[BRILL-ZINSER DISEASE AS A CONSEQUENCE OF RICKETTSIA PROWAZEKII PERSISTENCE IN PREVIOUSLY ILL WHO HAVE HAD EPIDEMIC TYPHUS (EPIDEMIOLOGIC ASPECTS)].

Materials, that summarize data of original research and scientific literature on epidemiology and problems of persistence during epidemic typhus, whose causative agent (Rickettsia prowazekii) is reactivated in the organism of the previously ill and is manifested as Brill-Zinser disease, are presented. A retrospective analysis was carried out with the data obtained by Russian (All-Union) Centre for Rickettsioses during study of epidemiologic examination maps of 5705 typhus nidi and results of 19 463 blood sera analysis during study of immunologic structure of population in the territories of the former USSR for the period from 1970 to 1992. A decrease of epidemic typhus morbidity and an increase of the fraction of Brill-Zinser disease took place as a result of pediculosis corporis control. In separate territories specific weight of Brill-Zinser disease was 48% in 1952, up to 80% in 1969, and from 1977 all the ill were previously ill. However, during the perestroika period and afterwards, due to a reduction of economic and hygienic living conditions, appearance of refugees, the immune structure regarding typhus began to change. Due to the buildup of the population migration process and the presence of risk groups (refugees, homeless) among population of regions, where local wars are waged, the enhancement of methods of epidemic typhus and Brill-Zinser disease diagnostics and pediculosis corporis eradication is necessary. Study of R. prowazekii by molecular-genetics methods is necessary for complete understanding of its mechanism of persistence.

Inhibition of the growth of Rickettsia prowazekii in cultured fibroblasts by lymphokines.

The effect of lymphokine treatment of mouse and human fibroblast cell lines on the growth of Rickettsia prowazekii within the fibroblasts was studied. Treatment of mouse L929 cells with concanavalin A- or antigen-induced mouse lymphokines both before and after infection with R. prowazekii led to clearance of the rickettsiae from a substantial proportion of the cells and suppression of rickettsial growth in those cells which remained infected. Similar but less dramatic anti-rickettsial effects were observed in L929 cells treated with mouse lymphokines either only before or after infection with rickettsiae. Mouse lymphokine treatment of L929 cells had similar anti-rickettsial effects on the avirulent E strain and the virulent Breinl strain of R. prowazekii. Addition of cycloheximide or emetine to L929 cells at the same time as the lymphokines markedly suppressed the inhibition of rickettsial growth by the lymphokines. Mouse lymphokine treatment inhibited rickettsial survival and growth in mouse 3T3-A31 cells as well as in mouse L929 cells, but had no effect on rickettsial survival and growth in human foreskin fibroblasts. Conversely, concanavalin A-induced human lymphokines inhibited rickettsial survival and growth in human foreskin fibroblasts but had no effect on rickettsial survival and growth in mouse L929 cells. The rickettsia inhibitory activity in concanavalin A-induced mouse lymphokines was destroyed by heating the lymphokines at 80 degrees C for 10 min or by holding the lymphokines at pH 2 for 24 h but was retained after heating at 56 degrees C for 30 min.

Interferonlike factors from antigen- and mitogen-stimulated human leukocytes with antirickettsial and cytolytic actions on Rickettsia prowazekii. Infected human endothelial cells, fibroblasts, and macrophages.

Unique features of the primary site of rickettsial replication in typhus fevers, i.e., within the endothelial cells of small blood vessels in tissues, suggest that effector mechanisms, other than those dependent on phagocytosis by activated macrophages with enhanced microbicidal properties, most likely are necessary to explain the cell-mediated immune control of intracellular rickettsial replication in these sites. Theoretically, such mechanisms might involve contact between infected endothelial cells and activated T lymphocyte subpopulations or macrophages or immunologically induced soluble factors or lymphokines. Support for the existence of at least one of these alternative effector mechanisms is presented here for Rickettsia prowazekii. Cultures of human blood leukocytes, upon immunologically specific stimulation with R. prowazekii antigen or nonspecific stimulation with the mitogen phytohemagglutinin, produce soluble factor(s) in the supernatant fluid which, in culture, have (a) an intracellular antirickettsial action on R. prowazekii-infected human endothelial cells, fibroblasts, and macrophages, and (b) a specific cytolytic action on R. prowazekii-infected, but not uninfected bystander, human fibroblasts. Neither action is demonstrable in R. prowazekii-infected chicken embryo fibroblasts. The factor(s) has no direct antimicrobial action on extracellular rickettsiae and is inactivated by heating at 56 degree C for 1 h or by acid treatment at pH 2. Expression of the antirickettsial action requires new host cell messenger transcription and protein synthesis, whereas the cytolytic action does not. The circumstances of production and action and the properties of the factor(s) responsible for the intracellular antirickettsial, and perhaps also the cytolytic action are consistent with those of immune interferon (IFN-gamma).

Avidity of IgG to Rickettsia prowazekii and the presence of specific IgM in blood sera for retrospective analysis of the 1998 epidemic typhus outbreak in Russia.

The authors applied a new methodological approach based not only on the study of IgM/IgG to Rickettsia prowazekii in sera, but also on the estimation of the avidity index of specific IgG. The data allowed the authors to draw new conclusions about the 1998 epidemic typhus outbreak in Russia.

Directed mutagenesis of the Rickettsia prowazekii pld gene encoding phospholipase D.

Rickettsia prowazekii, the causative agent of epidemic typhus, is an obligately intracytoplasmic bacterium, a lifestyle that imposes significant barriers to genetic manipulation. The key to understanding how this unique bacterium evades host immunity is the mutagenesis of selected genes hypothesized to be involved in virulence. The R. prowazekii pld gene, encoding a protein with phospholipase D activity, has been associated with phagosomal escape. To demonstrate the feasibility of site-directed knockout mutagenesis of rickettsial genes and to generate a nonrevertible vaccine strain, we utilized homologous recombination to generate a pld mutant of the virulent R. prowazekii strain Madrid Evir. Using linear DNA for transformation, a double-crossover event resulted in the replacement of the rickettsial wild-type gene with a partially deleted pld gene. Linear DNA was used to prevent potentially revertible single-crossover events resulting in plasmid insertion. Southern blot and PCR analyses were used to confirm the presence of the desired mutation and to demonstrate clonality. While no phenotypic differences were observed between the mutant and wild-type strains when grown in tissue culture, the pld mutant exhibited attenuated virulence in the guinea pig model. In addition, animals immunized with the mutant strain were protected against subsequent challenge with the virulent Breinl strain, suggesting that this transformant could serve as a nonrevertible, attenuated vaccine strain. This study demonstrates the feasibility of generating site-directed rickettsial gene mutants, providing a new tool for understanding rickettsial biology and furthering advances in the prevention of epidemic typhus.

Differential patterns of endothelial and leucocyte activation in 'typhus-like' illnesses in Laos and Thailand.

Scrub typhus is responsible for a large proportion of undifferentiated fevers in south-east Asia. The cellular tropism and pathophysiology of the causative agent, Orientia tsutsugamushi, remain poorly understood. We measured endothelial and leucocyte activation by soluble cell adhesion molecule enzyme-linked immunosorbent assays in 242 Lao and Thai patients with scrub or murine typhus, leptospirosis, dengue, typhoid and uncomplicated falciparum malaria on admission to hospital. Soluble E-selectin (sE-selectin) levels were lowest in dengue, sL-selectin highest in scrub typhus with a high sE-selectin to sL-selectin ratio in leptospirosis patients. In scrub typhus patients elevated sL-selectin levels correlated with the duration of skin rash (P = 0.03) and the presence of eschar (P = 0.03), elevated white blood cell (WBC) count (P = 0.007), elevated lymphocyte (P = 0.007) and neutrophil counts (P = 0.015) and elevated levels of sE-selectin correlated with the duration of illness before admission (P = 0.03), the presence of lymphadenopathy (P = 0.033) and eschar (P = 0.03), elevated WBC (P = 0.005) and neutrophil counts (P = 0.0003). In comparison, soluble selectin levels in murine typhus patients correlated only with elevated WBC counts (P = 0.03 for sE-selectin and sL-selectin). Soluble intercellular adhesion molecule-1 and soluble vascular adhesion molecule-1 levels were not associated significantly with any clinical parameters in scrub or murine typhus patients. The data presented suggest mononuclear cell activation in scrub typhus. As adhesion molecules direct leucocyte migration and induce inflammatory and immune responses, this may represent O. tsutsugamushi tropism during early dissemination, or local immune activation within the eschar.

Seroepidemiology of rickettsial infections in Northeast India.

BACKGROUND: Resurgence of scrub typhus was reported in Northeast India in 2010 after a gap of 67 years since World War II. However, the presence of other rickettsial infections remained unknown from this region. A seroepidemiological investigation was undertaken in the scrub typhus affected areas from 2013-2015 in Assam, Arunachal Pradesh and Nagaland to assess the exposure to other rickettsial diseases besides scrub typhus. METHODS: Samples were collected from people residing in scrub typhus reporting areas. Serology was performed by an indirect ELISA for the three rickettsial agents' viz., scrub typhus group orientiae (STGO), spotted fever group rickettsiae (SFGR) and typhus group rickettsiae (TGR). A sample with total net absorbance ≥1.000 was considered as positive. An entomological survey was also carried out in the affected areas. RESULTS: Overall, 1265 human blood samples were collected, of which 30.8% (n=390), 13.8% (175) and 4.2% (53) had antibodies against STGO, SFGR and TGR respectively. Presence of antibodies against more than one of the rickettsial groups was also detected. Among the arthropods collected, chiggers of Leptotrombidium deleinse, fleas belonging to Ctenocephalides felis and Pulex irritans, ticks belonging to Rhipicephalus microplus, Haemaphysalis spp. were predominant. Candidatus Rickettsia senegalensis was detected in C. felis. CONCLUSIONS: Our findings confirm wide circulation of rickettsial infections and their probable vectors in the northeast region of India.Accession numbers: KU163367, KU163368, KU499847, KU499848.

Murine typhus as a common cause of fever of intermediate duration: a 17-year study in the south of Spain.

BACKGROUND: Fever of intermediate duration (FID), characterized by a febrile syndrome lasting from 7 to 28 days, is a frequent condition in clinical practice, but its epidemiological and etiologic features are not well described. Murine typhus (MT) is a worldwide illness; nevertheless, to our knowledge, no studies describing its epidemiological and clinical characteristics have been performed in the south of Spain. Also, its significance as a cause of FID is unknown. OBJECTIVE: To determine the epidemiological features, clinical characteristics, and prognosis of MT and, prospectively, its incidence as a cause of FID. DESIGN: Prospective study of cases of MT over 17 years (1979-1995) and of all cases of FID treated in a tertiary teaching hospital in Seville, Spain. RESULTS: One hundred and four cases of MT were included, and MT was the cause in 6.7% of 926 cases of FID. Insect bites were reported in only 3.8% of the cases of MT previous to the onset of illness. Most cases (62.5%) occurred in the summer and fall. A high frequency of rash (62.5%) was noted. Arthromyalgia (77%), headache (71%), and respiratory (25%) and gastrointestinal (23%) symptoms were also frequent. Laboratory findings were unspecific. Organ complications were uncommon (8.6%), but they were severe in 4 cases. The mean duration of fever was 12.5 days. Cure was achieved in all cases, although only 44 patients received specific treatment. CONCLUSIONS: Murine typhus is prevalent in the south of Spain and is a significant cause of FID. Clinical signs are benign, but some patients may develop severe complications. A high degree of clinical suspicion is required for diagnosis.

Development of Rickettsia prowazekii DNA vaccine: cloning strategies.

Rickettsia prowazekii, the etiologic agent of louse-borne typhus, is listed as a category B agent under the select agent list of the United States Centers for Disease Control and Prevention. R. prowazekii was placed on the select agent list due to its potential to cause epidemic, high mortality in untreated and/or misdiagnosed cases, and ease of spread in vulnerable populations. Historically, R. prowazekii vaccines using crude antigen and/or inactivated rickettsia were partially protective but have been accompanied with undesirable toxic reactions and difficulties in standardization. The availability of the genome sequence of R. prowazekii allowed us to select genes that encode proteins with potential in immuno-protection against this human pathogen. We successfully PCR-amplified a group of genes involved in invasion (invA), cell division (fts), protein secretion (sec gene family), and virulence (ompA and ompB, virB gene family, cap and tlyA and tlyC). The generated PCR products were cloned into the Gateway cloning system and the cloned products will be introduced into Vical VR 1020-DV and VR 1012-DV DNA vaccine plasmids. Twenty-four target genes from R. prowazekii have been PCR amplified, of which fifteen have been introduced into the pENTR/SD/D-TOPO entry cloning vector.

Modification of antityphus antibodies on passage through the gut of the human body louse with discussion of some epidemiologic and evolutionary implications.

Evidence is presented to indicate that proteolytic and perhaps other enzymes of the louse midgut, essential to the nutrition of the louse, perform molecular dissection on the antirickettsial antibodies present in the blood of a typhus-immune host that selectively destroys, along with other functions, the portion of the antibody that determines the only known function by which antirickettsial antibodies may operate in host defense mechanisms, namely, opsonization of rickettsiae for enhanced ingestion by professional phagocytes and subsequent destruction. The epidemiologic significance of these findings is discussed in relation to the progressive destruction of cells that produce digestive enzymes of the louse midgut that occurs with progressive rickettsial infection, and the possibility of a negative feedback mechanism in transmission is introduced. Speculations that involve evolutionary concepts of both convergent and divergent varieties with respect to rickettsiae, potentially operational in a system that consists of an obligate blood-sucking arthropod vector and a vertebrate host capable of adaptive responses to both vector and rickettsial agent, are presented.

Evidence of Rickettsia prowazekii infections in the United States.

From January 1976 through January 1979 serum specimens from 1,575 individuals were received at the Center for Disease Control and tested for antibodies to rickettsiae. Of these, sera from eight persons gave serological results indicative of recent infections with epidemic typhus rickettsiae (Rickettsia prowazekii). Five of the persons were from Georgia, and one each was from Tennessee, Pennsylvania and Massachusetts. The illnesses occurred during the winter, chiefly in persons living in a rural environment. The clinical picture was compatible with louse-borne epidemic typhus. There was no apparent contact with human body or head lice, and no cases occurred in patient contacts, indicating that infection was not associated with the classic man-louse-man cycle of epidemic typhus. Two of the eight patients had contact with flying squirrels suggesting that they became infected from this known extrahuman reservoir of R. prowazekii.

Papilledema in endemic typhus.

A 21-year-old women developed severe bilateral papilledema during an acute febrile disease. Her optic disk margins were blurred and the disks were elevated up to 5 diopters. Splinter hemorrhages, cotton-wool exudates, cytoid bodies, and sheathing of veins were also present. The pyrexia was caused by murine typhus diagnosed by serologic tests. These tests revealed that Proteus OX-19 agglutination titer rose to 1:12800, and a positive complement fixation test titer was 1:640 with Rickettsia mooseri antigens. Neurological examination results, skull roentgenograms, brain scan, electroencephalogram, and the cerebrospinal fluid were all within normal range, thereby excluding intracranial hypertension. After the patient's recovery from the rickettsial disease, the papilledema abated gradually until her fundi reverted to normal.

Detection of antibodies against spotted fever group Rickettsia (SFGR), typhus group Rickettsia (TGR), and Coxiella burnetii in human febrile patients in the Philippines.

A total of 157 sera from febrile patients in the Philippine General Hospital in Manila, Luzon, and the Northern Samar Provincial Hospital, the Philippines, were used. Serum antibodies against spotted fever group Rickettsia (SFGR) and typhus group Rickettsia (TGR) were detected by indirect immunofluorescence test. Antibody positive rates were 1.3% for SFGR (Rickettsia japonica) and 2.5% for TGR (R. typhus), respectively. Rickettsial antibodies in humans in the Philippines were found for the first time. These results underscore the need for further epidemiological study of clinical rickettsioses in the Philippines.

Activity of macrophages from guinea pigs at various periods after infection with Rickettsia prowazeki.

The function of peritoneal macrophages from Rickettsia prowazeki-infected guinea pigs at various intervals of postinfection immunity was studied. The activity of macrophages in immunized animals was higher than in non-immunized ones; it was the highest in the period of the highest level of immunity and high levels of complement-fixing antibodies.

Thymus-independent antibody production to the antigen of Rickettsia prowazekii.

Antibody production has been studied in cotton B-rats and in CBA B-mice during immunization with chemical typhus vaccine (CTV) and during infection with Rickettsia prowazekii. Studies of the immune response to rickettsial antigen in T-deficient animals have shown a high immunogenicity of CTV and independence of antibody production on T-lymphocytes. Active antibody synthesis was also observed in B-rats and B-mice during Rickettsia prowazekii infection. The absence of T-lymphocyte dependence in experimental animals was tested by administration of sheep red blood cells (SRBC).

Electron microscopic analysis of in vitro interaction of Rickettsia prowazekii with guinea pig macrophages. II. Macrophages from immune animals.

Alike to macrophages from intact animals, reproduction, destruction and formation of spheroplast-like forms were observed in macrophages from immune guinea pigs 2 months post-infection (p.i.) with the virulent Breinl strain of Rickettsia prowazekii. Unlike to the former, immune macrophages revealed phagolysosomes which were larger in size and contained more rickettsiae showing morphologic signs of destruction. Spheroplast-like forms occurred more often and were more numerous than in intact animals. Structures morphologically similar to L-forms of gram-negative bacteria and that of chlamydiae were also detected. After adding immune serum, more intact rickettsiae and spheroplasts were found in phagosomes as well as more phagolysosomes contained rickettsiae and spheroplasts with morphologic signs of destruction. It is suggested that clearance of immune macrophages from rickettsiae is mediated by at least two processes: on one hand by destruction of rod-shaped rickettsiae within phagolysosomes and, on the other hand, by formation and subsequent destruction of spheroplast-like forms within vacuoles, which probably also function as phagolysosomes.

Electron microscopic analysis of in vitro interaction of Rickettsia prowazekii with guinea pig macrophages. I. Macrophages from nonimmune animals.

Monolayer cultures of peritoneal macrophages of intact guinea pigs were infected with Rickettsia prowazekii (strain Breinl) and examined by electron microscopy after 30 min, 4 and 24 hr post-infection (p.i.). Three parallel processes developed in infected macrophages: reproduction of rickettsiae in macrophage cytoplasm, destruction in phagolysosomes and production of spheroplast-like forms. Reproduction of rickettsiae yielded 2 cell types: those with dense and with light cytoplasm; they were located side by side in the microcolony and seemed to have a common capsule-like coat. Relatively small spheroplast-like forms of about 1 micron in size were regularly detected. Addition of immune serum to macrophages increased the number of rickettsiae, both of rod-shaped as well as of spheroplast-like ones located within phagosomes, but elicited no increase in the number of digested pathogen cells.

Protein antigens of genetically related Rickettsia prowazekii strains with different virulence.

The protein antigens of two distinct lines of genetically related strains, namely the nonpathogenic strain E and its virulent revertant EVir and of the standard virulent strain Breinl were compared in SDS-PAGE and immunoblot assay using typhus patient sera and immune rabbit sera. No differences in the polypeptide pattern as detected in SDS-PAGE were found between strain E and EVir; the Breinl strain differed in a 30 kD protein. The high immunogenicity of the protein antigens of E, EVir and Breinl strains was demonstrated by immunoblot assay with human sera, which did not show any differences between the strains studied. Immunoblot analysis with immune rabbit sera to the strain E, EVir, and Breinl showed differences in immunological response to the 70 kD and 60 kD polypeptides of low virulent strain E and those of virulent strains EVir and Breinl.

Immunization. Around the world in 80 shots.

Physicians counseling patients who are planning major travels should make sure that baseline immunizations (diphtheria-tetanus-pertussis, polio, measles, rubella) and any necessary boosters are current. In addition, several other immunizations may be warranted (yellow fever, typhoid, and cholera), depending on destination(s) and itinerary, and prophylaxis for malaria may be advisable. As worldwide requirements for immunization do change, the physician should verify current requirements before planning an immunization schedule for a particular patient.