Olle Lindquist

Association of Rickettsia helvetica with chronic perimyocarditis in sudden cardiac death

BACKGROUND Rickettsia helvetica is the only non-imported rickettsia found in Scandinavia. It was first detected in Ixodes ricinus ticks, but has never been linked to human disease. We studied two young Swedish men who died of sudden cardiac failure during exercise, and who showed signs of perimyocarditis similar to those described in rickettsial disease. METHODS Samples from the heart and other organs were analysed by PCR and DNA sequencing. May-Grünwald-Giemsa, Grocott, and acridine-orange stains were used for histopathological examinations. Staining of R. helvetica grown on shell-vials in vero cells, and the early descriptions of R. rickettsii by H T Ricketts and S B Wohlbach served as controls. Immunohistochemistry was done with Proteus OX-19 rabbit antisera as the primary antibody. The structure of rickettsia-like organisms was investigated by transmission electron microscopy. Serological analyses were carried out by indirect immunofluorescence with R. helvetica as the antigen. FINDINGS By use of a semi-nested PCR, with primers specific for the 16S rRNA and 17-kDa outer-membrane-protein genes, and sequence analysis of the amplified products, genetic material from R. helvetica was detected in the pericardium and in a lymph node from the pulmonary hilum in case 1, and in a coronary artery and the heart muscle in case 2. A serological response in case 1 revealed an endpoint titre for R. helvetica of 1/320 (1/256 with R. rickettsii as the antigen). Examination of PCR-positive tissue showed chronic interstitial inflammation and the presence of rickettsia-like organisms predominantly located in the endothelium. These organisms reacted with Proteus OX-19 antisera, and their size and form were consistent with rickettsia. Electron microscopy confirmed that the appearance of the organisms was similar to that described for spotted-fever rickettsia. INTERPRETATION R. helvetica, transmitted by I. ricinus ticks, may be an important pathogen in the aetiology of perimyocarditis, which can result in sudden unexpected cardiac death in young people.

Cause and Manner of Death Among Users of Anabolic Androgenic Steroids

Medicolegally investigated deaths among 34 male users of anabolic androgenic steroids (AAS) are described. Nine persons were victims of homicide, 11 had committed suicide, 12 deaths were judged as accidental and 2 as indeterminate. In two cases of accidental poisoning, the levels of pharmaceuticals and illicit drugs were considered too low to be the sole cause of death and AAS was considered part of the lethal polypharmacia. Chronic cardiac changes were observed in 12 cases. In two cases of accidental poisonous deaths, these changes were regarded as contributory cause of death. Homicides, suicides, and poisonings determined accidental or indeterminate in manner were related to impulsive, disinhibited behavior characterized by violent rages, mood swings, and/or uncontrolled drug intake. The observations in the present study indicate an increased risk of violent death from impulsive, aggressive behavior, or depressive symptoms associated with use of AAS. There are also data to support earlier reports of possible lethal cardiovascular complications from use of AAS. Furthermore, a contributing role of AAS in lethal polypharmacia is suggested. Finally, the observations indicate that use of AAS may be the gateway of approach to abuse of other psychotropic drugs.

Presence of Rickettsia helvetica in Granulomatous Tissue from Patients with Sarcoidosis

In samples obtained during the autopsies of 2 patients with sarcoidosis, genetic material from Rickettsia helvetica was detected by polymerase chain reaction, and histologic and immunohistochemical examination (using 3 different antibodies) of the polymerase chain reaction-positive tissues showed different degrees of granuloma formation and presence of rickettsia-like organisms predominantly located in the endothelium and macrophages. Electron microscopic examination clearly identified and demonstrated rickettsia-like organisms within the granuloma, with findings suggestive of ongoing infection. Immunogold labeling with Proteus OX-19 antiserum showed that the gold markers were localized to the rickettsia-like organisms. Paraffin-embedded biopsy specimens from 30 patients with confirmed sarcoidosis were also reexamined, and 26 specimens were judged to be positive for rickettsia-like organisms by histologic and immunohistochemical examination. In a specimen from 1 patient, rickettsia-like organisms also were demonstrated and identified by transmission electron microscopy. These results support the hypothesis that rickettsiae may contribute to a granulomatous process, as is seen in sarcoidosis.

Relationship of Chlamydia pneumoniae Infection to Severity of Human Coronary Atherosclerosis

BACKGROUND Infection with Chlamydia pneumoniae has been postulated to play a pathogenic role in atherosclerosis. We examined the role of infection with C pneumoniae in relation to the extent of coronary atherosclerosis. METHODS AND RESULTS Coronary atherosclerosis was graded microscopically on a postmortem basis in a blinded fashion in 60 subjects as mild (n=18) or severe (n=42) atherosclerosis. Serum antibodies to C pneumoniae were measured by microimmunofluorescence test. Paraffin-embedded coronary artery specimens were examined for the presence of chlamydia by use of a genus-specific direct immunofluorescence monoclonal antibody. Frozen coronary artery specimens were examined by immunoperoxidase for the presence of C pneumoniae by use of a specific monoclonal antibody RR-402. Direct immunofluorescence was reactive in 86% of cases with severe atherosclerosis but in only 6% of cases with mild atherosclerosis (P<0.01), whereas immunoperoxidase staining was reactive in 80% and 38% of cases with severe and mild atherosclerosis, respectively (P<0. 01). Elevated IgG and IgA levels against C pneumoniae were not different in cases with severe and mild atherosclerosis (61% and 30% for severe atherosclerosis and 67% and 42% for mild atherosclerosis, respectively). CONCLUSIONS This study supports the hypothesis that intracellular infection with C pneumoniae may relate to the severity of atherosclerosis in some subjects. Serum antibody titers against C pneumoniae do not differentiate between severe and mild atherosclerosis.

High incidence of Chlamydia pneumoniae in sclerotic heart valves of patients undergoing aortic valve replacement

Chlamydia pneumoniae has previously been demonstrated in the atherosclerotic lesions of various arteries, including the coronary arteries, and has been proposed to play a role in the pathogenesis of atherosclerosis. A prospective study of the incidence of C. pneumoniae in the sclerotic valves of patients undergoing aortic valve replacement because of aortic stenosis and in the aortic valves of cases dying of non-cardiac reasons and undergoing forensic autopsy was undertaken. The results were correlated to serological markers of past (IgG) or persistent (IgA) C. pneumoniae infection. C. pneumoniae, as determined by the polymerase chain reaction (PCR), was detected in the aortic valve in 19/39 (49%) patients and in 1/11 (9%) autopsy controls (p = 0.018) and confirmed by electron microscopy in one patient. There was no significant difference in the incidence rate of IgG or IgA antibody positivity between PCR-positive and PCR-negative cardiac patients. These results extend the hypothesis of a pathogenic role of C. pneumoniae in atherosclerosis to include also aortic valve sclerosis.

Subacute bartonella infection in Swedish orienteers succumbing to sudden unexpected cardiac death or having malignant arrhythmias.

During the period 1979-92, an increasing number of sudden unexpected cardiac deaths (SUCD) occurred in young, Swedish, male elite orienteers. Myocarditis was the most common diagnosis in the 16 victims, and in 4 cases was also associated with fatty infiltration mimicking arrhythmogenic right ventricular cardiomyopathy (ARVC). Tissues from autopsies of 5 orienteers were tested for Bartonella by PCR targeting the gltA (citrate-synthase) gene. The products were then sequenced. Antibodies to B. henselae, B. quintana and B. elizabethae were measured by indirect fluorescence antibody assay. Bartonella spp. DNA was detected in the hearts of 4 deceased orienteers, and in the lung of a fifth deceased case. The sequences were close to B. quintana in 2 cases and identical to B. henselae in 3. Four of these 5 cases, as well as 2 additional cases of elite orienteers with ARVC, indicated antibodies to Bartonella. It is suggested that Bartonella-induced silent subacute myocarditis, eventually leading to electric instability, caused the increased SUCD rate among the Swedish orienteers. It is further suggested that Bartonella infection may be a major pathogenetic factor in the development of ARVC-like disease. Although the mode of transmission is unknown, both zoonotic/vector-borne and parenteral person-to-person transmission may be involved.During the period 1979-92, an increasing number of sudden unexpected cardiac deaths (SUCD) occurred in young, Swedish, male elite orienteers. Myocarditis was the most common diagnosis in the 16 victims, and in 4 cases was also associated with fatty infiltration mimicking arrhythmogenic right ventricular cardiomyopathy (ARVC). Tissues from autopsies of 5 orienteers were tested for Bartonella by PCR targeting the gltA (citrate-synthase) gene. The products were then sequenced. Antibodies to B. henselae, B. quintana and B. elizabethae were measured by indirect fluorescence antibody assay. Bartonella spp. DNA was detected in the hearts of 4 deceased orienteers, and in the lung of a fifth deceased case. The sequences were close to B. quintana in 2 cases and identical to B. henselae in 3. Four of these 5 cases, as well as 2 additional cases of elite orienteers with ARVC, indicated antibodies to Bartonella. It is suggested that Bartonella-induced silent subacute myocarditis, eventually leading to electric instability, caused the increased SUCD rate among the Swedish orienteers. It is further suggested that Bartonella infection may be a major pathogenetic factor in the development of ARVC-like disease. Although the mode of transmission is unknown, both zoonotic/vector-borne and parenteral person-to-person transmission may be involved.

Sudden unexpected cardiac deaths among young Swedish orienteers - Morphological changes in hearts and other organs.

During the years 1979–1992 an accumulation of sudden unexpected cardiac deaths (SUD) occurred among young Swedish orienteers. A reevaluation of material saved from 16 autopsies was undertaken. Myocarditis was most frequent. It was found in different stages in the majority of cases, indicating subacute or chronic disease with ongoing reparative processes. There were severe morphological changes in all cases. All but one showed a picture of fibrosis and unspecific hypertrophy and/or degenerative changes in myocytes. The hearts were classified into three groups (A‐C), based on the morphological picture of the retrieved heart tissue and the macroscopic description. Group A comprised five cases in which areas with active myocarditis combined with areas of healing or healed myocarditis widely distributed in the left ventricle were the only morphological changes found. Group B comprised four cases demonstrating foci of myocarditis in different stages in the left ventricle and changes resembling those found in arrhythmogenic right ventricular dysplasia (ARVD), including degenerative changes with fibrosis and fatty infiltration located in either ventricle. Group C comprised the remaining seven cases. In none of the cases were coronary artery or valvular anomalies present, nor significant coronary sclerosis or changes outside the heart that could cause SUD.

Insulin in post-mortem blood

SummaryIn 29 cases of sudden death the insulin concentration in blood from the right heart and the femoral vein was determined by a radioimmunological method. The concentrations in the femoral venous blood were below 60 μU/ml serum (mean 23 μU/ml), i.e. in the same order of magnitude as in living persons. In right heart blood the insulin values were about 10 times higher, probably due to post-mortal diffusion of insulin via the portal vein. In suspected hyperinsulinism the measurements should therefore be made on peripheral venous blood.ZusammenfassungIn 29 Fällen von plötzlichem Tod wurden die Insulinkonzentrationen mit einer radioimmunologischen Methode gemessen im Blut von der rechten Herzkammer und von der Femoralvene. Die Todesursachen waren Herzkrankheit in 20 Fällen, Lungenembolie in 3, Gehirnblutung in 2, Erhängung oder Erdrosselung in 2, traumatische Aortaruptur in 1 Fall und Vergiftung mit Desimpramine in 1 Fall. Die Konzentrationen im Femoralvenenblut waren unter 60 μU/ml im Serum (Mittelwert 23 μU/ml): das ist die gleiche Größe wie bei lebenden Personen. Im rechten Herzkammerblut waren die Insulinkonzentrationen ungefähr 10mal höher, wahrscheinlich von postmortaler Diffusion des Insulin verursacht via der Portalvene. In verdächtigem Hyperinsulinismus müssen die Messungen deshalb an peripherem Venenblut vorgenommen werden.

Trace element changes in sclerotic heart valves from patients undergoing aortic valve surgery.

Several trace elements are essential nutrients for an optimal functioning of organs and tissues, including the immune system and the heart. The pathogenesis of some heart diseases has been associated with changes in the balance of certain trace elements. The etiology of nonrheumatic aortic valve sclerosis is unknown, however. A prospective study was performed on trace element changes in the sclerotic valves of 46 patients undergoing surgical aortic valve replacement because of aortic stenosis. Valves from 15 individual forensic cases without known cardiac disease served as controls. The contents of 15 trace elements (Al, As, Cd, Ca, Co, Cu, Fe, Pb, Mg, Mn, Hg, Se, Ag, V, and Zn) were measured by inductively coupled plasma — mass spectrometry (ICP-MS) of aortic valve tissue from both patients and forensic autopsy controls. Some trace elements showed similar concentrations in sclerotic and control valves (Al, Ag, Hg, Mn), whereas a few were moderately changed in the sclerotic as compared with the control valves, including an increase in Cd by 52% (p<0.05) and decreases in Se by 14% (p<0.05), in V by 42% (p<0,001), and in Cu by 45% (p<0.001). However, there were pronounced increases (p<0.001) in the concentrations of As (5-fold), Ca (70-fold), Co(10-fold), Fe (20-fold), Pb (8-fold), Mg (20-fold), and Zn (10-fold) in the sclerotic valves. Thus, sclerotic aortic valve disease is associated with a pronounced imbalance in several trace elements of well-known importance for cardiovascular and immune function as well as in trace elements with hitherto unknown significance.

Lethal Intoxications with Centrally Stimulating Amines in Sweden 1966--1973

SummaryFatal intoxications with centrally stimulating amines (CSA) have become increasingly common in Sweden. Toxicological data and pathological findings of 32 cases of amphetamine and phenmetrazine intoxications which occured from 1966–1973 in Sweden are described. Furthermore, 13 cases where these drugs were not the cause of death, but found in urine and organs, are reported.ZusammenfassungTödliche Vergiftungen mit Amphetamin und Phenmetrazin haben in den letzten Jahren in Schweden stark zugenommen. Es wird über 32 Fälle aus den Jahren 1966–1973 berichtet, bei denen diese Drogen als Todesursache festgestellt wurden. Toxikologische Daten (Konzentrationen in Körperflüssigkeiten und Organen) und pathologische Befunde werden mitgeteilt. Außderdem werden 13 Fälle beschrieben, bei denen zwar Amphetamin nachgewiesen, für den Tod jedoch andere Ursachen festgestellt wurden.