite complications, all patients recovered completely. Specific antitoxin treatment was not administered because it is no longer manufactured in France. The literature review covers the epidemiologic data reported from Europe and the USA to date and an assessment of the treatment options for botulism. The usefulness of establishing a European network to provide access to botulism antitoxins is discussed. Although their efficacy is not unanimously accepted, they remain the only specific treatment now known.
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Affiliation(s)
- P Abgueguen
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire d'Angers, 4 rue Larrey, 49033 Angers 01, France.
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49
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Abstract
There is general consensus that the bacterial agents or products most likely to be used as weapons of mass destruction are Bacillus anthracis, Yersinia pestis, Francisella tularensis and the neurotoxin of Clostridium botulinum. Modern supportive and antimicrobial therapy for inhalational anthrax is associated with a 45% mortality rate, reinforcing the need for better adjunctive therapy and prevention strategies. Pneumonic plague is highly contagious, difficult to recognize and is frequently fatal. Therefore, the development of vaccines against this agent is crucial. Although tularemia is associated with low mortality, the highly infectious nature of aerosolized F. tularensis poses a substantive threat that is best met by vaccine development. Safer antitoxins and a vaccine are required to meet the threat of the use of botulinum toxin as a weapon of mass destruction. In this article, the current status of research in these areas is reviewed.
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Affiliation(s)
- Ronald A Greenfield
- The Infectious Diseases Section, Department of Medicine, University of Oklahoma Health Sciences Center, & The Oklahoma City Veterans Administration Medical Center, Oklahoma City, OK 73190, USA.
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50
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Eddleston M, Senarathna L, Mohamed F, Buckley N, Juszczak E, Sheriff MHR, Ariaratnam A, Rajapakse S, Warrell D, Rajakanthan K. Deaths due to absence of an affordable antitoxin for plant poisoning. Lancet 2003; 362:1041-4. [PMID: 14522536 DOI: 10.1016/s0140-6736(03)14415-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There is a severe shortage of affordable antivenoms and antitoxins in the developing world. An anti-digoxin antitoxin for oleander poisoning was introduced in Sri Lanka in July, 2001, but because of its cost, stocks ran out in July, 2002. We looked at the effect of its introduction and withdrawal on case fatality, and determined its cost-effectiveness. The antitoxin strikingly reduced the case fatality; its absence resulted in a three-fold rise in deaths. At the present price of US2650 dollars per course, every life saved cost 10209 dollars and every life year cost 248 dollars. Reduction of the antitoxin's price to 400 dollars would reduce costs to 1137 dollars per life gained; a further reduction to 103 dollars would save money for every life gained. Treatments for poisoning and envenoming should be included in the present campaign to increase availability of affordable treatments in the developing world.
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Affiliation(s)
- Michael Eddleston
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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