Miguel M. Azar

Bacteremia with esophageal dilation

BACKGROUND Antibiotic prophylaxis has been recommended for selected patients undergoing esophageal stricture dilation because of a reported high rate of bacteremia. The aim of this study was to determine the rate of bacteremia after esophageal dilatation in a large series and the source of the organisms recovered. METHODS Blood cultures and oral temperatures were obtained before esophageal dilation and at 5 and 30 minutes after dilation. Dilators were cultured immediately before dilation. Procedural data collected included type of dilation, number of passes, and presence of malignancy. RESULTS Of 100 procedures in 86 patients undergoing esophageal dilation, 22 (22%) were associated with a positive post-dilation blood culture. Bacteremia was more frequent with dilation of malignant strictures compared with benign strictures (9 of 17 [52.9%] vs. 13 of 83 [15.7%], respectively, p = 0.002) and with passage of multiple dilators compared with passage of a single dilator (16 of 46 [34.8%] versus 6 of 54 [11.1%], respectively, p = 0.007). Bacterial isolates from 22 positive blood cultures matched those from a dilator in only one episode (4.5%). CONCLUSION The rate of bacteremia after esophageal dilation is 22% and is associated with dilation of malignant strictures or passage of multiple dilators. Organisms cultured from the blood are not transmitted from the dilator.

Molecular Analysis of a Hospital Cafeteria-Associated Salmonellosis Outbreak Using Modified Repetitive Element PCR Fingerprinting

ABSTRACT A hospital cafeteria-associated outbreak of gastroenteritis due toSalmonella enterica serotype Infantis was retrospectively evaluated using modified repetitive element PCR (rep-PCR) fingerprinting with the ERIC2 and BOXA1R primers and computer-assisted gel analysis and dendrogram construction. Rep-PCR yielded objective between-cycler, same-strain similarity values of from 92% (composite fingerprints) to 96% (ERIC2 fingerprints). The 70Salmonella isolates (which included 19 serotype Infantis isolates from the hospital outbreak, 10 other serotype Infantis isolates, and 41 isolates representing 14 other serotypes) were resolved well to the serotype level with each of the three fingerprint types (ERIC2, BOXA1R, and composite). Rep-PCR typing uncovered several historical serotyping errors and provided presumptive serotype assignments for other isolates with incomplete or undetermined serotypes. Analysis of replicate fingerprints for each isolate, as generated on two different thermal cyclers, indicated that most of the seeming subserotype discrimination noted in single-cycler dendrograms actually represented assay variability, since it was not reproducible in combined-cycler dendrograms. Rep-PCR typing, which would have been able to identify the presence of the hospital-associated serotype Infantis outbreak after the second outbreak isolate, could be used as a simple surrogate for serotyping by clinical microbiology laboratories that are equipped for diagnostic PCR.

The viability of Mycobacterium tuberculosis in formalin-fixed pulmonary autopsy tissue: Review of the literature and brief report

Formalin is commonly thought to decrease the risk of Mycobacterium tuberculosis infection. However, the true disinfection efficacy of formalin for tissue infected with M tuberculosis is unclear. We reviewed all pertinent literature from 1900 until the present regarding the disinfection efficacy of formalin for tissue infected with M tuberculosis. We also retrospectively cultured five cases of M tuberculosis from formalin-fixed archival pulmonary tissue. All cultures from our archived tissue were negative. The literature review revealed limited and contradictory information concerning the viability of M tuberculosis in formalin-fixed human tissue. There are no studies which specifically address the viability of M tuberculosis in tissue exclusively fixed in 10% buffered formalin. The disinfection efficacy of formalin for tuberculosis infected tissue remains unclear. Larger, prospective studies using current methodologies are needed to establish guidelines to ensure the safety for those handling infected, fixed tissue.

Nonantibody-mediated suppression of delayed hypersensitivity to human γ-globulin in mice☆

Abstract Development of delayed hypersensitivity (DHS) to human γ-globulin (HIgG) in mice was documented by histological analysis, by the kinetics of footpad swelling in animals exhibiting humoral or delayed responses, and by the failure of sera to transfer delayed reactions to normal, syngeneic recipients. Since cyclophosphamide (CY) treatment resulted in diminished humoral and augmented delayed reactions, we used this as a tool to explore the nature of the regulatory mechanisms which affect expression of this type of cell-mediated immunity. In order to evaluate the effect which the presence or absence of antigen-specific cells might exert on expression of DHS, we subjected mice to experimental regimes which would result in lymphocyte proliferation or depletion, respectively (see Bachvaroff, R., and Rapaport, F. T., Cell. Immunol. 15, 336, 1975). Cell proliferation was induced by injection of 80 μg of aqueous antigen on Day −4; this was followed by sensitization with HIgG-CFA (Freunds adjuvant) on Day 0, and footpad challenge on Day 13. These mice exhibited strong humoral reactivity; three of six died of anaphylaxis following footpad challenge, and the remaining three showed a diminished delayed response. Similarly treated mice that, in addition, received 6 mg of CY 3 days after injection of aqueous antigen and, therefore, would have antigen-specific cells present showed greatly diminished humoral reactivity, due to B-cell depletion. However, they also exhibited a marked diminution in delayed responsiveness. The data clearly demonstrate that a nonantibody-mediated, possibly cell-directed, regulatory influence is exerted on DHS where cell proliferation has occurred. We next examined the impact which the depletion of proliferating cells would exert on the expression of DHS. Cell depletion was attempted by giving one injection of aqueous antigen (Day 0) early in a regime of chronic CY administration (Days −1 through +3) ; antigen-induced proliferating cells would be susceptible to CY and, therefore, depleted under these conditions. The results show that mice receiving both aqueous antigen and CY have depressed humoral and markedly diminished delayed reactivity compared to animals that were injected with CY alone. Thus, the augmenting effect which CY exerts on DHS is abrogated by stimulation with aqueous antigen. One interpretation is that CY removes a regulatory cell population in the normal animal, thereby allowing enhanced expression of delayed responsiveness. Clearly, regulatory function cannot be attributed solely to bumoral antibody production.

Comparison of Murine Delayed Hypersensitivity Reactions Elicited with Particle-Associated Versus Soluble Human γ-Globulin

Footpad reactions elicited in DHS mice using human gamma-globulin (HGG)-coated polystyrene latex particles and soluble HGG (sHGG) were compared. Both the magnitude and the persistence of DHS lesions produced by HGG-latex were considerably greater; at 24, 48 and 72 h after challenge, the level of reactivity induced by HGG-latex was 24, 41 and 71% higher, respectively, than those elicited with sHGG. Early nonspecific swelling following injection of HGG-latex in footpads of normal mice was negligible by 24 h, whereas Arthus-responsive animals did not return to control levels until 48 h. The possible advantages and limitations of using particle-associated protein to elicit DHS reactions are discussed.

IMMUNE RESPONSES IN VITRO

The Mls locus was originally defined to have four alleles; three controlled products that were detectable in primary mixed leukocyte reactions (MLR), whereas one, b, was described as being null. Recently, other investigators postulated that the Mls locus is nonpolymorphic, being composed of the b null allele and of a singly expressed allele previously thought to be the a and d alleles. We previously reported that products controlled by Mlsaand Mlsdwere antigenically distinct and therefore are not controlled by the same allele, and the product of Mlsbon cells of three different strains was easily detectable by Mlsaand Mlsdresponding cells. Thus the b allele is not null. In the present report evidence is presented which indicates that both Mlsband Mlscencoded products were undetectable by MLR when in the presence of Mlsaor Mlsd. This was demonstrated by (a) the inability of Mlsa/Mlscand Mlsa/MlsbF1 cells to stimulate Mlsaresponding cells and Mlsd/Mlscand Mlsd/Mlsbcells to stimulate Mlsdcells; (b) the positive response of Mlsa/Mlsband Mlsd/MlsbF1-hybrid cells to Mlsb-encoded products; and (c) the reactivity of Mlsa/Mlscand Mlsd/MlscF1 hybrid cells to Mlsc-encoded determinants.The Mls locus was originally defined to have four alleles; three controlled products that were detectable in primary mixed leukocyte reactions (MLR), whereas one, b, was described as being null. Recently, other investigators postulated that the Mls locus is nonpolymorphic, being composed of the b null allele and of a singly expressed allele previously thought to be the a and d alleles. We previously reported that products controlled by Mlsa and Mlsd were antigenically distinct and therefore are not controlled by the same allele, and the product of Mlsb on cells of three different strains was easily detectable by Mlsa and Mlsd responding cells. Thus the b allele is not null. In the present report evidence is presented which indicates that both Mlsb and Mlsc encoded products were undetectable by MLR when in the presence of Mlsa or Mlsd. This was demonstrated by the inability of Mlsa/Mlsc and Mlsa/Mlsb F1 cells to stimulate Mlsa responding cells and Mlsd/Mlsc and Mlsd/Mlsb cells to stimulate Mlsd cells; the positive response of Mlsa/Mlsb and Mlsd/Mlsb F1-hybrid cells to Mlsb-encoded products; and the reactivity of Mlsa/Mlsc and Mlsd/Mlsc F1 hybrid cells to Mlsc-encoded determinants.

Effect of Fumaropimaric Acid on Mouse Complement and Immunological Tolerance

Summary Inhibition of C hemolytic activity by administration of fumaropimaric acid resulted in development of immune response to tolerogenic deaggregated HGG. Mice equally treated but without FPA regularly developed immunological tolerance. From these and prior studies the conclusion can be drawn that C activity of blood is involved in some way in development of immunologic tolerance.

Route of antigen administration for tolerance production.

Abstract Tolerance production is readily induced by inoculation of heterologous serum proteins in mice. The intravenous and intraperitoneal route are generally preferred because they allow rapid antigen equilibrium in the intra and extravascular spaces of the host. This report shows that the administration of particle-free antigen in the foot pad produces a greater number of tolerant animals at all concentrations used. The active participation of regional lymph nodes in tolerance production is postulated.

Characterization and Quantitation of Murine-Delayed Hypersensitivity Responses Elicited with Particle-Associated Human γ-Globulin

Parameters delineating the utilization of particle-associated human gamma-globulin to quantitate murine-delayed hypersensitivity (DHS) responses include: (1) the conditions used to prepare HGG-coated polystyrene latex particles; (2) the marked increase in sensitivity of detection of delayed immune responsiveness using particle-bound HGG; (3) a histologic analysis of the lesions induced by HGG-latex in DHS mice, and (4) the increased retention of particle-associated as opposed to soluble HGG at the site of challenge. The potential utilization of particle-bound antigens as a sensitive method of assessing the role of delayed-type responsiveness in tumor and transplantation immunity is discussed.

Adjuvant effect on maintenance and escape from tolerence.

Summary When mice are injected with deaggregated human gamma globulin (HGG), an HGG-tolerant state ordinarily is produced and persists despite subsequent challenges with an immunizing dose of HGG in saline or with an immunizing dose of HGG in Mycobacterium adjuvant. Subsequent administration of an immune elimination dose of radiolabeled HGG, at 27 days and 47 days does not break the tolerant state. Of special interest is the observation that when complete adjuvant containing increasing amounts of mycobacterial components was administered in conjunction with antigen very early in the tolerance induction phase 5 days after TID, it appears to prevent tolerance production. Mice challenged 5 and 17 days after the tolerance-inducing inoculation exhibit a statistically significant increase in circumvention of tolerance when compared with individuals challenged on the 7 and 17 day schedule. This increased circumvention of tolerance, as evidenced by 5 day challenge mice, seems to be related both to the mycobacterial content of the adjuvant and murine strain.