[Screening investigations during intensified immunosuppression in children and adolescents. Part 1]

The increasing use of combination therapies, including disease-modifying antirheumatic drugs (DMARD) and biologicals has improved the outcome for children and adolescents in several rheumatic diseases. However, this strategy has increased the risk of drug-specific side-effects, such as an increased risk of infections. Furthermore, the underlying rheumatic disease itself often includes an increased risk of infections and some patients additionally present with immunological or organic comorbidities (e.g. complement deficiency and interstitial pulmonary disease) further increasing the susceptibility to infections. The presented review is based on an analysis of the currently available literature proposing a checklist of diagnostic procedures and immunological laboratory tests specific for the detection of patients prone to infections. The combined stratification of the underlying disease, comorbidities and the immunological mechanisms of the medication enables (1) an individual risk stratification of planned immunosuppressive therapy and (2) a prediction of the risks of infection for the patient.

[Laboratory survey on the incidence of Pneumocystis jirovecii - obviously a peculiar fungus, but also a rare pathogen?]

Pneumocystsis jirovecii is a peculiar fungus for a variety of reasons. This opportunistic pathogen multiplies in humans only under certain conditions; a defect in the T-cell defense system creates a predisposition to this infection. In 2010 a data survey (IFT as well as PCR) from a few laboratories in Germany revealed 412 positive individuals. Even if only a few patients test positive for the colonization stage of this pathogen, the sheer number of individuals testing positive for other stages of infection indicate that the incidence of pneumocystosis in immunocompromised patients in Germany is underestimated.

Staphylococcus aureus in nasal lavage and biopsy of patients with chronic rhinosinusitis

BACKGROUND

Staphylococcus aureus may play a relevant etiologic role in chronic rhinosinusitis (CRS) and may explain the T(H2) shift observed in CRS with nasal polyps (CRSNP(+)). Naturally occurring S. aureus small colony variants (SASCV) escape immune surveillance, antibiotic treatment and microbiologic routine diagnostic techniques. The frequency of S. aureus and SASCV in CRS patients and S. aureus-related effects on the local immune response should be prospectively investigated.

METHODS

Nasal lavages and mucosal biopsies of CRS patients were examined with bacterial culture suitable for detecting SASCV, real time PCR and fluorescence in situ hybridization. To assess the effects of S. aureus positivity, interleukin-5 (IL-5), interferon-gamma, total immunoglobulin E (IgE), eotaxin, granulocyte-colony stimulating factor, and eosinophil cationic protein in nasal lavages were determined and gene transcription analysis of nasal biopsies from S. aureus positive and negative CRSNP(+) patients was performed.

RESULTS

Thirty-one CRSNP(+) patients, 13 CRS patients without polyps, and 21 control patients were evaluated. Staphylococcus aureus was detected by any method in 25 patients (39%). Staphylococcus aureus detection rates did not differ between the three disease groups (P = 0.3). Staphylococcus aureus small colony variants were not found. In nasal lavages, IL-5 and total IgE levels were higher in CRSNP(+) patients than in CRSNP(-) patients or controls (P < 0.05). Staphylococcus aureus positivity did not influence biomarker concentrations in nasal lavages. Genes for T(H2) cytokines were not differentially transcribed.

CONCLUSIONS

We could not observe a higher prevalence of S. aureus in CRS patients with or without nasal polyps than in controls. We could not substantiate that S. aureus intensifies the T(H2) shift in CRSNP(+) patients. Staphylococcus aureus small colony variants were not detected in any sample.

Evidence of Coinfection with Distinct Strains of Burkholderia multivorans in a Cystic Fibrosis Patient

We report a Cystic Fibrosis patient with chronic Burkholderia multivorans infection involving persistency of one strain and temporary, consecutive coinfection with two different strains. Comparison of the colony morphology with the genotype revealed no correlation. These data are important for interpretation of clinical outcome and transmission studies in CF patients.

[Cat-scratch disease as cause of Lymphadenitis colli]

Cat-scratch Disease as Cause of Lymphadenitis colli. Cat-scratch disease is a frequent cause of lymphadenitis colli. It mainly affects children and adolescents younger than 21 years. Since the clinical picture is not characteristic, a history of contact to cats or kittens is highly valuable for diagnosing the disease. Major aspects of the disease concerning epidemiology, diagnostic procedures, clinical presentation and therapy are discussed.

Detection of legionellae in hospital water samples by quantitative real-time LightCycler PCR

Contamination of hospital water systems with legionellae is a well-known cause of nosocomial legionellosis. We describe a new real-time LightCycler PCR assay for quantitative determination of legionellae in potable water samples. Primers that amplify both a 386-bp fragment of the 16S rRNA gene from Legionella spp. and a specifically cloned fragment of the phage lambda, added to each sample as an internal inhibitor control, were used. The amplified products were detected by use of a dual-color hybridization probe assay design and quantified with external standards composed of Legionella pneumophila genomic DNA. The PCR assay had a sensitivity of 1 fg of Legionella DNA (i.e., less than one Legionella organism) per assay and detected 44 Legionella species and serogroups. Seventy-seven water samples from three hospitals were investigated by PCR and culture. The rates of detection of legionellae were 98.7% (76 of 77) by the PCR assay and 70.1% (54 of 77) by culture; PCR inhibitors were detected in one sample. The amounts of legionellae calculated from the PCR results were associated with the CFU detected by culture (r = 0.57; P < 0.001), but PCR results were mostly higher than the culture results. Since L. pneumophila is the main cause of legionellosis, we further developed a quantitative L. pneumophila-specific PCR assay targeting the macrophage infectivity potentiator (mip) gene, which codes for an immunophilin of the FK506 binding protein family. All but one of the 16S rRNA gene PCR-positive water samples were also positive in the mip gene PCR, and the results of the two PCR assays were correlated. In conclusion, the newly developed Legionella genus-specific and L. pneumophila species-specific PCR assays proved to be valuable tools for investigation of Legionella contamination in potable water systems.

A new ImmunoCAP assay for detection of Echinococcus multilocularis-specific IgE

In alveolar echinococcosis (AE), caused by Echinococcus multilocularis (E.m.), increased levels of total and parasite-specific IgE are frequently found. These may not only have diagnostic but are also supposed to have prognostic value in the follow-up of AE patients. However, there is no commercial test available for quantification of E. m.-specific IgE (sIgE). The only commercial test available is based on E. granulosus (g.) hydatid antigen, which is not optimal for detection of E. m.-specific IgE. Therefore, a new ImmunoCAP with covalently bound crude antigen of E. m. was developed in cooperation with Pharmacia Research Forum for the analysis of E. m. sIgE. The E. m. ImmunoCAP was evaluated in 53 AE patients with different clinical disease progression and 20 healthy controls. Our data showed a higher sensitivity for sIgE determination with E. m. ImmunoCAP compared to the E. g. ImmunoCAP (73.6% vs 61.5%) and a positive correlation between total IgE and sIgE. Furthermore, there was a significant correlation between sIgE in both tests. In conclusion, the new E. m.-specific ImmunoCAP test proved to be a valuable tool for determination of sIgE. It may provide the basis for the development of further E. multilocularis-specific IgE immunotests which are essential for evaluation of sIgE during clinical course of AE.

Immunobiology of gestational zinc deficiency

The trace element zinc is an essential micronutrient for the proper functioning of the immune system. Zinc deficiency leads to impaired function of the unspecific and specific immune response and consequently to an increased susceptibility to bacterial, viral and fungal infections. Immunological defects are not only seen in pronounced but even in marginal and moderate zinc deficiency. Lack of zinc is especially harmful for the development of the immune system, which stresses the importance of a balanced zinc level during pregnancy. However, gestational zinc deficiency due to an imbalance between intake and increased requirements is a common problem world-wide. In animals, gestational zinc deficiency results in reduced thymic and spleen size and depressed active and passive immunity in the infant. For example, depressed immunoglobulin levels, altered antibody repertoire, reduced proliferative response of lymphocytes and diminished neutrophil functions have been reported. Interestingly, immune defects caused by prenatal zinc deficiency, such as depressed antibody levels and lymphocyte proliferation, may even persist in subsequent generations and are not reversible by postnatal zinc administration. Since gestational zinc deficiency is a common problem throughout all cultures and socioeconomic levels, it might have immense consequences for the health status of the population. Based on a summary of the immunobiology of zinc, this article reviews the significance of zinc deficiency during pregnancy and the effect of gestational zinc deficiency on passive and active immunity in the infant. It provides a rational basis for both immunological laboratory investigations and field studies, such as large community-based zinc supplementation trials in pregnant women.

Zinc inhibits the mixed lymphocyte culture

The mixed lymphocyte culture (MLC) is an established clinical method for bone marrow transplantation, as it serves as an in vitro model for allogenic reaction and transplantation. We previously showed that cytokine release into the supernatant is a more specific and sensitive parameter for cross-reactivity in the MLC than the common measurement of cell proliferation. Therefore we tried to find an inhibitor of the MLC in vitro with the least side effects in vivo, measuring interferon (IFN)-gamma as one of the most important cytokines in posttransplant medicine. Earlier studies showed that zinc is an important trace element for immune function with both stimulatory and inhibitory effects on immune cells. We found that slightly elevated zinc concentrations (three to four times the physiological level), which do not decrease T-cell proliferation in vitro nor produce immunosuppressive effects in vivo, suppress alloreactivity in the mixed lymphocyte culture. In this report we analyzed the mechanism whereby zinc influences the MLC to possibly find a nontoxic way of immunosuppression.

Increased levels of soluble Fas ligand in serum in Plasmodium falciparum malaria

Levels of soluble Fas ligand (sFasL) in serum were elevated in patients with Plasmodium falciparum malaria and showed a significant decline during disease course. sFasL levels that were elevated before antimalarial treatment began correlated significantly with depressed total lymphocyte and T-cell counts. These data suggest that Fas-induced apoptosis might play a role in malaria-associated lymphopenia.

Zinc serum level in human immunodeficiency virus-infected patients in relation to immunological status

In human immunodeficiency virus (HIV) infection, serum level of zinc, an important micronutrient for immune function, is frequently diminished. The aim of this study was to determine the zinc status in relation to immunological parameters and disease stage in 79 HIV-1 seropositive patients. The median serum level of zinc was within normal limits (12.5 micromol/L) but in 23% of patients, zinc deficiency was seen. Decreased serum zinc was associated with a low CD4 cell count, high viral load, and increased neopterin and IgA levels. According to current treatment recommendations, the majority of patients received antiretroviral triple therapy. Zinc levels in treated and untreated patients were comparable. Referring to disease stage (CDC classification, 1993), the mean zinc level was highest in stage C and lowest in stage A. In conclusion, even under antiretroviral triple therapy, zinc deficiency is still of great importance in HIV infection, and zinc substitution in zinc deficient individuals should be taken into account to optimize therapeutical success.

Genetic linkage of hyper-IgE syndrome to chromosome 4

The hyper-IgE syndrome (HIES) is a rare primary immunodeficiency characterized by recurrent skin abscesses, pneumonia, and highly elevated levels of serum IgE. HIES is now recognized as a multisystem disorder, with nonimmunologic abnormalities of the dentition, bones, and connective tissue. HIES can be transmitted as an autosomal dominant trait with variable expressivity. Nineteen kindreds with multiple cases of HIES were scored for clinical and laboratory findings and were genotyped with polymorphic markers in a candidate region on human chromosome 4. Linkage analysis showed a maximum two-point LOD score of 3.61 at recombination fraction of 0 with marker D4S428. Multipoint analysis and simulation testing confirmed that the proximal 4q region contains a disease locus for HIES.

Interleukin (IL)-4, IL-10 and IL-12 profile in serum of patients with alveolar echinococcosis

Alveolar echinococcosis (AE), caused by Echinococcus multilocularis (E.m.), provokes a characteristic immune response. Based mainly on in vitro studies, Th2 dominated immunity is associated with increased susceptibility to disease, while Th1 cell activation is assumed to induce protective immunity. We investigated serum levels of interleukin (IL)4, IL-10, and IL-12 in 40 AE patients and 20 controls to assess Th1/Th2 cell activation in vivo. Significantly higher levels of IL-10 were found in AE patients (P = 0.003) than in controls, with a tendency to higher concentrations in progressive cases. In contrast, IL-4 was only measurable in a minority of patients and controls. IL-12 levels (measured with an ELISA that detects both the p35/p40 heterodimer and free p40) were comparable between AE patients and controls and showed a similar distribution pattern to IL-10 with regard to disease progression. By using an IL-12-ELISA specific for the heterodimer, only minute amounts of IL-12 were detectable in merely a minority of samples. In conclusion, our data are suggestive of Th2 dominated immune response in AE in vivo.

Zinc status in patients with alveolar echinococcosis is related to disease progression

Zinc is an essential trace element for immune function that plays a role in immune response against parasites. To determine a possible relationship between zinc level and disease status in alveolar echinococcosis (AE), we investigated serum concentrations of zinc, immunoglobulin (Ig)E, IgG, and C-reactive protein (CRP) in 40 AE patients and 20 controls. Patients were classified into three groups: group A: patients after curative surgery, group B: patients with stabilized disease, group C: patients with progressive disease. Patients showed significantly higher levels of IgE and IgG than controls. Amounts of IgE and IgG were related to disease severity, achieving highest levels in group C and lowest in group A. Zinc levels were comparable in patients and controls. However, there was an obvious association between zinc concentration and disease severity. Zinc was far below the normal range in group C (median 9.2 micromol/l) and significantly diminished compared to group B and controls. An inverse pattern was seen for CRP. In conclusion, lowered zinc concentration in progressive cases may be caused by enhanced immune activation but consumption of zinc by the growing parasite may also play a role. Furthermore, decreased zinc levels may contribute to the observed immunosuppression in AE.

The significance of zinc for leukocyte biology

Zinc is an essential element important for growth, the nervous system, and especially the immune system. Zinc deficiency as well as levels well above normal, due to high-dose treatment, showed an impaired immune function. This review summarizes the current status of zinc's significance for leukocyte biology and health. In detail, the physiology of zinc and the impaired immune functions in zinc deficiency syndromes are described. The regulation of innate immunity as well as the function and maturation of lymphocytes and monocytes is critically discussed as a system dependent on the zinc concentration in vivo and in vitro. Furthermore, the influence of zinc on experimental systems as well as on widely used immunostimulants is described, showing the importance of the knowledge of zinc concentration in in vitro leukocyte studies. The specific interactions of zinc with immunologically important serum proteins, signal transduction components, and membrane functions is summarized, showing the molecular basis of this interaction as known so far. Finally, the therapeutic use of zinc is critically discussed with new aspects also using the immunosuppressive effects of zinc. In conclusion, these data show that the zinc concentration should be taken into account whenever complex alterations of immune functions are observed.

Hypothermia enhances the biological activity of lipopolysaccharide by altering its fluidity state

Lipopolysaccharides (LPS, endotoxin) of gram-negative bacteria are among the main causes of sepsis and septic shock. In the present study, the influence of temperature on the biological activity of LPS was investigated. Lowering the temperature from 37 degrees C to 34.5 degrees C or to 30 degrees C significantly enhances in vitro tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta and IL-6 release induced by different LPS chemotypes and heat-inactivated Escherichia coli. This cytokine-increasing effect of lowering the temperature is highly mediated by serum proteins, particularly by LPS-binding protein (LBP) and low-density lipoproteins (LDL). In contrast, cytokine production induced by the superantigen toxic shock syndrome toxin-1 (TSST-1) from Gram-positive Staphyloccoccus aureus decreases by around 70% at 30 degrees C as compared with 37 degrees C, corresponding to the expected effect of change in temperature and regardless of the presence of serum proteins. In order to explain the unexpected biological hypothermia effect with regard to LPS, the fluidity state of the lipid A portion of LPS as one important physico-chemical property possibly involved was investigated. The fluidity, determined by fluorescence polarization measurements, was found to decrease with decreasing temperature. These data suggest that a low fluid LPS chemotype is biologically more active than a more fluid one (and vice versa). Statistical analysis of the results shows a strong correlation between cytokine secretion and fluidity state of a given LPS chemotype (0.71 < r < 0.89, all P<0.01). As a clinical consequence, these data may be one possible explanation for the higher mortality rate of hypothermic Gram-negative sepsis.

[Chemotherapy of alveolar echinococcosis with benzimidazoles. A prospective long-term study]

BACKGROUND

Mebendazole and albendazole are the drugs of choice for the treatment of alveolar echinococcosis. In this prospective study we present and evaluate the outcome of the long-term treatment with both drugs.

PATIENTS AND METHODS

Forty-four patients were treated with either mebendazole or albendazole and they were followed up for an average of 42 months. Success of treatment was defined as non-progression for more than 1 year.

RESULTS

The overall success-rate was approximately 80% (35/44). An initial regimen was recurrence-free in 64% of cases under mebendazole and in 73% of cases under albendazole. Half of the cases with recurrent disease could be stabilized after changing the therapeutic regimen. Seven patients received a continuous regimen with albendazole. They were observed over an average of 19 months without signs of progression nor significant side effects.

CONCLUSION

This open-labelled prospective study demonstrates the high therapeutic efficacy of both mebendazole and albendazole with similar response rates in the treatment of alveolar echinococcosis. In Germany, serum levels for mebendazole can easily be obtained at numerous institutes, while serum levels for albendazole are rarely available. On the other hand, albendazole reduces costs by over 40%. A simplified mode of intake and a reduced number of side effects argue in favor of the preferred use of albendazole. Albendazole in alveolar echinococcosis is only licensed for intermittent application. Nonetheless, continuous treatment may be considered in inoperable cases or progressive disease.

Zinc inhibits interleukin-1-dependent T cell stimulation

Zinc is a trace element which is essential for immune functions. It directly induces monokine secretion by monocytes; however, effects of zinc on T cells appear contradictory. Apart from enhanced lymphocyte proliferation in peripheral blood mononuclear cells (PBMC), inhibitory properties of high zinc dosages have also been described. In this study, PBMC failed to produce lymphokines like interferon (IFN)-gamma after stimulation with zinc in a serum- and LPS-free cell culture system, whereas monokine secretion [interleukin (IL)-1 beta] occurred. Zinc-uptake studies with the zinc-specific fluorescent probe zinquin revealed that zinc is taken up by PBMC within a few minutes, reaching nearly equal levels in PBMC, isolated monocytes, and T cells. However, if zinc was depleted 1 h after monocyte induction, zinc-free pre-cultured T cells were stimulated to secrete IFN-gamma by zinc-induced monokines. Furthermore, the necessity for a cell-cell interaction between monocytes and T cells for IFN-gamma induction was elucidated. Zinc ions inhibited the proliferation of the IL-1-dependent T cell line D 10N in a dose-dependent manner, suggesting a direct inhibitory effect of zinc. By immunoprecipitation we revealed a specific inhibition of IL-1 receptor-associated protein kinase (IRAK) by zinc ions. Therefore, in contrast to an indirect stimulation of T cells due to zinc-induced monokines, higher concentrations of zinc directly inhibit T cell functions by means of specific inhibition of IRAK and subsequent signaling events such as NF kappa B activation. The divergent effects of zinc on different cell populations, depending on the zinc concentration, could explain contradictory results of zinc stimulation. Furthermore, our data suggest new strategies of specific zinc-mediated immune modulation.

Zinc enhances lipopolysaccharide-induced monokine secretion by alteration of fluidity state of lipopolysaccharide

Elevated zinc serum concentrations have been shown to restore impaired immune response. Therefore, pharmacologic zinc supplementation has been used to improve immune function, particularly in intensive care patients. In these patients, Gramnegative sepsis, the symptoms of which are predominantly caused by LPS-induced release of monokines, represents a serious problem. We have recently shown that zinc enhances induction of TNF-alpha and IL-1 beta in cultures of PBMC by LPS. By fluorescence polarization and infrared spectroscopic measurements we found that zinc addition leads to decreased fluidity of the hydrocarbon chains of LPS. Experiments at different temperatures showed that the less fluid gel (beta) phase of LPS is more effective in cytokine induction than the more fluid liquid-crystalline (alpha) phase. Our studies suggest that the synergistic effect of zinc on monokine induction by LPS is caused by direct interaction of zinc with LPS altering the fluidity of the hydrocarbon chains. Although this effect is zinc specific, other divalent ions, like cobalt and nickel, with a complex structure and size comparable to those of zinc also enhance LPS-induced monokine secretion but to a much lesser extent. Our data indicate that the zinc level represents a relevant clinical parameter in the treatment of Gram-negative infection. This reveals potential risks in the therapeutic application of zinc.

Zinc enhances lipopolysaccharide-induced monokine secretion by alteration of fluidity state of lipopolysaccharide

Elevated zinc serum concentrations have been shown to restore impaired immune response. Therefore, pharmacologic zinc supplementation has been used to improve immune function, particularly in intensive care patients. In these patients, Gramnegative sepsis, the symptoms of which are predominantly caused by LPS-induced release of monokines, represents a serious problem. We have recently shown that zinc enhances induction of TNF-alpha and IL-1 beta in cultures of PBMC by LPS. By fluorescence polarization and infrared spectroscopic measurements we found that zinc addition leads to decreased fluidity of the hydrocarbon chains of LPS. Experiments at different temperatures showed that the less fluid gel (beta) phase of LPS is more effective in cytokine induction than the more fluid liquid-crystalline (alpha) phase. Our studies suggest that the synergistic effect of zinc on monokine induction by LPS is caused by direct interaction of zinc with LPS altering the fluidity of the hydrocarbon chains. Although this effect is zinc specific, other divalent ions, like cobalt and nickel, with a complex structure and size comparable to those of zinc also enhance LPS-induced monokine secretion but to a much lesser extent. Our data indicate that the zinc level represents a relevant clinical parameter in the treatment of Gram-negative infection. This reveals potential risks in the therapeutic application of zinc.

Stimulation of human peripheral blood mononuclear cells by zinc and related cations

Zinc is an important trace element for immune function. Here, we show that zinc addition in a serum- and lipopolysaccharide-free cell culture system leads to significantly enhanced levels of interleukin 1 beta (IL-1 beta) and tumour necrosis factor alpha (TNF-alpha) and to expression of the corresponding mRNA in human peripheral blood mononuclear cells (PBMC). Structurally related divalent cations like cobalt, nickel, and mercury also partially increase monokine secretion but to a much lower and thus insignificant extent. They fail to induce mRNA of TNF-alpha after 3 h of culture. Therefore, monokine induction is a zinc-specific effect influenced by the physicochemical properties of the ion. Confirmation of the unique significance of zinc for immune function provides a better understanding of the mechanisms of specific zinc-mediated immune modulation.

Interaction of zinc ions with human peripheral blood mononuclear cells

Zinc is an important trace element for immune function. The mechanisms by which zinc ions interact with immune cells are, however, still poorly understood. In the present study, we succeeded in defining transferrin and insulin as proteins which selectively enhance zinc-induced monokine induction in peripheral blood mononuclear cells (PBMC). An involvement of the transferrin receptor and the insulin receptor was ruled out. Zinc stimulation of PBMC resulted in an increase of intracellular free zinc, measured by a zinc-specific fluorescence probe, zinquin, the amount of which could be raised by substitution of neither transferrin nor insulin. Inhibition of second messengers by herbimycin A and HA 1004 revealed a participation of protein tyrosine kinases and of cAMP- and cGMP-dependent protein kinases in zinc-induced monokine secretion. We therefore suggest that zinc acts synergistically with stimulants of the above-mentioned signal transduction pathways by direct influence on the second messenger niveau.

Influence of serum on zinc, toxic shock syndrome toxin-1, and lipopolysaccharide-induced production of IFN-gamma and IL-1 beta by human mononuclear cells

Measurement of cytokine secretion in vitro is usually performed in culture medium supplemented with human serum. We compared the secretion of interferon-gamma and interleukin-1 beta as a parameter for lymphocyte and monocyte activation in RPMI 1640 medium supplemented with fetal calf or autologous serum in serum-free medium and protein-free medium. Four different stimulatory mechanisms were tested: phytohemagglutinin, toxic shock syndrome toxin-1 (TSST-1), lipopolysaccharide (LPS), and zinc ions. We found that the optimal stimulatory zinc concentration depended on the total protein content of the medium, whereas the monokine levels were dependent on the concentration of transport proteins such as transferrin. Monokine induction by LPS or TSST-1 were each influenced by the protein and serum composition in a specific manner. Our results show that the differing mechanisms of cytokine induction are influenced by the medium and serum composition in a diverse but specific manner. Serum- or protein-free medium are especially suitable after superantigen challenge when LPS activity needs to be ruled out or after activation by agents with only a weak stimulatory capacity.