Foul smelling urine in an adult caused by Aerococcus urinae.

We describe the first adult case with Aerococcus urinae positive urine cultures as the proven cause of recurrent socially disabling malodorous urine. Bacterial strain specific factors as well as host factors are shown to play a role. The condition can be resolved with proper antibiotics.

Low-Threshold Testing for SARS-CoV-2 (COVID-19) in Long-Term Care Facilities Early in the First Pandemic Wave, the Twente Region, the Netherlands: A Possible Factor in Reducing Morbidity and Mortality.

During the first wave of the COVID-19 pandemic, there was a shortage of SARS-CoV-2 diagnostic tests, and testing patients with mild symptoms (low-threshold testing) was not recommended in the Netherlands. Despite these guidelines, to protect those who were most at risk, low-threshold testing was advocated and offered to the majority of long-term care institutions in the Twente region. In this manner, 144 healthcare workers and 96 residents tested SARS-CoV-2-positive and were isolated before the same service was provided nationwide by public health services. Strikingly, excess mortality rate in the Twente region 1 month after the introduction of this strategy was found to be 62%-89% lower than that in neighboring regions, which may be explained by this divergent testing strategy. In an emerging pandemic, early implementation of a liberal testing policy may be more effective than restricted testing in settings with a high death rate.

Defining a risk area for tick-borne encephalitis (TBE) in a country where TBE is emerging, the Netherlands, July 2016-October 2020.

TBE is an emerging infectious disease in the Netherlands since July 2016, and risk areas have not been defined yet. Until October 2020 twelve autochthonous cases of TBE have been identified. In six of these cases transmission of TBE virus likely occurred in the Twente region, which therefore is the region with the highest case number and risk of contracting the disease. Here we summarize the Twente cases so far and discuss if the Twente region should be considered a risk-area using criteria of traditional TBE endemic countries, and the public health measures that may accompany such designation.

Blood Culture-negative Endocarditis Caused by Tropheryma whipplei: Whipple's endocarditis.

CASE DESCRIPTION: A 67-year-old man was admitted with progressive heart failure due to blood culture-negative endocarditis of the aortic valve. Urgent aortic valve replacement was needed. Polymerase chain reaction (PCR) testing of samples of the explanted aortic valve revealed Tropheryma whipplei. The patient received ceftriaxone, followed by long-term co-trimoxazole. Recent arthralgia may have been a diagnostic clue. CONCLUSION: Whipple's endocarditis should be considered in patients with arthralgia and blood culture-negative endocarditis (BCNIE). LEARNING POINTS: Whipple's endocarditis should be considered in patients with symptoms of arthralgia and blood culture-negative endocarditis (BCNIE).Serum polymerase chain reaction is the main diagnostic test.Both physician awareness and multidisciplinary management by regional endocarditis teams are recommended strategies to provide optimal patient care.

Emergence of tick-borne encephalitis (TBE) in the Netherlands.

Recently, tick-borne encephalitis virus (TBEV) was detected in the Netherlands for the first time, in ticks collected in 2015 in the National Park Sallandse heuvelrug in response to the detection of anti-TBEV antibodies in roe deer. Hereafter, two human cases of autochthonous TBE have been reported, occurring in 2016. One case was geographically linked to the area of the previously reported ticks, which harbored a genetically divergent TBEV-Eu strain variant (TBEV-NL). So far these are the few reported events that point to endemic transmission of TBEV in the Netherlands and the true prevalence of TBEV and TBE disease in the Netherlands and its impact on the human population remains to be determined. We describe the third human case, identified in 2017, which geographically clusters with the aforementioned case and TBEV-positive ticks. We also describe the identification of another TBEV-NL-positive tick in the Netherlands, collected 2 years after the initial find in that same region (in 2017). These observations support the concept of continued circulation of TBEV-NL and the presence of a possible TBEV hot spot in the Sallandse Heuvelrug region.

Increasing evidence of tick-borne encephalitis (TBE) virus transmission, the Netherlands, June 2016.

We present a case of endemic tick-borne encephalitis (TBE) occurring in June 2016 in the eastern part of the Netherlands in an area where a strain of TBE virus, genetically different from the common TBE virus strains in Europe, was reported in ticks in 2016. With the start of the tick season in spring, this second autochthonous Dutch TBE case should remind physicians to consider the possibility of endemic TBE in patients with respective symptoms.

Increase in ECHOvirus 6 infections associated with neurological symptoms in the Netherlands, June to August 2016.

The Dutch virus-typing network VIRO-TypeNed reported an increase in ECHOvirus 6 (E-6) infections with neurological symptoms in the Netherlands between June and August 2016. Of the 31 cases detected from January through August 2016, 15 presented with neurological symptoms. Ten of 15 neurological cases were detected in the same province and the identified viruses were genetically related. This report is to alert medical and public health professionals of the circulation of E-6 associated with neurological symptoms.

Effect of viral membrane fusion activity on antibody induction by influenza H5N1 whole inactivated virus vaccine.

Whole inactivated virus (WIV) influenza vaccines are more immunogenic in unprimed individuals than split-virus or subunit vaccines. In mice, this superior immunogenicity has been linked to the recognition of the viral ssRNA by endosomal TLR7 receptors in immune cells, leading to IFNα production and Th1-type antibody responses. Recent data suggest that viral membrane fusion in target cell endosomes is necessary for TLR7-mediated IFNα induction. If so, virus inactivation procedures that compromise the fusion activity of WIV vaccines, like formaldehyde (FA) treatment, could potentially harm vaccine efficacy. Therefore, we measured the effect of fusion inactivation of H5N1 WIV on TLR7 activation in vitro, and on antibody isotype responses in vivo. Fusion inactivation of WIV reduced, but did not block, TLR7-dependent IFNα induction in murine dendritic cells in vitro. In vivo, fusion-inactive WIV was as potent as fusion-active WIV in inducing total H5N1-specific serum IgG and IgG2c subtype antibodies in unprimed mice. Both vaccines induced only small amounts of IgG1. However, FA treatment of WIV did reduce the capacity of the vaccine to induce hemagglutination-inhibiting (HI) antibodies. This possibly relates to modification of epitopes that are targets for HI antibodies rather than to loss of fusion activity. Antibody affinity maturation was not negatively affected by fusion inactivation. In conclusion, fusion activity of H5N1 WIV does not play a major role in Th1-type antibody induction. Yet, to preserve the full immunogenicity of WIV, or possibly also other inactivated influenza vaccines, harsh treatment with formaldehyde should be avoided.

Influenza vaccines: what do we want and how can we get it?

Influenza vaccines have been in use for more than 60 years and have proven to be efficacious in protecting from influenza infections during epidemics and the recent H1N1 pandemic. The development of influenza vaccines has so far been largely based on empirical grounds, which leaves room for vaccine improvement by implementation of recent insights in innate and adaptive immunity. Also, evaluation and approval of new vaccines rely on rather broad correlates of protection such as the hemagglutination inhibition titre, thereby neglecting qualitative aspects of the immune response. Here we discuss how current inactivated influenza vaccine formulations differ in the type of immune response they elicit, their protective capacity, and what causes these differences. Finally, we will discuss how this knowledge can guide the development of new adjuvants that optimize the protective efficacy of influenza vaccines.

Preservation of the immunogenicity of dry-powder influenza H5N1 whole inactivated virus vaccine at elevated storage temperatures.

Stockpiling of pre-pandemic influenza vaccines guarantees immediate vaccine availability to counteract an emerging pandemic. Generally, influenza vaccines need to be stored and handled refrigerated to prevent thermal degradation of the antigenic component. Requirement of a cold-chain, however, complicates stockpiling and the logistics of vaccine distribution. We, therefore, investigated the effect of elevated storage temperatures on the immunogenicity of a pre-pandemic influenza A H5N1 whole inactivated virus vaccine. Either suspended in liquid or kept as a freeze-dried powder, vaccines could be stored for 1 year at ambient temperature (20 degrees C) with minimal loss of immunogenicity in mice. Elevation of the storage temperature to 40 degrees C, however, resulted in a significant loss of immunogenic potency within 3 months if vaccines were stored in liquid suspension. In sharp contrast, freeze-dried powder formulations were stable at 40 degrees C for at least 3 months. The presence of inulin or trehalose sugar excipients during freeze-drying of the vaccine proved to be critical to maintain its immunogenic potency during storage, and to preserve the characteristic Th1-type response to whole inactivated virus vaccine. These results indicate that whole inactivated virus vaccines may be stored and handled at room temperature in moderate climate zones for over a year with minimal decline and, if converted to dry-powder, even in hot climate zones for at least 3 months. The increased stability of dry-powder vaccine at 40 degrees C may also point to an extended shelf-life when stored at 4 degrees C. Use of the more stable dry-powder formulation could simplify stockpiling and thereby facilitating successful pandemic intervention.

Superior immunogenicity of inactivated whole virus H5N1 influenza vaccine is primarily controlled by Toll-like receptor signalling.

In the case of an influenza pandemic, the current global influenza vaccine production capacity will be unable to meet the demand for billions of vaccine doses. The ongoing threat of an H5N1 pandemic therefore urges the development of highly immunogenic, dose-sparing vaccine formulations. In unprimed individuals, inactivated whole virus (WIV) vaccines are more immunogenic and induce protective antibody responses at a lower antigen dose than other formulations like split virus (SV) or subunit (SU) vaccines. The reason for this discrepancy in immunogenicity is a long-standing enigma. Here, we show that stimulation of Toll-like receptors (TLRs) of the innate immune system, in particular stimulation of TLR7, by H5N1 WIV vaccine is the prime determinant of the greater magnitude and Th1 polarization of the WIV-induced immune response, as compared to SV- or SU-induced responses. This TLR dependency largely explains the relative loss of immunogenicity in SV and SU vaccines. The natural pathogen-associated molecular pattern (PAMP) recognized by TLR7 is viral genomic ssRNA. Processing of whole virus particles into SV or SU vaccines destroys the integrity of the viral particle and leaves the viral RNA prone to degradation or involves its active removal. Our results show for a classic vaccine that the acquired immune response evoked by vaccination can be enhanced and steered by the innate immune system, which is triggered by interaction of an intrinsic vaccine component with a pattern recognition receptor (PRR). The insights presented here may be used to further improve the immune-stimulatory and dose-sparing properties of classic influenza vaccine formulations such as WIV, and will facilitate the development of new, even more powerful vaccines to face the next influenza pandemic.

Alum boosts TH2-type antibody responses to whole-inactivated virus influenza vaccine in mice but does not confer superior protection.

Clinical trials with pandemic influenza vaccine candidates have focused on aluminium hydroxide as an adjuvant to boost humoral immune responses. In this study we investigated the effect of aluminium hydroxide on the magnitude and type of immune response induced by whole-inactivated virus (WIV) vaccine. Balb/c mice were immunized once with a range of antigen doses (0.04-5 microg) of WIV produced from A/PR/8 virus, either alone or in combination with aluminium hydroxide. The hemagglutination inhibition (HI) titers of mice receiving WIV+aluminium hydroxide were 4-16-fold higher than HI titers in mice receiving the same dose of WIV alone, indicating the boosting effect of aluminium hydroxide. WIV induced a TH1 skewed humoral and cellular immune response, characterized by strong influenza-specific IgG2a responses and a high number of IFNgamma-secreting T cells. In contrast, immunization with WIV adsorbed to aluminium hydroxide resulted in skewing of this response to a TH2 phenotype (high IgG1 levels and a low number of IFNgamma-producing T cells). To assess the effect of the observed immune response skewing on viral clearance from the lungs mice immunized once with 1 microg WIV without or with aluminium hydroxide were challenged with A/PR/8 virus 4 weeks later. The immunized mice showed a significant decrease in viral lung titers compared to control mice receiving buffer. However, despite higher antibody titers, mice immunized with WIV adsorbed to aluminium hydroxide suffered from more severe weight loss and had significantly higher virus loads in their lung tissue than mice receiving WIV alone. Major difference between these groups of mice was the type of immune response induced, TH2 instead of TH1, indicating that a TH1 response plays a major role in viral clearance.

Whole inactivated virus influenza vaccine is superior to subunit vaccine in inducing immune responses and secretion of proinflammatory cytokines by DCs.

BACKGROUND: For protection against (re-)infection by influenza virus not only the magnitude of the immune response but also its quality in terms of antibody subclass and T helper profile is important. Information about the type of immune response elicited by vaccination is therefore urgently needed. OBJECTIVES: The aim of the study was to evaluate in detail the immune response elicited by three current influenza vaccine formulations and to shed light on vaccine characteristics which determine this response. METHODS: Mice were immunized with whole inactivated virus (WIV), virosomes (VS) or subunit vaccine (SU). Following subsequent infection with live virus, serum antibody titers and Th cell responses were measured. The effects of the vaccines on cytokine production by conventional and plasmacytoid dendritic cells were investigated in vitro. RESULTS AND CONCLUSIONS: In Balb/c mice (Th2 prone) as well as in C57Bl/6 mice (Th1 prone), WIV induced consistently higher hemagglutination-inhibition titers and virus-neutralizing antibody titers than VS or SU. In contrast to VS and SU, WIV stimulated the production of the antibody subclasses IgG2a (Balb/c) and IgG2c (C57BL/6), considered to be particularly important for viral clearance, and activation of IFN-gamma-producing T cells. Similar to live virus, WIV stimulated the production of proinflammatory cytokines by conventional dendritic cells and IFN-alpha by plasmacytoid cells, while VS and SU had little effect on cytokine synthesis by either cell type. We conclude that vaccination with WIV in contrast to VS or SU results in the desired Th1 response presumably by induction of type I interferon and other proinflammatory cytokines.

Search for morbillivirus proteins in multiple sclerosis brain tissue.

We investigated brain samples of patients with multiple sclerosis (MS) and controls with immunohistochemistry using monoclonal antibodies (MoAbs) against canine distemper virus (CDV) and measles virus (MV) proteins. All stained negative except for MoAb F3-5, which recognises a conserved epitope on the fusion protein of morbilliviruses. F3-5 immunostaining was found in 8/9 MS plaques and 2/5 herpes simplex virus encephalitis brain samples, but not in six controls or four patients with ischaemic stroke. Using RT-PCR we found no evidence for the presence of MV in MS plaques. The F3-5 epitope may represent a protein that is upregulated during inflammation or point to a yet unrecognised morbillivirus in the human central nervous system that might be implicated in MS pathogenesis.

Insulin-like growth factor binding protein-1-6 expression in activated microglia.

In the CNS insulin-like growth factor-1 (IGF-1) enhances survival of neurons, promotes myelin synthesis and acts as a mitogen for microglia. The effects of IGF-1 are regulated by a family of 6 IGF binding proteins (IGFBPs). We investigated mRNA expression patterns of IGFBPs in primary rat microglia under basal conditions and after activation with lipopolysaccharide (LPS). Under basal conditions, microglia expressed IGFBP-2 to -6, whereas, IGFBP-1 could not be detected. Following 2 h treatment with LPS mRNA levels for IGFBP-4 and -6 displayed a down regulation, and IGFBP-5 became undetectable. Levels of IGFBP-2 and -3 remained unaltered. Expression patterns of IGFBPs might play an important role in regulating the autocrine/paracrine IGF-1 actions on microglia under inflammatory conditions.