Animal Models of Q Fever (Coxiella burnetii)

Q fever, caused by the pathogen Coxiella burnetii, is an acute disease that can progress to become a serious chronic illness. The organism leads an obligate, intracellular lifecycle, during which it multiplies in the phagolytic compartments of the phagocytic cells of the immune system of its hosts. This characteristic makes study of the organism particularly difficult and is perhaps one of the reasons why, more than 70 y after its discovery, much remains unknown about the organism and its pathogenesis. A variety of animal species have been used to study both the acute and chronic forms of the disease. Although none of the models perfectly mimics the disease process in humans, each opens a window onto an important aspect of the pathology of the disease. We have learned that immunosuppression, overexpression of IL10, or physical damage to the heart muscle in mice and guinea pigs can induce disease that is similar to the chronic disease seen in humans, suggesting that this aspect of disease may eventually be fully understood. Models using species from mice to nonhuman primates have been used to evaluate and characterize vaccines to protect against the disease and may ultimately yield safer, less expensive vaccines.Coxiella burnetii is the causative agent of human Q fever. Infection can take several forms and has been described as clinically polymorphic.⁶ In humans, presentation ranges from asymptomatic, through acute disease, to chronic illness. In the majority of cases, acute disease presents as a self-limiting febrile illness, with half of cases also having severe headaches.⁸⁸ In severe cases of acute disease, atypical pneumonia is often found.⁸⁸ A small proportion (2% to 4%) of subjects with symptomatic acute Q fever are admitted to hospital.^70,88 Chronic disease may develop in approximately 5% of those infected;¹⁶ the vast majority of these cases will present as a bacterial culture-negative endocarditis^16,22 often in those with predisposing heart-damage¹⁹ or immunosuppression.¹⁶ Without effective treatment, Q fever endocarditis is generally fatal, but early diagnosis coupled with novel treatment strategies has brought the death rate down to less than 5%.⁶⁹ The 2009 outbreak in the Netherlands involved 2357 human cases, of which more than 400 required hospitalization.⁹⁰ The animal cost in the Netherlands was far higher, with more than 50,000 pregnant goats culled in an attempt to control the epidemic.⁸²Two other clinical manifestations of Q fever are worthy of mention owing to their less-than-satisfactory outcomes with current treatment strategies. These are Q fever during pregnancy and Q fever fatigue syndrome. C. burnetii infection during pregnancy results in premature delivery in almost half of those affected and spontaneous abortion in more than a quarter.¹⁴ There have been few studies in this area, but there are indications that among those infected during the first trimester and treated suboptimally, the abortion rate is 100%.⁶⁸ This effect is compounded by the fact that the frontline bactericidal drugs for treatment (doxycycline and hydroxychloroquine) are contraindicated for use during pregnancy.⁶⁸ A bacteriostatic regimen (cotrimoxazole) has therefore been proposed for use⁶⁸ until delivery. Without satisfactory treatment during and after pregnancy, there is also a high probability for infection to lead to chronic Q fever: an incidence of 70% was reported in a group of pregnant women in France.⁶⁸Post-Q fever fatigue syndrome was first reported in 1996,⁵² but an association between Q fever and chronic fatigue had been observed as early as 1982.⁵² Between 10% and 15% of those who have had acute Q fever develop a chronic fatigue syndrome that can last between 5 and 10 y—and even longer in some cases.⁵³ Some of these patients have been found to have long-term persistence of C. burnetii cell components and LPS associated with traces of genomic DNA,⁵³ suggesting that Q fever fatigue syndrome may be immunologically mediated rather than caused by the organism directly.Q fever is a zoonosis that has been described worldwide,⁵⁶ and human outbreaks are often associated with contact with the birth products of farm animals.⁵⁶ However, outbreaks associated with the birth products of domestic cats have also been reported.⁵⁴ Human infection primarily occurs via the inhalation of infectious aerosols.⁵⁶ Over the past 10 y, outbreaks have been reported in the Netherlands,⁷¹ Slovenia,²⁶ the United Kingdom,^91,97,99 Israel,² Iraq,¹⁸ the United States,¹¹ Germany,²⁴ Bulgaria,⁶³ Croatia,⁵⁸ Spain,²³ Italy,⁸³ and France.⁸⁸A very small number of C. burnetii organisms can cause infection by inhalation. Infection has been predicted to be possible after exposure to only a single organism.³³ This low dosage, coupled with the organism''s ability to cause debilitating disease and high levels of resistance to various means of inactivation^67,77,78 have resulted in it being listed as a category B biologic warfare and bioterrorism agent by the Centers for Disease Control.⁴⁹Prevention of Q fever in man can be achieved by vaccination; the only vaccine available for general use is Q-Vax, which was licensed in Australia in 1989.⁵¹ This vaccine consists of formalin-inactivated C. burnetii whole cells, produced in chick embryos. Its use has been associated with severe local reactions in those with preexisting immunity. As a precaution, prevaccination screening (history, skin test, and serology) must therefore be performed prior to administration.³⁵ Despite this safeguard, severe local reactions to vaccination are reported.⁴⁴ The vaccine is also hazardous to produce, with the organism requiring culture in chick-embryos at biosafety level 3 prior to inactivation.⁵¹ There is, therefore, a need for a vaccine that is safer to produce and safer to use and that does not require prevaccination screening.The organism displays antigenic phase variation often paralleled with the rough-smooth variation seen in Enterobacteriaceae. In C. burnetii, phase variation has been demonstrated to be due to differences in LPS. Phase I has been shown to contain a unique disaccharide galactosaminuronyl glucosamine and 9 unidentified components in addition to the components of phase II LPS.¹ Organisms with the phase I phenotype are the infectious and virulent form found in the environment. Organisms with the phase II phenotype are observed only during repeated subculture in laboratory chick embryo or cell culture systems;²⁷ they have a chemically simpler LPS¹ and several deletions in the genome.^32,92 Phagocytosis of phase I, but not phase II, organisms by macrophages involves an interaction between the bacterial LPS and Toll-like receptor 4. This mechanism also stimulates F-actin reorganization of the host cells and stimulates the release of type 1 cytokines including IFNγ and TNF.³⁰ This interaction appears important in the initial priming of the immune response and could provide an explanation for the limited protection of vaccines based on potential virulence genes (omp1, HspB, Pmm, Fbp, Orf 410, Crc, CbMip, MucZ, P28) singly and in combinations but containing no LPS.^47,89,102In addition to its antigenic phase variation, C. burnetii occurs in 2 morphologic forms, a large-cell variant and a small-cell variant. These forms differ antigenically due to differences in the proteins expressed on their surface. It has been suggested that the resistance of C. burnetii to host defense mechanisms may be enhanced by antigenic differences between the different developmental forms.^57,94 The small-cell morphologic form is highly resistant to destruction by chemical and environmental factors and is likely the transmissible form of the pathogen.^15,67 After infection, which generally occurs by inhalation of the small-cell form, the organisms are taken up by host alveolar macrophages.⁸¹ Morphogenesis from the small-cell to large-cell form then occurs, the large-cell variant being the replicative form of the organism.¹⁵ These organisms then replicate within parasitophorous vacuoles.⁵⁰ As the organisms enter the stationary phase of their growth within the cell, they condense back into the small-cell form.¹⁵ During replication within the host cell, the organism subverts cellular processes though active mechanisms to avoid and modify the host immune response.⁵⁰ C. burnetii possesses a type IV secretion system, and the proteins that cause this subversion are likely delivered to the host cell by this machinery.^50,93Because C. burnetii is an obligate intracellular organism, it has only been possible to study the organism within living animal hosts. Host-cell–free growth of the organism has been reported recently,⁶² but the technique has yet to be exploited fully. Cell-culture–based in vitro systems remain limited in the study of C. burnetii, given that the organism soon reverts to the avirulent (at least in immunocompetent hosts) phase II form (characterized by the loss of the phase I LPS phenotype) in these systems.¹⁰ A key problem in comparing models of C. burnetii infection is related to the organism''s intracellular nature, which complicates attempts to count the organisms used for infection. The literature reflects this difficulty in the fact that there are many different methods used (including plaque assay in primary cell cultures, median infectious doses in chick eggs or mice, and median lethal dose in SCID mice) and no way to directly compare them.     

Coxiella burnetii Shedding Routes and Antibody Response after Outbreaks of Q Fever-Induced Abortion in Dairy Goat Herds

Q fever is a zoonosis caused by Coxiella burnetii, a bacterium largely carried by ruminants and shed into milk, vaginal mucus, and feces. The main potential hazard to humans and animals is due to shedding of bacteria that can then persist in the environment and be aerosolized. The purpose of this study was to evaluate shedding after an outbreak of Q fever abortion in goat herds and to assess the relationship with the occurrence of abortions and antibody responses. Aborting and nonaborting goats were monitored by PCR for C. burnetii shedding 15 and 30 days after the abortion episodes. PCR analysis of all samples showed that 70% (n = 50) of the aborting and 53% (n = 70) of the nonaborting goats were positive. C. burnetii was shed into vaginal mucus, feces, and milk of 44%, 21%, and 38%, respectively, of goats that aborted and 27%, 20%, and 31%, respectively, of goats that delivered normally. Statistical comparison of these shedding results did not reveal any difference between these two groups. PCR results obtained for the vaginal and fecal routes were concordant in 81% of cases, whereas those for milk correlated with only 49% of cases with either vaginal or fecal shedding status. Serological analysis, using enzyme-linked immunosorbent assay (ELISA), indirect immunofluorescence assay (IFA), and complement fixation tests, showed that at least 24% of the seronegative goats shed bacteria. Positive vaginal and fecal shedding, unlike positive milk shedding, was observed more often in animals that were weakly positive or negative by ELISA or IFA. Two opposite shedding trends were thus apparent for the milk and vaginal-fecal routes. Moreover, this study showed that a nonnegligible proportion of seronegative animals that delivered normally could excrete C. burnetii.     

Presence and Persistence of Coxiella burnetii in the Environments of Goat Farms Associated with a Q Fever Outbreak

Q fever is a zoonotic disease caused by inhalation of the bacterium Coxiella burnetii. Ruminant livestock are common reservoirs for C. burnetii, and bacteria present in aerosols derived from the waste of infected animals can infect humans. The significance of infection from material deposited in the environment versus transmission directly from infected animals is not known. In 2011, an outbreak of Q fever cases on farms in Washington and Montana was associated with infected goats. A study was undertaken to investigate the quantity and spatial distribution of C. burnetii in the environment of these goat farms. Soil, vacuum, and sponge samples collected on seven farms epidemiologically linked to the outbreak were tested for the presence of C. burnetii DNA by quantitative PCR. Overall, 70.1% of the samples were positive for C. burnetii. All farms had positive samples, but the quantity of C. burnetii varied widely between samples and between farms. High quantities of C. burnetii DNA were in goat housing/birthing areas, and only small quantities were found in samples collected more than 50 m from these areas. Follow-up sampling at one of the farms 1 year after the outbreak found small quantities of C. burnetii DNA in air samples and large quantities of C. burnetii persisting in soil and vacuum samples. The results suggest that the highest concentrations of environmental C. burnetii are found in goat birthing areas and that contamination of other areas is mostly associated with human movement.     

Single-nucleotide-polymorphism genotyping of Coxiella burnetii during a Q fever outbreak in The Netherlands

Coxiella burnetii is the etiological agent of Q fever. Currently, the Netherlands is facing the largest Q fever epidemic ever, with almost 4,000 notified human cases. Although the presence of a hypervirulent strain is hypothesized, epidemiological evidence, such as the animal reservoir(s) and genotype of the C. burnetii strain(s) involved, is still lacking. We developed a single-nucleotide-polymorphism (SNP) genotyping assay directly applicable to clinical samples. Ten discriminatory SNPs were carefully selected and detected by real-time PCR. SNP genotyping appeared to be highly suitable for discrimination of C. burnetii strains and easy to perform with clinical samples. With this new method, we show that the Dutch outbreak is caused by at least 5 different C. burnetii genotypes. SNP typing of 14 human samples from the outbreak revealed the presence of 3 dissimilar genotypes. Two genotypes were also present in livestock at 9 farms in the outbreak area. SNP analyses of bulk milk from 5 other farms, commercial cow milk, and cow colostrum revealed 2 additional genotypes that were not detected in humans. SNP genotyping data from clinical samples clearly demonstrate that at least 5 different C. burnetii genotypes are involved in the Dutch outbreak.     

Risk factors of Coxiella burnetii (Q fever) seropositivity in veterinary medicine students

Background

Q fever is an occupational risk for veterinarians, however little is known about the risk for veterinary medicine students. This study aimed to assess the seroprevalence of Coxiella burnetii among veterinary medicine students and to identify associated risk factors.

Methods

A cross-sectional study with questionnaire and blood sample collection was performed among all veterinary medicine students studying in the Netherlands in 2006. Serum samples (n = 674), representative of all study years and study directions, were analyzed for C. burnetii IgG and IgM phase I and II antibodies with an immunofluorescence assay (IFA). Seropositivity was defined as IgG phase I and/or II titer of 1∶32 and above.

Results

Of the veterinary medicine students 126 (18.7%) had IgG antibodies against C. burnetii. Seropositivity associated risk factors identified were the study direction ‘farm animals’ (Odds Ratio (OR) 3.27 [95% CI 2.14–5.02]), advanced year of study (OR year 6: 2.31 [1.22–4.39] OR year 3–5 1.83 [1.07–3.10]) having had a zoonosis during the study (OR 1.74 [1.07–2.82]) and ever lived on a ruminant farm (OR 2.73 [1.59–4.67]). Stratified analysis revealed study direction ‘farm animals’ to be a study-related risk factor apart from ever living on a farm. In addition we identified a clear dose-response relation for the number of years lived on a farm with C. burnetii seropositivity.

Conclusions

C. burnetii seroprevalence is considerable among veterinary medicine students and study related risk factors were identified. This indicates Q fever as an occupational risk for veterinary medicine students.     

Seroprevalence and risk factors of Q fever in goats on commercial dairy goat farms in the Netherlands, 2009-2010

Background

Highly pathogenic avian influenza (HPAI) viruses have had devastating effects on poultry industries worldwide, and there is concern about the potential for HPAI outbreaks in the poultry industry in Great Britain (GB). Critical to the potential for HPAI to spread between poultry premises are the connections made between farms by movements related to human activity. Movement records of catching teams and slaughterhouse vehicles were obtained from a large catching company, and these data were used in a simulation model of HPAI spread between farms serviced by the catching company, and surrounding (geographic) areas. The spread of HPAI through real-time movements was modelled, with the addition of spread via company personnel and local transmission.

Results

The model predicted that although large outbreaks are rare, they may occur, with long distances between infected premises. Final outbreak size was most sensitive to the probability of spread via slaughterhouse-linked movements whereas the probability of onward spread beyond an index premises was most sensitive to the frequency of company personnel movements.

Conclusions

Results obtained from this study show that, whilst there is the possibility that HPAI virus will jump from one cluster of farms to another, movements made by catching teams connected fewer poultry premises in an outbreak situation than slaughterhouses and company personnel. The potential connection of a large number of infected farms, however, highlights the importance of retaining up-to-date data on poultry premises so that control measures can be effectively prioritised in an outbreak situation.     

Microevolution of the Chromosomal Region of Acute Disease Antigen A (adaA) in the Query (Q) Fever Agent Coxiella burnetii

The acute disease antigen A (adaA) gene is believed to be associated with Coxiella burnetii strains causing acute Q fever. The detailed analysis of the adaA genomic region of 23 human- and 86 animal-derived C. burnetii isolates presented in this study reveals a much more polymorphic appearance and distribution of the adaA gene, resulting in a classification of C. burnetii strains of better differentiation than previously anticipated. Three different genomic variants of the adaA gene were identified which could be detected in isolates from acute and chronic patients, rendering the association of adaA positive strains with acute Q fever disease disputable. In addition, all adaA positive strains in humans and animals showed the occurrence of the QpH1 plasmid. All adaA positive isolates of acute human patients except one showed a distinct SNP variation at position 431, also predominant in sheep strains, which correlates well with the observation that sheep are a major source of human infection. Furthermore, the phylogenetic analysis of the adaA gene revealed three deletion events and supported the hypothesis that strain Dugway 5J108-111 might be the ancestor of all known C. burnetii strains. Based on our findings, we could confirm the QpDV group and we were able to define a new genotypic cluster. The adaA gene polymorphisms shown here improve molecular typing of Q fever, and give new insights into microevolutionary adaption processes in C. burnetii.     

Seroepidemiological Survey for Coxiella burnetii Antibodies and Associated Risk Factors in Dutch Livestock Veterinarians

Since 2007, Q fever has become a major public health problem in the Netherlands and goats were the most likely source of the human outbreaks in 2007, 2008 and 2009. Little was known about the consequences of these outbreaks for those professional care providers directly involved. The aim of this survey was to estimate the seroprevalence of antibodies against C. burnetii among Dutch livestock veterinarians and to determine possible risk factors. Single blood samples from 189 veterinarians, including veterinary students in their final year, were collected at a veterinary conference and a questionnaire was filled in by each participant. The blood samples were screened for IgG antibodies against phase I and phase II antigen of C. burnetii using an indirect immunofluorescent assay, and for IgM antibodies using an ELISA. Antibodies against C. burnetii were detected in 123 (65.1%) out of 189 veterinarians. Independent risk factors associated with seropositivity were number of hours with animal contact per week, number of years graduated as veterinarian, rural or sub urban living area, being a practicing veterinarian, and occupational contact with swine. Livestock veterinarians should be aware of this risk to acquire an infection with C. burnetii. Physicians should consider potential infection with C. burnetii when treating occupational risk groups, bearing in mind that the burden of disease among veterinarians remains uncertain. Vaccination of occupational risk groups should be debated.     

Exposure and Risk Factors to Coxiella burnetii,Spotted Fever Group and Typhus Group Rickettsiae,and Bartonella henselae among Volunteer Blood Donors in Namibia

Background

The role of pathogen-mediated febrile illness in sub-Saharan Africa is receiving more attention, especially in Southern Africa where four countries (including Namibia) are actively working to eliminate malaria. With a high concentration of livestock and high rates of companion animal ownership, the influence of zoonotic bacterial diseases as causes of febrile illness in Namibia remains unknown.

Methodology/Principal Findings

The aim of the study was to evaluate exposure to Coxiella burnetii, spotted fever and typhus group rickettsiae, and Bartonella henselae using IFA and ELISA (IgG) in serum collected from 319 volunteer blood donors identified by the Blood Transfusion Service of Namibia (NAMBTS). Serum samples were linked to a basic questionnaire to identify possible risk factors. The majority of the participants (64.8%) had extensive exposure to rural areas or farms. Results indicated a C. burnetii prevalence of 26.1% (screening titre 1∶16), and prevalence rates of 11.9% and 14.9% (screening titre 1∶100) for spotted fever group and typhus group rickettsiae, respectively. There was a significant spatial association between C. burnetii exposure and place of residence in southern Namibia (P<0.021). Donors with occupations involving animals (P>0.012), especially cattle (P>0.006), were also significantly associated with C. burnetii exposure. Males were significantly more likely than females to have been exposed to spotted fever (P<0.013) and typhus (P<0.011) group rickettsiae. Three (2.9%) samples were positive for B. henselae possibly indicating low levels of exposure to a pathogen never reported in Namibia.

Conclusions/Significance

These results indicate that Namibians are exposed to pathogenic fever-causing bacteria, most of which have flea or tick vectors/reservoirs. The epidemiology of febrile illnesses in Namibia needs further evaluation in order to develop comprehensive local diagnostic and treatment algorithms.     

Detection of Coxiella burnetii in complex matrices by using multiplex quantitative PCR during a major Q fever outbreak in The Netherlands

Q fever, caused by Coxiella burnetii, is a zoonosis with a worldwide distribution. A large rural area in the southeast of the Netherlands was heavily affected by Q fever between 2007 and 2009. This initiated the development of a robust and internally controlled multiplex quantitative PCR (qPCR) assay for the detection of C. burnetii DNA in veterinary and environmental matrices on suspected Q fever-affected farms. The qPCR detects three C. burnetii targets (icd, com1, and IS1111) and one Bacillus thuringiensis internal control target (cry1b). Bacillus thuringiensis spores were added to samples to control both DNA extraction and PCR amplification. The performance of the qPCR assay was investigated and showed a high efficiency; a limit of detection of 13.0, 10.6, and 10.4 copies per reaction for the targets icd, com1, and IS1111, respectively; and no cross-reactivity with the nontarget organisms tested. Screening for C. burnetii DNA on 29 suspected Q fever-affected farms during the Q fever epidemic in 2008 showed that swabs from dust-accumulating surfaces contained higher levels of C. burnetii DNA than vaginal swabs from goats or sheep. PCR inhibition by coextracted substances was observed in some environmental samples, and 10- or 100-fold dilutions of samples were sufficient to obtain interpretable signals for both the C. burnetii targets and the internal control. The inclusion of an internal control target and three C. burnetii targets in one multiplex qPCR assay showed that complex veterinary and environmental matrices can be screened reliably for the presence of C. burnetii DNA during an outbreak.     

Coxiella burnetii infection of marine mammals in the Pacific Northwest, 1997-2010

Q fever is a zoonotic disease caused by the bacterium Coxiella burnetii. Humans are commonly exposed via inhalation of aerosolized bacteria derived from the waste products of domesticated sheep and goats, and particularly from products generated during parturition. However, many other species can be infected with C. burnetii, and the host range and full zoonotic potential of C. burnetii is unknown. Two cases of C. burnetii infection in marine mammal placenta have been reported, but it is not known if this infection is common in marine mammals. To address this issue, placenta samples were collected from Pacific harbor seals (Phoca vitulina richardsi), harbor porpoises (Phocoena phocoena), and Steller sea lions (Eumetopias jubatus). Coxiella burnetii was detected by polymerase chain reaction (PCR) in the placentas of Pacific harbor seals (17/27), harbor porpoises (2/6), and Steller sea lions (1/2) collected in the Pacific Northwest. A serosurvey of 215 Pacific harbor seals sampled in inland and outer coastal areas of the Pacific Northwest showed that 34.0% (73/215) had antibodies against either Phase 1 or Phase 2 C. burnetii. These results suggest that C. burnetii infection is common among marine mammals in this region.     

Seropositivity for Coxiella burnetii in suspected patients with dengue in São Paulo state,Brazil

Q fever and brucellosis are zoonoses that cause fever and other systemic clinical signs in humans; their occurrences are neglected and the differential diagnosis for some diseases is disregarded. This study aimed to investigate the seropositivity for Coxiella burnetii and Brucella spp. antibodies in patients suspected of dengue from 38 municipalities in the state of São Paulo, Brazil. The samples (n = 604) were obtained by convenience from the Adolfo Lutz Institute serum bank. Sera were subjected to an indirect immunofluorescence assay (IFA) using in-house and commercial diagnostic protocols to evaluate C. burnetii positivity. For Brucella spp., sera were subjected to rapid plate serum agglutination with buffered acidified antigen (AAT), slow tube serum agglutination (SAL), and 2-mercaptoethanol (2-ME) techniques. Associations and statistical inferences of the results were performed by logistic regression according to the clinical and demographic variables collected from the patients. Statistical analyses were performed using Statistical Analysis Software (SAS) and associations were considered when p value was <0.05. In all, 129 patients showed positive results for Q fever, indicating a seropositivity of 21.4% (95% CI 18.15–24.85). Patients with 14–20 days of symptoms had 2.12 (95% CI 1.34–3.35) times more chances of being seropositive for Q fever than patients with 7–13 days, and patients with 21–27 days of fever had 2.62 (95% CI 1.27–5.41) times more chances of being seropositive for Q fever than patients with 7–13 days. For the other variables analyzed, there were no significant associations between the groups. No positivity for brucellosis was observed. This is the most comprehensive study of people seropositive for Q fever in São Paulo state and provides additional data for the medical community in Brazil. It is suggested that Q fever may be an important differential diagnosis of febrile illnesses in the region, demanding the government’s attention and investment in health.     

A new plasmid (QpDV) common to Coxiella burnetii isolates associated with acute and chronic Q fever

Abstract Genetic studies of Coxiella burnetii strains suggested the possibility of differentiating new isolates according to their plasmid DNA content. Virulence and/or clinical manifestations ('chronic' and 'acute' Q fever) had been claimed to correlate with this plasmid typing. A new plasmid, named QpDV, was found to be common to C. burnetii isolates obtained from acute and chronic Q fever. According to the results obtained, plasmid usage for detection and differentiation of respective pathovars of C. burnetii and the correlation between gene specificity and pathovar has to be revised. Closer studies suggested a common origin of C. burnetii plasmids, but also showed some differences characteristic for each plasmid, probably reflecting divergent evolution.     

Isolation of Coxiella burnetii from Dairy Cattle and Ticks,and Some Characteristics of the Isolates in Japan

Coxiella burnetii was isolated from raw milk (36/214, 16.8%) and uterus swab samples (13/61, 21.3%) originating from dairy cattle with reproductive disorders, aborted bovine fetus samples (2/4, 50%), mammary gland samples (4/50, 8%) originating from healthy dairy cattle, and tick samples (4/15, 26.7%) originating from 2 pastures. Fifty-nine strains had various degrees of pathogenicity, high (8; 13.6%), moderate (28; 47.5%) and low (23; 39%), for guinea pigs. The results of isolation suggested a high prevalence of Coxiella infection in dairy cattle with reproductive problems in Japan. Twelve strains (7, 2 and 3 strains from cattle, ticks and humans, respectively) and the reference Nine Mile strain of phases I and II were propagated in both yolk sacs of embryonated hen eggs and Buffalo green monkey (BGM) cell cultures. Protein profiles of these strains were similar to those of the reference strain of phase I. Lipopolysaccharide (LPS) profiles of 12 strains were similar to those of the reference strain of phase I and different from those of the reference strain of phase II. The LPS profiles of 12 strains suggested that these strains are associated with an acute form of Q fever.     

High Seroprevalence of Mycoplasma pneumoniae IgM in Acute Q Fever by Enzyme-Linked Immunosorbent Assay (ELISA)

Q fever is serologically cross-reactive with other intracellular microorganisms. However, studies of the serological status of Mycoplasma pneumoniae and Chlamydophila pneumoniae during Q fever are rare. We conducted a retrospective serological study of M. pneumoniae and C. pneumoniae by enzyme-linked immunosorbent assay (ELISA), a method widely used in clinical practice, in 102 cases of acute Q fever, 39 cases of scrub typhus, and 14 cases of murine typhus. The seropositive (57.8%, 7.7%, and 0%, p<0.001) and seroconversion rates (50.6%, 8.8%, and 0%, p<0.001) of M. pneumoniae IgM, but not M. pneumoniae IgG and C. pneumoniae IgG/IgM, in acute Q fever were significantly higher than in scrub typhus and murine typhus. Another ELISA kit also revealed a high seropositivity (49.5%) and seroconversion rate (33.3%) of M. pneumoniae IgM in acute Q fever. The temporal and age distributions of patients with positive M. pneumoniae IgM were not typical of M. pneumoniae pneumonia. Comparing acute Q fever patients who were positive for M. pneumoniae IgM (59 cases) with those who were negative (43 cases), the demographic characteristics and underlying diseases were not different. In addition, the clinical manifestations associated with atypical pneumonia, including headache (71.2% vs. 81.4%, p=0.255), sore throat (8.5% vs. 16.3%, p=0.351), cough (35.6% vs. 23.3%, p=0.199), and chest x-ray suggesting pneumonia (19.3% vs. 9.5%, p=0.258), were unchanged between the two groups. Clinicians should be aware of the high seroprevalence of M. pneumoniae IgM in acute Q fever, particularly with ELISA kits, which can lead to misdiagnosis, overestimations of the prevalence of M. pneumoniae pneumonia, and underestimations of the true prevalence of Q fever pneumonia.     

The uptake of apoptotic cells drives Coxiella burnetii replication and macrophage polarization: a model for Q fever endocarditis

Patients with valvulopathy have the highest risk to develop infective endocarditis (IE), although the relationship between valvulopathy and IE is not clearly understood. Q fever endocarditis, an IE due to Coxiella burnetii, is accompanied by immune impairment. Patients with valvulopathy exhibited increased levels of circulating apoptotic leukocytes, as determined by the measurement of active caspases and nucleosome determination. The binding of apoptotic cells to monocytes and macrophages, the hosts of C. burnetii, may be responsible for the immune impairment observed in Q fever endocarditis. Apoptotic lymphocytes (AL) increased C. burnetii replication in monocytes and monocyte-derived macrophages in a cell-contact dependent manner, as determined by quantitative PCR and immunofluorescence. AL binding induced a M2 program in monocytes and macrophages stimulated with C. burnetii as determined by a cDNA chip containing 440 arrayed sequences and functional tests, but this program was in part different in monocytes and macrophages. While monocytes that had bound AL released high levels of IL-10 and IL-6, low levels of TNF and increased CD14 expression, macrophages that had bound AL released high levels of TGF-beta1 and expressed mannose receptor. The neutralization of IL-10 and TGF-beta1 prevented the replication of C. burnetii due to the binding of AL, suggesting that they were critically involved in bacterial replication. In contrast, the binding of necrotic cells to monocytes and macrophages led to C. burnetii killing and typical M1 polarization. Finally, interferon-gamma corrected the immune deactivation induced by apoptotic cells: it prevented the replication of C. burnetii and re-directed monocytes and macrophages toward a M1 program, which was deleterious for C. burnetii. We suggest that leukocyte apoptosis associated with valvulopathy may be critical for the pathogenesis of Q fever endocarditis by deactivating immune cells and creating a favorable environment for bacterial persistence.