Gun Britt Joø

The quantitative association of plasma endotoxin, antithrombin, protein C, extrinsic pathway inhibitor and fibrinopeptide a in systemic meningococcal disease

We have evaluated the quantitative relationship between lipopolysaccharide (LPS, endotoxin), fibrinopeptide A (FPA), antithrombin (AT), protein C (PC) and extrinsic pathway inhibitor (EPI) in plasma from 39 consecutively admitted patients with systemic meningococcal disease (SMD). The most severely ill patients with fulminant meningococcal septicemia (n = 13, 6 dead) had significantly (p less than 0.01) higher plasma levels of LPS and FPA and lower levels of PC and AT on admission as compared with the less severe clinical presentations (n = 26, 1 dead). The levels of EPI on admission were significantly (p less than 0.05) higher in nonsurvivors vs survivors with fulminant septicemia. As the disease progressed, the levels of LPS, FPA, AT and PC declined, while the levels of EPI increased. Three of six nonsurviving septicemic patients had levels of EPI greater than 200% within 16 hours of admission vs two of 30 survivors (p = 0.02). The results suggest that increasing levels of LPS in SMD elicit increasing consumption coagulopathy, contributing to the organ pathophysiology. The kinetics of EPI, inhibiting the thromboplastin-FVIIa-FXa complex, differs markedly from the kinetics of AT and PC i.e. increases as opposed to decreases.

Plasminogen activator inhibitor 1 and 2, alpha-2-antiplasmin, plasminogen, and endotoxin levels in systemic meningococcal disease

We have studied the activation state of the fibrinolytic system in 39 patients with systemic meningococcal disease (SMD). Patients defined as having fulminant septicemia (n = 13) with high (greater than 700 ng/L) levels of endotoxin (LPS) in plasma and severe coagulopathy, had significantly lower functional levels of plasminogen (P less than 0.05) and alpha-2-antiplasmin (P less than 0.01) and higher antigen levels of plasminogen activator inhibitor 1 (PAI-1) (P less than 0.01), and fibrin degradation products (FDP) (P less than 0.01), but not of PAI-2 (P greater than 0.1) as compared with less severely ill patients (meningitis and meningococcemia) (n = 25). A positive correlation existed between the admission (maximum) levels of LPS and PAI-1 (r = 0.86, P less than 0.0001). Decreasing admission levels of platelets were associated with increasing levels of PAI-1 (r = -0.55, P less than 0.001). After initiation of treatment with antibiotics and fresh frozen plasma, the PAI-1 levels declined rapidly. PAI-1 levels greater than 360 micrograms/L on admission predicted the development of a severe septic shock combined with renal impairment correctly in 12 of 13 patients (92%). None of 25 patients without multiple organ failure had PAI-1 levels greater than 260 micrograms/L. PAI-1 levels greater than 1850 micrograms/L were associated with 100% fatality. The results suggest that in the early phase of fulminant meningococcal septicemia an extensive plasmin generation occurs. On admission, however, high levels of PAI-1 seem to inhibit the plasmin generation, and thereby promote DIC.

Chemokine patterns in meningococcal disease

Chemokines are important in regulating leukocyte traffic during infection. We analyzed plasma chemokine levels of monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1 alpha , interleukin (IL)-8, and RANTES in patients with meningococcal infection and correlated these to plasma lipopolysaccharide (LPS) levels, which are closely associated with clinical presentation. In patients with fulminant meningococcal septicemia, versus distinct meningitis or mild systemic meningococcal disease, MCP-1 (both P<.0001), MIP-1 alpha (both P<.0001), and IL-8 (P<.0001 and P=.011) were significantly higher and RANTES significantly lower (P=.007 and P=.021). MCP-1 (r=.88), MIP-1 alpha (r=.82), and IL-8 (r=.89) were positively correlated to plasma LPS levels, whereas RANTES was negatively correlated (r=-.49). In an ex vivo whole-blood model, heat-inactivated wild-type Neisseria meningitidis, purified meningococcal LPS, and (to a negligible extent) heat-inactivated LPS-deficient mutant N. meningitidis induced these chemokines. N. meningitidis LPS is the major cause of chemokine release in meningococcal disease.

Invited review: Neisseria meningitidis lipopolysaccharides in human pathology:

Neisseria meningitidis causes meningitis, fulminant septicemia or mild meningococcemia attacking mainly children and young adults. Lipopolysaccharides (LPS) consist of a symmetrical hexa-acyl lipid A and a short oligosaccharide chain and are classified in 11 immunotypes. Lipid A is the primary toxic component of N. meningitidis . LPS levels in plasma and cerebrospinal fluid as determined by Limulus amebocyte lysate (LAL) assay are quantitatively closely associated with inflammatory mediators, clinical symptoms, and outcome. Patients with persistent septic shock, multiple organ failure, and severe coagulopathy reveal extraordinarily high levels of LPS in plasma. The cytokine production is compartmentalized to either the circulation or to the subarachnoid space. Mortality related to shock increases from 0% to > 80% with a 10-fold increase of plasma LPS from 10 to 100 endotoxin units/ml. Hemorrhagic skin lesions and thrombosis are caused by up-regulation of tissue factor which induces coagulation, and by inhibition of fibrinolysis by plasminogen activator inhibitor 1 (PAI-1). Effective antibiotic treatment results in a rapid decline of plasma LPS (half-life 1—3 h) and cytokines, and reduced generation of thrombin, and PAI-1. Early antibiotic treatment is mandatory. Three intervention trials to block lipid A have not significantly reduced the mortality of meningococcal septicemia.

LPS-induced release of IL-1β, IL-6, IL-8, TNF-α and sCD14 in whole blood and PBMC from persons with high or low levels of HDL-lipoprotein

We have examined basal and lipopolysaccharide (LPS)-induced release of interleukin 1 beta (IL-1 beta), interleukin 6 (IL-6), interleukin 8 (IL-8), tumour necrosis factor-alpha (TNF-alpha) and soluble CD14 (sCD14) in whole blood and peripheral blood mononuclear cells (PBMC) from 20 persons with either high (1.62-2.47 mmol/L) or low (0.43-1.29 mmol/L) levels of high-density lipoprotein (HDL). Whole blood was incubated at 37 degrees C for 2 h with 100 ng LPS/ml, while PBMC were incubated with 100 ng LPS/ml for up to 160 h. The LPS-induced release of IL-1 beta, IL-6, IL-8 and TNF-alpha into plasma showed no differences between the two HDL-groups; whereas levels of sCD14 were significantly higher in plasma in persons with low HDL (P < 0.01). PBMC incubated with LPS showed a significantly higher release of IL-1 beta (P = 0.01) and IL-6 (P = 0.02) in persons with high HDL at all sampling times. sCD14 was found not to be released by PBMC. These findings indicate that PBMC from persons with high or low levels of HDL have different functional properties, possibly of importance in inflammation and atherogenesis.

Identification of meningococcal LPS as a major monocyte activator in IL-10 depleted shock plasmas and CSF by blocking the CD14-TLR4 receptor complex

We have examined the in vitro stimulatory effects of lipopolysaccharide (LPS)-containing samples (meningococcal shock plasma, n = 10; non-shock plasma, n = 10; cerebrospinal fluid (CSF), n = 7) before and after immunodepletion of interleukin (IL)-10 in a monocyte target assay. We also studied the stimulatory effects of plasma collected from 3 patients with lethal septicemia caused by Streptococcus pneumoniae without detectable LPS but with 100-fold increased levels of heat-shock protein 70 (HSP70). HSP70 may, like LPS, activate monocytes via the Toll-like receptor 4 (TLR4). The samples were analyzed for LPS, tumor necrosis factor (TNF)-α, IL-10 and HSP70; applied on human monocytes (purity > 95%) before and after IL-10 immunodepletion, in the absence or presence of CD14 blocking mAb (60bca) or the lipid A antagonist, Rhodobacter sphaeroides diphosphoryl lipid A (RsDPLA) which blocks TLR4. Monocyte activation was measured by increased TNF-α secretion and tissue factor (TF) up-regulation by monocyte procoagulant activity (PCA). There was a positive correlation between patientplasma LPS levels (n = 10) and increases in TNF-α secretion by the monocytes after immunodepletion of IL-10 ( r = 0.82). Pretreatment of the monocytes with mAbCD14 or RsDPLA reduced TNF-α secretion to median 5% and 12%, respectively, of the levels before the receptor complex was blocked. The median levels of HSP70 were 543 ng/ml (range, 468—962 ng/ml) in pneumococcal shock plasma, 81.5 ng/ml (range, 41—331 ng/ml) in meningococcal shock plasma and 24 ng/ml (range, < 0.8—41 ng/ml) in meningococcal non-shock plasma. Pneumococcal septic shock plasmas with significantly higher levels of HSP70 (P < 0.05) did not induce TNF-α secretion in the monocytes. The results strongly suggest that LPS in meningococcal shock plasma is the major activator of monocytes whereas HSP70 (in plasma concentrations up to 963 ng/ml) does not activate monocytes in this assay.

Effects of bacterial cell wall components (PAMPs) on the expression of monocyte chemoattractant protein-1 (MCP-1), macrophage inflammatory protein-1α (MIP-1α) and the chemokine receptor CCR2 by purified human blood monocytes

Regulation of chemokine production and the expression of chemokine receptors play an important role during inflammation and infectious diseases. The present study was designed to study the effects of five different bacterial cell wall components (PAMPs) on the production of MCP-1 and MIP-1α and the expression of CCR2 by highly purified human blood monocytes. All five PAMPs induced high expression of mRNA and protein synthesis of both chemokines. Generally, MCP-1 mRNA and protein levels were higher than MIP-1α levels. Expression of MCP-1 and MIP-1α differed both at the mRNA and at the protein levels, MIP-1α always showing a more rapid initial increase, attaining lower protein levels than MCP-1. Antibodies against CD14 significantly inhibited the inducing effects of all the PAMPs used. Antibody against TLR2 inhibited the chemokine production induced by LTA and AraLAM by more than 36% (P < 0.05) while chemokine production induced by Escherichia coli-LPS, purified E. coli-LPS and Neisseria meningitidis-LPS was inhibited by more than 60% by antibody against TLR4 (P < 0.05). The inducing effects of all five PAMPs could be inhibited by rIL-4, rIL-10 and rIL-13. rIL-4 was the most effective. Generally, IC50 of these anti-inflammatory cytokines were lower for the MIP-1α than for the MCP-1 production. The cell surface expression of CCR2 was significantly down-regulated by all five PAMPs in addition to a decrease in cytosolic free calcium and binding of rMCP-1. We conclude that MCP-1 and MIP-1α as well as the MCP-1 receptor CCR2 will be substantially regulated upon monocyte contact with various cell wall components (PAMPs) from Gram-negative and Gram-positive bacteria as well as from mycobacteria.

The fate of monocytes during 24 h of culture as revealed by flow cytometry and electron microscopy

Culturing elutriation-purified and cryopreserved human monocytes gives a cell loss of about 60% after a week. The main loss is during the first 24 h when one cell population dies by apoptosis and secondary necrosis, while another survives with minimal signs of apoptosis and necrosis. We have studied this initial cell loss using flow cytometry (FCM) and electron microscopy (EM) in parallel. Thawed cells were cultured in ultra low attachment wells and studied by FCM using Annexin V, Propidium iodide (PI), JC-1, APO2.7 and APO-BrDU. The EM studies comprised both transmission EM (TEM) and scanning EM (SEM), the latter employing cells labelled with antiCD14/gold and Annexin V/gold. Cells were counted by light microscopy to provide cell recoveries. DNA ladder patterns were investigated by electrophoresis. Camptothecin (CAM) was used as an apoptosis inducer. In the first 6 h of culture, there was an apoptotic phase with Annexin V(+)/PI(-) positive cells in FCM, chromatin condensation in TEM, a rapid and short phase with Annexin V/gold positively labelled cells in SEM and the cells disappeared by 6 h. All of these effects were enhanced by CAM. The necrotic phase (6-24 h) was associated with Annexin V(+)/PI(+) in FCM, and the data at 24 h was in agreement with the semiquantitatvive results from TEM. Discrepancies in the results for CD14 and Annexin V between FCM and SEM indicated phagocytosis. APO2.7 and APO-BrDU increases also indicated an accumulation of ingested material in vital cells. Centrifugation of supernatants, labelling pellets with Annexin V/FITC and examination by flow cytometry revealed no Annexin V positive cell fragments. We found evidence of rapid and efficient phagocytosis. CAM not only induced apoptosis, but also appeared to stabilise the cell membrane and increase both cell recovery and phagocytosis.

LPS induced procoagulant activity and plasminogen activator activity in mononuclear cells from persons with high or low levels of HDL lipoprotein

UNLABELLED We have examined spontaneous and lipopolysaccharide (LPS) induced procoagulant activity (PCA) and plasminogen activator activity (PA) in peripheral blood mononuclear cells (PBMC) from ten persons with high, and ten persons with low levels of serum high-density lipoprotein (HDL). PBMC were incubated +/- 100 ng LPS/ml up to 160 h. Additionally, we have measured the release of urokinase (uPA), tissue plasminogen activator (tPA), plasminogen activator inhibitor 1 (PAI-1) and plasminogen activator inhibitor 2 (PAI-2) into the cell culture media. Spontaneous PA was significantly higher in PBMC from persons with low HDL, combined with lower release of uPA to the media and higher uPA-receptor (uPA-R) bound uPA on PBMC. Upon stimulation with LPS, PCA and released PAI-2 increased sharply, while PA and released uPA declined. These changes were not significantly different between the two groups. tPA and PAI-1 were not detected in cell lysates or in cell culture media. CONCLUSIONS 1) LPS sharply stimulated PBMC PCA (similar in both groups). 2) PBMC from persons with low HDL showed higher spontaneous PA, due to higher uPA-R bound uPA, probably of importance in cell migration during the early events of atherosclerosis.

Lipopolysaccharide-induced monocyte procoagulant activity, fibrinopeptide A, and PAI-I levels in persons with high or low levels of HDL-lipoprotein

We have examined basal and stimulated monocyte procoagulant activity (PCA) in 10 persons with high HDL (1.62-2.47 mmol/L) and 10 persons with low HDL (0.43-1.29 mmol/L). Heparinized whole blood was incubated at 37 degrees C for 2 hours with 100 ng/ml of E. Coli lipopolysaccharide (LPS). Monocytes were isolated by density gradient centrifugation (purity > 70%), and PCA measured with a chromogenic peptide substrate assay. LPS-induced PCA was significantly higher in the high HDL group (p = 0.02), whereas basal levels were similar. Furthermore, the levels of total HDL, HDL2, as well as apo-A1 were all significantly correlated with LPS-induced monocyte PCA (p < 0.01, p < 0.01, and p = 0.03), whereas VLDL was inversely correlated (p = 0.02). PAI-I activity was significantly lower in the high HDL group (p < 0.01). LPS recovery in plasma after incubation, by LAL test, was significantly higher in the high HDL group (p = 0.02) and correlated to HDL2 (p = 0.04), and inversely correlated with triglycerides (p = 0.04). There was no significant difference between the two groups in plasma fibrinopeptide A (FPA) levels after LPS incubation.