Michele M. Estabrook

Outcomes from pandemic influenza A H1N1 infection in recipients of solid-organ transplants: a multicentre cohort study

BACKGROUND There are few data on the epidemiology and outcomes of influenza infection in recipients of solid-organ transplants. We aimed to establish the outcomes of pandemic influenza A H1N1 and factors leading to severe disease in a cohort of patients who had received transplants. METHODS We did a multicentre cohort study of adults and children who had received organ transplants with microbiological confirmation of influenza A infection from April to December, 2009. Centres were identified through the American Society of Transplantation Influenza Collaborative Study Group. Demographics, clinical presentation, treatment, and outcomes were assessed. Severity of disease was measured by admission to hospital and intensive care units (ICUs). The data were analysed with descriptive statistics. Proportions were compared by use of chi(2) tests. We used univariate analysis to identify factors leading to pneumonia, admission to hospital, and admission to an ICU. Multivariate analysis was done by use of a stepwise logistic regression model. We analysed deaths with Kaplan-Meier survival analysis. FINDINGS We assessed 237 cases of medically attended influenza A H1N1 reported from 26 transplant centres during the study period. Transplant types included kidney, liver, heart, lung, and others. Both adults (154 patients; median age 47 years) and children (83; 9 years) were assessed. Median time from transplant was 3.6 years. 167 (71%) of 237 patients were admitted to hospital. Data on complications were available for 230 patients; 73 (32%) had pneumonia, 37 (16%) were admitted to ICUs, and ten (4%) died. Antiviral treatment was used in 223 (94%) patients (primarily oseltamivir monotherapy). Seven (8%) patients given antiviral drugs within 48 h of symptom onset were admitted to an ICU compared with 28 (22.4%) given antivirals later (p=0.007). Children who received transplants were less likely to present with pneumonia than adults, but rates of admission to hospital and ICU were similar. INTERPRETATION Influenza A H1N1 caused substantial morbidity in recipients of solid-organ transplants during the 2009-10 pandemic. Starting antiviral therapy early is associated with clinical benefit as measured by need for ICU admission and mechanical ventilation. FUNDING None.

Development of sucking rhythm in preterm infants

We studied the ontogeny and temporal organization of non-nutritive sucking during active sleep in 6 healthy preterm infants (mean birthweight 1.1 kg (range 0.8-1.3 kg) gestational age 28.6 weeks (range 26-30 w] from 30 to 35 weeks of post-menstrual (PM) age. Recognizable rhythmical sucking bursts were recorded at 28 weeks in one infant and by 31-33 weeks in the others. Results were analyzed for the periods 30-31, 32-33 and 34-35 PM weeks. The number of bursts/min increased with age, while the duration of each burst was stable (mean 4.1 s). The pause between bursts decreased. Sucking pace within bursts increased with age which resulted in an increase in the overall rate of sucking. The coefficient of variation (CV) for intersuck time within bursts and for interburst time was computed to examine the stability of the sucking rhythm. For intersuck time the CV was relatively low and constant across ages. However, for interburst time CV was relatively large across ages. Thus, there appears to be a stability of the intraburst sucking rhythm from 30 weeks of gestation, whereas the interburst rhythm is less regular. This documentation of temporal organization in sucking from 30 weeks is one of the earliest indications of an intrinsic rhythm in human behavior.

Mannose-Binding Lectin Binds to Two Major Outer Membrane Proteins, Opacity Protein and Porin, of Neisseria meningitidis

Human mannose-binding lectin (MBL) provides a first line of defense against microorganisms by complement activation and/or opsonization in the absence of specific Ab. This serum collectin has been shown to activate complement when bound to repeating sugar moieties on several microorganisms, including encapsulated serogroup B and C meningococci, which leads to increased bacterial killing. In the present study, we sought to identify the meningococcal cell surface components to which MBL bound and to characterize such binding. Outer membrane complex containing both lipooligosaccharide (LOS) and proteins and LOS from Neisseria meningitidis were examined for MBL binding by dot blot and ELISA. MBL bound outer membrane complex but not LOS. The binding to bacteria by whole-cell ELISA did not require calcium and was not inhibited by N-acetyl-glucosamine or mannose. With the use of SDS-PAGE, immunoblot analysis, and mAbs specific for meningococcal opacity (Opa) proteins and porin proteins, we determined that MBL bound to Opa and porin protein B (porB). The N-terminal amino acid sequences of the two MBL binding proteins confirmed Opa and PorB. Purified PorB inhibited the binding of MBL to meningococci. Escherichia coli with surface-expressed gonococcal Opa bound significantly more MBL than did the control strain. The binding of human factor H to purified PorB was markedly inhibited by MBL in a dose-dependent manner. Meningococci incubated with human serum bound MBL as detected by ELISA. We conclude that MBL binds to meningococci by a novel target recognition of two nonglycosylated outer membrane proteins, Opa and PorB.

Meningococcal molecular mimicry and the search for an ideal vaccine

The carbohydrates expressed on the surface of meningococcal strains of groups B and C mimic those commonly found on human cells and thus are not functionally antigenic in infancy. In order to develop an effective vaccine, it will be necessary to find ways of circumventing this molecular mimicry. Three possible ways of achieving this are discussed. (i) The surface polysaccharides can theoretically present conformationally different epitopes, some of which might be recognized as antigenic by the host. Experimental evidence is presented that such differences do indeed exist; what is needed is to determine which of these conformations are unique to the organism and hence potentially antigenic. (ii) Precursors of the surface lipooligosaccharides may be unable to mimic human antigens, and so may be potential candidates for vaccine development. (iii) Natural immunity to some strains of meningococci develops in young children who are colonized with strains of Neisseria lactamica, and it is possible that its development could be enhanced by widespread intentional colonization by N. lactamica strains that are particularly efficient inducers of broad immunity.

RNA Respiratory Viruses in Solid Organ Transplantation

1. The seasonality of respiratory viral infections among transplant recipients usually follows that of the general population (2,3). 2. The viruses all cause a range of disease, from mild congestion and rhinorrhea to more severe tracheobronchitis, bronchiolitis and pneumonia. No one virus is exclusively associated with one clinical syndrome (i.e. influenza-like illness, croup, etc.). As such, diagnostic strategies should initially be broad, attempting to screen for all recognized viruses (3,4) with particular emphasis on ones that might be amenable to therapy. 3. Transplant recipients often present with mild or atypical symptoms and fever may be absent. Lung transplant recipients, for example, may initially only have subjective symptoms of shortness of breath or subtle changes in pulmonary function testing without more typical symptoms (5). 4. Viral shedding is usually prolonged among transplant recipients. Prolonged shedding is seen even with the use of antivirals and therefore may contribute to the increased risk of resistant variant emergence (1,6). 5. Transplant recipients are at higher risk of infectious complications compared to immunocompetent hosts. Respiratory viral infections are a significant risk factor for subsequent development of fungal and bacterial pneumonia (1). 6. Respiratory viral infections appear to be a risk factor for both acute and chronic rejection with the greatest risk in lung transplant recipients (5,7–9) (II-2), although data on this topic in the literature are conflicting (10). The pathogenesis of the link between respiratory viral infections and rejection is not clearly understood. 7. All pediatric solid organ and lung transplant recipients appear to have the greatest risk of both respiratory viral infections and more severe courses and complications (1). 8. All are potential nosocomial pathogens that can be potentially spread by staff or visitor with mild upper respiratory illness.

Affinity-Purified Human Immunoglobulin G That Binds a Lacto-N-Neotetraose-Dependent Lipooligosaccharide Structure Is Bactericidal for Serogroup B Neisseria meningitidis

ABSTRACT Despite technological advances, no vaccine to prevent serogroup B meningococcal disease is available. The failure to develop a vaccine has shifted the focus to an alternative outer membrane structure, lipooligosaccharide (LOS), because disseminated disease induces bactericidal immunoglobulin G (IgG) that binds LOS. The purpose of this study was to identify the LOS structure(s) that induces human bactericidal IgG by purification and characterization of these antibodies. Human LOS IgG antibodies were affinity purified by passage of intravenous immunoglobulin through purified, type-specific LOS having a known structure coupled to epoxy-activated Sepharose 6B. Pathogenic group B strains representing the major LOS serotypes were used to examine the binding and bactericidal activities of four LOS-specific IgG preparations. All four LOS-specific IgG preparations bound to strains expressing homologous, as well as heterologous, LOS serotypes as determined by flow cytometry and an enzyme-linked immunosorbent assay. With human complement, IgG that was purified with L7 LOS was bactericidal for strains expressing L3,7 and L2,4 LOS, serotypes expressed by the majority of disease-associated group B and C meningococci. In conclusion, we purified human LOS-specific IgG that binds meningococci across LOS glycose-specific serotypes. An antigen that is dependent on the glycose lacto-N-neotetraose induces IgG in humans that is bactericidal for L2, L3, L4, and L7 strains. A vaccine containing this antigen would have the potential to protect against the vast majority of group B meningococcal strains.

Catheter-Associated Nocardia higoensis Bacteremia in a Child with Acute Lymphocytic Leukemia

ABSTRACT A 23-month-old child with leukemia who was receiving chemotherapy developed fevers. Serial blood cultures from a central venous catheter and a peripheral venous site grew an organism identified by 16S rRNA gene sequencing and phenotypic analysis as Nocardia higoensis, an opportunistic organism isolated once previously from a pulmonary infection in Japan.

Human Lipooligosaccharide IGG That Prevents Endemic Meningococcal Disease Recognizes an Internal Lacto-N-neotetraose Structure

Background: IgG that protects children from meningococcal disease binds lipooligosaccharides, but the antigen was not known. Results: The lacto-N-neotetraose α chain conforms at least four antigens; IgG that killed strains with a lacto-N-neotetraose α chain bound internal antigens. Conclusion: Only the internal lacto-N-neotetraose antigens induce broadly protective IgG. Significance: Induction of IgG that recognizes internal lacto-N-neotetraose antigens by vaccination would prevent endemic meningococcal disease. Antibodies that initiate complement-mediated killing of Neisseria meningitidis as they enter the bloodstream from the oropharynx protect against disseminated disease. Human IgGs that bind the neisserial L7 lipooligosaccharide (LOS) are bactericidal for L3,7 and L2,4 meningococci in the presence of human complement. These strains share a lacto-N-neotetraose (nLc4) LOS α chain. We used a set of mutants that have successive saccharide deletions from the nLc4 α chain to characterize further the binding and bactericidal activity of nLc4 LOS IgG. We found that the nLc4 α chain conforms at least four different antigens. We separately purified IgG that required the nLc4 (non-reducing) terminal galactose (Gal) for binding and IgG that bound the truncated nLc3 α chain that lacks this Gal residue. IgG that bound the internal nLc3 α chain killed both L3,7 and L2,4 strains, whereas IgG that required the nLc4 terminal Gal residue for binding killed L2,4 stains but not L3,7 strains. These results show that the diversity of LOS antibodies in human serum is as much a function of the conformation of multiple antigens by a single glycoform as of the production of multiple glycoforms. Differences in sensitivity to killing by human nLc4 LOS IgG may account for the fact that fully two-thirds of endemic group B meningococcal disease in infants and children is caused by L3,7 strains, but only 20% is caused by L2,4 stains.

RAPID TYPING OF NEISSERIA MENINGITIDIS ISOLATES BY REPETITIVE ELEMENT-BASED PCR (rep-PCR) DNA FINGERPRINTING. † 1115

RAPID TYPING OF NEISSERIA MENINGITIDIS ISOLATES BY REPETITIVE ELEMENT-BASED PCR (rep-PCR) DNA FINGERPRINTING. † 1115