Biomedical subjects
Publications and source records attributed to P Ferrieri.
Chrysosporium species caused an invasive infection in an 18-year-old patient following allogeneic sibling bone marrow transplant for T lineage acute lymphoblastic leukemia. This infection began as a facial swelling and extended into the central nervous system. Fungal disease spread rapidly despite antifungal agents. An autopsy showed fungal involvement of brain, lungs, liver and kidneys.
A retrospective review of 832 bone marrow transplant patients was performed to determine the clinical spectrum and risk factors for viridans streptococci infections. The incidence of viridans streptococci cultured from the blood and/or cerebrospinal fluid was 15% (123/832), occurring within 15 days of bone marrow transplant in 78% of patients, usually during profound neutropenia. Strep. mitis was the most frequent isolate (47%). Only 27% (33/123) of patients were symptomatic beyond fever, usually with neurologic, pulmonary, and/or cardiovascular manifestations. Ten (8%) of 123 culture positive patients developed a fulminant cardiorespiratory collapse, with a 60% mortality. One additional death occurred due to cerebritis. However, a time dependent covariate analysis found no significant difference in overall mortality (p = 0.30) or duration of hospitalization (p = 0.50) in patients with or without viridans streptococci infections. A multivariate analysis revealed that age less than 18 years (RR = 1.5, p = 0.04) and a primary diagnosis of acute lymphocytic leukemia (RR = 1.5, p = 0.07) were independent and significant risk factors for viridans streptococci infections. Sex, conditioning regimen, donor type, in vitro bone marrow treatment, and acute graft-versus-host disease were not significant. Viridans streptococci should be recognized as pathogens in bone marrow transplant patients which require appropriate antibiotics and aggressive supportive therapy.
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Clinical isolates of group B streptococci from body fluids and mucosal surfaces were examined for production of a trypsin-resistant antigen known as R protein. R protein was extracted with 1% trypsin from cells grown in a semidefined medium. The extracts were tested by immunodiffusion in agarose with a panel of antisera for detection and precise identification of the four species of R protein described by Wilkinson. R antigen was present in 49 of 131 (37%) of the strains tested. Analysis by serotype revealed that 0 of 2 type Ia, 0 of 11 Ib, 1 of 16 (6%) Ia/c, 12 of 15 (80%) II, 0 of 20 II/c, 35 of 49 (71%) III, 0 of 6 IV, and 1 of 12 (8%) nontypeable strains produced R antigen. Production of the R protein and the trypsin-resistant or alpha component of the c protein appeared to be mutually exclusive. R antigen was more prevalent in isolates from blood (50%) than in those from mucosal sites (27%) for type II strains; no difference was seen for type III strains from these sites. Concordant results were obtained with five paired body fluid-mucosal surface isolates from individual patients and with isolates from 17 mother-baby pairs. The most frequent species of R antigen was R4 (45 of 49), followed by R1 (4 of 49). These two species of R protein were biochemically (trypsin resistant and pepsin sensitive) and immunologically identical to the R-protein antigens produced by prototype strains of groups A, B, and C streptococci.
Oral mucosal ulceration complicating bone marrow transplantation interferes with patients' comfort, nutrition and may lead to systemic infection derived from the mouth. The mucosal injury results from epithelial damage due to the cytotoxic effects of chemotherapy and radiation conditioning as well as from superficial oropharyngeal infection. Because chlorhexidine gluconate is a broad spectrum topical antimicrobial which has been demonstrably effective in preventing oral infection and gingivitis, we performed a randomized, placebo controlled, double-blind trial of chlorhexidine as a mouth rinse in BMT recipients to study the severity of oral mucositis and both oral and systemic infectious complications. One hundred patients were randomly assigned to receive either chlorhexidine gluconate 0.12% mouth rinse or placebo three times daily from the initiation (day -8) of chemoradiotherapy conditioning until day +35 post-BMT. Chlorhexidine use resulted in a trend toward improved oral hygiene index (reduced dental plaque) (p = 0.06) but did not modify the oral mucositis. Patients using chlorhexidine developed a maximum ulceration of 18 +/- 22% of their oral mucosa, while placebo patients ulcerated 25 +/- 31% of the mouth. Ulcerative mucositis was significantly worse in adults compared with children, in individuals who received methotrexate for graft-versus-host disease prophylaxis, and was most prominent on non-keratinized epithelium. Overall, there was no clinically demonstrable additional therapeutic advantage to the use of chlorhexidine in either reducing the mucositis, controlling oral pain, facilitating oral nutrition, shortening hospital stay, or reducing oral infection with herpes simplex virus. There was a trend toward diminished oral candidiasis in chlorhexidine users (p = 0.06).(ABSTRACT TRUNCATED AT 250 WORDS)
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This study analyzed the clinical characteristics of 69 neonates who were admitted to the University of Minnesota Hospital between January, 1972, and June, 1984, with early onset Group B streptococcal infection (EOGBS) and determined those features associated with fatal infection. The incidence of EOGBS was 1.6 cases/1000 live births among 7960 inborn infants; the mortality rate for inborn and outborn infants was 28%. Multivariate analysis identified five features adequately predicting fatal outcome: birth weight less than 2500 g, absolute neutrophil count less than 1500 cells/mm3, hypotension, apnea and a pleural effusion on the initial chest radiographs. With these five variables and an initial blood pH less than 7.25, a clinical score was constructed that correctly predicted outcome in 93% of patients in this study (87% sensitivity, 95% specificity). Autopsy findings in 16 of 19 infants with fatal EOGBS suggested that surfactant deficiency respiratory distress syndrome was common in preterm infants with EOGBS and contributed to their higher mortality compared with term infants.
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Opportunistic infections with fungal organisms have been well described in patients undergoing intensive chemotherapy and bone marrow transplantation. In two patients, invasive infections with the saprophyte Scopulariopsis developed either following intensive chemotherapy or bone marrow transplant. Fungal disease persisted in both patients despite resection of the primary focus and prolonged treatment with the usual antifungal agents, and contributed to the death of one patient.
The correlation of fecal gram-negative bacilli (GNB), neutropenia, and bacteremia was studied in 45 bone marrow transplant recipients. Weekly stool cultures were prospectively monitored for GNB resistant to routine prophylactic and empiric antimicrobial agents. Seven cases of GNB bacteremia occurred in 45 patients described as follows. Twenty-three patients had no fecal or blood GNB. Fifteen patients had fecal GNB and no blood GNB; three of these latter patients had less than or equal to 50/mm3 circulating white blood cells (WBC) at the time of isolation of fecal GNB but two of the three were concurrently receiving appropriate empiric antibiotics. Two patients had blood GNB but no fecal GNB: one patient had a trimethoprim/sulfamethoxazole (TMP-SMZ)-sensitive isolate that would not be detectable in the feces by our methodology and one patient had feces analyzed only after the bacteremic event. Five patients had fecal GNB and blood GNB: one of these patients did not have a fecal sample analyzed prior to bacteremia but the remaining four patients had the same species/antibiogram of GNB isolated from the feces two to three days prior to the detection of bacteremia. Thus, the fecal GNB could have been used to predict the antibiogram of the subsequent blood GNB. In addition, all four of these latter bacteremic patients had less than or equal to 50/mm3 circulating WBC at the time of documented fecal GNB. Thus, bone marrow transplant recipients with fecal GNB coupled with severe neutropenia (less than or equal to 50/mm3 circulating WBC) were more likely to develop bacteremia (P less than 0.02) than were those with fecal GNB and greater than 50/mm3 circulating WBC.
Monoclonal antibodies that recognize "rheumatic" antigens of peripheral blood non-T cells were used to study the compartmentalization of such cells in peripheral blood and tonsils of individuals with rheumatic heart disease (RHD) and suitable control subjects. The peripheral blood of most (71%) of the 42 individuals with RHD contained cells reacting with monoclonal antibody 83S19.23 or 256S.10, whereas these cells were present in only 17% of the 41 control subjects (P less than .02). However, none of 21 individuals with RHD had such cells in their tonsils, although they were present in the tonsils of 50% of the 40 control subjects (P less than .03). These results may reflect a failure in RHD or organ-specific homing of cells with the epitopes recognized by the antibodies. The presence of these cells in tonsils may be important in the immune response to streptococcal pharyngeal infection, and their absence in RHD may be involved in the unusual immune responses characteristic of this disease.
In a test of the hypothesis that lysogeny of group A streptococci by a temperate bacteriophage might confer nephritogenicity, 283 sera from 69 patients were examined for IgG and IgM antibodies to M 49 streptococcal bacteriophage hyaluronidase. The IgG and IgM response to bacteriophage hyaluronidase was greatest in M 49 streptococci-infected individuals with nephritis, but M 49 streptococci-infected subjects without nephritis also had a greater immune response than did subjects infected with serotypes other than M 49. Although antibody to bacterial hyaluronidase was detected in all Streptococcus-infected groups, antibody to M 49 streptococcal bacteriophage hyaluronidase usually was found in only M 49 streptococci-infected patients. Although the greatest IgG and IgM antibody response to bacteriophage hyaluronidase can be demonstrated in individuals with glomerulonephritis, the antibody response does not indicate a direct relation of lysogeny and nephritis because subjects with and without nephritis after M 49 streptococcal infection all had a significant rise in antibody titer.
The influence of antibody and complement on the polymorphonuclear leukocytic uptake and killing of type II group B streptococci (GBS) was examined with 11 adult sera and three type II strains possessing the trypsin-resistant and trypsin-sensitive components (II/TR+TS) of the "c" (formerly Ibc) protein or two type II strains lacking both components (II/no c) of the c protein. All tested sera mediated a greater than 1 log10 reduction in colony-forming units (CFUR) of a type II/no c strain, even in the absence of measurable type-specific antibody (less than 1.08 micrograms/ml), but only 5 of 11 mediated a greater than 1 log10 CFUR of any type II/TR/TS strain, even in the presence of moderate levels of type-specific antibody. The classical pathway of complement activation appeared to be more important than the alternative pathway, and even absorbed or immunoglobulin G (IgG)-depleted serum (IgG, 10 mg/dl) mediated a greater than 1 log10 CFUR without magnesium ethylene glycol-bis(beta-aminoethyl ether)-N,N,N',N'-tetraacetic acid (magnesium EGTA) chelation. Chelation with magnesium EGTA reduced the CFUR in 4 of 11 test sera and greatly reduced the CFUR in absorbed or IgG-depleted sera for type II/no c strains. Despite variation in the phagocytic killing of two representative strains of type II GBS, both strains were well phagocytized, as measured by radiolabeled bacterial uptake or electron microscopy. This study suggested that poorly killed type II/TR+TS GBS were easily phagocytized but apparently resisted intracellular killing.
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After three serial passages of Haemophilus influenzae type b strain Fuju in rats, we recovered a variant, which differed in colonial morphology, serum sensitivity, and lipopolysaccharide configuration from the parent strain. The parent organism (Fuju) appeared iridescent and transparent on Levinthal agar, and the rat-passaged variant (rat3 Fuju) appeared iridescent and opaque. The transparent, parent strain Fuju was sensitive to the complement-mediated bactericidal activity of normal rat serum, and the opaque, rat-passaged strain rat3 Fuju was serum resistant. Serum killing of the serum-sensitive strain appeared to be mediated by the classic complement pathway. Both serum-resistant and serum-sensitive strains were killed equally well by immune rat and human serum. These two strains did not differ in the amount of capsular polysaccharide that they elaborated nor in their major outer membrane protein patterns on SDS-PAGE. Lipopolysaccharide isolated from these two strains demonstrated different electrophoretic mobility patterns. Furthermore, the organisms showed different reactivities with two monoclonal antibodies directed against determinants of Hib lipopolysaccharide. Thus, the difference in susceptibility to complement-mediated bactericidal activity of normal rat serum displayed by these two strains is associated with their phenotypes, appears to be unrelated to differences in major outer membrane proteins or in the amounts of capsular polysaccharide elaborated, and is associated with differences in surface lipopolysaccharides.
The type-specific polysaccharide and the R protein antigens from filtered culture supernatants of the bacterial phase and L-phase of the group B, type III streptococcal strain 76-043 were studied by several immunological methods. In the L-phase of growth, the two antigens were separate and distinct molecules which were found principally in the culture supernatant even on the 254th serial subculture in the cell-wall-defective state. Only trace amounts of these antigens were detected in extracts of L-phase cells. The type III polysaccharide antigens in the supernatant of cultures of the parent bacterium and the L-phase gave reactions of identity in immunodiffusion. Precipitin bands obtained by immunoelectrophoresis (IEP) revealed that the type-specific antigen of the bacterial phase of growth migrated toward the anode, whereas that of the L-phase remained near the antigen well. The R protein antigen in the L-phase supernatant was immunologically identical to the R protein of the supernatant and 1% trypsin-extracted antigens from whole cells of the parent bacterial strain, and other groups A, B and C streptococcal strains sharing a common R antigen. Immunologically, the R antigen appeared to be the species R4. The R protein of the L-phase and bacterial phase cultures was resistant to 5% trypsin but sensitive to 0.5% pepsin at 37 degrees C/2hr. Antiserum prepared in rabbits against L-phase cells contained an antibody reactive with the R protein antigens of the bacterial and L-phase cultures. The soluble, naturally released type III and R protein streptococcal antigens of the L-phase of growth permitted immunological confirmation of its bacterial origin.
Thirty-one type II and eight nontypable group B streptococcal isolates were categorized by the presence of the trypsin-resistant and trypsin-sensitive components of the Ibc protein antigen and studied for opsonization differences by using polymorphonuclear leukocyte chemiluminescence (CL). Type II strains varied in their ease of opsonization: strains possessing both components of the Ibc protein elicited a significantly lower mean CL peak (P less than or equal to .05) and a smaller CL integral (P less than or equal to .01) than did type II strains lacking both components or strains lacking type polysaccharide antigen but possessing the Ibc protein antigen. These strain differences were seen consistently with different sera and were also observed in an opsonophagocytic killing assay. Differences in opsonizing ability and bacterial killing were found for three standard test sera but could not be related to the concentration of type-specific antibody to capsular polysaccharide antigen. Our studies suggested that the Ibc protein antigen was one factor that contributed to the resistance to opsonization of strains of type II group B streptococci.
Nasopharyngeal colonization of infant rats with Haemophilus influenzae type b was investigated by two methods of intranasal inoculation. After traumatic instillation of the bacteria, 100% of the animals became colonized, compared with 75.5% of animals after atraumatic instillation. Among colonized rats, significantly more animals in the traumatic group developed bacteremia compared with those in the atraumatic group. Rats in the traumatic group had an onset of bacteremia at a mean of 2.6 days after inoculation compared with 7.3 days in the atraumatic group. The duration of colonization and bacteremia was the same in both groups. The majority of heavily colonized rats developed bacteremia compared with none of the lightly colonized rats. Thus, the development of bacteremia appeared to be related independently to both heavy colonization and traumatic instillation. Protection against intraperitoneal bacterial challenge with H. influenzae type b developed in rats that had been bacteremic; in the majority of animals, this correlated with the development of serum bactericidal activity. Protection and bactericidal activity were only rarely observed in nonbacteremic rats that had been either heavily or lightly colonized. The development of serum bactericidal activity was not related to either the duration or peak level of bacteremia. Thus, in this rat model, H. influenzae type b nasopharyngeal colonization without bacteremia did not appear to stimulate circulating antibodies that protected the animals against challenge.