Omega-3 Fatty Acid and Iron Supplementation Alone, but Not in Combination, Lower Inflammation and Anemia of Infection in Mycobacterium tuberculosis-Infected Mice

Progressive inflammation and anemia are common in tuberculosis (TB) and linked to poor clinical outcomes. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have inflammation-resolving properties, whereas iron supplementation in TB may have limited efficacy and enhance bacterial growth. We investigated effects of iron and EPA/DHA supplementation, alone and in combination, on inflammation, anemia, iron status markers and clinical outcomes in Mycobacterium tuberculosis-infected C3HeB/FeJ mice. One week post-infection, mice received the AIN-93 diet without (control) or with supplemental iron (Fe), EPA/DHA, or Fe+EPA/DHA for 3 weeks. Mice supplemented with Fe or EPA/DHA had lower soluble transferrin receptor, ferritin and hepcidin than controls, but these effects were attenuated in Fe+EPA/DHA mice. EPA/DHA increased inflammation-resolving lipid mediators and lowered lung IL-1α, IFN-γ, plasma IL-1β, and TNF-α. Fe lowered lung IL-1α, IL-1β, plasma IL-1β, TNF-α, and IL-6. However, the cytokine-lowering effects in the lungs were attenuated with Fe+EPA/DHA. Mice supplemented with EPA/DHA had lower lung bacterial loads than controls, but this effect was attenuated in Fe+EPA/DHA mice. Thus, individually, post-infection EPA/DHA and iron supplementation lowered systemic and lung inflammation and mitigated anemia of infection in TB, but not when combined. EPA/DHA also enhanced bactericidal effects and could support inflammation resolution and management of anemia.

Oral iron exacerbates colitis and influences the intestinal microbiome

Inflammatory bowel disease (IBD) is associated with anaemia and oral iron replacement to correct this can be problematic, intensifying inflammation and tissue damage. The intestinal microbiota also plays a key role in the pathogenesis of IBD, and iron supplementation likely influences gut bacterial diversity in patients with IBD. Here, we assessed the impact of dietary iron, using chow diets containing either 100, 200 or 400 ppm, fed ad libitum to adult female C57BL/6 mice in the presence or absence of colitis induced using dextran sulfate sodium (DSS), on (i) clinical and histological severity of acute DSS-induced colitis, and (ii) faecal microbial diversity, as assessed by sequencing the V4 region of 16S rRNA. Increasing or decreasing dietary iron concentration from the standard 200 ppm exacerbated both clinical and histological severity of DSS-induced colitis. DSS-treated mice provided only half the standard levels of iron ad libitum (i.e. chow containing 100 ppm iron) lost more body weight than those receiving double the amount of standard iron (i.e. 400 ppm); p<0.01. Faecal calprotectin levels were significantly increased in the presence of colitis in those consuming 100 ppm iron at day 8 (5.94-fold) versus day-10 group (4.14-fold) (p<0.05), and for the 400 ppm day-8 group (8.17-fold) versus day-10 group (4.44-fold) (p<0.001). In the presence of colitis, dietary iron at 400 ppm resulted in a significant reduction in faecal abundance of Firmicutes and Bacteroidetes, and increase of Proteobacteria, changes which were not observed with lower dietary intake of iron at 100 ppm. Overall, altering dietary iron intake exacerbated DSS-induced colitis; increasing the iron content of the diet also led to changes in intestinal bacteria diversity and composition after colitis was induced with DSS.

Delivery strategies for malaria chemoprevention with monthly dihydroartemisinin-piperaquine for the post-discharge management of severe anaemia in children aged less than 5 years old in Malawi: a protocol for a cluster randomized trial

BACKGROUND

Children initially hospitalized with severe anaemia in Africa are at high risk of readmission or death within 6 months after discharge. No intervention strategy specifically protects children during the post-discharge period. Recent evidence from Malawi shows that 3 months of post-discharge malaria chemoprevention (PMC) with monthly treatment with artemether-lumefantrine in children with severe malarial anaemia prevented 31% of deaths and readmissions. While a confirmatory multi-centre trial for PMC with dihydroartemisinin-piperaquine is on going in Kenya and Uganda, there is a need to design and evaluate an effective delivery strategy for this promising intervention.

METHODS

This is a cluster-randomized trial with 5 arms, each representing a unique PMC delivery strategy. Convalescent children aged less than 5 years and weighing more than 5 kg admitted with severe anaemia and clinically stable are included. All eligible children will receive dihydroartemisinin-piperaquine at 2, 6 and 10 weeks after discharge either: 1) in the community without an SMS reminder; 2) in the community with an SMS reminder; 3) in the community with a community health worker reminder; 4) at the hospital with an SMS reminder; or 5) at the hospital without an SMS reminder. For community-based strategies (1, 2 and 3), mothers will be given all the PMC doses at the time of discharge while for hospital-based strategies (4 and 5) mothers will be required to visit the hospital each month. Each arm will consist of 25 clusters with an average of 3 children per cluster giving approximately 75 children and will be followed up for 15 weeks. The primary outcome measure is uptake of complete courses of PMC drugs.

DISCUSSION

The proposed study will help to identify the most effective, cost-effective, acceptable and feasible strategy for delivering malaria chemoprevention for post-discharge management of severe anaemia in under-five children in the Malawian context. This information is important for policy decision in the quest for new strategies for malaria control in children in similar contexts.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02721420 . Protocol registered on 29 March 2016.The study was not retrospectively registered but there was a delay between date of submission and the date it first became available on the registry.

Association of anaemia with Helicobacter pylori infection: a retrospective study

The role of Helicobacter pylori (H. pylori) infection in haematological system diseases is not well understood. We conducted this retrospective study to explore the association between H. pylori infection and anaemia in the Chinese population. This retrospective study was performed in Aerospace Center Hospital in Beijing. We derived the data from the registration system of the physical population between 2012-2016. Logistic regression models were used to explore the association between H. pylori infection and anaemia. Among 17,791 subjects, there were 7,804 (43.9%) subjects with H. pylori infection and 950 (5.3%) with anaemia. The prevalence of anaemia in the H. pylori (+) group was significantly higher than in the H. pylori (-) group after adjusting for age, sex, marriage, underlying diseases and body mass index. Compared to H. pylori (-), the OR of H. pylori (+) was 1.39 for moderate-to-severe anaemia and 1.05 for mild anaemia. The level of haemoglobin was lower in the H. pylori (+) group than in the H. pylori (-) group. This study indicates that H. pylori infection may be related to anaemia and haemoglobin level in the Chinese population.

Intravenous Iron Carboxymaltose as a Potential Therapeutic in Anemia of Inflammation

Intravenous iron supplementation is an effective therapy in iron deficiency anemia (IDA), but controversial in anemia of inflammation (AI). Unbound iron can be used by bacteria and viruses for their replication and enhance the inflammatory response. Nowadays available high molecular weight iron complexes for intravenous iron substitution, such as ferric carboxymaltose, might be useful in AI, as these pharmaceuticals deliver low doses of free iron over a prolonged period of time. We tested the effects of intravenous iron carboxymaltose in murine AI: Wild-type mice were exposed to the heat-killed Brucella abortus (BA) model and treated with or without high molecular weight intravenous iron. 4h after BA injection followed by 2h after intravenous iron treatment, inflammatory cytokines were upregulated by BA, but not enhanced by iron treatment. In long term experiments, mice were fed a regular or an iron deficient diet and then treated with intravenous iron or saline 14 days after BA injection. Iron treatment in mice with BA-induced AI was effective 24h after iron administration. In contrast, mice with IDA (on iron deficiency diet) prior to BA-IA required 7d to recover from AI. In these experiments, inflammatory markers were not further induced in iron-treated compared to vehicle-treated BA-injected mice. These results demonstrate that intravenous iron supplementation effectively treated the murine BA-induced AI without further enhancement of the inflammatory response. Studies in humans have to reveal treatment options for AI in patients.

Helicobacter pylori Infection Induces Anemia, Depletes Serum Iron Storage, and Alters Local Iron-Related and Adult Brain Gene Expression in Male INS-GAS Mice

Iron deficiency anemia (IDA) affects > 500 million people worldwide, and is linked to impaired cognitive development and function in children. Helicobacter pylori, a class 1 carcinogen, infects about half of the world’s population, thus creating a high likelihood of overlapping risk. This study determined the effect of H. pylori infection on iron homeostasis in INS-GAS mice. Two replicates of INS-GAS/FVB male mice (n = 9-12/group) were dosed with H. pylori (Hp) strain SS1 or sham dosed at 6–9 weeks of age, and were necropsied at 27–29 weeks of age. Hematologic and serum iron parameters were evaluated, as was gene expression in gastric and brain tissues. Serum ferritin was lower in Hp SS1-infected mice than uninfected mice (p < 0.0001). Infected mice had a lower red blood cell count (p<0.0001), hematocrit (p < 0.001), and hemoglobin concentration (p <0.0001) than uninfected mice. Relative expression of gastric hepcidin antimicrobial peptide (Hamp) was downregulated in mice infected with Hp SS1 compared to sham-dosed controls (p<0.001). Expression of bone morphogenic protein 4 (Bmp4), a growth factor upstream of hepcidin, was downregulated in gastric tissue of Hp SS1-infected mice (p<0.001). Hp SS1-infected mice had downregulated brain expression of tyrosine hydroxylase (Th) (p = 0.02). Expression of iron-responsive genes involved in myelination (myelin basic protein (Mbp) and proteolipid protein 2 (Plp2)) was downregulated in infected mice (p = 0.001 and p = 0.02). Expression of synaptic plasticity markers (brain derived neurotrophic factor 3 (Bdnf3), Psd95 (a membrane associated guanylate kinase), and insulin-like growth factor 1 (Igf1)) was also downregulated in Hp SS1-infected mice (p = 0.09, p = 0.04, p = 0.02 respectively). Infection of male INS-GAS mice with Hp SS1, without concurrent dietary iron deficiency, depleted serum ferritin, deregulated gastric and hepatic expression of iron regulatory genes, and altered iron-dependent neural processes. The use of Hp SS1-infected INS-GAS mice will be an appropriate animal model for further study of the effects of concurrent H. pylori infection and anemia on iron homeostasis and adult iron-dependent brain gene expression.

Role of Helicobacter pylori infection in Hispanic patients with anemia

Pernicious anemia represents the final phase of a process that begins with Helicobacter pylori-associated gastritis and evolves through progressive levels of atrophy until loss of parietal cell mass. Numerous studies have suggested an association between H. pylori infection, unexplained iron deficiency anemia and cobalamin deficiency. Our research question was to determine whether there is an association between with H. pylori infection and development of anemia in Hispanic patients. This cross sectional pilot study involved data analysis of individual from years 2010-2012 examining the association between H. pylori infection and hemoglobin levels in patients with Hispanic ethnicity. A total of 189 records were evaluated, of which 33 fulfilled the inclusion criteria. The study sample was divided in two groups. Group-A: 5 subjects with H. pylori infection and anemia; Group-B: 28 patients with H. pylori without anemia. Fisher exact test applied between categorical variables to determine the statistical significance of symptoms comparing anemic vs. non-anemic H. pylori infected patients yielded a p = 0.0027. In addition, restoration of anemia in two subjects following eradication therapy without previous iron or cobalamin replacement therapy suggested a potential role of this bacterium in the development of anemia in Hispanics. In conclusion, from the results of this study a potential association between Helicobacter pylori infection and anemia in Hispanic patients is suggested. Restoration of hemoglobin after eradication of bacteria further supports this concept.

A longitudinal study on anaemia in children with Plasmodium falciparum infection in the Mount Cameroon region: prevalence, risk factors and perceptions by caregivers

BACKGROUND

In heavily endemic malaria areas, it is almost inevitable that malarial infection will be associated with anaemia, although malaria may not be the prime cause of it. Anaemia is a major public health problem in Cameroon. We hypothesized that, factors other than falciparum malaria account for anaemia in the study area.

METHODS

A longitudinal study was conducted among 351 Plasmodium falciparum positive children to determine the prevalence, risk factors and the perception of anaemia by the caregivers in a semi-rural community. The investigative methods included the use of a structured questionnaire, clinical evaluation and laboratory investigations.

RESULTS

At enrolment the overall prevalence of anaemia as assessed by Hb concentration (Hb < 11 g/dl) was 80.3% (282). Following treatment the prevalence of persistent anaemia was 6% and 46.2% of the children achieved haematological recovery by day 42. Exploratory multiple linear regression analysis showed the following; parasitaemia density (P < 0.01), enlarged spleen (P < 0.05), duration of fever > 2 days (P < 0.01), high white blood cell count (P < 0.001), sex (P < 0.05), iron status indicators (ferritin and transferrin) (P < 0.001), level of education of the caregiver (P < 0.05), management of onset of malaria by caregiver (P < 0.005) and wasting (P < 0.05) to be risk factors for anaemia in children with falciparum infection. Approximately 75.5% (265) of the caregivers had some knowledge about anaemia.

CONCLUSION

The identified risk factors revealed the important contributors to the pathogenesis of anaemia in the Mount Cameroon region. Control efforts should therefore be directed towards proper health education emphasizing on proper health seeking behaviour and attitudes of the population.

Pyomyositis in the upper Negro river basin, Brazilian Amazonia

Pyomyositis remains poorly documented in tropical Latin America. We therefore performed a retrospective review of cases admitted to a hospital in the upper Negro river basin during 2002-2006. Seasonality was assessed by the cosinor model and independent predictors of outcome were identified by logistic regression. Determinants of time-to-fever resolution were analysed using Cox regression. No seasonal trend was observed (p=0.284) among 82 hospitalised patients. The disease predominated in young males and the most commonly affected part of the body was the lower limb (68 [63.5%] out of 107 lesions). Staphylococcus aureus was the only identified infecting organism (18 of 20 culture results, 90%). Complications occurred in 17 patients (20.7%) and the case fatality rate was 2.4%. Children were more likely to present with eosinophilia than adults (OR= 4.20, 95% CI 1.08-16.32, p=0.048), but no other significant differences regarding clinical presentation and outcomes were observed. The time-to-fever resolution was the only independent determinant of poor outcome (OR=1.52, 95% CI 1.22-1.92, p<0.001) and was significantly longer in patients treated with combined antibiotic therapy than in those treated with single antibiotics (HR=0.523, 95% CI 0.296-0.926, p=0.026). Further studies to determine the best antibiotic therapy modality for the treatment of pyomyositis are required.

Is there delay in diagnosis of pulmonary tuberculosis in an intermediate-to-low TB incidence setting

A cross-sectional study on pulmonary TB diagnosis delay in an intermediate TB incidence setting showed average patient's delay of 44 +/- 61.65 days and total delay of 103 +/- 148 days. Alcoholism, lack of TB cases in family, diabetes mellitus, relapse, cough or tachycardia (p< 0.01), absence of hemoptysis, dyspnea and anemia (p < 0.01), age > or = 40 (p < 0.05), negative auscultation and positive sputum smear findings (p < 0.05) were significantly associated with patient's delay > 30 days. Age < 40 years, negative auscultation and sputum smear findings (p < 0.01), female sex, city as residence (p < 0.05), absence of cough, sputum, weight loss, fever, excavation (p < 0.01), and night sweats (p < 0.05) were significantly associated with total delay > 103 days. Further population education and continual medical education are waranted.

Detection of Candidatus Mycoplasma haemobos in cattle with anaemia

Haemotrophic mycoplasmas are unculturable eperythrocytic pathogens that are found in a wide range of domestic and wild animals. In this study an outbreak of haemotrophic mycoplasmosis in cattle herds in Northern Germany is reported. Affected animals exhibited anaemia and depression and infection was confirmed following microscopic examination of blood smears and on PCR. Sequence analysis indicated that in addition to infection with Mycoplasma wenyonii, animals were infected with a novel bovine haemotrophic mycoplasma Candidatus Mycoplasma haemobos.

Hematological changes in tuberculous spondylitis patients at the Hospital Universiti Sains Malaysia

In this study, we compared the platelet count with erythrocyte sedimentation rates (ESR) in patients with tuberculous spondylitis to evaluate the correlation. This was a retrospective 3-year study covering January 2004 to December 2006 at the Hospital Universiti Sains Malaysia. Platelet counts, hemoglobin levels, ESR, peripheral blood counts and peripheral blood smears on 17 patients with tuberculous spondylitis were obtained. The ages of the patients ranged from 20- to 70-years-old. The male to female ratio was 3.2:1. The majority of the patients were anemic (88.2%) and 52.9% of the patients had thrombocytosis. All the patients had normal lymphocyte counts and a high in ESR at diagnosis. There was a linear correlation between the platelet count and ESR (r = 0.60, p < 0.01). The platelet count was also significantly correlated with the hemoglobin level (r = -0.6, p < 0.02). The degree of thrombocytosis was related to the degree of inflammation measured by the ESR. Thrombocytosis also correlated with the hemoglobin level. We suggest that evaluating hematological values in suspected cases of tuberculosis should be considered. The presence of hematological changes should raise the suspicion of tuberculosis in spondylitis patients.

Prevalence of active Helicobacter pylori infection among patients referred for endoscopy in Brunei Darussalam

INTRODUCTION

The prevalence of Helicobacter pylori (H. pylori) infection has been reported to vary between and even within countries. We retrospectively assessed the prevalence among patients referred for endoscopy in our local setting.

METHODS

4,700 patients, who had endoscopy and H. pylori testing for the first time over a five-year period, were reviewed.

RESULTS

The mean age was 45.4 +/- 17.1 years (male 51.1 percent), with racial breakdown similar to the national breakdown. The main indications for endoscopy were dyspepsia (59.6 percent), anaemia (12.6 percent), gastrointestinal bleeding (9.4 percent) and gastro-oesophageal reflux (7.6 percent). The overall prevalence of H. pylori was 26.9 percent, highest in the 30-39 years (30.3 percent) age group. This was higher in males compared to females (30.3 percent versus 23.3 percent, p-value is less than 0.001). Among the racial groups, the expatriate (35.3 percent, p-values are less than 0.001) and the indigenous (31.3 percent, p-values are less than 0.001) groups had significantly higher prevalence rates compared to the Malays (25.9 percent) and the Chinese (23.2 percent). Patients with dyspepsia had the highest prevalence (29.8 percent) compared to the other indications. In patients with peptic ulcer disease, the prevalence rate was 46.9 percent. Over the five-year period, there was a decline in prevalence from 32.3 percent to 25.6 percent. This trend was seen in the Malays and the Chinese, but not the indigenous and the expatriate groups.

CONCLUSION

Similar to reported data from the regions, prevalence of H. pylori infection varies, with the Malays and the Chinese having the lowest prevalence rate. The prevalence among those with peptic ulcer disease was lower than reported. There was also a decline in the overall prevalence.

Use of conventional and real-time polymerase chain reaction to determine the epidemiology of hemoplasma infections in anemic and nonanemic cats

BACKGROUND

The goals of this study were to develop and apply conventional (c) and real-time TaqMan polymerase chain reaction (PCR) assays for Mycoplasma haemofelis (Mhf), 'Candidatus Mycoplasma haematoparvum' (Mhp), and 'Candidatus Mycoplasma haemominutum' (Mhm) to blood samples of cats to determine the epidemiology of these infections in cats.

HYPOTHESIS

Cats are infected with >2 hemoplasma species, and organism load correlates with disease induced by these organisms.

ANIMALS

Blood samples from 263 anemic and nonanemic cats were used.

METHODS

A retrospective study was conducted.

RESULTS

Forty-seven (18%) samples were positive. Three samples (1%) yielded 170 base pair cPCR products, 1 of which was positive for Mhf using real-time PCR. Forty-four samples (17%) yielded 193 base pair cPCR products, 40 of which were positive for Mhm using real-time PCR. Organism loads ranged from 375 X 10(6)/mL to 6.9 x 10(6)/mL of blood. Sequencing of cPCR products from samples testing negative using real-time PCR identified 2 Mhp-like sequences, 1 Mhm-like sequence, and 1 sequence resembling 'Candidatus Mycoplasma turicensis'. Cats infected with Mhm were less likely to be anemic than uninfected cats. Older age, outdoor exposure, feline immunodeficiency virus (FIV) seropositivity, cutaneous squamous cell carcinoma (SCC), and stomatitis were associated with Mhm infection. Cats from the Sacramento Valley were more often infected with Mhm than cats from the San Francisco bay area.

CONCLUSIONS AND CLINICAL IMPORTANCE

Cats may be infected with 4 hemoplasma species. The association between Mhm infection, FIV, and SCC may reflect outdoor roaming status of infected cats. The clustered distribution of infection suggests an arthropod vector in transmission.

[Detection frequency of haemoplasma infections of the domestic cat in Germany]

We present epidemiological data on the frequency of infections with haemotrophic Mycoplasma spp. (feline haemoplasmas) in domestic cats in Germany. From November 2004 to October 2006 135 blood samples of anaemic patients and cats without clinical symptoms were examined with conventional and real-time PCR methods. In 15,6 % of the samples DNA of one or more haemoplasma species could be detected. 8,9 % of the samples (12 cats) were infected with "Candidatus Mycoplasma haemominutum, whereas 7,4 % (10 cats) were infected with Mycoplasma haemofelis. Out of these, one cat harboured both species. The recently described species "Candidatus Mycoplasma turicensis" was found in 2.2 % of all samples (3 cats) and was restricted to animals coinfected with M. haemofelis. No correlation could be detected between the infection with haemotrophic Mycoplasma spp. and clinical signs of anaemia or disease. Infections were significantly correlated with age, male gender or coinfections with retroviruses (FIV, FeLV). Our data indicate, that chronically infected carriers without clinical symptoms are frequent in the investigated cat populations in Germany and that the screening of blood-donors for the presence of Mycoplasma spp. infections is advisable before clinical use.

Increased plasma malondialdehyde and fructosamine in anemic H pylori infected patients: Effect of treatment

AIM: To unravel the possible association of malon-dialdehyde (MDA) and fructosamine in anemic H pylori infected patients and to observe the alteration in MDA and fructosamine levels in these patients after treatment for one month.

METHODS: Fructosamine, MDA and glucose were estimated in 22 anemic H pylori infected patients and 16 healthy controls. Hematological parameters were also evaluated in both the groups using Sysmex-K-100 automated cell counter. The H pylori infected patients were randomly divided into two groups. H pylori infected patients in GroupIreceived both iron supplementation and anti-H pylori therapy, while patients in Group II received only iron supplementation. All the biochemical and hematological parameters were estimated after one month of treatment.

RESULTS: In anemic H pylori infected patients, while MDA (5.41 ± 2.16 vs 2.26 ± 0.50; P < 0.05) and fructosamine (2.64 ± 0.93 vs 1.60 ± 0.35; P < 0.05) were significantly increased, iron (32.72 ± 14.93 vs 110.25 ± 26.58; P < 0.05), hemoglobin (6.9 ± 2.6 vs 12.66 ± 0.74; P < 0.05) and ferritin (28.82 ± 16.27 vs 140.43 ± 30.72; P < 0.05) levels were significantly decreased compared with the controls. With partial correlation analysis, fructosamine was found to have a significant positive correlation with MDA. In GroupI, while MDA level decreased significantly (3.11 ± 1.73 vs 5.50 ± 2.46; P < 0.05), there was a significant increase in iron (84.09 ± 29.51 vs 36.09 ± 17.81; P < 0.05), hemoglobin (10.40 ± 1.11 vs 7.42 ± 1.90; P < 0.05) and ferritin (116.91 ± 63.34 vs 30.46 ± 17.81; P < 0.05) levels after one month. There was no significant change in the levels of fructosamine in groupIafter treatment. Similarly, no significant alterations were noted in the levels of MDA, fructosamine, hemoglobin or ferritin in Group II patients after one month of treatment.

CONCLUSION: An increased level of fructosamine and MDA was found in anemic H pylori infected patients. Present data supports the premise that lipid peroxides per se do play a role in the glycation of plasma proteins. Furthermore, the findings from this study indicate that treatment for both anemia and H pylori infections is required for lowering the levels of lipid peroxides in these patients.

Successful treatment of polymicrobial multivalve infective endocarditis

A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.

Identification of a haemomycoplasma species in anemic reindeer (Rangifer tarandus)

During an 18-mo period (May 2002-November 2003), 10 animals in a herd of 19 reindeer (Rangifer tarandus) at the National Animal Disease Center (NADC) experienced episodes of anemia. Affected animals had histories of weight loss, unthriftiness, occasionally edema of dependent parts and moderate anemia characterized by microcytosis or macrocytosis, hypochromasia, schistocytosis, keratocytosis, acanthocytosis, and dacryocytosis. Numerous basophilic punctate to ring-shaped bodies, measuring less than 1.0 microm, were found on the surface of red blood cells and were often observed encircling the outer margins of the cells. Based on cytologic findings, DNA preparations from selected affected animals in the NADC herd and one animal from a private herd experiencing similar episodes of anemia were assayed by polymerase chain reaction (PCR) for the presence of hemotropic bacteria using primers targeting the 16S rRNA genes of Mycoplasma (Eperythrozoon) suis, Mycoplasma (Haemobartonella) haemofelis, Anaplasma marginale, Anaplasma spp., and Ehrlichia spp. Amplification products were detected from four of the affected animals using primers specific for the 16S rRNA gene of M. haemofelis and Mycoplasma haemocanis. Product from one of the animals was sequenced and internal primers were designed from the resulting sequence to perform a nested PCR assay. Samples from 10 reindeer were positive using the nested PCR reaction and products from seven animals were sequenced; BLAST searches and phylogenetic analysis were performed on the resulting sequences. Sequence data from six animals revealed homology to an organism most closely related to Mycoplasma ovis, Mycoplasma wenyonii, and Mycoplasma haemolamae; sequence from a single animal was most closely related to M. haemofelis and M. haemocanis. This represents the first identification of a haemomycoplasma species in reindeer. Although several animals were also infected with abomasal nematodes, the presence of this newly described haemomycoplasma may have contributed to the anemic syndrome.

[Interaction between bacteria and erythrocytes and their role in the development of infectious anaemia]

The concentration of hemoglobin in blood of patients with pyoinflammatory diseases was shown to depend on the ability of bacteria to interact with erythrocytes. Bacteria with high hemolytic activity (> or = 70% hemolysis) and anti-hemoglobin activity (>3 g/1) were isolated from pyoinflammatory foci of patients suffering from anaemia. Structural changes were investigated in vitro and in vivo erythrocytes in terms of their interaction with microorganisms by electron microscopy. For the first time, the phenomenon of coccal location within erythrocytes was established. Staphylococci with a high level of hemolytic and anti-hemoglobin activity appear to survive and multiply within erythrocytes that results in destroying hemoglobin. Staphylococci with a low level of mentioned activities are subjected to destructive changes within erythrocytes and subsequent killing.

Syphilis returns to the suburbs

Congenital syphilis is now rare in Australia, particularly in suburban areas. The disease is both preventable and treatable, however, missed or late diagnosis can lead to catastrophic effects. We report an infant who developed congenital syphilis after multiple opportunities for preventing this condition were missed.

Detection of a new weak A blood-group allele (Aw11)

BACKGROUND AND OBJECTIVES

Weak ABO variants may escape tests using unlicensed sera.

MATERIALS AND METHODS

Prior to transfusion, ABO grouping was performed using an automated system and in-house diluted sera, and manual and bedside test techniques. Genotyping and sequencing were performed using standard methods.

RESULTS

Initially, the red blood cells (RBC) of the first-time blood donor were typed as B, but pretransfusion testing carried out using the bedside test indicated the presence of an additional A phenotype. Serological re-examination confirmed the bedside test results, and the allele in question was identified, by genotyping, as a new weak A variant (Aw11).

CONCLUSIONS

The use of CE-marked and licensed antisera is recommended to avoid ABO mistyping.

Canine mycoplasmas

This review aims to summarise our current understanding of the role of mycoplasmas in domestic dogs. Canine mycoplasmology is a small field, with less than 50 publications in the past 40 years. In this time we have gained knowledge about the number of species and have made associations with infections in dogs. However much evidence is still lacking. The importance of all canine mycoplasmas remains unknown, yet certain species are associated with canine anaemia (Mycoplasma haemocanis), respiratory disease (Mycoplasma cynos) and urogenital tract infections (Mycoplasma canis). Mycoplasmas can be isolated in pure culture from canine clinical specimens and it is hoped that this review will stimulate veterinarians to consider mycoplasmas as a potential cause of disease in dogs, especially when antibiotic therapy is failing.

Detection of Chlamydophila pneumoniae in the bone marrow of two patients with unexplained chronic anaemia

Anaemia of chronic disease (ACD) is a common finding involving iron deficiency and signs of inflammation. Here, we report on two patients with ACD where a persistent infection with Chlamydophila (Chlamydia) pneumoniae (CP) was detected in bone marrow (BM) biopsies. Infection was suspected by routine cytology and confirmed by immunofluorescence, electron microscopy, polymerase chain reaction (PCR) including different primer sets and laboratories and sequencing of the PCR product. This is a first report of chlamydial presence in the BM of anaemic patients. The cases are presented because persistent chlamydial infection may contribute more frequently to chronic refractory anaemia than previously suspected.

The prevalence of Helicobacter pylori in Japanese children with gastritis or peptic ulcer disease

BACKGROUND

Although Helicobacter pylori infection is typically acquired in childhood, the role of H. pylori infection in gastroduodenal diseases in childhood remains to be defined. The purpose of this study was to evaluate the prevalence of H. pylori infection in children with gastritis, duodenal ulcer, and gastric ulcer.

METHODS

This was a retrospective analysis of 283 Japanese children (mean age, 11.5 years) with non-nodular gastritis ( n = 73), nodular gastritis ( n = 67), duodenal ulcer ( n = 100), and gastric ulcer ( n = 43). H. pylori status was based on biopsy tests. Clinical symptoms at the time of endoscopy were analyzed with regard to a possible association with the infection.

RESULTS

The prevalence of H. pylori in non-nodular gastritis, nodular gastritis, duodenal ulcer, and gastric ulcer was 28.8%, 98.5%, 83.0%, and 44.2%, respectively. H. pylori was significantly linked to duodenal ulcer and gastric ulcers in the age group of 10-16 years, but not in the age group of 9 years and under. In children with H. pylori infection, nodular gastritis was observed in 26.3% of gastric ulcer patients and in 74.7% of duodenal ulcer patients ( P < 0.001). H. pylori infection was significantly associated with the prevalence of anemia ( P < 0.05).

CONCLUSIONS

H. pylori is the most important causal factor for the development of duodenal ulcer in childhood. While H. pylori infection appears to be a risk factor in gastric ulcer, other causes are responsible for most cases. Nodular gastritis is the most common type of H. pylori gastritis in childhood. Chronic infection with H. pylori is associated with anemia.

E-test method for detecting antibiotic synergy against Pseudomonas aeruginosa from neutropenic patients: a cost-effective approach

The aim of this study was to evaluate the accuracy of E-test for the detection of synergy or antagonism of antibiotic combinations against Pseudomonas aeruginosa isolates from neutropenic patients. The activity of levofloxacin or grepafloxacin combined with ceftriaxone or cefotaxime against 20 P. aeruginosa clinical strains was assessed by checkerboard technique in comparison with results performed by E-test. The combination grepafloxacin + ceftriaxone appeared to be most effective (synergy, 55%) by checkerboard technique. The agreement between checkerboard and E-test results was 71.2%. Synergy was detected by checkerboard and E-test methods in 35 (43.8%) and 23 (31.3%) of 80 possible combinations, respectively. Antagonism was detected once (1.2%) by checkerboard method only. No major errors were recorded. E-test was preferable to checkerboard method for the total cost (reagent cost + cost of technologist time) (8,60 vs 21,80 euros/test, respectively). E-test appeared a promising alternative for testing antibiotic combinations although further testing should be performed to better refine this metodology.

Pneumococcus-induced T-antigen activation in hemolytic uremic syndrome and anemia

The hemolytic uremic syndrome (HUS) is most commonly associated with Escherichia coli, but has been associated with other infections such as Streptococcus pneumoniae. Pneumococcus-induced HUS carries an increased risk of mortality and renal morbidity compared with E. coli-induced HUS. The pneumococcal organism produces an enzyme, which can expose an antigen (T-antigen) present on erythrocytes, platelets, and glomeruli. Antibodies to the T-antigen, normally found in human serum, bind the exposed T-antigen, and the resultant antigen-antibody reaction (T-activation) can lead to HUS and anemia. Clinicians need to be aware to request specific testing when pneumococcus-induced HUS/anemia is suspected, as current blood banking techniques do not routinely test for the presence of the T-antigen. Once this association is documented, washing all blood products and avoiding plasma products, if possible, is recommended. Plasmapheresis can be considered for the more critically ill patient. The incidence of pneumococcus-induced HUS may be increasing. We report six cases of pneumococcus-induced HUS/anemia presenting at our hospital.

Experimental Corynebacterium pseudotuberculosis mastitis in dairy cows

The inoculation of 2000 colony-forming units of Corynebacterium pseudotuberculosis into one teat canal of each of three cows resulted in severe, chronic, pyogranulomatous mastitis. Within three days the cows had a reduced haematocrit, haemoglobin concentration and red cell count. The anaemia was initially normocytic, normochromic and non-regenerative, and was associated with a brief peak of neutrophilia; a regenerative response became evident two to three weeks later. Clinical signs of mastitis appeared seven to 14 days after the inoculation, with a peak of high fever, more severe anaemia, a second peak of neutrophilia and the complete cessation of milk production from all quarters; extensive and severe pyogranulomatous mastitis developed in the inoculated quarters. No other lesions were detected postmortem, and C pseudotuberculosis was cultured from the affected quarters but not from the supramammary lymph nodes and viscera.

Identification of Haemobartonella felis (Mycoplasma haemofelis) in captive nondomestic cats

This study was undertaken to determine whether Haemobartonella felis (Mycoplasma haemofelis), the causative bacterial agent of feline infectious anemia, infects nondomestic cats. Routine complete blood count and polymerase chain reaction (PCR) were performed to detect the gene for 16S ribosomal RNA for the organism. Sixty-four blood samples were collected from 54 nondomestic cats, including tigers (Panthera tigris), cheetahs (Acinonyx jubatus), lions (P. leo), mountain lions (Felis concolor), snow leopards (P. unica), and a jaguar (P. onca). Some cats were sampled on two or three different dates. Two tigers were positive for H. felis by PCR analysis. As previously described in domestic cats, the parasitemia appears to be intermittent in nondomestic cats.

Antibody response in typhoid fever in endemic Indonesia and the relevance of serology and culture to diagnosis

Culture and serology were performed on blood and serum samples collected at or shortly after admission from 473 patients presented with suspected clinical typhoid. Clinical symptoms at first presentation including confusion, hepatomegaly, splenomegaly, abdominal pain, anemia, and gastrointestinal bleeding were non-specific as they were observed even more often in non-typhoid patients. Culture confirmed the diagnosis in 65.3% of the patients with typhoid fever as the final diagnosis. The sensitivity (58%) and specificity (98.1%) of a rapid dipstick assay for the detection of S. typhi-specific immunoglobulin M were somewhat lower than those of culture but higher than those of the Widal test. The dipstick assay thus may well be used in the serodiagnosis of typhoid in situation where culture facilities are not available. Combination of test results of dipstick and culture improved sensitivity to 82.5%. In laboratories that perform blood culture the dipstick assay may be used as a rapid screening tests to facilitate a rapid diagnosis. Sensitivity of the dipstick assay strongly increased with duration of illness and was higher for culture positive than for culture negative patients. Duration of illness, and different pathogen and host factors including dose of infection, pathogenicity and antigenicity, and prior antibiotic use are likely to influence the immune response, therefore the result of the dipstick assay. Duration of illness and presence of S. typhi in the blood are major factors that determine severity of disease.

Effect of preexisting FeLV infection or FeLV and feline immunodeficiency virus coinfection on pathogenicity of the small variant of Haemobartonella felis in cats

OBJECTIVE

To investigate the effects of preexisting FeLV infection or FeLV and feline immunodeficiency (FIV) coinfection on the pathogenicity of the small variant of Haemobartonella felis (Hfsm, California variant) in cats.

ANIMALS

20 FeLV infected, 5 FeLV-FIV coinfected, and 19 retrovirus-free cats.

PROCEDURES

A client-owned cat, coinfected with FeLV and Hfsm, was the source for Hfsm. Inoculum 1 (FeLV free) was obtained by passage of source Hfsm through 4 FeLV-resistant cats. Inoculum 2 was obtained by further passage of Hfsm (inoculum 1) through 2 specific pathogen-free cats.

RESULTS

A mild-to-moderate anemia started 21 days after inoculation, with its nadir occurring at 35 to 42 days after inoculation. Infection with Hfsm induced greater decrease in hemoglobin concentration in FeLV infected cats, compared with retrovirus free cats. Reticulocytosis, macrocytosis, and polychromasia of erythrocytes developed in anemic cats regardless of retrovirus infection status. Mean neutrophil counts decreased during the hemolytic episode. For most cats, the anemia was transient. Four FeLV infected cats, 1 of which was also FIV infected, developed fatal FeLV-associated myeloproliferative diseases. Of the surviving cats, 8 died over the next 24 months from other FeLV-related diseases. Hemolysis did not recur after the initial episode. Inoculum 1 induced more severe anemia than inoculum 2.

CONCLUSIONS AND CLINICAL RELEVANCE

Our results support the clinical observation that cats coinfected with FeLV and H felis develop more severe anemia than cats infected with H felis alone. Infection with Hfsm may induce myeloproliferative disease in FeLV infected cats. The small variant of H felis may lose pathogenicity by passage through FeLV-free cats.

Murine typhus in Greece: epidemiological, clinical, and therapeutic data from 83 cases

Over a period of 5 years (1993-97), 83 cases of murine typhus were identified and studied in the city of Chania, on the island of Crete. Of these cases, 4.8% were registered in 1993, 19.3% in 1994, 47.0% in 1995, 10.8% in 1996, and 18.1% in 1997. The greatest incidence of the disease occurred during the third trimester of the year. Direct contact with rats was noted in 45 (54.2%) of 83 patients. Two strains of Rickettsia typhi were isolated in cell cultures. The predominant clinical manifestations were: fever (100%), headache (88%), chills (86.7%), and rash (79.5%). In 4 of the patients (4.8%), the disease was complicated by acute renal failure, and in 4 other patients (4.8%), by pulmonary consolidations. The outcome under appropriate treatment was favourable for all patients.

Inoculation of two genotypes of Hemobartonella felis (California and Ohio variants) to induce infection in cats and the response to treatment with azithromycin

OBJECTIVES

To describe clinical and laboratory findings associated with cats experimentally infected by inoculation with the 2 recognized genotypes of Hemobartonella felis (small variant, Hfsm; large variant, Hflg) and to determine the response of cats to treatment with azithromycin.

ANIMALS

18 young adult domestic shorthair cats of both sexes.

PROCEDURES

Cats were inoculated with H felis and monitored weekly, using CBC counts and a polymerase chain reaction (PCR) designed to detect both genetic variants of H felis. Beginning 26 days after inoculation, 11 cats were administered azithromycin (15 mg/kg of body weight, PO, q 12 h, for 7 days).

RESULTS

Inoculation resulted in coinfection with Hflg and Hfsm, and both variants were detected by PCR. Clinical abnormalities and anemia were most severe in Hflg- and dual-infected cats. Results of PCR and CBC were positive for H felis in 112/112 (100%) and 42/112 (37.5%), respectively, samples collected after inoculation. Administration of azithromycin had little effect on clinical variables, including anemia. All cats, regardless of treatment with azithromycin, had positive results for the PCR at the end of the study period.

CONCLUSIONS AND CLINICAL RELEVANCE

In these cats, Hflg was more pathogenic than Hfsm, and coinfection with both variants was detected. Results of the PCR were superior to results of CBC for detecting infection with H felis. Azithromycin administered at the dose and duration reported here was not efficacious for the treatment of cats with hemobartonellosis.

Utility of bone marrow biopsy for rapid diagnosis of febrile illnesses in patients with human immunodeficiency virus infection

BACKGROUND

Histochemical staining of bone marrow biopsy samples for microorganisms may provide a presumptive diagnosis weeks before culture.

METHODS

To identify predictors of histochemical positivity, we reviewed 161 bone marrow biopsies from febrile patients with human immunodeficiency virus (HIV) infection.

RESULTS

By multivariate analysis, both hematocrit value <30% and white blood cell count <4,000/mm3 predicted biopsy positivity by culture or staining, but only anemia predicted histochemical stain positivity. Of cases with serum lactate dehydrogenase (LDH) levels >600 U/L, histoplasmosis was diagnosed in 31.6% versus 7.8% with lower LDH levels. Among histoplasmosis cases, staining showed fungi in all, with LDH levels >600 U/L versus 44.4% with lower levels.

CONCLUSIONS

Bone marrow biopsy will most likely provide a rapid diagnosis in patients with anemia. Markedly elevated LDH levels suggest stain positivity for Histoplasma capsulatum. Histopathologic patterns may also guide empiric therapy.

Specific in situ hybridization of Haemobartonella felis with a DNA probe and tyramide signal amplification

Haemobartonella felis is an epierythrocytic bacterium suspected to be the causative agent of feline infectious anemia. Previous studies with a polymerase chain reaction assay have identified a mycoplasmal 16S rRNA gene sequence that coincides with clinical disease and the presence of organisms in the blood. Tissues from a cat experimentally infected with H. felis were used for in situ hybridization studies to physically link this 16S rRNA gene to the organisms on the red cells. A biotin-labeled probe was used in conjunction with tyramide signal amplification to visualize the hybridization signal. This study clearly demonstrates a specific hybridization signal on the red cells in the tissues of the H. felis-infected cat. This in situ hybridization study is the final step in fulfilling the molecular guidelines for disease causation and proves that H. felis, a mycoplasmal organism, is the causative agent of feline infectious anemia.

Brucellosis in children in south Jordan

Retrospectively we evaluated the records of 68 children with brucellosis. We found 58.2% had consumed unpasteurized milk and dairy products. Nonspecific manifestations included: arthralgia (78%), fever (75%) and sweating (60%). Localized manifestations included limping (75%) and arthritis (54%). Leukopenia was found in 51% of children and anaemia in 24%. Brucella species was cultured for blood of 16 (23.5%) patients. Combination therapy containing streptomycin was more effective than gentamicin combinations.

Pseudomonas aeruginosa orbital phlegmon in a patient treated for myelodysplastic syndrome with concomitant Sjögren's syndrome

Pseudomonas aeruginosa orbital infections have been described very rarely in patients with neutropenia after chemotherapy. We report the case of a woman with the unusual association of Sjögren's disease and myelodysplasia, who suffered from a Pseudomonas aeruginosa orbital phlegmon after chemotherapy for her myelodysplastic syndrome. Partial intestinal antibiotic decontamination with ciprofloxacine did not prevent the infection. She was treated successfully with intravenous ceftazidime, netilmicin and granulocyte-colony stimulating factor (G-CSF). The normalization of the granulocyte count seems to play a crucial role for recovery. We present the clinical and radiological findings, discuss the therapy and review the literature concerning ocular infections due to Pseudomonas. Other infections due to this germ in immunocompromised hosts are briefly reviewed.

Extra-pulmonary tuberculosis in patients with fever of unknown origin: clinical features and diagnosis

One hundred twenty-nine patients with extra-pulmonary tuberculosis admitted at the Abbassia Fever Hospital, NAMRU-3 during a seven year period (1991 to 1997) are described. Tuberculous peritonitis was diagnosed in 35 patients, tuberculous lymphadenitis in 32, intestinal tuberculosis in 19, genito-urinary tuberculosis in 14, skeletal tuberculosis in 13, disseminated miliary tuberculosis in 11, and splenic tuberculosis in 5 patients. The clinical picture included fever, and weight loss accompanied by anaemia and an elevated erythrocyte sedimentation rate in all patients.

Iron, infections, and anemia of inflammation

Iron is essential to all microorganisms. To obtain iron from the very low concentrations present in their environment, microorganisms have developed sophisticated mechanisms such as the siderophore system. As a primitive defense mechanism, humans have developed mechanisms to withhold iron from microorganisms. Iron-binding proteins such as transferrin, ferritin, and lactoferrin have a central role in human ferrokinetics. These iron-binding proteins also participate in the process of decreasing iron availability for the microorganisms. They do so by decreasing iron reutilization. Anemia of inflammation (previously called anemia of chronic disease) is seen in the setting of infectious, inflammatory, and neoplastic diseases. It results, in part, from changes in the intracellular metabolism of iron. Alterations of iron physiology seen in many clinical circumstances make excess iron available to microorganisms, thus enhancing their pathogenicity. Understanding the molecular basis of iron withholding by the human host, both in the absence of and during infection, and that of iron acquisition by microorganisms may provide us with new and innovative antimicrobial agents and vaccines.

Prevalence of tuberculosis in Kishtwar Tehsil of Jammu region in Jammu and Kashmir State

A study of prevalence of tuberculosis in Kishtwar tehsil of Jammu region was conducted from June 1991 to May 1992. A total of one thousand two hundred ninety-eight rural as well as urban population suffering from various types of lung diseases was studied for prevalence of tuberculosis and a sizeable number (98) of patients were found to be positive of various types of tuberculosis, viz, pulmonary tuberculosis, tuberculous pleural effusion and miliary tuberculosis. Of the population studied 7.55% were found to be positive for tuberculosis and among them 88.76% patients were anaemic and the commonest type of anaemia was normocytic normochromic and normocytic hypochromic. The ESR was raised in almost of all the patients. Of the population, 80.61% were seen to be positive on skiagram chest and 58.16% were found to be positive on other diagnostic tests like Mantoux's tests, sputum for acid-fast bacilli, etc. Mantoux's test was positive in 27.55% cases and sputum was positive in 30.61% cases. All the cases studied were subjected to special investigations. The changes in parameters are consistent with the diagnosis of tuberculosis. Large family size, poverty, excessive smoking, illiteracy, etc, are the major contributing factors.