A protective role for interleukin 18 in interferon γ-mediated innate immunity to Cryptosporidium parvum that is independent of natural killer cells.

Innate immunity against some intracellular parasitic protozoa involves interleukin 18 (IL-18)-mediated interferon γ (IFN-γ) production by natural killer (NK) cells, but the role of IL-18 in innate resistance to Cryptosporidium infection is unknown. Adult Rag2(-/-)γc(-/-) mice that lack NK cells, T cells, and B cells demonstrated resistance to Cryptosporidium parvum infection that was IFN-γ dependent. Treatment with anti-IL-18-neutralizing antibodies resulted in loss of resistance correlating with reduced intestinal IFN-γ expression. Intestinal mature IL-18 expression increased in vivo during infection and also in the intestinal epithelial cell line CMT-93 following combined IFN-γ treatment/infection. Peritoneal macrophages produced IFN-γ when stimulated with IL-18 combined with interleukin 12, and the latter was expressed in vivo during infection. Macrophage depletion in infected mice caused a rapid growth of infection with no increase in IFN-γ expression. These findings provide evidence of an NK cell-independent, IFN-γ-mediated innate immune pathway against C. parvum in which IL-18 and macrophages play prominent parts.

Binding to complement factors and activation of the alternative pathway by Acanthamoeba.

Acanthamoeba can cause severe ocular and cerebral diseases in healthy and immunocompromised individuals, respectively. Activation of complement appears to play an important role in host defence against infection. The exact mechanism, however, is still unclear. The aim of the present study was to investigate the effect of normal human serum (NHS) and normal mouse serum (NMS) on Acanthamoeba trophozoites, the binding of different complement factors to Acanthamoeba and the activation of the complement system. Moreover, we aimed to work out any possible differences between different strains of Acanthamoeba. A virulent T4 strain, a non-virulent T4 strain and a virulent T6 strain were included in the study. It was shown that NHS, but not NMS clearly has amoebicidal properties. After 5min of incubation with NHS, amoebae showed plasma membrane disruption and extrusion of intracellular components. Cells were completely destroyed within 60min of incubation in NHS but stayed intact after incubation in heat-inactivated serum. The binding of human C3 and C9 to amoebae was established by immunoblotting. Although incubation with mouse serum did not result in lysis of Acanthamoeba trophozoites an immunofluorescence assay (IFA) demonstrated a strong deposition of mouse complement factor C3 activation products, moderate binding of C1q, but no binding of MBL-A and MBL-C. EDTA inhibited the binding of C3 to acanthamoebae. Binding of amoebae to C3b was observed with sera from C1qa-/- and MBL-A/C-/- mice, but not with serum from Bf/C2-/- mice demonstrating an activation of complement via the alternative pathway. There were no significant differences between the three Acanthamoeba strains investigated. Altogether, our results prove that NHS is amoebolytic and that Acanthamoeba binds to C3 and C9 and activates the complement system via the alternative pathway.

Host immune response to Cryptosporidium parvum infection.

Species of the genus Cryptosporidium are protozoan parasites (Apicomplexa) that cause gastroenteritis in animals and humans. Of these Cryptosporidium parvum and Cryptosporidium hominis are the major causative agents of human cryptosporidiosis. Whereas infection is self-limiting in the immunocompetent hosts, immunocompromised individuals develop a chronic, life-threatening disease. As specific therapeutic or preventive interventions are not yet available, better understanding of the immune response to the parasite is required. This minireview briefly summarizes the factors involved in the innate and acquired immune response in this pathogen-host interaction with an emphasis on more recent data from mouse models of infection.

Molecular characterization of Cryptosporidium isolates from humans in Ethiopia.

In this study, 1034 faecal samples from patients with diarrhoea were screened for Cryptosporidium oocysts. Samples were collected from nine different regions in Ethiopia. Of these, 79 samples (7.6%) were positive for Cryptosporidium by modified Ziehl-Neelson staining. From all positive samples DNA was extracted and PCR amplification of the COWP, SSU-rRNA and GP60 gene fragments was performed. A total of 41 samples (52%) were positive in any of the three typing methods. The majority of isolates (39 of 41) was identified as Cryptosporidium parvum, with one Cryptosporidium hominis and one mixed infection. Sequencing of the GP60 gene fragments of 13 isolates resulted in three different subgenotypes of C. parvum, all belonging to the zoonotic subtype family IIa and one subtype of C. hominis (Ib). These data identify C. parvum as the major cause of human cryptosporidiosis in Ethiopia and suggest a zoonotic transmission of the disease in contrast to reports from other developing countries.

Adoptive transfer of protective immunity from Cryptosporidium parvum-infected interferon-gamma and interleukin-12-deficient mice to naive recipients.

We investigated the possibility of transfer immunity from Cryptosporidium parvum-infected interferon-gamma (GKO) and interleukin-12p40 (IL-12KO) deficient C57BL/6 mice to naive mice by transfer of intraepithelial lymphocytes (IELs) and CD4(+) T cells from spleen and mesenteric lymph nodes (MLNs). Three days after the transfer recipients were infected with C. parvum. IELs isolated from GKO donor mice after resolution of infection (day 15) but not at the peak of infection (day 8) significantly reduced the parasite load in recipient mice. In IL-12KO mice, IELs and also CD4(+) T cells isolated from the spleen and MLNs of donor mice at the peak of infection (day 5) and after resolution (day 15) significantly reduced the parasite excretion, emphasizing the role of interferon-gamma in the host-parasite interaction. However, after resolution of infection, interferon-gamma-independent mechanisms have evolved that render GKO IELs capable of protecting mice from severe infection.

Morphology and in vitro infectivity of sporozoites of Cryptosporidium parvum.

An important obstacle in studying Cryptosporidium parvum is the lack of a permanent in vitro cultivation system of the parasite. While short-term cultures using various host cell lines have been widely employed, long-term cultures that would facilitate the immortalization of C. parvum isolates have not yet been developed. The description of the complete development of C. parvum in cell-free culture in 2004 has been received with great interest and also with some astonishment. Unfortunately, attempts to reproduce these results with different isolates of C. parvum and also C. hominis have failed. In this report, we provide an alternative interpretation of the nature of a parasite stage that occurs 24 hr after excystation of oocysts which, morphologically, is similar to stages that have been regarded as being extracellular trophozoites or merozoites by other investigators.

Dynamics of gut mucosal and systemic Th1/Th2 cytokine responses in interferon-gamma and interleukin-12p40 knock out mice during primary and challenge Cryptosporidium parvum infection.

Cryptosporidium parvum is an intracellular parasite causing enteritis which can become life-threatening in the immunocompromised host. CD4+ T cells and interferon (IFN)-gamma play dominant roles in host immune response to infection. However, effector mechanisms that are responsible for recovery from infection are poorly understood. In the present study we analyzed mice deficient in IFN-gamma or interleukin (IL)-12 in parallel to C57BL/6 wild type mice as models for murine cryptosporidiosis. Our results identified IFN-gamma as the key cytokine in the innate as well as adaptive immunity during primary and also challenge C. parvum infection. Furthermore, both Th1 and Th2 cytokines appear to contribute to the resolution of a primary infection, the former being dominant over the latter. Dramatic changes in the expression of cytokine genes were seen in the ileum (the site of infection) but not in the mesenteric lymph nodes and spleen. During re-challenge, a significant increase of IFN-gamma was recorded in IL-12 deficient mice (IL-12KO). Additionally, we present data suggesting a contribution of IL-18 in resistance of C. parvum infection even in the absence of IFN-gamma. Anti-IL-18 antibody treatment led to increased susceptibility to infection in both strains of immunodeficient mice. Besides its function in inducing IFN-gamma in IL-12 knock out mice, IL-18 appears to be involved in the regulation of the Th1/Th2 responses in C. parvum. Neutralization resulted in a cytokine imbalance with up regulation of systemic (spleen) Th2 cytokine genes, notably IL-4 and IL-13. These data demonstrate that susceptibility or resistance to C. parvum infection depends on a delicate balance between the production of Th1 cytokines, needed to control parasite growth, and Th2 cytokines, to limit pathology.

Crucial role of aspartic acid at position 265 in the CH2 domain for murine IgG2a and IgG2b Fc-associated effector functions.

Replacement of aspartic acid by alanine at position 265 (D265A) in mouse IgG1 results in a complete loss of interaction between this isotype and low-affinity IgG Fc receptors (Fc gammaRIIB and Fc gammaRIII). However, it has not yet been defined whether the D265A substitution could exhibit similar effects on the interaction with two other Fc gammaR (Fc gammaRI and Fc gammaRIV) and on the activation of complement. To address this question, 34-3C anti-RBC IgG2a and IgG2b switch variants bearing the D265A mutation were generated, and their effector functions and in vivo pathogenicity were compared with those of the respective wild-type Abs. The introduction of the D265A mutation almost completely abolished the binding of 34-3C IgG2a and IgG2b to all four classes of Fc gammaR and the activation of complement. Consequently, these mutants were hardly pathogenic. Although oligosaccharide side chains of these mutants were found to contain higher levels of sialic acids than those of wild-type Abs, the analysis of enzymatically desialylated D265A variants ruled out the possibility that very poor Fc-associated effector functions of the D265A mutants were due to an increased level of the mutant Fc sialylation. Thus, our results demonstrate that aspartic acid at position 265 is a residue critically implicated in triggering the Fc-associated effector functions of IgG, probably by defining a crucial three-dimensional structure of the Fc region.

Impact of a three amino acid deletion in the CH2 domain of murine IgG1 on Fc-associated effector functions.

Four murine IgG subclasses display markedly different Fc-associated effector functions because of their differential binding to three activating IgG Fc receptors (FcgammaRI, FcgammaRIII, and FcgammaRIV) and C1q. Previous analysis of IgG subclass switch variants of 34-3C anti-RBC monoclonal autoantibodies revealed that the IgG1 subclass, which binds only to FcgammaRIII and fails to activate complement, displayed the poorest pathogenic potential. This could be related to the presence of a three amino acid deletion at positions 233-235 in the CH2 domain uniquely found in this subclass. To address this question, IgG1 insertion and IgG2b deletion mutants at positions 233-235 of 34-3C anti-RBC Abs were generated, and their ability to initiate effector functions and their pathogenicity were compared with those of the respective wild-type Abs. The insertion of amino acid residues at positions 233-235 enabled the IgG1 subclass to bind FcgammaRIV but did not improve the binding to C1q. Accordingly, its pathogenicity was enhanced but still inferior to that of IgG2b. In contrast, the IgG2b deletion mutant lost its ability to bind to FcgammaRIV and activate complement. Consequently, its pathogenicity was markedly diminished to a level comparable to that of IgG1. Our results demonstrated that the initiation of FcgammaR- and complement-mediated effector functions of IgG2b was profoundly affected by the three amino acid deletion at positions 233-235, but that this natural three amino acid deletion could only partially explain the poor binding of IgG1 to FcgammaRIV and C1q. This indicates the lack in the IgG1 subclass of as yet unknown motifs promoting efficient interaction with FcgammaRIV and C1q.

Increased susceptibility of complement factor B/C2 double knockout mice and mannan-binding lectin knockout mice to systemic infection with Candida albicans.

Candida albicans is the major cause of systemic fungal infections in immunocompromised patients. We investigated the susceptibility of mice deficient in complement factor B and C2 (Bf/C2-/-), C1q (C1qa-/-), and mannan-binding lectin (MBL)-A (MBL-A) and MBL-C (MBL-A/C-/-) to systemic infection with C. albicans. Animals were infected i.p. with 10(8)C. albicans blastoconidia and monitored for mortality. Bf/C2-/- mice showed high mortality (over 90%) within the study period of 3 weeks. In contrast, mortality in C1qa-/- mice was below 15% whereas that of MBL-A/C-/- mice was 40% (P<0.001). Intravenous infection of mice with 8x10(5) blastoconidia resulted in the same trend with Bf/C2-/- mice being highly susceptible compared to the other strains. Histology of kidney sections of infected Bf/C2-/- mice showed widespread mycelia confirming the high CFU counts from cultured tissue homogenates. In C1qa-/-, MBL-A/C-/- and wild type C57BL/6 mice hyphal growth was limited. However, massive inflammatory infiltration was apparent, which was not seen in Bf/C2-/- mice. The ability of the mouse sera to opsonize C. albicans was determined by quantification of phagocytosis of C. albicans by peritoneal phagocytes. Whilst phagocytosis mediated by Bf/C2-/- mouse serum was low (10.6%), more phagocytosis could be seen in MBL-A/C-/- (19.9%), C1qa-/- mice (23.9%) and wild type mice (29%). Deficiency of classical pathway activation has only a low impact whereas the lectin pathway contributes to the host defence against candidosis. The more pronounced lack of complement activation in Bf/C2-/- mice leads to uncontrolled infection due to an opsonophagocytic defect.

Binding and activation of human and mouse complement by Cryptosporidium parvum (Apicomplexa) and susceptibility of C1q- and MBL-deficient mice to infection.

Cryptosporidium parvum is a protozoan parasite (Apicomplexa) that causes gastrointestinal disease in animals and humans. Whereas immunocompetent hosts can limit the infection within 1 or 2 weeks, immunocompromised individuals develop a chronic, life-threatening disease. The importance of the adaptive cellular immune response, with CD4+ T-lymphocytes being the major players, has been clearly demonstrated. Several non-adaptive immune mechanisms have been suggested to contribute to the host defence, such as interferon-gamma (IFN-gamma) from NK cells, certain chemokines, beta-defensins and pro-inflammatory cytokines, but the influence of the complement systems has been less well studied. We analysed the in vitro binding and activation of the human and mouse complement systems and tested the susceptibility to infection in complement-deficient mouse strains. We found that C. parvum can activate both the classical and lectin pathways, leading to the deposition of C3b on the parasite. Using real-time PCR, parasite development could be demonstrated in adult mice lacking mannan-binding lectin (MBL-A/C-/-) but not in mice lacking complement factor C1q (C1qA-/-) or in wild type C57BL/6 mice. The contribution of the complement system and the lectin pathway in particular to the host defence against cryptosporidiosis may become apparent in situations of immunodeficiency such as HIV infections or in early childhood.

Differential expression of Cryptosporidium parvum genes encoding sporozoite surface antigens in infected HCT-8 host cells.

Intracellular replication of Cryptosporidium parvum (Apicomplexa) involves the generation of several asexual and sexual forms of the parasite. During the stage conversions, complex mechanisms lead to differential structural and functional properties of the parasite. These require a well tuned gene transcription machinery. For the first time the gene expression of four surface proteins of C. parvum sporozoites, CP15, CP17, P23, and GP900 were analysed in parallel by reverse transcription polymerase chain reaction. In addition, CP17 and P23 antigens were detected in infected host cells by immunofluorescence using antisera raised against recombinant forms of the proteins. The results show that expression of each gene follows a unique time schedule during intracellular development, suggesting that the functions of these proteins during the life cycle are not restricted to the invasive stages.

Early diagnosis of Acanthamoeba infection during routine cytological examination of cerebrospinal fluid.

Early identification of Acanthamoeba in cerebrospinal fluid is mandatory to prevent fatal granulomatous amebic encephalitis. In the case presented here amebic trophozoites were detected in a routine cerebrospinal fluid sample. The antibiotic treatment and the apparently low virulence of this isolate were responsible for the benign progression of the infection.

Common silent mutations in all types of hereditary complement C1q deficiencies.

Hereditary complete deficiency of complement component C1q is a rare genetic disorder that is associated with severe recurrent infections and a high prevalence of lupus-erythematosus-like symptoms. In the past, several single nucleotide polymorphisms have been identified in all three genes coding for the C1q A, B, and C chains. These point mutations which either lead to termination codons, frameshift, or amino acid exchanges were thought to be responsible for these defects as no other nonsense or missense mutations were found. As a result of the aberrations, either a nonfunctional C1q antigen is present or no C1q protein is detectable in the patients' sera. Screening 46 individuals from seven families with different forms of C1q deficiencies identified a homologous silent mutation at position Gly70 (GGG > GGA) of the C1q A gene of all 11 C1q-deficient patients. A high number of family members that were heterozygous for the coding mutations carried the silent mutation in the homozygous (18%) or heterozygous (36%) state. In addition to the Gly70 mutation in the A gene, another homozygous silent mutation (C gene at position Pro14, CCT >CCC) was detected in all C1q-deficient patients.

[Hospital risk management from the viewpoint of insurers]. / Risiko-Management im Krankenhaus aus Sicht der Versicherer.

The present article deals with the significance of risk management in hospitals from the viewpoint of liability insurers. From the perspective of insurance companies, the liability risk of a hospital and its personnel has considerably increased during the past 25 years. The present risk situation is characterized by a growing number of reported liability cases, as well as by an enormous increase of average compensation claims. This development has led some insurance companies to financial deficits in the segment of hospital liability. While some insurers have withdrawn their activities from this market segment, others have reacted by raising their premiums. Since in Germany the premiums usually depend on the number of beds held by a hospital, the problem of rising premiums is exacerbated by the general increase of the number of clinical cases in the face of a parallel reduction of the number of beds. In the process of finding new criteria or methods for adequate premium calculation, a key role will be played by the individual future risk development of a hospital and by the evaluation of this risk by its insurance company. An extensive system of clinical quality management supported by elements of risk management will have persistent positive effects on the development of individual insurance premiums and on the insurability of clinical liability. Risk management is defined as the totality of measures taken by a company to identify risks that could lead to reduced success. Clinical risk management must be regarded in the context of a general trend that is not limited to the field of health service. In this process, the handling of errors and their causes plays a central role. Further variants of hospital risk management are the technical and economic risk management, both of which are increasingly important and are in part implemented in the German legislation. Clinical risk management has originated from the U.S., where as early as in the nineteen-seventies instruments and methods have been developed to avoid errors. Important application fields are anesthetics, surgery, orthopedics, and obstetrics. Risk management is primarily a task of the internal personnel of a hospital. The support by external consultants promises additional benefits for the hospital. Measures of classical risk management usually are essential elements of any quality management system; as such, they are therefore certifiable. Certification alone, however, does not prove the sustained efficiency of a risk-prevention system.

Structural analysis of Cryptosporidium parvum.

Cryptosporidium parvum (Apicomplexa, formerly Sporozoa) is the causative agent of cryptosporidiosis, an enteric disease of substantial medical and veterinary importance. C. parvum shows a number of unique features that differ from the rest of the class of coccidea in which it is currently grouped taxonomically. Differences occur in the overall structure of the transmission form and the invasive stages of the parasite, its intracellular location, the presence of recently described additional extracellular stages, the host range and target cell tropism, the ability to autoinfection, the nonresponsiveness to anticoccidial drugs, the immune response of the host, and immunochemical and genetic characteristics. These differences have an important impact on the infectivity, the epidemiology, the therapy, and the taxonomy of the parasite. The present article describes the structural analysis of the parasite using light and electron microscopy with an emphasis on structural details unique to C. parvum.

Restoration of C1q levels by bone marrow transplantation attenuates autoimmune disease associated with C1q deficiency in mice.

C1q deficiency in both humans and mice is strongly associated with autoimmunity. We have previously shown that bone marrow transplantation (BMT) restored C1q levels in C1q-deficient (C1qa(-/-)) mice. Here, we studied the effect of BMT on autoimmunity in C1qa(-/-) mice. Following irradiation, young C1qa(-/-) or wild-type MRL/Mp mice received bone marrow cells (BMC) from strain-matched wild-type or C1qa(-/-) animals. C1q levels increased rapidly when C1qa(-/-) mice received BMC from wild-type mice. Conversely, they decreased slowly in wild-type mice transplanted with C1qa(-/-) BMC. C1qa(-/-) animals transplanted with C1qa(-/-) BMC demonstrated accelerated disease when compared with wild-type mice given wild-type BMC. In contrast, a significant delay in the development of autoantibodies and glomerulonephritis was observed in C1qa(-/-) mice reconstituted with wild-type BMC, and the impaired clearance of apoptotic cells, previously described in C1qa(-/-) mice, was rectified. Moreover, the autoimmune disease was accelerated in wild-type mice given C1qa(-/-) BMC compared to animals transplanted with wild-type cells. These results provide supporting evidence that BMT may be a therapeutic option in the treatment of autoimmunity associated with human C1q deficiency.

Effect of antiretroviral protease inhibitors alone, and in combination with paromomycin, on the excystation, invasion and in vitro development of Cryptosporidium parvum.

With the spread of the human immunodeficiency virus in the early 1980s, cryptosporidiosis was regarded as an AIDS-defining disease. As an opportunistic pathogen, the intestinal parasite Cryptosporidium parvum became an important cause of chronic diarrhoea, leading to high morbidity and mortality in immunocompromised patients. To date, no effective chemotherapy is available. With the introduction of protease inhibitors (PIs) in highly active antiretroviral therapy (HAART), the incidence of cryptosporidiosis in AIDS patients has declined substantially in western countries. We have therefore tested the effect of five PIs used in HAART on the excystation, invasion and development of the parasite in a cell culture system. The human ileocaecal adenocarcinoma cell line HCT-8 served as a host cell. None of the substances had an effect on the excystation rate, and only nelfinavir moderately, but statistically significantly, inhibited the host cell invasion over a period of 2 h. There were more pronounced inhibitory effects when PIs were present over the total time of intracellular development (48 h). Indinavir, nelfinavir and ritonavir inhibited parasite development significantly. The inhibitory effect was increased when the aminoglycoside paromomycin was combined with the PIs indinavir, ritonavir, and to a lesser extent saquinavir, compared to the PIs alone.

Structure of the Cryptosporidium parvum microneme: a metabolically and osmotically labile apicomplexan organelle.

From an EM study of thin sections, the rod-like microneme organelles within conventionally glutaraldehyde fixed Cryptosporidium parvum sporozoites have been shown to undergo a shape change to a more spherical structure when the sporozoites age in vitro for a period of approximately 12 to 24 h. This correlates with the shape change of intact sporozoites, from motile hence viable thin banana-shaped cells to swollen pear-shaped cells, shown by differential interference contrast light microscopy of unstained unfixed and glutaraldehyde-fixed samples, as well as by thin section EM of fixed sporozoites. From negatively stained EM specimens of unfixed and fixed sporozoites the cellular shape change has been confirmed as has the rod to sphere micronemal shape change. Intact micronemes released directly from sporozoites exclude negative stain and appear as smooth-surfaced electron transparent particles. Biochemically purified rod-shaped C. parvum micronemes are shown to be fragile organelles that inevitably undergo variable damage during isolation, storage and subsequent specimen preparation for EM study. In the absence of glutaraldehyde fixation, damaged micronemes allow the negative stain to enter and loose their contents and during storage undergo a rod-to-sphere shape transformation. Glutaraldehyde-fixed micronemes maintain the rod shape; intact fixed micronemes still exclude negative stain but damaged micronemes reveal a complex quasi-helical arrangement of internal protein within the rod-like micronemes. Loss of this internal organized structure appears to be responsible for the micronemal shape change. This interpretation has been advanced from mutually supportive data obtained from cryoelectron microscopy of unstained vitrified samples, conventional air-dry negative staining and cryo-negative staining. Attempts to biochemically solubilize the micronemal content by lysis and ultrasonication, and separate it from the micronemal membranes, have so far met with limited success as the internal material tends to remain as a disorganized cluster of particles upon release.