Infective endocarditis with left to right intracardiac fistula due to Streptococcus anginosus - a rare complication caused by an even rarer bacterium

Although infective endocarditis (IE) has been described in reports dating from the Renaissance, the diagnosis still challenges and the outcome often surprises. In the course of time, diagnostic criteria have been updated and validated to reduce misdiagnosis. Some risk factors and epidemiology have shown dynamic changes since degenerative valvular disease became more predominant in developed countries, and the mean age of the affected population increased. Despite streptococci have been being well known as etiologic agents, some groups, although rare, have been increasingly reported (e.g., Streptococcus milleri.) Intracardiac complications of IE are common and have a worse prognosis, frequently requiring surgical treatment. We report a case of a middle-aged diabetic man who presented with prolonged fever, weight loss, and ultimately severe dyspnea. IE was diagnosed based on a new valvular regurgitation murmur, a positive blood culture for Streptococcus anginosus, an echocardiographic finding of an aortic valve vegetation, fever, and pulmonary thromboembolism. Despite an appropriate antibiotic regimen, the patient died. Autopsy findings showed vegetation attached to a bicuspid aortic valve with an associated septal abscess and left ventricle and aortic root fistula connecting with the pulmonary artery. A large thrombus was adherent to the pulmonary artery trunk and a pulmonary septic thromboemboli were also identified.

Antiphospholipid syndrome plus rheumatic fever: a higher risk factor for stroke?

To compare clinical and laboratory findings between patients with primary antiphospholipid syndrome (PAPS) versus secondary APS due to rheumatic fever (APS-RF) (according to Jones criteria). Seventy-three APS patients (Sapporo criteria) were enrolled, and demographic, clinical, and laboratory data were collected. Exclusion criteria were heart congenital abnormalities and previous infectious endocarditis. Patients were divided into two groups: PAPS (n = 68) and APS-RF (n = 5). The mean current age, disease duration, frequencies of female gender, and Caucasian race were similar in APS-RF and PAPS patients (P > 0.05). Remarkably, the frequency of stroke was significantly higher in APS-RF compared to PAPS patients (80% vs. 25%, P = 0.02). Of note, echocardiogram of these patients did not show intracardiac thrombus. No significant differences were found in peripheral thromboembolic events (P = 1.0), pulmonary thromboembolism (P = 1.0), miscarriage (P = 0.16), thrombocytopenia (P = 0.36), arterial events (P = 0.58), and thrombosis of small vessels (P = 1.0). There were no differences in the frequencies of comorbidities such as diabetes mellitus, hypertension, smoking, and hyperlipidemia in both groups (P > 0.05). The frequencies of lupus anticoagulant, IgG, and IgM anticardiolipin were similar in two groups. APS patients associated with rheumatic fever without infective endocarditis may imply a high stroke risk as compared with PAPS, and future studies are needed to confirm this finding.

Coronary to Bronchial Artery Fistula: Are We Treating it Right?

Fistulas between coronary artery and bronchial artery may be present from birth, with few hemodynamic consequences, and may remain closed due to similarity of the filling pressures at these 2 sites.(1) They can also be secondary to pulmonary artery occlusive disease or chronic pulmonary inflammation.(2,3) These pulmonary changes may cause a dilation of the fistula and make it functional, causing angina pectoris by coronary steal syndrome, which is the most common symptom. The presentation may also be composed of episodes of hemoptysis, heart failure, and infective endocarditis. However, most patients remain asymptomatic. The ones that need treatment may not have a good response to the medical management, requiring an intervention. This can be done using embolization coils, stents grafts, and performing surgical ligation of the fistulas.(2-4) J INVASIVE CARDIOL 2012;24(11):E303-E304

Mycotic aneurysm of the tibioperoneal trunk: a first manifestation of an infected endocarditis

Infrapopliteal mycotic aneurysm resulting from endocarditis is rare, with only a few reported cases. We describe the case of a 28-year-old male patient who was suffering with pain and edema in the right leg. The ultrasound revealed an aneurysm of the right tibioperoneal trunk and a deep vein thrombosis (DVT). The patient was admitted and developed acute congestive heart failure, being diagnosed with possible endocarditis. A pseudo-aneurysm was revealed by arteriography. Aggressive antibiotic treatment was initiated, and open surgery confirmed a mycotic pseudo-aneurysm of the tibioperoneal trunk. To our knowledge, this is the 8th case reported of an infected aneurysm in this particular location.

Bacteroides fragilis endocarditis: a case report and review of literature

Endocarditis due to Bacteroides fragilis is a rare disorder. This article describes a case of Bacteroides fragilis endocarditis associated with portal and superior mesenteric venous thrombosis in a patient without preexisting valvular heart disease and review the cases of endocarditis due to this anaerobic bacterium in medical literature since 1980.

Co-presentation of human T-cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy/tropical spastic paraparesis and adult-onset infective dermatitis associated with HTLV-1 infection

Background  Human T-cell lymphotropic virus type 1 (HTLV-1) is the etiologic agent of adult T-cell leukemia/lymphoma (ATLL), HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), infective dermatitis associated with HTLV-1 (IDH), and various other clinical conditions. Several of these diseases can occur in association. Objective  Report an association of diseases related to HTLV-1 infection, occurring in an unusual age group. Methods  Dermatological and laboratory exams were consecutively performed in HTLV-1-infected individuals from January 2008 to July 2010 in the HTLV Outpatient Clinic at the Institute of Infectious Diseases “Emilio Ribas” in São Paulo, Brazil. Results  A total of 193 individuals (73 HAM/TSP and 120 asymptomatic carriers) were evaluated, three of which were associated with adult-onset IDH and HAM/TSP. In all three cases, the patients were affected by IDH after the development and progression of HAM/TSP-associated symptoms. Limitations  Small number of cases because of the rarity of these diseases. Conclusion  We draw attention to the possibility of co-presentation of adult-onset IDH in patients with a previous diagnosis of HAM/TSP, although IDH is a disease classically described in children. Thus, dermatologists should be aware of these diagnoses in areas endemic for HTLV-1 infection.

On estimating the basic reproduction number in distinct stages of a contagious disease spreading

In epidemiology, the basic reproduction number R-0 is usually defined as the average number of new infections caused by a single infective individual introduced into a completely susceptible population. According to this definition. R-0 is related to the initial stage of the spreading of a contagious disease. However, from epidemiological models based on ordinary differential equations (ODE), R-0 is commonly derived from a linear stability analysis and interpreted as a bifurcation parameter: typically, when R-0 >1, the contagious disease tends to persist in the population because the endemic stationary solution is asymptotically stable: when R-0 <1, the corresponding pathogen tends to naturally disappear because the disease-free stationary solution is asymptotically stable. Here we intend to answer the following question: Do these two different approaches for calculating R-0 give the same numerical values? In other words, is the number of secondary infections caused by a unique sick individual equal to the threshold obtained from stability analysis of steady states of ODE? For finding the answer, we use a susceptibleinfective-recovered (SIR) model described in terms of ODE and also in terms of a probabilistic cellular automaton (PCA), where each individual (corresponding to a cell of the PCA lattice) is connected to others by a random network favoring local contacts. The values of R-0 obtained from both approaches are compared, showing good agreement. (C) 2012 Elsevier B.V. All rights reserved.

Efeito da penicilina G a cada três semanas sobre o surgimento de Streptococcus viridans resistentes à penicilina na microflora oral

FUNDAMENTO: Penicilina G benzatina a cada 3 semanas é o protocolo padrão para a profilaxia secundária para febre reumática recorrente. OBJETIVO: Avaliar o efeito da penicilina G benzatina em Streptococcus sanguinis e Streptococcus oralis em pacientes com doença valvular cardíaca, devido à febre reumática com recebimento de profilaxia secundária. MÉTODOS: Estreptococos orais foram avaliados antes (momento basal) e após 7 dias (7º dia) iniciando-se com penicilina G benzatina em 100 pacientes que receberam profilaxia secundária da febre reumática. Amostras de saliva foram avaliadas para verificar a contagem de colônias e presença de S. sanguinis e S. oralis. Amostras de saliva estimulada pela mastigação foram serialmente diluídas e semeadas em placas sobre agar-sangue de ovelhas seletivo e não seletivo a 5% contendo penicilina G. A identificação da espécie foi realizada com testes bioquímicos convencionais. Concentrações inibitórias mínimas foram determinadas com o Etest. RESULTADOS: Não foram encontradas diferenças estatísticas da presença de S. sanguinis comparando-se o momento basal e o 7º dia (p = 0,62). No entanto, o número existente de culturas positivas de S. oralis no 7º dia após a Penicilina G benzatina apresentou um aumento significativo em relação ao valor basal (p = 0,04). Não houve diferença estatística existente entre o momento basal e o 7º dia sobre o número de S. sanguinis ou S. oralis UFC/mL e concentrações inibitórias medianas. CONCLUSÃO: O presente estudo mostrou que a Penicilina G benzatina a cada 3 semanas não alterou a colonização por S. sanguinis, mas aumentou a colonização de S. oralis no 7º dia de administração. Portanto, a susceptibilidade do Streptococcus sanguinis e Streptococcus oralis à penicilina G não foi modificada durante a rotina de profilaxia secundária da febre reumática utilizando a penicilina G.

Porphyromonas gingivalis infection at different gestation periods on fetus development and cytokines profile

Oral Diseases (2012) 18, 648654 Aim: Infective agents may affect pregnancy outcomes by deregulating homeostasis. Objectives: The effects of Porphyromonas gingivalis infection before and at different gestation periods were evaluated. Materials and Methods: Wistar rats infected via subcutaneous with P. gingivalis W83, one week before mating (BM), days 1 (PR1) and 11 of gestation (PR11), and controls were evaluated, and samples were obtained at the end of gestation. P. gingivalis was detected by PCR. Cytokine was determined by ELISA. Results: Infected rats had lower maternal gain of weight. Implantation was not observed in 2/12 BM rats. PR11 presented more fetal-placental resorptions and lower placenta/fetus weight than controls. P. gingivalis was detected in placenta and fetus. IL-6 and TNF-a levels were higher in placenta and serum of infected groups, except for TNF-a in placenta of PR1. IL-1 beta levels were higher in placenta of PR11, but lower in serum and placenta of PR1. There were no differences in IL-10 and PGE2 concentrations among the groups (P < 0.05). Conclusions: The experimental infection by P. gingivalis resulted in alterations in the gestational pattern and in fetal development. The consequences of infection at mid-gestation were more severe than at the beginning, possibly due to the induction of pro-inflammatory cytokines in the fetal compartment.

On the search for potential anti-Trypanosoma cruzi drugs: Synthesis and biological evaluation of 2-hydroxy-3-methylamino and 1,2,3-triazolic naphthoquinoidal compounds obtained by click chemistry reactions

Five 2-hydroxy-3-substituted-aminomethyl naphthoquinones, nine 1,2,3-triazolic para-naphthoquinones, five nor-beta-lapachone-based 1,2,3-triazoles, and several other naphthoquinonoid compounds were synthesized and evaluated against the infective bloodstream form of Trypanosoma cruzi, the etiological agent of Chagas disease, continuing our screening program for new trypanocidal compounds. Among all the substances, 16-18, 23, 25-29 and 30-33 were herein described for the first time and fifteen substances were identified as more potent than the standard drug benznidazole, with IC50/24 h values in the range of 10.9-101.5 mu M. Compounds 14 and 19 with Selectivity Index of 18.9 and 6.1 are important structures for further studies. (C) 2012 Elsevier Masson SAS. All rights reserved.

Repertoire, Genealogy and Genomic Organization of Cruzipain and Homologous Genes in Trypanosoma cruzi, T. cruzi-Like and Other Trypanosome Species

Trypanosoma cruzi, the agent of Chagas disease, is a complex of genetically diverse isolates highly phylogenetically related to T. cruzi-like species, Trypanosoma cruzi marinkellei and Trypanosoma dionisii, all sharing morphology of blood and culture forms and development within cells. However, they differ in hosts, vectors and pathogenicity: T. cruzi is a human pathogen infective to virtually all mammals whilst the other two species are non-pathogenic and bat restricted. Previous studies suggest that variations in expression levels and genetic diversity of cruzipain, the major isoform of cathepsin L-like (CATL) enzymes of T. cruzi, correlate with levels of cellular invasion, differentiation, virulence and pathogenicity of distinct strains. In this study, we compared 80 sequences of genes encoding cruzipain from 25 T. cruzi isolates representative of all discrete typing units (DTUs TcI-TcVI) and the new genotype Tcbat and 10 sequences of homologous genes from other species. The catalytic domain repertoires diverged according to DTUs and trypanosome species. Relatively homogeneous sequences are found within and among isolates of the same DTU except TcV and TcVI, which displayed sequences unique or identical to those of TcII and TcIII, supporting their origin from the hybridization between these two DTUs. In network genealogies, sequences from T. cruzi clustered tightly together and closer to T. c. marinkellei than to T. dionisii and largely differed from homologues of T. rangeli and T. b. brucei. Here, analysis of isolates representative of the overall biological and genetic diversity of T. cruzi and closest T. cruzi-like species evidenced DTU- and species-specific polymorphisms corroborating phylogenetic relationships inferred with other genes. Comparison of both phylogenetically close and distant trypanosomes is valuable to understand host-parasite interactions, virulence and pathogenicity. Our findings corroborate cruzipain as valuable target for drugs, vaccine, diagnostic and genotyping approaches.

Leishmania Metacyclogenesis Is Promoted in the Absence of Purines

Leishmania parasites, the causative agent of leishmaniasis, are transmitted through the bite of an infected sand fly. Leishmania parasites present two basic forms known as promastigote and amastigote which, respectively, parasitizes the vector and the mammalian hosts. Infection of the vertebrate host is dependent on the development, in the vector, of metacyclic promastigotes, however, little is known about the factors that trigger metacyclogenesis in Leishmania parasites. It has been generally stated that "stressful conditions" will lead to development of metacyclic forms, and with the exception of a few studies no detailed analysis of the molecular nature of the stress factor has been performed. Here we show that presence/absence of nucleosides, especially adenosine, controls metacyclogenesis both in vitro and in vivo. We found that addition of an adenosine-receptor antagonist to in vitro cultures of Leishmania amazonensis significantly increases metacyclogenesis, an effect that can be reversed by the presence of specific purine nucleosides or nucleobases. Furthermore, our results show that proliferation and metacyclogenesis are independently regulated and that addition of adenosine to culture medium is sufficient to recover proliferative characteristics for purified metacyclic promastigotes. More importantly, we show that metacyclogenesis was inhibited in sand flies infected with Leishmania infantum chagasi that were fed a mixture of sucrose and adenosine. Our results fill a gap in the life cycle of Leishmania parasites by demonstrating how metacyclogenesis, a key point in the propagation of the parasite to the mammalian host, can be controlled by the presence of specific purines.

Adhesion of Trypanosoma cruzi Trypomastigotes to Fibronectin or Laminin Modifies Tubulin and Paraflagellar Rod Protein Phosphorylation

Background: The unicellular parasite Trypanosoma cruzi is the causative agent of Chagas disease in humans. Adherence of the infective stage to elements of the extracellular matrix (ECM), as laminin and fibronectin, is an essential step in host cell invasion. Although members of the gp85/TS, as Tc85, were identified as laminin and fibronectin ligands, the signaling events triggered on the parasite upon binding to these molecules are largely unexplored. Methodology/Principal Findings: Viable infective parasites were incubated with laminin, fibronectin or bovine serum albumin for different periods of time and the proteins were separated by bidimensional gels. The phosphoproteins were envisaged by specific staining and the spots showing phosphorylation levels significantly different from the control were excised and identified by MS/MS. The results of interest were confirmed by immunoblotting or immunoprecipitation and the localization of proteins in the parasite was determined by immunofluorescence. Using a host cell-free system, our data indicate that the phosphorylation contents of T. cruzi proteins encompassing different cellular functions are modified upon incubation of the parasite with fibronectin or laminin. Conclusions/Significance: Herein it is shown, for the first time, that paraflagellar rod proteins and alpha-tubulin, major structural elements of the parasite cytoskeleton, are predominantly dephosphorylated during the process, probably involving the ERK1/2 pathway. It is well established that T. cruzi binds to ECM elements during the cell infection process. The fact that laminin and fibronectin induce predominantly dephosphorylation of the main cytoskeletal proteins of the parasite suggests a possible correlation between cytoskeletal modifications and the ability of the parasite to internalize into host cells.

Involvement of TSSA (trypomastigote small surface antigen) in Trypanosoma cruzi invasion of mammalian cells

TSSA (trypomastigote small surface antigen) is a polymorphic mucin-like molecule displayed on the surface of Trypanosoma cruzi trypomastigote forms. To evaluate its functional properties, we undertook comparative biochemical and genetic approaches on isoforms present in parasite stocks from extant evolutionary lineages (CL Brener and Sylvio X-10). We show that CL Brener TSSA, but not the Sylvio X-10 counterpart, exhibits dose-dependent and saturable binding towards non-macrophagic cell lines. This binding triggers Ca2+-based signalling responses in the target cell while providing an anchor for the invading parasite. Accordingly, exogenous addition of either TSSA-derived peptides or specific antibodies significantly inhibits invasion of CL Brener, but not Sylvio X-10, trypomastigotes. Non-infective epimastigote forms, which do not express detectable levels of TSSA, were stably transfected with TSSA cDNA from either parasite stock. Although both transfectants produced a surface-associated mucin-like TSSA product, epimastigotes expressing CL Brener TSSA showed a similar to 2-fold increase in their attachment to mammalian cells. Overall, these findings indicate that CL Brener TSSA functions as a parasite adhesin, engaging surface receptor(s) and inducing signalling pathways on the host cell as a prerequisite for parasite internalization. More importantly, the contrasting functional features of TSSA isoforms provide one appealing mechanism underlying the differential infectivity of T. cruzi stocks.

Lack of signaling by IL-4 or by IL-4/IL-13 has more attenuating effects on Leishmania amazonensis dorsal skin - than on footpad-infected mice

Lesion development in tegumentary leishmaniasis is markedly influenced by the inoculation site and the type and number of injected infective forms. This and the yet unclear contribution of Th2 cytokines as susceptibility factors to Leishmania amazonensis infection prompted us to investigate the roles of IL-4, IL-13 and IL-10 on C57BL/6 and BALB/c mice infected in the footpad (paw) or rump with low-dose L. amazonensis purified-metacyclics. Wild-type (WT) mice of either strain developed, in the rump, a single large ulcerated lesion whereas paw lesions never ulcerated and were much smaller in C57BL/6 than in BALB/c mice. However, rump-inoculated IL-4-deficient (IL-4(-/-))C57BL/6 mice did not develop any visible lesions although parasites remained in the dermis and lymph nodes, even after systemic IL-10-receptor blocking. By comparison, all IL-4(-/-) BALB/c mice developed rump ulcers. Strikingly, only 30% of rump-infected IL-4R alpha(-/-) BALB/c mice developed lesions. IL-4(-/-) mice had higher IFN-gamma and lower IL-10 and IL-13 levels than WT mice. Paw-infected IL-4R alpha(-/-) BALB/c mice developed minimal paw lesions. While other factors contributing to L amazonensis susceptibility cannot be discounted, our results indicate that absent signalling by IL-4 or by IL-4/IL-13 have more intense attenuating effects on rump than on paw lesions but do not eradicate parasitism. (C) 2011 Elsevier Inc. All rights reserved.