Tobias Tenenbaum

Natalizumab Use During the Third Trimester of Pregnancy

IMPORTANCEnNatalizumab reduces multiple sclerosis relapses very effectively; however, severe disease activity may return once natalizumab treatment is withdrawn, as recommended during pregnancy. Sometimes restarting natalizumab treatment may be the best option for the mother, but the consequences for the infant are unknown. Except for a few single case reports, to our knowledge, comprehensive data about third-trimester natalizumab exposure are scant.nnnOBSERVATIONSnIn a case series of 12 women with 13 pregnancies and highly active multiple sclerosis who were treated with natalizumab during their third trimester of pregnancy, we assessed the clinical and laboratory effects on the newborns. We observed mild to moderate hematologic alterations in 10 of 13 infants including thrombocytopenia and anemia. In a subsample of 5 mother-child pairs, we analyzed natalizumab levels in the umbilical cord blood. Natalizumab was detectable in all 5 newborns.nnnCONCLUSION AND RELEVANCEnNatalizumab can be a therapeutic option in patients with highly active multiple sclerosis during pregnancy. We recommend that a pediatrician be available at the time of delivery to evaluate for potential complications of anemia and thrombocytopenia in newborns exposed to natalizumab during the third trimester.

Natalizumab treatment during pregnancy - effects on the neonatal immune system.

Pregnancies in women with severe relapsing‐remitting multiple sclerosis treated with natalizumab constitute a major challenge, because withdrawal of the drug may cause relapses but continuation might have unknown effects on the infantile immune system.

In vitro transcriptome analysis of porcine choroid plexus epithelial cells in response to Streptococcus suis: release of pro-inflammatory cytokines and chemokines.

The Gram-positive zoonotic bacterium Streptococcus suis (S. suis) is responsible for a wide range of diseases including meningitis in pigs and humans. The blood-cerebrospinal fluid (CSF) barrier is constituted by the epithelial cells of the choroid plexus, which execute barrier function also after bacteria have entered the central nervous system (CNS). We show that the bacterial capsule, a major virulence factor, strongly attenuates adhesion of S. suis to the apical side of porcine choroid plexus epithelial cells (PCPEC). Oligonucleotide microarray analysis and quantitative PCR surprisingly demonstrated that adherent wild-type and capsule-deficient S. suis influenced expression of a pronounced similar pattern of genes in PCPEC. Investigation of purified capsular material provided no evidence for a significant role of the capsule. Enriched among the regulated genes were those involved in inflammatory response, defense response and cytokine activity. These comprised several cytokines and chemokines including the interleukins 6 and 8, which could be detected on protein level. We show that after infection with S. suis the choroid plexus contributes to the immune response by actively producing cytokines and chemokines. Other virulence factors than the bacterial capsule may be relevant in inducing a strong inflammatory response in the CNS during S. suis meningitis.

Involvement of CD44v6 in InlB‐dependent Listeria invasion

Listeria monocytogenes, a Gram‐positive bacterium, is the causative agent for the disease called listeriosis. This pathogen utilizes host cell surface proteins such as E‐cadherin or c‐Met in order to invade eukaryotic cells. The invasion via c‐Met depends on the bacterial protein InlB that activates c‐Met phosphorylation and internalization mimicking in many regards HGF, the authentic c‐Met ligand. In this paper, we demonstrate that the activation of c‐Met induced by InlB is dependent on CD44v6, a member of the CD44 family of transmembrane glycoproteins. Inhibiting CD44v6 by means of a blocking peptide, a CD44v6 antibody or CD44v6‐specific siRNA prevents the activation of c‐Met induced by InlB. Subsequently, signalling, scattering and the entry of InlB‐coated beads into host cells are also impaired by CD44v6 blocking reagents. For the entry process, ezrin, a protein that links the CD44v6 cytoplasmic domain to the cytoskeleton, is required as well. Most importantly, this collaboration between c‐Met and CD44v6 contributes to the invasion of L.u2003monocytogenes into target cells as demonstrated by a drastic decrease in bacterial invasion in the presence of blocking agents such as the CD44v6 peptide or antibody.

Chemotaxis of T-cells after infection of human choroid plexus papilloma cells with Echovirus 30 in an in vitro model of the blood-cerebrospinal fluid barrier.

Enterovirus is the most common pathogen causing viral meningitis especially in children. Besides the blood-brain barrier (BBB) the choroid plexus, which forms the blood-cerebrospinal-fluid (CSF) barrier (BCSFB), was shown to be involved in the pathogenesis of enteroviral meningitis. In a human in vitro model of the BCSFB consisting of human choroid plexus papilloma cells (HIBCPP), the permissiveness of plexus epithelial cells for Echovirus 30 (EV30) was analyzed by immunoblotting and quantitative real-time PCR (Q-PCR). HIBCPP could be directly infected by EV30 from the apical as well as from the physiological relevant basolateral side. During an infection period of 5h no alterations of barrier function and cell viability could be observed. Analysis of the cytokine/chemokine-profile following enteroviral infection with a cytometric bead array (CBA) and Q-PCR revealed an enhanced secretion of PanGRO (CXCL1, CXCL2 and CXCL3), IL8 and CCL5. Q-PCR showed a significant upregulation of CXCL1, CXCL2 and CXCL3 in a time dependant manner. However, there was only a minor effect of HIBCPP-infection with EV30 on transepithelial T lymphocyte migration with or without the chemoattractant CXCL12. Moreover, CXCL3 did not significantly enhance T cell migrations. Therefore additional factors must be involved for the in vivo reported enhanced T cell migration into the CNS in the context of enteroviral meningitis. As HIBCPP are permissive for infection with EV30, they constitute a valuable human in vitro model to study viral infection at the BCSFB.

Candidiasis caused by Candida kefyr in a neonate: Case report

BackgroundSystemic Candidia infections are of major concern in neonates, especially in those with risk factors such as longer use of broad spectrum antibiotics. Recent studies showed that also term babies with underlying gastrointestinal or urinary tract abnormalities are much more prone to systemic Candida infection. We report a very rare case of candidiasis caused by Candida kefyr in a term neonate.Case PresentationRenal agenesis on the left side was diagnosed antenatally and anal atresia postnatally. Moreover, a vesico-ureteral-reflux (VUR) grade V was detected by cystography. The first surgical procedure, creating a protective colostoma, was uneventful. Afterwards our patient developed urosepsis caused by Enterococcus faecalis and was treated with piperacillin. The child improved initially, but deteriorated again. A further urine analysis revealed Candida kefyr in a significant number. As antibiotic resistance data about this non-albicans Candida species are limited, we started liposomal amphotericin B (AMB), but later changed to fluconazole after receiving the antibiogram. Candiduria persisted and abdominal imaging showed a Candida pyelonephritis. Since high grade reflux was prevalent we instilled AMB into the childs bladder as a therapeutic approach. While undergoing surgery (creating a neo-rectum) a recto-vesical fistula could be shown and subsequently was resected. The child recovered completely under systemic fluconazole therapy over 3 months.ConclusionsCandidiasis is still of major concern in neonates with accompanying risk factors. As clinicians are confronted with an increasing number of non-albicans Candida species, knowledge about these pathogens and their sensitivities is of major importance.

Sequential transmigration of polymorphonuclear cells and naive CD3+ T lymphocytes across the blood-cerebrospinal-fluid barrier in vitro following infection with Echovirus 30

Viral meningitis by non-polio enteroviruses (NPEV) is a major public health burden causing fatal outcomes especially in the younger population. Strong evidence exists that the blood-cerebrospinal-fluid (CSF) barrier (BCSFB) serves as an entry point for enterovirus and leucocytes into the central nervous system (CNS). Moreover, analysis of clinical CSF specimens of patients with a NPEV infection revealed a predominance of polymorphonuclear granulocytes (PMN) in the early phase and mononuclear cells in the later course of meningitis. By applying a functional in vitro model of the BCSFB consisting of human choroid plexus papilloma (HIBCPP) cells, we aimed to analyse the mechanisms of sequential migration of PMN and naive CD3+ T lymphocytes following infection with Echovirus 30 (EV30). EV30 infection led to increased transmigration of PMN and naive CD3+ T lymphocytes. Transmigration of PMN was significantly enhanced in the presence of naive CD3+ T lymphocytes, but not vice versa. The barrier function was not differentially altered under the respective conditions. Infection with EV30 led to an upregulation of CXCL3 and CXCL11 on the RNA-level. Additional analysis of cytokine secretion revealed relatively high concentrations of IL-8, CCL20, CXCL3, CXCL10 and M-CSF. Overall, there was a predominantly polar direction of cytokine secretion to the basolateral side. IL-7 was the only cytokine which was strongly secreted to the apical side and that was enhanced following EV30 infection in our model. In conclusion, this study highlights the role of the choroid plexus and cytokines in regulating leucocyte entry into the CNS in the context of EV30 infection.

A newborn infant with sepsis-like clinical picture and petechial bleeding (case presentation).

infiltration in papillary dermis and around dermal vessels. His serum was positive for antinuclear antibodies (1:640, speckled), anti-SSA ⁄ Ro (325 AU ⁄ mL) and anti-SSB ⁄ La (600 AU ⁄ mL). Other serological tests, including anti-RNP antibody, anti-Sm antibody, IgM and IgG class antiphospholipid antibodies and rheumatoid factors, were all negative. Elevated serum complement levels (C3 86.6 mg ⁄ dL, C4 16.2 mg ⁄ dL) were also noted. His echocardiography, electrocardiography and abdominal sonography were all normal. He was treated with topical steroids for these skin lesions. Empiric antibiotics were quitted once infectious possibilities had been ruled out. He was discharged and all these skin lesions cleared within 5 months, leaving some residual hyperpigmentation and telangiectasias on the face. In addition, the baby’s mother was closely followed up in our rheumatological outpatient clinics for more than 1 year, but none of any collagen vascular disorders, Sjögren’s syndrome or systemic lupus erythematosus has been diagnosed until now.

Strain-dependent effects of clinical echovirus 30 outbreak isolates at the blood-CSF barrier

BackgroundEchovirus (E) 30 (E-30) meningitis is characterized by neuroinflammation involving immune cell pleocytosis at the protective barriers of the central nervous system (CNS). In this context, infection of the blood-cerebrospinal fluid barrier (BCSFB), which has been demonstrated to be involved in enteroviral CNS pathogenesis, may affect the tight junction (TJ) and adherens junction (AJ) function and morphology.MethodsWe used an in vitro human choroid plexus epithelial (HIBCPP) cell model to investigate the effect of three clinical outbreak strains (13-311, 13-759, and 14-397) isolated in Germany in 2013, and compared them to E-30 Bastianni. Conducting transepithelial electrical resistance (TEER), paracellular dextran flux measurement, quantitative real-time polymerase chain reaction (qPCR), western blot, and immunofluorescence analysis, we investigated TJ and AJ function and morphology as well as strain-specific E-30 infection patterns. Additionally, transmission electron and focused ion beam microscopy electron microscopy (FIB-SEM) was used to evaluate the mode of leukocyte transmigration. Genome sequencing and phylogenetic analyses were performed to discriminate potential genetic differences among the outbreak strains.ResultsWe observed a significant strain-dependent decrease in TEER with strains E-30 Bastianni and 13-311, whereas paracellular dextran flux was only affected by E-30 Bastianni. Despite strong similarities among the outbreak strains in replication characteristics and particle distribution, strain 13-311 was the only outbreak isolate revealing comparable disruptive effects on TJ (Zonula Occludens (ZO) 1 and occludin) and AJ (E-cadherin) morphology to E-30 Bastianni. Notwithstanding significant junctional alterations upon E-30 infection, we observed both para- and transcellular leukocyte migration across HIBCPP cells. Complete genome sequencing revealed differences between the strains analyzed, but no explicit correlation with the observed strain-dependent effects on HIBCPP cells was possible.ConclusionThe findings revealed distinct E-30 strain-specific effects on barrier integrity and junctional morphology. Despite E-30-induced barrier alterations leukocyte trafficking did not exclusively occur via the paracellular route.

What We Have Learned from the Influenza A pH1N1 2009/10 Pandemic : High Clinical Impact of Human Metapneumovirus and Respiratory Syncytial Virus in Hospitalized Pediatric Patients

The influenza pandemic in 2009/2010 shifted public awareness to respiratory tract infections caused by the influenza virus. A prospective study was conducted during the influenza pandemic from November 2009 through April 2010 to determine the causative pathogens and clinical symptoms present in all children and adolescents admitted to the University Childrens Hospital, Duesseldorf, Germany, with signs and symptoms of respiratory tract infection. A total of 272 children and adolescents were admitted with symptoms of acute respiratory tract infection (ARI) or influenza-like illness. Viral pathogens were detected in 80% (218/272). However, influenza A pH1N1 infection was only detected in 11% (30/272) of children. Human metapneumovirus (HMPV) and respiratory syncytial virus (RSV) were the predominant identified pathogens that led to the admission of young tachypneic children with pneumonia in the post pandemic phase and the requirement for more intense treatment. During the pandemic and early post-pandemic phase the clinical impact of other respiratory viruses, such as HMPV and RSV, led to a higher clinical disease burden than pH1N1. Consequently, HMPV testing should be performed as routinely as RSV testing in patients hospitalized for ARI. Even while preparing for pandemics, the awareness of other respiratory viruses must be maintained.