Lily G. Carlin

Post-Diarrhea Chronic Intestinal Symptoms and Irritable Bowel Syndrome in North American Travelers to Mexico

OBJECTIVES:Irritable bowel syndrome (IBS) has been reported to complicate bacterial diarrhea. Because of the frequency of international travel and the common occurrence of bacterial diarrhea, we studied the occurrence of chronic gastrointestinal complaints and post-diarrhea IBS in North U.S. travelers to Mexico.METHODS:One hundred and sixty-nine healthy students were followed prospectively for 5 wk for the occurrence and etiology of diarrhea while studying for 5 wk in Mexico. Subjects recorded their symptoms during travel and completed a gastrointestinal symptom questionnaire 6 months after returning to the United States to determine the presence of IBS using the Rome II criteria.RESULTS:Ninety-seven (57%) subjects returned a completed questionnaire. Sixty-one (63%) developed diarrhea while in Mexico, mostly due to enterotoxigenic and enteroaggregative Escherichia coli. Six months after travel the following chronic symptoms were reported: loose stools, abdominal pain, and fecal urgency in 17 (18%), 17 (18%), and 9 (9%) respectively. Of the 60 patients surveyed who had acquired diarrhea in Mexico, 7 (11%) met the criteria for IBS 6 months later of which 6 (10%) were newly diagnosed. No identified pathogen in the initial illness was associated with the development of IBS.CONCLUSIONS:Chronic gastrointestinal complaints including IBS are common in returning travelers having experienced diarrhea. Postinfectious complications of travelers diarrhea require further study for etiology and strategy for prevention.

Human Lactoferrin Impairs Virulence of Shigella flexneri

Lactoferrin is a glycoprotein present in most human mucosal secretions, including human milk. Lactoferrin is bacteriostatic in low iron media and, in some settings, bactericidal. Lactoferrin impairs ability of Shigella flexneri serotype 5 strain M90T to invade HeLa cells. To determine the mechanism by which lactoferrin decreases invasiveness of Shigella organisms, its effect on the major virulence proteins responsible for bacterial uptake by host cells was evaluated. Lactoferrin induced degradation of invasion plasmid antigens IpaB and, to a lesser extent, IpaC, the key proteins responsible for bacteria-directed phagocytosis by mammalian cells. The lipid A-binding N-terminal portion of lactoferrin (residues 1-33) induces release of invasion antigens but does not induce degradation of IpaBC. Lactoferrin does not directly degrade previously released invasion plasmid antigens but works by making IpaBC susceptible to breakdown by surface-expressed protease(s).

Lactoferrin protects rabbits from Shigella flexneri-induced inflammatory enteritis.

ABSTRACT Shigella species cause bacillary dysentery in humans by invasion, intracellular multiplication, spread to adjacent cells, and induction of brisk inflammatory responses in the intestinal epithelium. In vitro data suggest that lactoferrin, a glycoprotein present in human mucosal secretions, has a role in protection from bacterial enteric infections. We sought to determine the activity of lactoferrin in vivo, using the concentration present in human colostrum, to investigate its effect on the development of clinical and pathological evidence of inflammation in a rabbit model of enteritis. Lactoferrin protected rabbits infected with Shigella flexneri from developing inflammatory intestinal disease. Typical histological changes in ill animals included villous blunting with sloughing of epithelial cells, submucosal edema, infiltration of leukocytes, venous congestion, and hemorrhage. Lactoferrin at a concentration normally found in human colostrum blocks development of S. flexneri-induced inflammatory enteritis.

A single-nucleotide polymorphism in the gene encoding osteoprotegerin, an anti-inflammatory protein produced in response to infection with diarrheagenic Escherichia coli, is associated with an increased risk of nonsecretory bacterial diarrhea in North American travelers to Mexico

BACKGROUND Osteoprotegerin (OPG), an immunoregulatory member of the TNF receptor superfamily, is expressed in inflamed intestinal mucosa. We investigated whether OPG is produced by intestinal epithelial cells and tested the hypothesis that single-nucleotide polymorphisms (SNPs) in the gene encoding OPG (TNFRSF11B) are associated with travelers diarrhea (TD) among North American travelers to Mexico. METHODS OPG concentration was measured in the supernatants of T84 cells infected with various diarrheagenic Escherichia coli pathotypes. Genotyping was performed for 4 SNPs in the OPG gene for 968 North American travelers with or without TD. Stool samples from travelers with TD were evaluated for the presence of enteric pathogens. RESULTS T84 cells produced higher OPG levels in response to infection with various diarrheagenic E. coli pathotypes than with E. coli controls (P<.05). A SNP in the exon 1 region of the OPG gene (OPG+1181G>C) was associated with TD in white travelers who stayed in Mexico for >1 week during the summer (P=.009) and for TD due to nonsecretory pathogens (P=.001). CONCLUSIONS Our study suggests that OPG is secreted by intestinal epithelial cells in response to enteropathogens and that a polymorphism in the OPG gene is associated with an increased susceptibility to TD.

Seroprevalence of the enteroaggregative Escherichia coli virulence factor dispersin among USA travellers to Cuernavaca, Mexico: A pilot study

This pilot study examined the change in the seroprevalence of the enteroaggregative Escherichia coli (EAEC) virulence factor dispersin in USA students during a short stay in Cuernavaca, Mexico, between June and August 2004. One hundred and ninety-five students provided paired serum samples - one on arrival to Mexico (pre-serum) and a second on departure from Mexico (post-serum) after a mean stay of 19 days. Serum samples were tested for IgG antibody to a recombinant purified dispersin protein by ELISA. For all travellers, with and without diarrhoea, the mean+/-sd pre-serum absorbance value (read at 450 and 570 nm) was 0.340+/-0.212 and the mean post-serum value was 0.513+/-0.316 (P<0.00001). Both travellers who developed diarrhoea and those who did not develop diarrhoea had an increase in IgG antibody to dispersin from the time of arrival to the time of departure from Cuernavaca (diarrhoea group 0.323+/-0.197 to 0.501+/-0.311, P<0.00001, and the asymptomatic group 0.354+/-0.224 to 0.525+/-0.321, P<0.00001). The pre-serum absorbance value (read at 450 and 570 nm) for IgG antibody to dispersin was not associated with protection against the development of diarrhoeal illness. These results indicate that USA travellers to Mexico show seroconversion for the EAEC virulence factor dispersin. Further studies are needed to characterize in more detail the host clinical and immunological responses to the dispersin protein.

Clinical features and molecular epidemiology of diarrheagenic Escherichia coli pathotypes identified by fecal gastrointestinal multiplex nucleic acid amplification in patients with cancer and diarrhea

Diarrheagenic Escherichia coli (DEC) pathotypes with differing epidemiology and clinical features, are known causes of disease with worldwide occurrence. At a major cancer center in the U.S., we studied patients with cancer and diarrhea for whom a GI Biofire FilmArray multiplex GI panel (BFM) was performed. An enteropathogen was identified in 382 of 2017 (19%) samples distributed across 311 patients. Of these, 60/311(19%) were positive for DEC. Patients receiving hematopoietic stem cell transplants (HSCT) 29/60 (48%) or with a hematologic malignancy 17/60 (28%) accounted for the majority of DEC cases. Enteropathogenic E. coli (EPEC, n=35 [58%]), enteroaggregative E. coli (EAEC, n=10 [17%]) and Shiga toxin producing E. coli (STEC, n=3 [5%]) were the most common DEC identified and peaked in the summer months. Stool cultures confirmed infections in 6/10 (60%) EAEC (five typical AggR+), and EPEC was recovered in 8/35 (22%) samples (all atypical eaeA+, bfp-). DEC was identified in 22 cases (37%) that developed diarrhea >48hours after admission suggesting health care acquisition. Chronic infections were found in 2 EPEC and 1 EAEC cases that were tested at 1month or beyond with shedding that ranged from 58 to >125days. Two patients that underwent hematopoietic stem cell transplantation carried EAEC strains resistant to multiple antibiotics including fluoroquinolones and expressed extended spectrum beta lactamases. While in some instances BFM results were not verified in culture and could represent false positives, DEC pathotypes, especially EPEC and EAEC, caused chronic infections with antimicrobial-resistant strains in a subset of immunosuppressed cancer patients.

Novel Segment- and Host-Specific Patterns of Enteroaggregative Escherichia coli Adherence to Human Intestinal Enteroids

ABSTRACT Enteroaggregative Escherichia coli (EAEC) is an important diarrheal pathogen and a cause of both acute and chronic diarrhea. It is a common cause of pediatric bacterial diarrhea in developing countries. Despite its discovery in 1987, the intestinal tropism of the pathogen remains unknown. Cell lines used to study EAEC adherence include the HEp-2, T-84, and Caco-2 lines, but they exhibit abnormal metabolism and large variations in gene expression. Animal models either do not faithfully manifest human clinical symptoms or are cumbersome and expensive. Using human intestinal enteroids derived from all four segments of the human intestine, we find that EAEC demonstrates aggregative adherence to duodenal and ileal enteroids, with donor-driven differences driving a sheet-like and layered pattern. This contrasts with the colon, where segment-specific tropisms yielded a mesh-like adherence pattern dominated by interconnecting filaments. Very little to no aggregative adherence to jejunal enteroids was observed, regardless of the strain or donor, in contrast to a strong duodenal association across all donors and strains. These unique patterns of intestinal segment- or donor-specific adherence, but not the overall numbers of associated bacteria, were dependent on the major subunit protein of aggregative adherence fimbriae II (AafA), implying that the morphology of adherent clusters and the overall intestinal cell association of EAEC occur by different mechanisms. Our results suggest that we must give serious consideration to inter- and intrapatient variations in what is arguably the first step in pathogenesis, that of adherence, when considering the clinical manifestation of these infections. IMPORTANCE EAEC is a leading cause of pediatric bacterial diarrhea and a common cause of diarrhea among travelers and immunocompromised individuals. Heterogeneity in EAEC strains and lack of a good model system are major roadblocks to the understanding of its pathogenesis. Utilizing human intestinal enteroids to study the adherence of EAEC, we demonstrate that unique patterns of adherence are largely driven by unidentified factors present in different intestinal segments and from different donors. These patterns are also dependent on aggregative adherence fimbriae II encoded by EAEC. These results imply that we must also consider the contribution of the host to understand the pathogenesis of EAEC-induced inflammation and diarrhea. EAEC is a leading cause of pediatric bacterial diarrhea and a common cause of diarrhea among travelers and immunocompromised individuals. Heterogeneity in EAEC strains and lack of a good model system are major roadblocks to the understanding of its pathogenesis. Utilizing human intestinal enteroids to study the adherence of EAEC, we demonstrate that unique patterns of adherence are largely driven by unidentified factors present in different intestinal segments and from different donors. These patterns are also dependent on aggregative adherence fimbriae II encoded by EAEC. These results imply that we must also consider the contribution of the host to understand the pathogenesis of EAEC-induced inflammation and diarrhea.

Lactoferrin Impairs the Initial Steps of Shigella flexneri-induced Phagocytosis in HeLaCells |[diams]| 842

Introduction: Previously we have shown that human lactoferrin decreases significantly the invasiveness of S. flexneri in a HeLa cell model. A unique aspect of Shigella invasion is that the bacteria induces its own uptake by mammalian cells that are not normally phagocytic (bacterium-induced phagocytosis). The earliest step in this process is induction of pseudopods projecting from the HeLa cell surface, a process that can be seen within minutes of exposure of HeLa cells to Shigella.