Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review.

Neuraxial anaesthesia is widely utilised for elective caesarean section, but the prevalence of inadequate intra-operative anaesthesia is unclear. We aimed to determine the prevalence of inadequate neuraxial anaesthesia for elective caesarean section; prevalence of conversion from neuraxial anaesthesia to general anaesthesia following inadequate neuraxial anaesthesia; and the effect of mode of anaesthesia. We searched studies reporting inadequate neuraxial anaesthesia that used ≥ ED95 doses (effective dose in 95% of the population) of neuraxial local anaesthetic agents. Our primary outcome was the prevalence of inadequate neuraxial anaesthesia, defined as the need to convert to general anaesthesia; the need to repeat or abandon a planned primary neuraxial technique following incision; unplanned administration of intra-operative analgesia (excluding sedatives); or unplanned epidural drug supplementation. Fifty-four randomised controlled trials were included (3497 patients). The overall prevalence of requirement for supplemental analgesia or anaesthesia was 14.6% (95%CI 13.3-15.9%); 510 out of 3497 patients. The prevalence of general anaesthesia conversion was 2 out of 3497 patients (0.06% (95%CI 0.0-0.2%)). Spinal/combined spinal-epidural anaesthesia was associated with a lower overall prevalence of inadequate neuraxial anaesthesia than epidural anaesthesia (10.2% (95%CI 9.0-11.4%), 278 out of 2732 patients vs. 30.3% (95%CI 26.5-34.5%), 232 out of 765 patients). Further studies are needed to identify risk factors, optimise detection and management strategies and to determine long-term effects of inadequate neuraxial anaesthesia.

Plasma brain-derived neurotrophic factor levels are associated with clinical severity in school age children with asthma.

BACKGROUND: Asthma is characterized by chronic inflammation of the airways with significant changes in leucocyte trafficking, cellular activation and tissue remodelling. Brain-derived neurotrophic factor (BDNF) has been involved with asthma and allergic diseases but its role as a severity marker in paediatric asthma has not been clinically assessed. OBJECTIVES: To evaluate plasma BDNF and inflammatory markers in order to address their relationships with disease severity in children (6-15 years) with controlled persistent asthma. METHODS: Children with persistent asthma were selected and lung function and skin prick tests were performed in all patients. Plasma BDNF levels and various inflammatory markers (CCL3, CCL11, CCL22, CCL24, CXCL8, CXCL9, CXCL10, soluble TNF receptors) were assessed by ELISAs. RESULTS: Subjects with moderate and severe asthma had higher BDNF levels than mild asthma and controls (P<0.001). The chemokines studied and soluble TNF receptors did not differ between the studied groups. CONCLUSION AND CLINICAL RELEVANCE: Our results indicate BDNF as a potential biomarker for clinical severity in children with asthma.

Relationship between postpartum mood disorder and birth experience: a prospective observational study.

BACKGROUND: This study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder. METHODS: In this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum. RESULTS: We enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02). CONCLUSION: Depression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.

Spontaneous cell proliferation is associated with poor sensitivity to glucocorticoids in patients infected with HTLV.

BACKGROUND: Human T-cell lymphotropic viruses (HTLV)-I/II have a special tropism for infecting T cells and inducing spontaneous lymphocyte proliferation. Leukaemia and neurological manifestations are associated with HTLV-I/II infections, and treatment is usually based on anti-inflammatory drugs including glucocorticoids. Although steroid resistance has been reported, it is unknown whether this condition is related to the infection itself or to the treatment. OBJECTIVE: We investigated whether spontaneous cell proliferation is associated with T-cell sensitivity to glucocorticoids. MATERIALS AND METHODS: Twenty-eight HTLV-I/II patients and 11 healthy age-matched controls took part in this study. Lymphocytes were isolated and cultured in vitro to measure spontaneous and mitogen-induced proliferation as well as cellular sensitivity to dexamethasone. RESULTS: Patients with HTLV-I/II infection showed similar stimulated and unstimulated T-cell proliferation as well as comparable sensitivity to dexamethasone in vitro. There were no group differences in the frequency of glucocorticoid responders versus non-responders. However, T cells of patients with spontaneous proliferation were unresponsive to mitogenic stimulation and were remarkably more resistant to dexamethasone than cells of patients with normal proliferation. CONCLUSION: These data suggest that the poor clinical response to steroids may be associated with spontaneous cell proliferation during HTLV infection.

Epstein-Barr virus-induced transformation of B cells for the diagnosis of genetic metabolic disorders--enumerative conditions for cryopreservation.

Epstein-Barr virus (EBV) infection in vitro causes transformation of B cells and generates B lymphoblastoid cell lines (LCLs). These LCLs have been widely used for the diagnostic of several genetic metabolic disorders. However, up to now, efficiency of LCL generation has been based on misleading subjective analysis. In this study, quantitative analyses have been performed to indicate efficiency of B-cell transformation to measuring human lysosomal acid hydrolases associated with: GM1-gangliosidosis type I, Gaucher disease and mucopolysaccharidosis type I. Peripheral blood mononuclear cells were isolated from 13 subjects, and LCLs were produced by culturing them with EBV for 12 days. Activities of the enzymes beta-galactosidase, beta-glucosidase and alpha-iduronidase were measured before and after cryopreservation in liquid nitrogen for 30 days. Efficiency of the B-cell transformation was screened every 4 days by the enumeration of cell proliferation, cell counts and changes in granularity estimated by flow cytometry. We observed the generation of 13 LCLs. Cell transformation was confirmed by the gradual increase of cellular clusters, cell size and granularity. In addition, we determined that the activity of the enzymes mentioned above did not change following cryopreservation. These data suggest that our enumerative approach for screening of EBV-LCLs is efficient for the enzymatic determination of human lysosomal acid hydrolases and may thus replace misleading subjective analyses.

Genetic characterization of mannose-sensitive hemagglutinin (MSHA)-negative mutants of Vibrio cholerae derived by Tn5 mutagenesis.

El Tor biotype Vibrio cholerae strains express a cell-associated mannose-sensitive hemagglutinin (MSHA) which is a putative attachment factor. Several MSHA-negative mutants from V. cholerae strain JBK70 were previously generated by Tn5 mutagenesis [Finn et al., Infect. Immun. 55 (1987) 942-946]. The chromosomal DNA regions containing the Tn5 insertions were isolated from eight strains for further analysis. Nucleotide sequencing of the insertional junctions and corresponding clones containing the intact chromosomal region from the parental strain revealed the presence of several contiguous ORFs. Only two ORFs of this region had received insertions, and these showed remarkable homology to genes involved in the general secretory pathway found in several Gram- bacterial species. Proteins corresponding to the observed ORFs were visualized with the T7 promoter/RNA polymerase expression system. Marker exchange mutagenesis was used to insert kanamycin-resistance cassettes and TnphoA insertions into different locations of this region in the chromosome of wild-type V. cholerae strains. The phenotypes of these mutants showed that this DNA region is involved in MSHA production, but is not required for general extracellular protein secretion.

Chronic stress in caregivers of dementia patients is associated with reduced lymphocyte sensitivity to glucocorticoids.

Caring for the chronically ill is associated with chronic distress. In view of the adverse effects of distress on cellular immune function, such distress may have implications for health. Indeed, it has been proposed that the hypothalamic-pituitary-adrenal (HPA) axis is a potential psychobiological mediator of these effects. In this study, we observed that elderly caregivers experienced greater distress and increased salivary cortisol than non-caregivers. In addition, caregivers had blunted mitogen-induced lymphocyte proliferation, lower mitogen-induced IL-2 production, and reduced lymphocyte sensitivity to glucocorticoids. These results indicate that chronic distress is associated with impaired cell-mediated immunity which is, in turn, associated with elevated basal steroid levels and altered steroid immunoregulation at the level of the lymphocyte.

Serum progesterone levels correlate with decreased cerebral edema after traumatic brain injury in male rats.

Previous animal research suggests that progesterone may have powerful neuroprotective effects in traumatic brain injury (TBI). This experiment tested the hypothesis that progesterone levels correlate with decreased cerebral edema in male rats with bilateral medial frontal cortex injuries. Three groups of male Sprague-Dawley rats were used: injured given progesterone (4 mg/kg), injured given vehicle (oil), and uninjured controls given vehicle. Progesterone or vehicle was administered intraperitoneally at 1, 6, and 24 h postinjury. At 48 h postinjury, the rats were killed, brains extracted, and assayed for edema. Percent difference in water content of the area surrounding the lesion was compared to posterior cortex. A strong inverse relationship was found between serum progesterone levels and percent cerebral edema; the higher the progesterone levels, the lower the percent edema. Both progesterone and oil-treated animals had some edema compared to sham-operated controls. The brains of the injured animals given control solution were higher in water content than either the uninjured group or injured progesterone-treated rats 48 h postinjury. These findings confirm that progesterone significantly decreases cerebral edema after TBI in adult male subjects.

Effects of repeated administration of desipramine or electroconvulsive shock on norepinephrine uptake sites measured by [3H]nisoxetine autoradiography.

To determine if repeated administration of desipramine (DMI) or electroconvulsive shock (ECS) regulate uptake sites for norepinephrine (NE) in rat brain, the binding of [3H]nisoxetine ([3H]NIS) was measured using quantitative autoradiography. Groups of animals were given DMI intraperitoneally, either a single injection or repeated doses of 10 mg/kg once daily for 21 days and were killed 48 h after the last injection. Another group of rats received ECS daily for 12 days (150 mA, 300 ms, 60 Hz) and was killed 24 h after the last shock. Repeated administration of DMI caused statistically significant decreases (20-40%) in the binding of [3H]NIS in 8 out of 17 brain regions measured; these areas included the hippocampus, thalamus and the amygdala. Acute treatment with DMI had no effect on the binding of [3H]NIS in any of the regions analyzed except the centrolateral nucleus of the amygdala. By contrast, except for the paraventricular nucleus of the thalamus where ECS caused a modest (20%) increase in binding, no other brain region was affected by ECS. Thus it appears that repeated administration of DMI and chronic ECS treatment have different effects on the binding of [3H]NIS to uptake sites for NE in rat brain.

Are adhesion molecules involved in stress-induced changes in lymphocyte distribution?

Acute psychological stress is associated with important changes in circulating cell populations and reductions in cell-mediated immune responses. However, the mechanisms underlying these phenomena are poorly understood. In this study, we investigated (i) acute and chronic restraint stress effects in Sprague-Dawley rats on peripheral lymphocyte subsets and (ii) adhesion molecule (beta2 integrins) expression and (iii) also determined whether glucocorticoids could underlie stress-related changes in cellular redistribution. We observed time-dependent changes in lymphocyte distribution including decreased (-21%) percentages of peripheral T helper cells and increased (88%) NK cell numbers following acute brief restraint. Acute stress was also found to overall upregulate beta2-integrin (CD11a and CD11b) expression on T cells and to raise (1049%) plasma corticosterone levels. However, this stress response was found habituated (-75% vs. acute) in the animals previously exposed to chronic restraint stress. Stress effects on circulating lymphocytes were not observed in animals previously exposed to chronic intermittent restraint stress or chronically stressed animals re-exposed to the same stressor. Our results indicate that 1) stress alters lymphocyte distribution, 2) that adhesion molecules may be involved in stress-induced alterations of T-cell distribution and 3) that these changes may be related to circulating glucocorticoids and subjected to adaptation with repeated stress exposure.

Evaluation of immune parameters in depressed patients.

The association between depression and altered immunological activities has repeatedly been suggested, but experimental data show contradictory results. In this work, cellular and humoral immunological activities were evaluated in patients presenting major depression, unipolar subtype. Natural killer cell activity (NKCA) was significantly reduced in patients as compared to healthy controls (p < 0.001). However, lymphocyte mitogenic responses and immunoglobulin titers (IgG, IgM, and IgA) were similar for all samples. Hematological, hormonal, and nutritional variables presented normal values in patients and in controls. A familial history of depression was related to lower NKCA and higher phytohemagglutinin responses (p < 0.01). These data suggest possible differential inhibition of cellular immune responses in depressed patients.

Restraint stress is associated with changes in glucocorticoid immunoregulation.

Psychological stress has been associated with activation of the hypothalamic-pituitary-adrenal (HPA) axis and impaired cell-mediated immune (CMI) responses. There is also evidence suggesting that intermittent chronic stress differentially alters CMI across different immune compartments, but the mechanisms underlying this phenomenon have not been explored in detail. In the present study, we investigated (i) acute and chronic restraint stress effects in Sprague-Dawley rats on both peripheral blood lymphocyte (PBL) and splenocyte mitogen-induced proliferation and (ii) also determined whether differential stress effects within these immune compartments might reflect alterations in lymphocyte sensitivity to glucocorticoids. It was found that while acute stress exposure significantly raised plasma corticosterone levels (1048% vs. controls, P<.001), this response was attenuated in the animals previously exposed to chronic intermittent stress (-79.66% vs. acute; P<.001). Acute stress increased phytohemagglutinin (PHA)-induced lymphocyte proliferation in the spleen (69.04%, P=.01) and suppressed PBL proliferation (-45.52%, P<.001). Neither of these changes were observed following chronic stress. We also demonstrated that reexposure to the stressor rapidly increased splenocyte sensitivity to in vitro dexamethasone (P<.05) and corticosterone (P<.05) in chronically stressed rats. Our data (1) confirm that acute stress is associated with compartment-specific changes in CMI function, (2) indicate that chronic stress is associated with habituated endocrine and immune responses and (3) that stressor exposure rapidly alters splenocyte sensitivity to glucocorticoids and we suggest that the latter may contribute to differential stress effects across immune compartments.

Neuroprotective effects of a new skin care formulation following ultraviolet exposure.

BACKGROUND: Chronic ultraviolet (UV) exposure is a major environmental factor involved in extrinsic skin ageing (photo-ageing). Skin nerve fibres are significantly reduced in number following UV irradiation and new skincare compounds with neuroprotective effects are thus highly warranted. OBJECTIVES: We developed a new skincare formulation from a plant extract and evaluated its neuroprotective effects of ex vivo UV irradiation. MATERIALS AND METHODS: The new skincare emulsion was formulated from Echinacea purpurea extract and was enriched with antioxidants (patent no. PROV020110087075). Skin samples were obtained from 20 healthy patients enrolled for plastic surgery and were immediately treated with placebo (SPF 15) or test emulsions. Skin samples were exposed to UVA and UVB for 60 min. Nerve fibres were identified by immunofluorescence using a monoclonal antibody, anti-human CD56. Cell damage was quantified by image analysis. RESULTS: UVA and UVB significantly reduced (40-60%) densities of nerve endings in control samples treated with placebo (P < 0.001). Samples treated with test emulsion completely blocked UV-related effects on skin nerve endings. These neuroprotective effects were similarly observed regardless of age or tissue analysed (breast versus abdomen). CONCLUSIONS: Our new skincare formulation obtained from E. purpurea provides important neuroprotective effects of UV irradiation and could be used together with SPFs to prevent chronic deleterious effects of solar exposure.

Risk factors for failed conversion of labor epidural analgesia to cesarean delivery anesthesia: a systematic review and meta-analysis of observational trials.

BACKGROUND: This systematic review and meta-analysis evaluates evidence for seven risk factors associated with failed conversion of labor epidural analgesia to cesarean delivery anesthesia. METHODS: Online scientific literature databases were searched using a strategy which identified observational trials, published between January 1979 and May 2011, which evaluated risk factors for failed conversion of epidural analgesia to anesthesia or documented a failure rate resulting in general anesthesia. RESULTS: 1450 trials were screened, and 13 trials were included for review (n=8628). Three factors increase the risk for failed conversion: an increasing number of clinician-administered boluses during labor (OR=3.2, 95% CI 1.8-5.5), greater urgency for cesarean delivery (OR=40.4, 95% CI 8.8-186), and a non-obstetric anesthesiologist providing care (OR=4.6, 95% CI 1.8-11.5). Insufficient evidence is available to support combined spinal-epidural versus standard epidural techniques, duration of epidural analgesia, cervical dilation at the time of epidural placement, and body mass index or weight as risk factors for failed epidural conversion. CONCLUSION: The risk of failed conversion of labor epidural analgesia to anesthesia is increased with an increasing number of boluses administered during labor, an enhanced urgency for cesarean delivery, and care being provided by a non-obstetric anesthesiologist. Further high-quality studies are needed to evaluate the many potential risk factors associated with failed conversion of labor epidural analgesia to anesthesia for cesarean delivery.

Effects of ultraviolet radiation on human cutaneous nerve fibres.

UNLABELLED: Due to an increasing number of skin diseases as a result of exposure to ultraviolet (UV) radiation, it is necessary to evaluate the effectiveness of new skin care formulations with broad-spectrum sunscreens. OBJECTIVES: This study aims to assess the status of nerve fibres in healthy human skin, to quantify effects of UV radiation on nerve endings, and to evaluate neuroprotective effects of new skin care formulations against UV exposure damage. METHODS: Samples were obtained from 34 female patients enrolled for plastic surgery and were immediately treated (10 min) with three emulsions: Cream 1, Cream 2 (placebo) and a sunscreen with sun protection factor 15 (SPF15). Control samples and those treated with the cream emulsions were exposed to UVA and UVB for 60 min. Nerve fibres were identified by immunofluorescence using a monoclonal antibody (anti-human CD56/NCAM). Cell damage was assessed by image analysis. RESULTS: Several cellular nervous structures were identified in the skin samples, including free nerve endings. UVA and UVB significantly decreased (40-60%) density of nerve endings in the control samples and those treated with placebo (Cream 2) or SPF15 (all P < 0.001). Cream 1 completely blocked effects of UV radiation on nerve endings (P > 0.05 vs. control). CONCLUSIONS: Quantification of cell damage induced by UV radiation provides useful information for identification of new skin care compounds with neuroprotective properties.

The effects of fructose-1,6-bisphosphate and dexamethasone on acute inflammation and T-cell proliferation.

OBJECTIVE AND DESIGN: Chronic glucocorticoid treatment is associated with pharmacological resistance. We investigated the auxiliary effects of fructose-1,6-bisphosphate (FBP) on dexamethasone (DEX)-related modulation of inflammation and T-cell proliferation. METHODS: Acute inflammation (pleurisy) was induced by injection of carrageenan into the pleural cavity of rats that were treated in vivo with DEX s. c. and FBP i. p. Peripheral blood mononuclear cells were isolated and T-cell sensitivity to FBP and DEX was evaluated in vitro. RESULTS: FBP and DEX reduced the exudate volume, protein concentration and neutrophils in the pleural cavity. However no synergistic effects were observed when these compounds were tested simultaneously. In contrast, both compounds dose-dependently and synergistically suppressed T-cell proliferation. CONCLUSION: These data suggest that FBP may be beneficial as auxiliary drug for the treatment of patients with acquired glucocorticoid resistance.

Characterization of an RTX toxin from enterohemorrhagic Escherichia coli O157:H7.

A hemolytic determinant of enterohemorrhagic Escherichia coli O157:H7 is encoded on a 90-kbp plasmid (pO157). This enterohemorrhagic E. coli toxin (Ehx) is a newly described RTX cytotoxin. The prototype RTX toxin is the E. coli hemolysin (Hly) associated with extraintestinal E. coli infections. We expressed Ehx from E. coli K-12 strains harboring either pSK3, a pO157 derivative marked with Tn801 unlinked to Ehx, or a recombinant plasmid containing an 11.9-kbp subclone (pEO40) of pSK3. The Ehx activities and antibody reactivities were compared with those of Hly. Little Ehx was secreted extracellularly from the strain harboring pSK3; however, when the Hly transport genes hlyBD were supplied in trans, both intracellular and extracellular levels of Ehx were enhanced more than 15-fold. The strain harboring pEO40 secreted at least 140-fold more Ehx than did the strain harboring pSK3, and neither intracellular nor extracellular levels were significantly enhanced by the addition of hlyBD in trans. Polyclonal anti-HlyA antiserum and several anti-HlyA monoclonal antibodies, including the monoclonal antibody A10, which is panreactive for nearly all RTX toxins, reacted with EhxA antigen by immunoblot analysis. In hemolysis and 51Cr release assays, Ehx demonstrated similar efficiencies in lysis of BL-3 cells (cells from a bovine lymphoma cell line) and sheep and human erythrocytes. Surprisingly, it demonstrated very little activity against two human lymphoma cell lines. In contrast, Hly lysed all five cell types tested, each to a greater extent than that demonstrated by comparable amounts of Ehx. As with other RTX toxins, Ehx activity was calcium dependent and heat labile.

Pleiotropic effects of a mutation in rfaC on Escherichia coli hemolysin.

Several genes involved in the lipopolysaccharide (LPS) biosynthetic pathway have been shown to affect the expression or activity of Escherichia coli hemolysin (Hly), a secreted cytotoxin that is the prototype of the RTX family of toxins. To further study this relationship, E. coli K-12 strains harboring mutations in the LPS biosynthetic genes rfaS, rfaQ, rfaJ, rfaP, and rfaC were transformed with a recombinant plasmid harboring the hlyCABD operon and examined for their effects on extracellular expression and hemolytic activity. A mutation in rfaC that affected both extracellular expression and activity of Hly was studied in greater detail. This mutation led to a growth-phase-dependent decrease up to 16-fold in the steady-state level of extracellular HlyA, although transcription and secretion of HlyA were decreased no more than 2-fold. Specific hemolytic activity in toxin produced from the rfaC mutant strain was significantly reduced, in a growth-phase-dependent manner. With the rfaC gene supplied in trans, both the decreased expression and activity of Hly were restored to wild-type levels. Hly from the rfaC mutant strain exhibited much slower kinetics of hemolysis, a more rapid rate of decay of activity, and greater formation of apparently inactive HlyA-containing aggregates in culture supernatants than was exhibited in the wild-type strain. A model is proposed for a physical interaction between LPS and Hly in which LPS with intact inner core participates in forming or maintaining an active conformation of Hly and helps to protect it from aggregation or degradation.

Association of RTX toxins with erythrocytes.

A critical step in the target cell attack by RTX cytotoxins is their association with target cells. A binding assay was used to study the association of the Escherichia coli hemolysin protein (HlyA) with erythrocytes. Several parameters required for lysis by HlyA were tested for their effects on its initial association with erythrocytes. The results demonstrate that HlyA binding to target cells is independent of several structural components of the active toxin, including the N-terminal hydrophobic region, the glycine-rich repeat region, and the HlyC-dependent acylation of HlyA. Further, the association with erythrocytes was independent of Ca2+ concentration or temperature, while the lytic event is both Ca2+ dependent and temperature dependent. The association of two other RTX toxin proteins, the Pasteurella haemolytica leukotoxin (LktA) and the enterohemorrhagic E. coli toxin (EhxA), were also examined; these toxins bound to erythrocytes much less efficiently than did HlyA. The association of HlyA with erythrocytes occurred rapidly, within 12 s of incubation, and demonstrated no measurable dissociation. HlyA bound to erythrocytes with a maximum of approximately 2,000 molecules per cell. Competition between active HlyA and unacylated HlyA demonstrated no inhibition of binding by unacylated HlyA; rather, active HlyA appeared to displace unacylated HlyA on the cell surface. These data demonstrate that binding and lysis by HlyA are separable events and challenge the concept of nonspecific binding to the cell surface by RTX toxins.

Localization of Haemophilus ducreyi at the pustular stage of disease in the human model of infection.

To localize Haemophilus ducreyi in vivo, human subjects were experimentally infected with H. ducreyi until they developed a painful pustule or for 14 days. Lesions were biopsied, and biopsy samples were fixed in 4% paraformaldehyde, and cryosectioned. Sections were stained with polyclonal anti-H. ducreyi antiserum or H. ducreyi-specific monoclonal antibodies (MAbs) and fluorescently tagged secondary antibodies and examined by confocal microscopy. We identified H. ducreyi in 16 of 18 pustules but did not detect bacteria in the one papule examined. H. ducreyi was observed as individual cells and in clumps or chains. Staining with MAbs 2D8, 5C9, 3B9, 2C7, and 9D12 demonstrated that H. ducreyi expresses the major pilus subunit, FtpA, the 28-kDa outer membrane protein Hlp, the 18-kDa outer membrane protein PAL, and the major outer membrane protein (MOMP) or OmpA2 in vivo. By dual staining with polyclonal anti-H. ducreyi antiserum and MAbs that recognize human skin components, we observed bacteria within the neutrophilic infiltrates of all positively staining pustules and in the dermis of 10 of 16 pustules. We were unable to detect bacteria associated with keratinocytes in the samples examined. The data suggest that H. ducreyi is found primarily in association with neutrophils and in the dermis at the pustular stage of disease in the human model of infection.