Mini review: surveillance of Lyme borreliosis in Southeast Asia and method of diagnosis

Lyme borreliosis is caused by the Gram-negative spirochetes Borrelia spp., particularly Borrelia burgdorferi sensu lato complex. The disease is transmitted through the bite of the infected black-legged Ixodes tick. Lyme borreliosis extensively occurs in the Northern Hemisphere, mainly in the United States. Lyme borreliosis cases are also detected in Asian countries including Korea, Nepal, China, Taiwan, and Japan. However, there is an inadequate understanding of Lyme borreliosis in the Southeast Asian region. Hence, this review aims to provide a brief update on the prevalence of Lyme borreliosis infection in Southeast Asia based on the latest literature on this issue. Lyme borreliosis has been discovered in human serum in Indonesia, Malaysia, and Singapore. The human serum samples were mainly examined with ELISA test using Borrelia spp. IgG and IgM antigens. Borrelia spp. also has been detected in ticks found on host animals such as Sundamys muelleri and Python in Malaysia, Thailand, and Laos. Polymerase chain reaction (PCR) is used to detect the presence of Borrelia DNAs in the samples. The published studies have demonstrated that Borrelia spp. exists in Southeast Asia and although the incidence is relatively low, it is believed that Lyme disease cases are under-reported.

Plasmodium falciparum protein kinase as a potential therapeutic target for antimalarial drugs development

Malaria is one of the most dangerous infectious diseases due to its high infection and mortality rates, especially in the tropical belt. Plasmodium falciparum (P. falciparum), the most virulent malaria parasite in humans, was recently reported to develop resistance against the final efficient antimalarial drug, artemisinin. Little is known about the resistance mechanisms, which further complicates the problem as a proper counteraction is unable to be taken. Hence, the understanding of drug mode of action and its molecular target is valuable knowledge that needs to be considered to develop the next generation of antimalarial drugs. P. falciparum protein kinase (Pf PK) is an attractive target for antimalarial chemotherapy due to its vital roles in all P. falciparum life stages. Moreover, overall structural differences and the presence of unique Pf PKs that are absent in human kinome, suggesting specific inhibition of Pf PK without affecting human cells is achievable. To date, at least 86 eukaryotic protein kinases have been identified in P. falciparum kinome, by which less than 40 were validated as potential targets at the erythrocytes stage. In this review, recent progress of the furthest validated Pf PKs; Pf Nek-1, Pf CDPK1, Pf CDPK4, Pf PKG, and Pf CLK-3 will be briefly discussed.

AB0256 INCREASED SERUM PROCALCITONIN CONCENTRATION IN PATIENTS WITH RHEUMATOID ARTHRITIS FREE OF ACTIVE INFECTION

Background:

Rheumatoid arthritis (RA) is the most common inflammatory arthritis, affecting 0.5-1% of the general population worldwide. Patients with RA are often in a relatively immunocompromised status. Previous study have evaluated procalcitonin (PCT) application among autoimmune and autoinflammatory diseases for the diagnosis of systemic bacterial infection (1, 2) To date, the correlation of baseline PCT levels and RA disease activities, different treatment, or the expression of proinflammatory cytokines in patients with RA remained unknown.

Objectives:

To investigate the baseline PCT levels among patients with RA without active infection compared with healthy controls and to understand the relationship of PCT with RA disease activity, treatment received by patients, and the expression of proinflammatory cytokines.

Methods:

Patients aged 20 years and above, with clinician-confirmed diagnosis of RA were included during regular outpatient visits. RA disease activity was measured using the DAS28-ESR.

Results:

A total of 623 patients with RA and 40 healthy subjects were recruited in this study. The mean PCT were significantly higher in patients with RA (6.90 ± 11.81 * 10-3ng/mL) compared with healthy controls (1.14 ± 3.26 * 10-3ng/mL) (p = 0.002). After adjusted for age and sex, the PCT levels remain significantly elevated in patients with RA (p = 0.001). PCT was not significantly correlated with biologic agent, age, sex, disease duration, disease activity, C-reactive protein, conventional synthetic disease-modifying antirheumatic drugs (csDMARD), and comorbidities. Multiple linear regression analysis showed that PCT was inversely associated with the expression of IL-1β (B = −0.883; CI 95% −1.388, −0.378, p = 0.001) and IFN-α (B = −1.197; CI 95% −2.153, −0.242, p = 0.014) after adjusted for age and sex.

Conclusion:

Patients with RA have significantly higher baseline PCT compared with healthy controls. The treatment received by patients with RA did not affect the level of PCT. Further investigation is required to determine the optimal cutoff value of PCT among patients with RA before applying it in daily clinical practice.

References:

[1]Scire CA, Cavagna L, Perotti C, Bruschi E, Caporali R, Montecucco C. Diagnostic value of procalcitonin measurement in febrile patients with systemic autoimmune diseases. Clin Exp Rheumatol. 2006;24(2):123−8.

[2]Delevaux I, Andre M, Colombier M, Albuisson E, Meylheuc F, Begue RJ, et al. Can procalcitonin measurement help in differentiating between bacterial infection and other kinds of inflammatory processes? Ann Rheum Dis. 2003;62(4):337−40.

Acknowledgments:

The authors gratefully acknowledge Dr. Malcolm Koo for advice on statistical analysis and manuscript preparation.

Disclosure of Interests:

None declared

Screening and characterization of microbial inhibitors against eukaryotic protein phosphatases (PP1 and PP2A)

AIM

To identify novel microbial inhibitors of protein phosphatase 1 (PP1).

METHODS AND RESULTS

750 actinomycetes and 408 microfungi were isolated from Sabah forest soils and screened for production of potential PP1 inhibitors using an in vivo screening system, in which candidate inhibitors were identified through mimicking the properties of PP1-deficient yeast cells. Acetone extracts of two fungi, H9318 (Penicillium) and H9978 (non-Penicillium) identified in this way showed inhibitory activity towards both mammalian PP1 and PP2A in an in vitro phosphatase assay, while extract from H7520 (Streptomyces) inhibited PP2A but not PP1. Consistently, using a drug-induced haploinsufficiency test, strains with either reduced PP1 or PP2A function were hypersensitive to H9318 and H9978 extracts whereas only the latter strain showed hypersensitivity to H7250 extract. H9318 extract was fractionated using RP-HPLC into two active peaks (S1 and S2). A yeast strain with reduced PP1 function showed hypersensitivity to fraction S2 whereas a strain with reduced PP2A function was hypersensitive to fraction S1. However, S1 and S2 inhibited both PP1 and PP2A activities to a similar extent.

CONCLUSION

Three candidate PP inhibitors have been identified.

SIGNIFICANCE AND IMPACT OF THE STUDY

Further development may generate useful research tools and ultimately therapeutic agents.

Prevention of autoantibody formation and prolonged survival in New Zealand Black/New Zealand White F1 mice with an ancient Chinese herb, Ganoderma tsugae

For centuries, Chinese medicine has regarded Ganoderma, a fungus (Myceteae, Amastigomycota, Busidomycetes, Aphyllophorales, Polyporaceae, Ganoderma) also known as 'Ling Zhi' in Mandarin, as a premium remedy for many diseases. Until now, no convincing data regarding its therapeutic effects in vivo on autoimmune diseases have been demonstrated. In this study, a controlled protocol was conducted in which New Zealand Black/White F1 mice were fed standard chow with prednisolone (0.5 mg/kg/day) or Ganoderma tsugae extract, commencing at 2 months of age. It was found that the F1 mice responded well to Ling Zhi extract. Ling Zhi improved the survival rate of lupus mice, decreased the amount of proteinuria, decreased serum levels of anti-dsDNA autoantibody, and showed evidence of decreased perivascular and parenchyma mononuclear cell infiltration in vital organs.

Allergic eosinophilic gastroenteritis in a boy with congenital duodenal obstruction

Eosinophilic gastroenteritis (EG) is a rare allergy-related disease, especially in early childhood. We present the case of a 1 year 4 month old boy with congenital duodenal obstruction who developed EG. That diagnosis of EG was made by a series of imaging studies and was confirmed by upper gastrointestinal (UGI) endoscopic biopsy studies which showed significant tissue eosinophilia in both mucosal and submucosal layers. No evidence of parasite segment or ova was found in the stool and biopsy specimen. Specific IgE antibodies to milk were estimated to be 2 + (CAP system). Cow's milk allergy was highly suspected but not confirmed by consecutive elimination and challenge tests since the child was too much suffered to be tested. There was partial response to the 2-week treatment with Alfare (semi-elemental formula) and oral prednisolone 1 mg/kg/day. One month after initial examination, perforation of the stomach occurred and exploratory laparotomy disclosed stenosis of the duodenum. Congenital duodenal obstruction was diagnosed based on operative findings and previous sonographic findings. There has been only one report of EG in an infant with congenital duodenal obstruction. The nature of the relationships among cow's milk allergy as a possible etiologic factor, congenital duodenal obstruction as an predisposing factor and EG involvement at both mucosal and submucosal layers remains unclear.

Evaluation of cerebrospinal anticardiolipin antibodies in lupus patients with neuropsychiatric manifestations

To evaluate the role of cerebrospinal fluid (CSF) anticardiolipin antibody (aCL) in lupus patients with neuropsychiatric manifestations, paired measurements of aCL, in the serum and CSF, were performed using the ELISA method in lupus patients (n=31) and controls with other medical diseases (n=8). High titers of CSF IgG-aCL were detected in cerebral lupus patients with lupus headache, acute psychosis, cognitive impairment, high cortical dysfunction, and altered consciousness. Intrathecal synthesis, rather than the diffusion of IgG-aCL from serum to compartment of the central nervous system, occurred in these NPLE patients. The binding of aCL to brain components might play a role in the development of neuropsychiatric manifestations in cerebral lupus patients.

Two color analysis of HLA-B27 antigen by flow cytometer--a comparative study by conventional microlymphocytotoxicity, DNA genotyping polymerase chain reaction and flow cytometric measurement

For evaluation of specificity and sensitivity of flowcytometric determination of HLA-B27 antigen, we determined the HLA-B27 on lymphocytes using HLA-B27 monoclonal antibody by flow cytometer. Data were compared to those by conventional Terasaki microlymphocytoxicity test and DNA genotyping Polymerase Chain Reaction (PCR) method. One hundred and ninety four patients with various forms of arthritis were included in this study. Forty one of them were HLA-B27 positive, confirmed by three methods concomitantly with complete accordance. None of serological B27 negative, B7 CREG positive cells were found to be flowcytometric fluorescence positive. Furthermore, there was no significant difference of B27 intensity between different B27 DNA subtypes, nor was there any difference between primary ankylosing spondylitis (AS) and other secondary spondylitis patients as measured by mean channel of fluorescence. It is suggested that flowcytometric measurement of HLA-B27 antigen is a rapid and reliable method for HLA-B27 determination.

Churg-Strauss syndrome presenting with pulmonary capillaritis and diffuse alveolar hemorrhage

Churg-Strauss syndrome (CSS) is a rare disorder characterized by the histopathological triad of systemic necrotizing vasculitis, extravascular granuloma, and eosinophilic infiltrate, occurring in individuals with asthma or a history of allergy. We report a case of CSS with rare presentation of diffuse pulmonary hemorrhage. A transbronchial lung biopsy showed necrotizing vasculitis, pulmonary capillaritis, and prominent eosinophilic infiltrate. At autopsy, necrotizing granuloma and diffuse alveolar hemorrhage were found in the lungs. Laboratory data showed hypereosinophilia, disseminated intravascular coagulopathy, and positive anti-proteinase 3 antineutrophil cytoplasmic antibody (ANCA). This case emphasize that CSS should be considered in the differential diagnosis of ANCA-positive vasculitis with diffuse alveolar hemorrhage.

Treatment of DMARDs-resistant rheumatoid arthritis with minocycline: a local experience among the Chinese

We report a local experience with minocycline (100 mg b.i.d.) in treating Chinese patients with rheumatoid arthritis (RA) who were resistant to the conventional disease-modifying antirheumatic drug (DMARD) treatment. In contrast to a preliminary observation in seven patients with rheumatoid arthritis, minocycline was effective and safe in treating our patients when added to the previous, relatively ineffective DMARD regimen. The antirheumatic effect of minocycline was impressive early in the first month. Drug compliance was fair; all patients continued to receive the study drugs, with no obvious adverse drug reactions. The reason why minocycline showed dramatic effects in reducing disease activity remains to be determined; however, minocycline-associated immune modulation, as indicated in this study, may be one of the important mechanisms in its antiarthritic effects.

Renal vein thrombosis in Chinese patients with systemic lupus erythematosus

OBJECTIVES

To evaluate the risk factors associated with renal vein thrombosis (RVT) in Chinese patients with systemic lupus erythematosus (SLE).

METHODS

Data on clinical symptoms, renal biopsy, antiphospholipid antibody syndrome profile, and serological examinations of lupus features were examined retrospectively in six patients with RVT confirmed by angiography from a total of 625 patients with SLE over a 14 year period (1982-1996).

RESULTS

The lupus patients with RVT did not have acute symptoms of severe flank pain, haematuria, and oligouria. In contrast, most patients were suspected to have RVT because of peripheral oedema and worsening proteinuria. Roentgenological examinations (including renal sonography, renal computer tomography, or renal Doppler, or all three) were positive only in some patients. Positive antiphospholipid antibody profiles were found in four of six lupus patients. By renal biopsy, only two samples were confirmed as World Health Organisation (WHO) class V lupus membranous glomerulonephritis. The others were class IV in three patients, and class III in the remaining one. No RVT was found in lupus patients without nephrotic syndrome. Peripheral thrombophlebitis was, however, noted in only one patient.

CONCLUSION

Nephrotic syndrome could be a distinct risk factor in the development of RVT in Chinese SLE patients, in contrast with that reported in white populations in whom the peripheral thrombotic events were recognised as a determining factor.

Outbreak of bronchiolitis obliterans associated with consumption of Sauropus androgynus in Taiwan

BACKGROUND

In August, 1995, there was an outbreak in Taiwan of rapidly progressive respiratory distress associated with consumption of uncooked Sauropus androgynus, a vegetable with a claimed yet unconfirmed effect on weight control. We report on 23 patients with strikingly similar clinical presentations.

METHODS

A structured questionnaire for clinical manifestations was completed. Radiographic findings, pulmonary physiological changes, immunological and microbiological studies, and pathological examination were evaluated.

FINDINGS

All patients were young and middle-aged women (mean age 39 years [range 21-52]). They took uncooked S androgynus juice, generally mixed with guava or pineapple juice, for a mean duration of 10 weeks. Progressive dyspnoea and persistent cough were the main symptoms on presentation. Pulmonary function testing uniformly revealed moderate to severe airflow obstruction with mean forced expiratory volume in 1 s (FEV1) of 0.66 L (26% of predicted). No bronchodilator response was observed. Room-air arterial blood gas analysis showed hypoxaemia (mean PaO2 9.6 [SD 1.6] kPa). Chest radiographs were essentially normal. High-resolution computed tomography showed bilateral bronchiectasis and patchy low attenuation of lung parenchyma with mosaic perfusion. Ventilation-perfusion scintigraphic findings were compatible with obstructive lung disease. Histopathology of open lung biopsy specimens in four patients confirmed the presence of bronchiolitis obliterans. Immunohistochemical stains of the open lung biopsy specimens showed predominance of T cells over B cells. Immunofluorescent stains for IgG, IgM, IgA, C1q, C3, and C4 were negative. Serum concentrations of tumour necrosis factor alpha were higher than those of normal controls. Clinical response to prednisolone was limited.

INTERPRETATION

We describe an unusual association between bronchiolitis obliterans and ingestion of the vegetable S androgynus. T-cell mediated immunity may be involved in the pathogenesis.

CYFRA 21-1 enzyme-linked immunosorbent assay. Evaluation as a tumor marker in non-small cell lung cancer

BACKGROUND

The CYFRA 21-1, a newly developed sandwich enzyme-linked immunosorbent assay (ELISA), was used to measure soluble cytokeratin 19 fragment in serum that is expressed in simple epithelium and its malignant counterpart. The present study was designed to investigate whether CYFRA 21-1 is a sensitive and specific tumor marker for non-small cell lung cancer.

METHODS

CYFRA 21-1 assay, using two specific monoclonal antibodies (KS 19.1 and BM 19.21) for cytokeratin 19, was measured in 312 serum samples, including 164 lung cancer, 118 benign pulmonary disease, and 30 healthy individuals. The sensitivity of CYFRA 21-1 was also compared with two other markers, carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC), in 164 patients with lung cancer.

RESULTS

The median value of healthy individuals was 1.3 ng/mL (95th percentile 1.8). In patients with benign pulmonary diseases, the median was 1.5 ng/mL (95th percentile 2.9). There is no significant difference between sexes, smoking habit, and the subgroups of benign pulmonary disease, such as tuberculosis, pneumonia, or COPD. Using the cutoff value of 3.3 ng/mL, defined at 95% specificity for benign lung disease, the sensitivities of CYFRA 21-1 for squamous cell carcinoma (n=74), adenocarcinoma (n=54), undifferentiated large cell carcinoma (n=11), and small cell lung cancer (n=25) were 62%, 39%, 36%, and 20%, respectively. Despite the cell types, the sensitivities of CYFRA 21-1 in non-small cell lung cancer (NSCLC, n=169) were 51% (CEA 42%, SCC 20%). The sensitivity of CEA was significantly higher in patients with adenocarcinoma (58%) than other markers; while in patients with squamous cell carcinoma, CYFRA 21-1 assay has the highest sensitivity. The median level of CYFRA 21-1 in squamous cell carcinoma is significantly higher than that of other cell types (Mann-Whitney test, p<0.001). The serum level and sensitivity of CYFRA 21-1 were well correlated with staging and tumor size in squamous cell carcinoma. The CYFRA 21-1 values were measured for monitoring progression of disease in 20 patients with squamous cell carcinoma. There is significant difference in paired observation of CYFRA 21-1 level in patients with progressive disease (Wilcoxon signed-rank test, p<0.05), but no difference was observed in patients with stabilized disease (p>0.1).

CONCLUSION

For patients with NSCLC, especially in squamous cell carcinoma, CYFRA 21-1 is not only a sensitive and specific tumor marker, but also may be a useful adjunctive marker for disease monitoring.

Role of tumor necrosis factor-alpha in the regulation of activated synovial T cell growth: down-regulation of synovial T cells in rheumatoid arthritis patients

To characterize the role of tumor necrosis factor (TNF)-alpha in regulating synovial T cell growth, cell cycle progression associated with TNF-alpha in mitogen-activated synovial T cells of patients with rheumatoid arthritis (RA) were analyzed. After mitogen stimulation, the majority of synovial T cells in RA patients accumulated in S-phase. Anti-human TNF-alpha monoclonal antibody and soluble recombinant human TNF receptor (rhTNFR) can block S-phase accumulation. Furthermore, synovial fluid (SF) from RA patients was able to inhibit the proliferation of these S-phase-accumulated T cells. These data indicate that TNF-alpha could regulate activated synovial T cell growth by driving them into S-phase. Combined with the activities of other components of SF, TNF-alpha seems to play an important role in down-regulating activated synovial T cells in RA patients. In addition, the elevated level of soluble TNFR in the SFof disease-active RA patients is believed to be associated with the promotion of synovial T cell responses.

A dominant human leucocyte antigen DR4-Dw15 restricted mycobacterial 65 kDa antigen-specific T-cell immunity in Chinese patients with rheumatoid arthritis

The human leucocyte antigen DR4-associated immune responses to Mycobacterium tuberculosis 65 kDa heat shock protein were considered to be relevant to the pathogenesis of rheumatoid arthritis (RA). In the Chinese population, DR4-Dw15 was found to be the predominant DR4 subtype in RA. To further define the immune responses associated with DR4-Dw15 molecules, the proliferative responses of peripheral (PBMC) and synovial mononuclear cells (SFMC) to mycobacterial 65 kDa antigen were evaluated. The SFMC of all of our RA patients responded significantly to 65 kDa mycobacterial antigen. The responses of PBMC to this antigen in RA were much lower than those of SFMC. Our results further indicated that relatively low numbers of peripheral antigen-specific T-cells, but not incompetence of peripheral antigen presenting cells, might be related to the observed low responsiveness to 65 kDa antigen in PBMC of RA patients. Of utmost importance, DR4-Dw15 was proved to be one of the major restrictive molecules in mycobacterial 65 kDa antigen-specific immune responses in Chinese RA patients.

Antibody to Mycobacterium tuberculosis 65 kDa heat shock protein in patients with rheumatoid arthritis--a survey of antigen-specific antibody isotypes and subclasses in an endemic area of previous tuberculosis infection

OBJECTIVE

To clarify the significance of the humoral immune response triggered by the Mycobacterium tuberculosis (M.tb) 65 kDa heat shock protein (hsp) in the pathogenesis of rheumatoid arthritis (RA).

METHODS

M.tb 65 kDa hsp-specific IgG, IgA, IgM, and IgG subclass antibodies in serum or synovial fluid (SF) of RA and other disease patients were determined by enzyme linked immunosorbent assay (ELISA).

RESULTS

RA patients did not show any characteristic increase in mycobacterial 65 kDa hsp-specific antibodies compared with healthy individuals. In contrast, antigen-specific IgG and IgG2 antibody titres in the serum of RA patients were significantly lower than those of patients with tuberculosis and normal controls. In addition, there was also no significant difference in antibody titre between the serum and SF of RA patients, nor was any significant difference found between the SF of RA and Reiter's patients.

CONCLUSION

The failure to detect a significant increase in IgG anti-M.tb 65 kDa hsp antibodies in RA patients does not exclude the possibility of microbial immunity in the aetiology of RA. Nevertheless, anti-M.tb 65 kDa hsp antibodies clearly do not appear to be the disease specific markers for RA and their relatively reduced concentrations may argue against their playing a major role in the disease pathogenesis.