Promising proteins detected by Western blot from Echinococcus granulosus protoscoleces for predicting early post-surgical outcomes in CE-affected Tunisian children.

BACKGROUND: Cystic echinococcosis (CE) affects predominantly young patients in highly endemic areas. Improved serological methods are needed for the follow-up of CE cases, especially given the high rates of post-surgical relapse that require detection as soon as possible. METHODS: We designed a study to investigate the value of antigenic proteins extracted from Echinococcus granulosus (E. granulosus) protoscoleces, and of recombinant B2t and 2B2t proteins, for assessing the efficacy of surgical treatment carried out on CE-affected children. This study was performed on 278 plasma samples collected from 59 Tunisian children surgically treated for CE and monitored for 3 years post-surgery. The patients were classified according to post-surgical outcomes into a "non-relapsed" (NRCE) and a "relapsed" (RCE) group. We performed in-house ELISAs to measure anti-B2t and anti-2B2t IgG and immunoblotting for the detection of IgG against SDS-PAGE-resolved E. granulosus protoscoleces-specific antigens. The Wilcoxon test was applied to assess anti-B2t and anti-2B2t IgG levels. We applied the Cochran Q test to compare the distribution of immunoblotting antigenic bands between 1-month and 1-year post-surgery. RESULTS: The probability of being "relapse-free" when a decrease in antibody titers occurred between 1 month and 1 year post-surgery was 81% and 75%, respectively, for anti-B2t and anti-2B2t IgG. We identified five protoscolex protein bands of 20, 26/27, 30, 40 and 46 kDa as highly immunoreactive by immunoblot for both RCE and NRCE patients at 1 month post-surgery, and significantly lower immunoreactivity after 1 year (p < 10-4) for NRCE compared to RCE patients. The proteins at 26/27 and 40 kDa displayed the best performance in predicting the outcome, with an 84% probability of being relapse-free when the reactivity against the 40 kDa antigen, the doublet at 26/27 kDa, or both was absent or disappeared between 1 month and 1 year post-surgery, and a 93% probability of being relapsed when both bands remained reactive or increased in intensity between the two time points. CONCLUSIONS: The B2t protein could be useful for the prediction of CE early post-surgical outcomes. The proteins of E. granulosus protoscoleces, especially the doublet P26/27 and P40, could be promising predictive biomarkers for the post-surgical follow-up of CE cases as well.

Lateral flow dipstick antigen assay for human cystic echinococcosis.

Cystic echinococcosis (CE) is a neglected zoonotic disease with a worldwide distribution and is a major public health problem in some areas. Diagnosis of CE is mainly based on clinical symptoms, imaging and serological testing, however, improvement in serodiagnosis is still needed. This study was aimed at detecting circulating Echinococcus antigen in CE patients using a lateral flow dipstick (LFD) assay. Three types of hydatid antigens i.e. hydatid cyst fluid (HCF), native antigen B (nAgB) and recombinant antigen B (rAgB) were prepared and polyclonal rabbit antiserum was raised against each antigen. Purified IgG fractions were prepared and a portion was conjugated to gold nanoparticles. After a series of optimizations, a final antigen detection LFD assay was developed using a combination of anti-nAgB-IgG and gold-conjugated anti-HCF-IgG. Evaluation of the assay showed that 27 out of 35 (77%) serum samples from CE patients gave positive results. Meanwhile, the test showed a diagnostic specificity of 82% when tested with sera from 38 healthy individuals and 13 patients with other parasitic diseases. In conclusion, the antigen detection LFD assay seemed to be useful for diagnosis of CE and possibly for post-treatment follow-up, and merit further evaluation studies. We foresee that it may improve serodiagnosis of CE when used in tandem with an antibody detection test.

Usefulness of gel filtration fraction as potential biomarker for neurocysticercosis in serum: towards a new diagnostic tool.

There is an increasing interest in improving neurocysticercosis (NCC) diagnosis through the search of new and alternative antigenic sources, as those obtained from heterologous antigens. The aim of this study was to obtain potential biomarkers for NCC diagnosis after gel filtration chromatography [gel filtration fraction (GFF)] from the total saline extract (SE) from Taenia saginata metacestodes, followed by protein identification and application in immunodiagnostic. SE and GFF proteic profiles were characterized in gel electrophoresis, and diagnostic performance was verified by testing 160 serum samples through enzyme-linked immunosorbent assay and immunoblotting. Sensitivity (Se), specificity (Sp) and other diagnostic parameters were calculated. Polypeptides of interest in the diagnosis of human NCC present at GFF were analysed by mass spectrometry (MS) and B-cell epitopes were predicted. GFF had the best diagnostic parameters: Se 93·3%; Sp 93%; AUC 0·990; LR+ = 13·42 and LR- = 0·07, and proved to be useful reacting with serum samples in immunoblotting. Proteic profile ranged from 64 to 68 kDa and enolase and calcium binding protein calreticulin precursor were identified after MS. The enolase and calcium-binding protein calreticulin precursor showed 18 and 10 predicted B-cell epitopes, respectively. In conclusion we identified important markers in the GFF with high efficiency to diagnose NCC.

Dirofilaria immitis exhibits sex- and stage-specific differences in excretory/secretory miRNA and protein profiles.

The canine heartworm Dirofilaria immitis releases excretory/secretory molecules into its host and in culture. We report analyses of the types, amounts and stage-dependence of microRNAs and proteins found in D. immitis culture media recovered after incubating 800,000 microfilariae for 6days, 500L3 and 500L4 for 7days, as well as 40 adult females and 40 adult males for 48h, all separately. In addition, the presence of exosome-like particles was established by nanoparticle tracking analysis. Our results are in concordance with the D. immitis molecules previously detected in dog blood and in culture medium, but add additional insight into the sex- and stage-specificity of these processes. Of 131 miRNA candidates analyzed, none of the most abundant sequences was exclusively associated with one stage. Several isoforms of the nematode miR-100 family, miR-279, miR-71, were highly represented and overlapped substantially with the profile of heartworm miRNAs described from infected dog blood. lin-4 was primarily associated with males. We also report 4, 27 and 72 proteins in media from microfilariae, females and males, respectively. The only protein in common to all samples was actin, and only 9/88 proteins with a gene ontology description had not been reported in other studies of filarial secretomes. Exosomal proteins were well represented, dominated by cytoskeletal proteins, metabolic enzymes, zeta polypeptide, and chaperones.

A Study of Cross-Reactivity Between Recombinant EPC1 Antigen of Echinococcus granulosus in Serum from Patients with Confirmed Cystic Echinococcosis Infection and Other Parasitic Infections.

A standardized test for the serodiagnosis of cystic echinococcosis (CE) remains an important challenge because of the problems in specificity and sensitivity of the available commercial kits and lack of proper evaluation of antigen. Using appropriate sources of antigenic material is crucial in improvement of the serological methods such as enzyme-linked immunosorbent assay (ELISA). This study was conducted to evaluate the performance of protein named Echinococcus protoscolex calcium binding protein EPC1 for the detection of antibodies in sera from patients with CE. Expressed and purified recombinant protein EPC1 (rEPC1) was used as antigen in ELISA method. Characterization of the rEPC1 antigen was evaluated using the serum of 25 patients with both surgical and imaging confirmed CE and 25 healthy donors as negative controls. Also, a panel of sera including chronic toxoplasmosis (IgG positive), strongyloidosis, fascioliasis, toxocariasis, and kala azar were used and patients with related parasites were confirmed by medical laboratories or clinically by research centers using microscopy or specific ELISA. rEPC1 showed relatively promising performance in total IgG ELISA for the detection of antibodies in sera from the negative controls, and the cut off value 0.4 units of optical density at 490 nm was calculated for ELISA. In this study, sensitivity of 100%, specificity of 93.7, positive predictive value of 92.6%, and negative predictive value of 100% were calculated for rEPC1. On the other hand, commercial ELISA kit based on the native antigen B of Echinococcus granulosus had sensitivity of 96.2% and specificity of 96.8%. No significant difference was found for sensitivity or specificity between the rEPC1 and commercial kit. However, rEPC1 may be a valuable antigen for diagnosis of human CE.

Echinococcus metacestode: in search of viability markers.

Epidemiological studies have demonstrated that most humans infected with Echinococcus spp. exhibit resistance to disease. When infection leads to disease, the parasite is partially controlled by host immunity: in case of immunocompetence, the normal alveolar echinococcosis (AE) or cystic echinococcosis (CE) situation, the metacestode grows slowly, and first clinical signs appear years after infection; in case of impaired immunity (AIDS; other immunodeficiencies), uncontrolled proliferation of the metacestode leads to rapidly progressing disease. Assessing Echinococcus multilocularis viability in vivo following therapeutic interventions in AE patients may be of tremendous benefit when compared with the invasive procedures used to perform biopsies. Current options are F18-fluorodeoxyglucose-positron emission tomography (FDG-PET), which visualizes periparasitic inflammation due to the metabolic activity of the metacestode, and measurement of antibodies against recEm18, a viability-associated protein, that rapidly regresses upon metacestode inactivation. For Echinococcus granulosus, similar prognosis-associated follow-up parameters are still lacking but a few candidates may be listed. Other possible markers include functional and diffusion-weighted Magnetic Resonance Imaging (MRI), and measurement of products from the parasite (circulating antigens or DNA), and from the host (inflammation markers, cytokines, or chemokines). Even though some of them have been promising in pilot studies, none has been properly validated in an appropriate number of patients until now to be recommended for further use in clinical settings. There is therefore still a need to develop reliable tools for improved viability assessment to provide the sufficient information needed to reliably withdraw anti-parasite benzimidazole chemotherapy, and a basis for the development of new alternative therapeutic tools.

A survey of seropositivity to antigen B, an immunodiagnostic antigen for human cystic echinococcosis, in domestic animals in Mongolia.

Cystic echinococcosis (CE) is well known to be an important zoonotic disease and national disease due to the traditional nomadic life style in Mongolia. The present study was carried out to obtain data on the seropositivity to antigen B, in domestic livestock, goats, sheep and cattle, in each province of Mongolia. The seropositivity to antigen B varied by province and ranged from 0% to 25.0% in goats, 0% to 12.5% in sheep, and 0% to 13.3% in cattle. In total, 9.2% of goats, 3.6% of sheep and 5.9% of cattle in Mongolia showed seropositivity.

[Analysis of the diagnostic efficiency of excretory-secretory antigens of Trichinella spiralis and Trichinella nativa with sera from rats experimentally infected with arctic Trichinella, by using ELISA].

The diagnostic efficiency of excretory-secretory antigens of Trichinella spiralis and Trichinella nativa with sera from Wistar rats experimentally infected with arctic Trichinella was comparatively tested. Trichinella derived from the muscles of wild carnivorous mammals inhabiting the biocenoses of Chukotka were used to infest animals and to obtain the antigen. There was a considerable excess of the effectiveness of enzyme immunoassay when the antigen derived from T. native larvae was used to analyze the titers of sera from the rats experimentally infected with arctic Trichinella.

Comparison of the usefulness of hydatid cyst fluid, native antigen B and recombinant antigen B8/1 for serological diagnosis of cystic echinococcosis.

For serodiagnosis of cystic echinococcosis (CE), the usefulness of three native antigens, a hydatid cyst fluid (HCF) obtained from infected sheep in China, two types of antigen B prepared from each HCF obtained in Iran and China, and one recombinant antigen B8/1 (RAgB), were evaluated by ELISA using a total of 155 serum samples from Iran, Turkey, China and Japan. Both the Iranian native antigen B and RAgB had high sensitivity, but RAgB showed an excellent specificity in comparison with native antigens because none of the serum samples of healthy people from Iran and Japan became positive with this antigen except one case of taeniasis. The taeniasis case exceptionally showing cross reactivity with all antigens was considered to be co-infected with Echinococcus granulosus and Taenia saginata. The recombinant antigen showing a high diagnostic odds ratio in comparison with other evaluated antigens might be recommended for diagnosis of CE in different CE-endemic areas.

Echinococcus granulosus: immunoprotection accompanyied by humoral and cytokine response against secondary hydatidosis in mice immunized with rEg.myophilin.

OBJECTS: This study aimed to investigate the immunoprotection of the recombinant Eg.myophilin (rEg.myophilin) and tentatively analyze mechanism of this protection. MATERIALS AND METHOD: Three groups of female mice were immunized subcutaneously with rEg.myophilin and contrasts, after two boosters, mice were challenged with Eg protoscoleces (PSCs) intraperitoneally, and then analyzed the humoral immune response with specific IgG, IgG1, IgG2a, IgG2b, IgG3 and IgE, and also evaluated the cellular immune with IFN-γ, IL-4, IL-10. RESULTS: Mice immunized with rEg.myophilin produced effective immunity protection (reductions in cyst load more than 86.11%). Mice immunized with rEg.myophilin showed specific IgG, IgG1, IgG2a and IgE accompanied by IFN-γ and IL-4 significantly increased after one or more times of immunization, but neither IgG2b nor IgG3 increased. Nevertheless, IL-10 significantly increased in the control groups but a decline trend in rEg.myophilin group. CONCLUSIONS: rEg.myophilin showed a effectively protective immunity, which may attribute to: (1) IgGs and IgE-mediated humoral immune response, as well as cell-mediated immunity which was marked by IFN-γ. (2) IL-4 assists to stimulate type transformation of IgE which plays an important role in Eosinophils-related anti-parasite immunity. (3) Immunosuppressive effect (marked by IL-10), the key obstacle to clean of parasites in the patient, was inhibited in the rEg.myophilin group compared with control groups.

Bioactive molecules of Taenia solium metacestode, a causative agent of neurocysticercosis.

Neurocysticercosis (NC), an infection of the CNS with Taenia solium metacestode, exemplifies formidable public health concerns associated with significant morbidity and mortality. The disease is a complex phenomenon involving molecular cell biological cross-talks between the parasite and human host. To effectively combat NC, specific diagnosis and proper management are prerequisites. Bioactive molecules implicated in host-parasite interactions and parasitic homeostasis should be elucidated. This article provides an overview of currently available serological biomarkers, especially those comprising low-molecular-weight proteins, and discusses available immunoproteomics for identification of such molecules. T. solium metacestode bioactive molecules, which might be critically implicated in the progression of NC disease, are summarized. Comprehensive understanding of the biochemical properties and biological functions of bioactive molecules may contribute to the development of novel intervention strategies against NC.

Identification and characterization of Schistosoma japonicum Sjp40, a potential antigen candidate for the early diagnosis of schistosomiasis.

The pathogenesis of schistosomiasis is mainly caused by egg-induced granuloma formation and subsequent fibrosis. If Schistosoma japonicum infections could be detected in the early stage, especially before the egg deposition in the host tissues, the development of severe pathologic lesions might be prevented efficiently. The present study identified and characterized S. japonicum Sjp40, a potential antigen candidate for the early diagnosis of schistosomiasis. From the S. japonicum cercariae cDNA library, a clone encoding Sjp40 was identified by screening with the pooled rabbit sera collected on day 21 postinfection. Then, the recombinant Sjp40 protein (rSjp40) and monoclonal antibodies (McAbs) anti-rSjp40 were developed. The expression profiles of Sjp40 at 3 stages of S. japonicum, including egg, cercariae, and adult, were also determined at both mRNA and protein level, which displayed that the expression pattern of Sjp40 varied at different stages. Quantification of circulatory anti-Sjp40 IgG in the infected mice sera by time-resolved fluoroimmunoassay showed a statistically significant increase on days 21, 28, 35, and 42 postinfection compared with the mice sera prior to infection and the control mice. It was further confirmed by Western blot that all 8 clones of anti-rSjp40 McAbs could react specifically with the native antigen in S. japonicum cercariae, and rSjp40 could be recognized by the pooled infected mouse sera on days 21, 28, 35, and 42 postinfection as well as the pooled patient sera with acute schistosomiasis japonica. These findings indicated that Sjp40 and its antibodies are detectable from the host at a relatively early phase (day 21 postinfection with S. japonicum) and suggested that Sjp40 is a potential antigen candidate for the early diagnosis of schistosomiasis.

Serological proteome-oriented screening and application of antigens for the diagnosis of Schistosomiasis japonica.

Schistosomiasis remains a major parasitic disease, with 200 million people infected and 779 million people at risk worldwide. The lack of reliable diagnostic techniques makes this disease difficult to control. In an attempt to discover useful candidates for the diagnosis of schistosomiasis, proteomics in combination with western blotting were employed in this study. This serological proteome assay yielded more than 30 immunodominant spots. Ten of these spots were precisely matched with a homologous two-dimensional electrophoresis (2-DE) gel and successfully identified by LC/MS-MS as corresponding to four different proteins. Of these proteins, SjLAP and SjFBPA were successfully expressed, and their recombinant protein products were further applied in the diagnosis of human Schistosomiasis japonica using ELISA. The ELISA results revealed sensitivities of 98.1% and 87.8% for acute and chronic schistosomiasis with rSjLAP and 100% and 84.7% with rSjFBPA, whereas the assays showed a specificity of 96.7% with both recombinant proteins. After treatment with praziquantel, the titres of the antibodies against both antigens declined significantly (P<0.001). Our data therefore suggest that these antibody-oriented recombinant proteins had a high efficacy for the diagnosis of S. japonica, and 2-DE based screening followed by LC/MS-MS has promising potential in the screening of candidate antigens for the diagnosis of schistosomiasis.

Detection of the Sm31 antigen in sera of Schistosoma mansoni- infected patients from a low endemic area.

Schistosoma mansoni cathepsin B (Sm31) is a major antigen from adult worms that circulates in the blood of infected patients (Li et al., Parasitol Res 1996; 82: 14-18). An analysis of the Sm31 sequence (Klinkert et al., Mol Biochem Parasitol 1989; 33: 113-122) allowed the prediction of seven hydrophilic regions that were confirmed to be exposed on the surface of a 3D model of Sm31; the species specificity of these regions was checked using BLAST analysis. The corresponding peptides were chemically synthesized in polymerazible forms using the t-Boc technique. Rabbits developed a high humoral response against these peptides as tested by a multiple antigen blot assay; it recognized native Sm31 in crude S. mansoni extracts and as circulating antigen in sera of S. mansoni-infected patients by western blot. Relevant antigenic determinants were located at the N- and C-terminus sequences. Antibodies against these regions recognized the native enzyme in an ELISA-like assay called cysteine protease immuno assay in which the immunocaptured enzyme was revealed by the intrinsic cathepsin B hydrolytic activity of Sm31. The method successfully and specifically detected Sm31 in sera of infected individuals, most of them (83.3%) with light infections, offering a rationale for the development of parasite enzyme capture assays using anti-synthetic peptide antibodies for possible use in the diagnosis of schistoso,iasis.

A diagnostically useful 200-kDa protein is secreted through the surface pores of the filarial parasite Setaria digitata.

The excretory/secretory (ES) materials from filarial parasites form an important tool for immunodiagnosis of filariasis. We have raised monoclonal antibodies against ES proteins isolated from the medium incubated with live adult bovine filarial parasite Setaria digitata. The hybridoma were cloned and characterised with respect to the individual proteins of the ES materials. A secretory glycoprotein with molecular weight 200-kDa (gp200) was purified, localised and characterised using the specific monoclonal antibodies raised against it. The immunolocalisation study clearly showed that the protein is secreted out through the pores on the surface of both male and female parasites. The gp200 on reduced sodium dodecyl sulphate-polyacrylamide gel electrophoresis showed dissociation into 11- to 66-kDa 'ladder' polypeptides, and all of them could be identified with the same monoclonal antibody. The gp200 is normally shed along with the ES materials. The screening of human sera samples using the monoclonal antibodies give promising results which showed that gp200 could be a potent candidate protein for the immunodiagnosis of filariasis by the method of antigen detection.

Seropositivity to a major allergen of Anisakis simplex, Ani s 1, in dyspeptic patients with Helicobacter pylori infection: histological and laboratory findings and clinical significance.

Previous studies have demonstrated a high prevalence of seropositivity to the Ani s 1 protein in dyspeptic patients with Helicobacter pylori infection, but it is not known whether this represents episodes of anisakiasis misdiagnosis or previous exposure to the parasite without clinical relevance. To investigate the clinical significance of seropositivity to the Ani s 1 protein, a cohort study was performed with 87 consecutive dyspeptic patients who were treated for H. pylori infection. Fourteen (16.5%) patients were seropositive for the Ani s 1 protein, which was associated with the consumption of uncooked fish (p 0.0002). There were no differences in histological findings between subjects seropositive or seronegative for Ani s 1, but seropositive patients had increased eosinophil and basophil leukocyte counts (p < 0.05). Anti-Ani s 1 IgE was associated with a lack of improvement in the group of patients with non-ulcer dyspepsia after successful eradication of H. pylori (p 0.016). Thus, in at least a subset of patients with H. pylori infection, seropositivity to Ani s 1 could have clinical relevance. In addition, these data highlight that only anisakiasis associated with severe allergic or gastric symptoms is currently being diagnosed.

Praziquantel treatment of individuals exposed to Schistosoma haematobium enhances serological recognition of defined parasite antigens.

BACKGROUND: Schistosomiasis is a major parasitic disease affecting >200 million people in the developing world, and 400 million people are at risk for infection. This study aimed to identify and compare proteins recognized by serum samples from schistosome-exposed individuals before and after curative praziquantel treatment. METHODS: Proteins recognized by pooled serum samples from Schistosoma haematobium-exposed Zimbabweans were determined by 2-dimensional Western blotting and identified by mass spectrometry. RESULTS: Serum samples recognized 71 spots, which resolved to 26 different characterized proteins. Eleven of these proteins have not previously been shown to be immunogenic in natural human infection or in experimental models of schistosomiasis, making them novel antigens in the parasite. Pretreatment serum samples recognized 59 spots, which resolved to 21 different identified proteins. Posttreatment serum samples recognized an additional 12 spots, which resolved to 8 different identified proteins. Of these 8 proteins, 3 had putative isoforms recognized before treatment, and 5 (calreticulin, tropomyosin 1, tropomyosin 2, paramyosin, and triose phosphate isomerase) did not. CONCLUSIONS: This study is the most comprehensive characterization of S. haematobium antigens to date and describes novel antigens in all schistosome species. Posttreatment results are consistent with praziquantel treatment inducing quantitative and qualitative changes in schistosome-specific antibody responses.

Persistence of reactivity against the 45 k Da glycoprotein in late trichinellosis patients.

Over the years, the opinions of clinicians on the existence of the so-called chronic trichinellosis or late sequelae of infection have differed. However, the persistence of a humoral immune response against Trichinella in these late-stage patients has been confirmed using specific tests such as the competitive inhibition assay (CIA). We evaluated sera from late-stage trichinellosis patients (2--8 years from acute infection), for their reactivity against Trichinella spiralis antigens. The following tests were carried out: (i) indirect immunofluorescence assay (IFA), performed on muscle sections from mice, 30 days following synchronous infection by intramuscular injection with T. spiralis newborn larvae (NBL); (ii) enzyme immunoassay, employing a synthetic beta-tyvelose antigen conjugated to bovine serum albumin (BSA-Ag); and (iii) western blot (WB) with both an "in house" kit and a commercial kit. The results of IFA obtained by confocal laser microscopy showed that sera reacted against both surface and internal structures of L(1) larvae but at varying levels. Employing the synthetic antigen, EIA showed that 50% of sera tested were positive for the presence of specific antibodies against beta-tyvelose. By WB, all sera were reactive with the 45 k Da glycoprotein (45 gp). These data suggest that reactivity against the beta-tyvelosylated 45 gp persists even in very late stages of human trichinellosis.

Taenia solium metacestode glycoproteins as diagnostic antigens for solitary cysticercus granuloma in Indian patients.

Taenia solium metacestode glycoproteins specific for lentil lectin were evaluated as diagnostic antigens for solitary cysticercus granulomas in Indian patients, using both an ELISA and immunoblotting. In 250 patients suspected to have neurocysticercosis and subjected to a computerized tomography scan or magnetic resonance imaging, the proteins were diagnostic by the ELISA in 86 patients (80%) and by immunoblots in 67 (62%) of 107 patients with solitary cysticerus granuloma. Among 100 non-cysticercosis patients, the ELISA and immunoblot were negative in 94% and 97% respectively. No cross-reactions were observed with sera from patients with central nervous system tuberculosis. Proteins of

Schistosomiasis does not contribute to death or recurrence of nontyphoid Salmonella bacteremia in human immunodeficiency virus-infected Malawian adults.

Nontyphoid Salmonella (NTS) bacteremia has a very high mortality and recurrence rate among human immunodeficiency virus (HIV)-infected Malawian adults. Concurrent schistosomal infection might cause persistence of NTS infection and poor response to antibiotic therapy. Therefore, we tested serum samples for Schistosoma-specific circulating anodic antigen to diagnose coinfection with schistosomiasis among consecutive HIV-positive adults with NTS bacteremia. The results suggest that active schistosomiasis is not associated with adverse outcome of NTS bacteremia in this population, in contrast to other groups.