Immunity in cryptococcosis: An overview

Cryptococcosis is an often fatal opportunistic fungal infection. Despite efforts to elucidate the role of immunity in host defense against the disease, much remains to be learned. The purpose of this brief review is to provide the reader with an overview of the history of research concerned with host immunity in cryptococcosis. Both humoral and cell-mediated studies are included. An effort has been made to present the reader with a comprehensive list of references in the hope of encouraging additional reading and research in this important area.     

Decreased virulence in stable,acapsular mutants ofCryptococcus neoformans

Six acapsular strains ofCryptococcus neoformans obtained by chemical mutagenesis failed to produce a capsulein vivo and were avirulent in mice following high dose intramuscular, intraperitoneal or intravenous inoculation. Peritoneal granulomas were observed in all animals inoculated with the acapsular mutants. These granulomas were characterized by a large central mass consisting of intact, degenerating and necrotic yeast cells. This was surrounded by concentric layers of a broad band of histiocytes, a narrow band of fibroblasts, and around the periphery, a mass of lymphocytes and plasma cells. These isolates did not revert to an encapsulated or virulent state after more than a year of subculturing or 18 passages through mice.     

Comparison of methods for isolation of dematiaceous fungi from nature

Direct plating and animal inoculation techniques were compared for effectiveness in isolating dematiaceous fungi from nature. The direct plating technique involved comparison of aqueous and mineral oil extraction of the samples with subsequent plating on Mycobiotic and Sabhi agar. Twenty four different organisms were recovered from 19 samples using both extraction procedures and both media. Dematiaceous fungi isolated by direct plating were Alternaria alternata, Cladosporium spp., Exophiala jeanselmei, Wangiella dermatitidis and 6 unidentified organisms. Direct plating resulted in more isolations of dematiaceous fungi partly because of the frequent isolations of A. alternata and W. dermatitidis. Both more and a larger variety of organisms were recovered on Mycobiotic than on Sabhi agar. The aqueous extraction of samples resulted in more direct plating isolations of fungi than oil extraction.Only dematiaceous fungi were isolated with the animal inoculation techniques. Fungi isolated from hamsters included Cladosporium spp., Exophiala spinifera, Phialophora verrucosa, Rhinocladiella sp. and 3 unidentified organisms. Fungi isolated by the mouse inoculation technique included Bispora betulina, Cladosporium spp., W. dermatitidis and 1 unidentified organism. In general there was variation in the types of organisms isolated from the same samples depending on the isolation procedure used.     

Taxonomy and morphology of dematiaceous fungi isolated from nature

The Hughes system of classification was applied to the identification of dematiaceous fungi isolated from nature. The majority of the isolates encountered could be identified with this system using brightfield microscopy. However, phase contrast microscopy was needed to determine the mode of conidial ontogeny with some species of Phialophora, Exophiala and Wangiella. The identifications based upon phase contrast microscopy were confirmed using the scanning electron microscope (SEM). Scanning electron photomicrographs are presented for Bispora betulina, Cladosporium trichoides, Exophiala jeanselmei, Phialophora revens, P. verrucosa and Wangiella dermatitidis. SEM observations of W. dermatitidis support the present classification of this organism as proposed by other workers. It is suggested that the Hughes system of classification and phase contrast microscopy be used to facilitate identification of isolates of dematiaceous fungi encountered in the clinical laboratory.     

Multigeneration Cross-Contamination of Mail with Bacillus anthracis Spores

The release of biological agents, including those which could be used in biowarfare or bioterrorism in large urban areas, has been a concern for governments for nearly three decades. Previous incidents from Sverdlosk and the postal anthrax attack of 2001 have raised questions on the mechanism of spread of Bacillus anthracis spores as an aerosol or contaminant. Prior studies have demonstrated that Bacillus atrophaeus is easily transferred through simulated mail handing, but no reports have demonstrated this ability with Bacillus anthracis spores, which have morphological differences that may affect adhesion properties between spore and formite. In this study, equipment developed to simulate interactions across three generations of envelopes subjected to tumbling and mixing was used to evaluate the potential for cross-contamination of B. anthracis spores in simulated mail handling. In these experiments, we found that the potential for cross-contamination through letter tumbling from one generation to the next varied between generations while the presence of a fluidizer had no statistical impact on the transfer of material. Likewise, the presence or absence of a fluidizer had no statistically significant impact on cross-contamination levels or reaerosolization from letter opening.     

Early Indicators of Fatal Leptospirosis during the 2010 Epidemic in Puerto Rico

Background

Leptospirosis is a potentially fatal bacterial zoonosis that is endemic throughout the tropics and may be misdiagnosed as dengue. Delayed hospital admission of leptospirosis patients is associated with increased mortality.

Methodology/Principal Findings

During a concurrent dengue/leptospirosis epidemic in Puerto Rico in 2010, suspected dengue patients that tested dengue-negative were tested for leptospirosis. Fatal and non-fatal hospitalized leptospirosis patients were matched 1:1–3 by age. Records from all medical visits were evaluated for factors associated with fatal outcome. Among 175 leptospirosis patients identified (4.7 per 100,000 residents), 26 (15%) were fatal. Most patients were older males and had illness onset during the rainy season. Fatal case patients first sought medical care earlier than non-fatal control patients (2.5 vs. 5 days post-illness onset [DPO], p < 0.01), but less frequently first sought care at a hospital (52.4% vs. 92.2%, p < 0.01). Although fatal cases were more often diagnosed with leptospirosis at first medical visit (43.9% vs. 9.6%, p = 0.01), they were admitted to the hospital no earlier than non-fatal controls (4.5 vs. 6 DPO, p = 0.31). Cases less often developed fever (p = 0.03), but more often developed jaundice, edema, leg pain, hemoptysis, and had a seizure (p ≤ 0.03). Multivariable analysis of laboratory values from first medical visit associated with fatal outcome included increased white blood cell (WBC) count with increased creatinine (p = 0.001), and decreased bicarbonate with either increased WBC count, increased creatinine, or decreased platelet count (p < 0.001).

Conclusions/Significance

Patients with fatal leptospirosis sought care earlier, but were not admitted for care any earlier than non-fatal patients. Combinations of routine laboratory values predictive of fatal outcome should be considered in admission decision-making for patients with suspected leptospirosis.     

Multigeneration Cross Contamination of Mail with Bacillus Species Spores by Tumbling

In 2001, envelopes loaded with Bacillus anthracis spores were mailed to Senators Daschle and Leahy as well as to the New York Post and NBC News buildings. Additional letters may have been mailed to other news agencies because there was confirmed anthrax infection of employees at these locations. These events heightened the awareness of the lack of understanding of the mechanism(s) by which objects contaminated with a biological agent might spread disease. This understanding is crucial for the estimation of the potential for exposure to ensure the appropriate response in the event of future attacks. In this study, equipment to simulate interactions between envelopes and procedures to analyze the spread of spores from a “payload” envelope (i.e., loaded internally with a powdered spore preparation) onto neighboring envelopes were developed. Another process to determine whether an aerosol could be generated by opening contaminated envelopes was developed. Subsequent generations of contaminated envelopes originating from a single payload envelope showed a consistent two-log decrease in the number of spores transferred from one generation to the next. Opening a tertiary contaminated envelope resulted in an aerosol containing 10³ B. anthracis spores. We developed a procedure for sampling contaminated letters by a nondestructive method aimed at providing information useful for consequence management while preserving the integrity of objects contaminated during the incident and preserving evidence for law enforcement agencies.In September and October of 2001, letters containing Bacillus anthracis spores were distributed through the U.S. Postal Service (USPS), resulting in contamination of the mail processing and distribution center in Hamilton, NJ, as well as affiliated processing centers in Washington, DC, in New York City, NY, and in Wallingford, CT, as well as postal facilities along the path transited by letters mailed to a targeted media company in Florida. Subsequently, 22 individuals, including postal workers, persons who received or handled the contaminated letters, and persons exposed to environments contaminated by the letters, developed cases of anthrax, including both the inhalation and cutaneous forms of the disease (5, 18-20). Five of these cases of anthrax resulted in death (4, 7). There have been investigations into the relationships of infection and exposure in areas where known exposures occurred (1, 6, 8). However, for two of the individuals who developed inhalational anthrax, an elderly woman in Connecticut and a nurse in New York City, no B. anthracis spores were detected (based on environmental sampling) on their mail or in their homes (2, 17, 19, 20). A third individual, a bookkeeper from New Jersey, survived a cutaneous anthrax infection, and only a single positive environmental sample in her workplace was identified (19).For the three specific cases mentioned above, the authors of the corresponding studies hypothesized that infection may have resulted from exposure to mail cross contaminated by mail that went through the same sorting equipment around the time that the letters to Senators Leahy and Daschle were processed. Without evidence of B. anthracis spores in their homes and other areas they were known to have frequented and the lack of additional cases in these geographic areas, there is no way to confirm the route of their exposure. We hypothesize that these people may have been exposed by inhaling spores released from envelopes that they tore open and then discarded. The delay between exposure and disease would have been sufficient to permit the discarded items to enter into the solid waste or recycling stream, and any residual spores may have been removed by normal housekeeping activities. Alternatively, the true source of exposure may have been undetectable due to a low concentration of spores.Those cases of anthrax raise the question of what, if any, hazards may have been encountered in handling mail with secondary and tertiary contamination. These cases raise particular questions concerning the ability of disease-causing organisms to spread through cross contamination of second- and even third-generation fomites in sufficient numbers to cause infection and possible death.Following the attacks, numerous studies were conducted in the contaminated postal buildings to assess the degree of contamination and to better understand sampling methodologies. Subsequent laboratory studies have been performed to improve B. anthracis sample collection and detection (11, 16, 22, 24, 30). Programs have monitored aerosols within federal buildings, hospitals, and mail facilities (10, 15, 25, 27). Additionally, studies of mail sorting machinery and the potential of this machinery to cross contaminate mail have been done (3, 10). However, to date, no laboratory studies that examined the potential for cross contamination of mail through contact or mixing with contaminated letters have been published.Reaerosolization in general is a poorly studied phenomenon. Characterization of reaerosolization under a variety of circumstances was undertaken following the B. anthracis incidents in 2001 (21, 29). The concept of fomite-to-fomite transference of powdered pathogen residues has been even less well studied.The settling of a primary aerosol comprised of charged particles may be due at least in part to an increase in the mass of these charged particles that occurs when they interact with oppositely charged particles. Once deposited on a surface, several factors may act against reaerosolization. Charged particles that have interacted with oppositely charged particles and have effectively increased in mass may be substantially more difficult to entrain in an aerosol than the initial particles. For charged particles that have not interacted with other particles, there may be a direct electrostatic interaction between the charged particle and the surface on which it has landed which would tend to hold these particles onto the surface. Both of these effects should reduce the potential for reaerosolization.Particulate preparations have a variety of properties, such as hydrophobicity, zeta potential, particle shape, and other characteristics that may also affect the potential for reaerosolization. It would be interesting to characterize a large number of powders, to create a database of the characteristics and their potential for aerosol formation and reaerosolization of these powders, and to use this database of information for comparison of unknown powders. Knowing this information may assist in the public health and risk management decision making processes. Unfortunately, there is no comprehensive database for these characteristics, nor is there any well-accepted unifying theory for deriving the likelihood of reaerosolization from the characteristics of powders that are commonly measured. In addition, there may be unknown variables that have an impact on aerosolization or reaerosolization that become known over time with improvements in understanding the theory of aerosolization and technology for measurement of these variables. A further confounding factor would be the inability to collect this information from the actual material used in any incident. In the case of the 2001 attacks (and likely in future incidents), there was (and will likely be) little material available for such study. The material used in the attacks is inherently hazardous and must be handled in highly controlled settings. The material is therefore difficult and expensive to work with (23). Material used in an attack is also generally sequestered as evidentiary material, and information concerning preparation of a biological weapon used in an attack may be considered too sensitive for public release. This sensitivity may include unwillingness to provide access to information on the efficacy of a specific preparation method to malevolent individuals and the requirement to preserve information for use in successful identification and prosecution of the perpetrator of such an attack. However, it may be possible to collect fomites contaminated with trace amounts of the agent in the course of public health investigations. The current study details a method for dealing with these contaminated fomites to yield information useful for public health protection.A confounding factor in these cases may be the necessity to treat as much of the available bulk material as can be collected as evidence. As evidence, even small amounts of this material may not be available for scientific testing. There may also be restrictions on the handling and treatment of fomites contaminated with residual traces of biological threat agents. For instance, the owners of the fomites may value them highly and may not wish to see them destroyed in the hope that the object may be somehow decontaminated and returned or the owner may wish to prevent public disclosure of the nature or contents of a contaminated object, such as a letter. It is therefore incumbent upon researchers to develop methods that are as minimally invasive and destructive as possible to investigate the potential for fomite-to-fomite transmission.We constructed a device designed to expose uncontaminated fomites to envelopes bearing a powdered preparation of spores or to fomites that had been exposed to other fomites contaminated by the initial powder-bearing envelope. Specifically, fomites used in this study were envelopes containing a piece of paper. This device was designed to conduct the exposure in a consistent, reproducible manner and to allow investigation of the interaction and cross contamination that might be encountered between a “payload” letter (a letter that had been loaded internally with a powdered spore preparation) and other pieces of mail. Uncontaminated envelopes were tumbled with a single envelope containing a payload of milled Bacillus atrophaeus subsp. globigii spores. After tumbling three successive generations of envelopes, CFU counts from the outsides of the envelopes were taken. These estimates of spore loads on the outside of these envelopes may be compared to published human 50% lethal dose (LD₅₀) estimates for aerosolized B. anthracis spores (12, 13). An additional series of envelopes was exposed to envelopes that had been contaminated during this first round of exposures, and those envelopes were found to be externally contaminated as well. We also studied opening an envelope that had been exposed to a payload envelope with either a finger or a letter opener to determine if these activities caused an aerosolization or reaerosolization of a sufficient number of spores to pose a risk of disease through inhalation.It is difficult to balance the concerns of making information public during a public health response and providing sufficient information for information risk management decision making while at the same time preserving the evidence for use by law enforcement agencies for eventual prosecution of individuals accused of committing crimes. We identified a nondestructive procedure by which contaminated mail can be analyzed and biological material collected while still preserving evidence for law enforcement agencies, allowing the payload envelope to be used as evidence while still permitting an assessment of its biological contaminant burden.     

An unusual presentation of a malignant jejunal tumor and a different management strategy

BACKGROUND: Malignant small bowel tumors are very rare and leiomyosarcoma accounts for less than 15% of the cases. Management of these tumors is challenging in view of nonspecific symptoms, unusual presentation and high incidence of metastasis. In this case report, an unusual presentation of jejunal sarcoma and management of liver metastasis with radiofrequency ablation (RFA) is discussed. CASE PRESENTATION: A 45-year-old male presented with anemia and features of small bowel obstruction. Operative findings revealed a mass lesion in jejunum with intussusception of proximal loop. Resection of bowel mass was performed. Histopathological findings were suggestive of leiomyosarcoma. After 3-years of follow-up, the patient developed recurrence in infracolic omentum and a liver metastasis. The omental mass was resected and liver lesion was managed with radiofrequency ablation. CONCLUSION: Jejunal leiomyosarcoma is a rare variety of malignant small bowel tumor and a clinical presentation with intussusception is unusual. We suggest that an aggressive management approach using a combination of surgery and a newer technique like RFA can be attempted in patients with limited metastatic spread to liver to prolong the long-term survival in a subset of patients.     

Species loss of stoneflies (Plecoptera) in the Czech Republic during the 20th century

1. Rapid expansion and intensification of anthropogenic activities in the 20th century has caused profound changes in freshwater assemblages. Unfortunately, knowledge of the extent and causes of species loss (SL) is limited due to the lack of reliable historical data. An unusual data set allows us to compare changes in the most sensitive of aquatic insect orders, the Plecoptera, at some 170 locations in the Czech Republic between two time periods, 1955–1960 and 2006–2010. Historical data (1890–1911) on assemblages of six lowland rivers allow us to infer even earlier changes. 2. Regional stonefly diversity decreased in the first half of the 20th century. Streams at lower altitudes lost a substantial number of species, which were never recovered. In the second half of the century, large‐scale anthropogenic pressure caused SL in all habitats, leading to a dissimilarity of contemporary and previous assemblages. The greatest changes were found at sites affected by organic pollution and a mixture of organic pollution and channelisation or impoundment. Colonisation of new habitats was observed in only three of the 80 species evaluated. 3. Species of moderate habitat specialisation and tolerance to organic pollution were most likely to be lost. Those with narrow specialisations in protected habitats were present in both historical and contemporary collections. 4. Contemporary assemblages are the consequence of more than a 100 years of anthropogenic impacts. In particular, streams at lower altitude and draining intensively exploited landscapes host a mere fragment of the original species complement. Most stonefly species are less frequently present than before, although their assemblages remain almost intact in near‐natural mountain streams. Our analyses demonstrate dramatic restriction of species ranges and, in some cases, apparent changes in altitudinal preference throughout the area.     

Moderate alcohol consumption is associated with better endothelial function: a cross sectional study

Background

Natural heterologous valved conduits with a diameter greater than 22 mm that can be used for right ventricular outflow tract reconstruction in adults are not commercially available. The purpose of this study was to measure by ultrasonography the maximum diameter of the distended jugular veins of horses and cattle, respectively, to identify a population of animals that would be suitable for post-mortem collection of jugular veins at sizes greater than 22 mm.

Methods

The study population included 60 Warmblood horses, 25 Freiberger horses, 20 Brown Swiss cows, and 20 Holstein cows (including 10 Holstein and 10 Red Holstein). The maximum cross-sectional diameter of the distended jugular veins was measured at a location half-way between the mandibular angle and the thoracic inlet. The thoracic circumference (heart girth length) was used as a surrogate of body size. The jugular vein diameters of the different populations were compared by analysis of variance and the association between heart girth length and jugular vein diameter was determined in each of the four study populations by linear regression analysis.

Results

There was considerable individual variation of jugular vein diameters within each of the four study populations. There was no statistically significant relationship between thoracic circumference and jugular vein diameter in any of the populations. The jugular vein diameters of Brown Swiss cows were significantly larger than those of any of the other populations. Warmblood horses had significantly larger jugular vein diameters compared to Freiberger horses.

Conclusion

The results of this study suggest that the production of bovine or equine xenografts with diameters of greater than 22 mm would be feasible. Differences between species and breeds need to be considered. However, prediction of the jugular vein diameter based on breed and heart girth length in an individual animal is inaccurate.