Successful treatment with doxycycline monotherapy for human infection with Babesia venatorum (Babesiidae, Sporozoa) in China: a case report and proposal for a clinical regimen.

BACKGROUND: Human babesiosis is a worldwide disease caused by intraerythrocytic protozoa of the genus Babesia. It is transmitted by bites from ixodid ticks, and mechanically transmitted by blood transfusion. It is primarily treated with quinine and/or atovaquone, which are not readily available in China. In this study, we developed a novel treatment regimen involving doxycycline monotherapy in a patient with severe Babesia venatorum infection as an alternative therapeutic medication. The aim of our study is to provide a guidance for clinical practice treatment of human babesiosis. CASE PRESENTATION: A 73-year-old man who had undergone splenectomy and blood transfusion 8 years prior, presented with an unexplained fever, headache, and thrombocytopenia, and was admitted to the Fifth Medical Center of the PLA General Hospital. He was diagnosed with B. venatorum infection by morphological review of thin peripheral blood smears, which was confirmed by multi-gene polymerase chain reaction (PCR), and sequencing of the entire 18s rRNA and partial ß-tubulin encoding genes, as well as isolation by animal inoculation. The doxycycline monotherapy regimen (peros, 0.1 g bisindie) was administered following pharmacological guidance and an effective outcome was observed. The patient recovered rapidly following the doxycycline monotherapy. The protozoan load in peripheral blood samples decreased by 88% in hematocrit counts after 8 days, and negative PCR results were obtained after 90 days of follow-up at the hospital. The treatment lasted for 3 months without any side effects or sequelae. The nine-month follow-up survey of the patient did not reveal any signs of recrudescence or anti-babesial tolerance. CONCLUSIONS: We have reported a clinical case of successful doxycycline monotherapy for human babesiosis caused by B. venatorum, which provides an optional medical intervention for human babesiosis.

Clinical and Virological Characteristics of Ebola Virus Disease Patients Treated With Favipiravir (T-705)-Sierra Leone, 2014.

BACKGROUND: During 2014-2015, an outbreak of Ebola virus disease (EVD) swept across parts of West Africa. No approved antiviral drugs are available for Ebola treatment currently. METHODS: A retrospective clinical case series was performed for EVD patients in Sierra Leone-China Friendship Hospital. Patients with confirmed EVD were sequentially enrolled and treated with either World Health Organization (WHO)-recommended supportive therapy (control group) from 10 to 30 October, or treated with WHO-recommended therapy plus favipiravir (T-705) from 1 to 10 November 2014. Survival and virological characteristics were observed for 85 patients in the control group and 39 in the T-705 treatment group. RESULTS: The overall survival rate in the T-705 treatment group was higher than that of the control group (56.4% [22/39] vs 35.3% [30/85]; P = .027). Among the 35 patients who finished all designed endpoint observations, the survival rate in the T-705 treatment group (64.8% [11/17]) was higher than that of the control group (27.8% [5/18]). Furthermore, the average survival time of the treatment group (46.9 ± 5.6 days) was longer than that of the control group (28.9 ± 4.7 days). Most symptoms of patients in the treatment group improved significantly. Additionally, 52.9% of patients who received T-705 had a >100-fold viral load reduction, compared with only 16.7% of patients in the control group. CONCLUSIONS: Treatment of EVD with T-705 was associated with prolonged survival and markedly reduced viral load, which makes a compelling case for further randomized controlled trials of T-705 for treating EVD.

Age and Ebola viral load correlate with mortality and survival time in 288 Ebola virus disease patients.

BACKGROUND: A Chinese medical team managed Ebola virus disease (EVD) patients in Sierra Leone from October 2014 to March 2015 and attended to 693 suspected patients, of whom 288 had confirmed disease. METHODS: A retrospective study was conducted of the 288 patients with confirmed disease. Clinical symptoms, manifestations, and serum viral load were analyzed and compared among the different groups for mortality and survival time. RESULTS: Among the 288 confirmed EVD patients (149 male and 139 female, median age 28 years, and median log viral load 6.68), 98 died, 36 recovered, and 154 were lost to follow-up. Common symptoms were fever (77.78%), fatigue (64.93%), abdominal pain (64.58%), headache (62.85%), and diarrhea (61.81%). Compared to patients aged<18 years, those who were older than 40 years had a higher probability of death (odds ratio 2.855, p=0.044). Patients with a viral load of >10(6) copies/ml had a higher case fatality rate than those with <10(6) copies/ml (odds ratio 3.095, p=0.004). Cox regression showed that age, viral load, and the presence of diarrhea correlated with mortality. CONCLUSION: Patients with a high viral load, of older age, and with diarrhea had a higher mortality and shorter survival time.

Ebola Virus Outbreak Investigation, Sierra Leone, September 28-November 11, 2014.

During 2014-2015, an outbreak of Ebola virus disease (EVD) swept across parts of West Africa. The China Mobile Laboratory Testing Team was dispatched to support response efforts; during September 28-November 11, 2014, they conducted PCR testing on samples from 1,635 suspected EVD patients. Of those patients, 50.4% were positive, of whom 84.6% lived within a 3-km zone along main roads connecting rural towns and densely populated cities. The median time from symptom onset to testing was 5 days. At testing, 75.7% of the confirmed patients had fever, and 94.1% reported at least 1 gastrointestinal symptom; all symptoms, except rash and hemorrhage, were more frequent in confirmed than nonconfirmed patients. Virus loads were significantly higher in EVD patients with fever, diarrhea, fatigue, or headache. The case-fatality rate was lower among patients 15-44 years of age and with virus loads of <100,000 RNA copies/mL. These findings are key for optimizing EVD control and treatment measures.

Genetic diversity and evolutionary dynamics of Ebola virus in Sierra Leone.

A novel Ebola virus (EBOV) first identified in March 2014 has infected more than 25,000 people in West Africa, resulting in more than 10,000 deaths. Preliminary analyses of genome sequences of 81 EBOV collected from March to June 2014 from Guinea and Sierra Leone suggest that the 2014 EBOV originated from an independent transmission event from its natural reservoir followed by sustained human-to-human infections. It has been reported that the EBOV genome variation might have an effect on the efficacy of sequence-based virus detection and candidate therapeutics. However, only limited viral information has been available since July 2014, when the outbreak entered a rapid growth phase. Here we describe 175 full-length EBOV genome sequences from five severely stricken districts in Sierra Leone from 28 September to 11 November 2014. We found that the 2014 EBOV has become more phylogenetically and genetically diverse from July to November 2014, characterized by the emergence of multiple novel lineages. The substitution rate for the 2014 EBOV was estimated to be 1.23 × 10(-3) substitutions per site per year (95% highest posterior density interval, 1.04 × 10(-3) to 1.41 × 10(-3) substitutions per site per year), approximating to that observed between previous EBOV outbreaks. The sharp increase in genetic diversity of the 2014 EBOV warrants extensive EBOV surveillance in Sierra Leone, Guinea and Liberia to better understand the viral evolution and transmission dynamics of the ongoing outbreak. These data will facilitate the international efforts to develop vaccines and therapeutics.

Cross-sectional study of the relationship of peripheral blood cell profiles with severity of infection by adenovirus type 55.

BACKGROUND: The immunologic profiles of patients with human adenovirus serotype 55 (HAdV-55) infections were characterized in subjects diagnosed with silent infections (n = 30), minor infections (n = 27), severe infections (n = 34), and healthy controls (n = 30) during a recent outbreak among Chinese military trainees. METHODS: Blood was sampled at the disease peak and four weeks later, and samples were analyzed to measure changes in leukocyte and platelet profiles in patients with different severities of disease. Differential lymphocyte subsets and cytokine profiles were measured by flow cytometry and Luminex xMAP®, and serum antibodies were analyzed by ELISA and immunofluorescence staining. RESULTS: Patients with severe HAdV infections had higher proportions of neutrophils and reduced levels of lymphocytes (p < 0.005 for both). Patients with minor and severe infections had significantly lower platelet counts (p < 0.005 for both) than those with silent infections. The silent and minor infection groups had higher levels of dendritic cells than the severe infection group. Relative to patients with silent infections, patients with severe infections had significantly higher levels of IL-17+CD4+ cells, decreased levels of IL-17+CD8+ cells, and higher levels of IFN-γ, IL-4, IL-10, and IFN-α2 (p < 0.001 for all comparisons). CONCLUSIONS: Patients with different severities of disease due to HAdV-55 infection had significantly different immune responses. These data provide an initial step toward the identification of patients at risk for more severe disease and the development of treatments against HAdV-55 infection.

Inhibition of CXCR4 expression by recombinant adenoviruses containing anti-sense RNA resists HIV-1 infection on MT4 cell lines.

CXCR4-tropic (X4) variants are associated with faster disease progression than CCR5-tropic variants in HIV infection. We previously reported inhibition of CCR5 expression on U937 cells could protect the cells from HIV-1 infection. Here, we established recombinant adenoviruses containing anti-sense CXCR4 cDNA, to investigate its role in the protection of HIV entering into target cells. A fragment of 636 bp cDNA from CXCR4 mRNA was recombined into adenoviral vector and the recombinant adenovirus was obtained from AD-293 cells. The rates of CXCR4 expression on the MT4 cells infected with recombinant adenovirus were measured by FACS. The MT4 cells infected by recombinant adenovirus were challenged by T-tropic HIV-1 strains and then P24 antigen was assayed. The rate of expression of CXCR4 on MT4 cell infected with recombinant adenovirus was decreased from 42% to 1.12% at 24 h, and to 1.03%, 1.39%, and 1.23% at 48 h, 72 h and 10 days respectively. Compared with Ad-control cells, recombinant adenovirus infected MT4 cells produced much less P24 antigen after being challenged with HIV-1. Furthermore, the recombinant adenovirus had no effects on chemotactic activity and proliferation of the MT4 cells. In conclusion, recombinant adenoviruses containing anti-sense can inhibit CXCR4 expression and resist HIV-1 infection on MT4 cell lines.

[Characteristics of γδ T cell subsets induced from peripheral blood mononuclear cells of HIV/AIDS patients in vitro].

AIM: To investigate the characteristics of γδ T cell subsets in peripheral blood and Vδ1 and Vδ2 T cell subsets proliferation after induction in vitro, and to provide experimental basis for γδ T cells expansion methods in vitro. METHODS: Percentages of γδ T cells, Vδ1 and Vδ2 T cells in CD3 T cells from 25 cases of HIV/AIDS patients (HIV group) and 31 cases of healthy adults as control (HC group) were investigated with flow cytometry (FCM); and 10 cases peripheral blood mononuclear cells (PBMCs) from each group were induced and cultured for 14 d by using anti-γδ TCR mAb and IL-2, then the cell amounts were counted, γδ T cells and Vδ1, Vδ2 T cells were detected and analyzed with flow cytometry (FCM) at 0 d, 7 d and 14 d. RESULTS: The percentages and absolute counts of γδ T cells and V δ2 T cells in HIV group were significantly lower than those in HC group, but those of Vδ1 subsets were significantly higher than those of HC group. After culture for 14 day, the total cell amount of HC group expanded almost 3 times, but those of HIV group expanded a little; The percentages of γδ T cells in HC group were above 80%, but those in HIV group were only about 35%; the percentages of Vδ2 T cells in HC group were about 65%, but those in HIV group were only about 17%. CONCLUSION: The proportion of γδ T cells in peripheral blood of HIV/AIDS patients decreased significantly, and Vδ1/Vδ2 ratio was inversed; the expansion effect was not so good to use anti-γδ TCR mAb and IL-2 to induce γδ T cells and Vδ2 subsets of HIV/AIDS, and the Vδ1/Vδ2 ratio inversion could not reverse. More efficient culture methods should be explored.

[The comparison between HIV-infected patients' Vdelta2 T cells expansion efficiencies by zoledronic acid and gammadelta TCR monoclonal antibody in vitro].

OBJECTIVE: To find out the more efficient induction method through investigating the expansion efficiencies of HIV-infected patients' Vdelta2 T cells induced by zoledronic acid (Zol) or gammadelta TCR monoclonal antibody (mAb). METHODS: 38 healthy control subjects (HC group) and 65 HIV infected patients (HIV group) were enrolled in this research. Peripheral blood mononuclear cells (PBMCs) of individuals were stimulated by Zol or gammadelta TCR mAb respectively for 14 days at 2.0 x 10(7) cells/ well, and then gammadelta T cells and Vdelta2 subsets frequencies were measured by flow cytometry (FCM) on 0, 7 and 14 day. The absolute numbers of Vdelta2 T cells were calculated and the Vdelta2 T cell expansion efficiencies by these two methods were compared. RESULTS: The absolute numbers and frequencies of Vdelta2 T cell of HIV groups were lower than those of HC groups significantly on 0 day. After 14 days, the frequencies of Vdelta2 T cell of HIV group and HC group were(17.6 +/- 19.8)% and(64.3 +/- 4.5)% respectively, and the expansion indexes of Vdelta2 T cell were 54 +/- 40 and 74 +/- 29 respectively by induction of gammadelta TCR mAb. However, the frequencies of Vgammadelta2 T cell of HIV group and HC group were (69.6 +/- 21.2)% and (97.3 +/- 1.7)% respectively, and the Vgammadelta2 T cell expansion indexes were 538 +/- 11 and 5984 +/- 721 respectively by induction of Zol. CONCLUSION: Zol could induce the vast expansion of Vgammadelta2 T cells of HIV infected patients. The expansion efficiency by Zol was better than that by the gammadelta TCR mAb.

[Diagnostic analysis of hospitalized patients with fever of unknown origin at department of infectious diseases].

OBJECTIVE: To explore the etiology, diagnostic methods and procedures for patients with fever of unknown origin (FUO) at department of infectious diseases. METHODS: A total of 368 FUO patients admitted to department of infectious diseases from 2002 to 2009 were retrospectively reviewed. The correlations of etiologies and diagnostic methods with gender, age and progress of fever were analyzed. RESULTS: Among them, 112 (30.4%) cases were recognized in 2 weeks (diagnosis, n = 107; recovery with unknown causes, n = 5). A final diagnosis was established in 241 (94.1%) from the remaining 256 FUO patients (124 males, 132 females). Among them, the causes were infectious diseases (n = 193), rheumatologic/autoimmune diseases (n = 32) and hematological diseases/tumors (n = 16). The etiologies were infectious diseases (n = 95), rheumatologic/autoimmune diseases (n = 10), hematological diseases/tumors (n = 10) and unknown etiology (n = 9) in males respectively; infectious diseases (n = 98), rheumatologic diseases (n = 22), hematological diseases or tumors (n = 6) and unknown etiology (n = 6) in females respectively. Age of patients: < 14 yr (n = 10), 15 - 20 yr (n = 37), 21 - 50 yr (n = 110), 51 - 60 yr (n = 48) and > 61 yr (n = 51). Thermal process was < 4 weeks (n = 83) including 74 infectious diseases cases and > 8 weeks (n = 63), including infectious diseases (n = 21) and rheumatologic disease (n = 20). CONCLUSION: Some FUO outpatients may be promptly confirmed by history taking, physical examination and routine examinations. The major cause is infection. Other causes of FUO are infectious diseases, rheumatological/autoimmune diseases and hematological diseases/tumors. For the diagnosis of FUO patients, gender, age and thermal process should be considered.

Progressive CD127 down-regulation correlates with increased apoptosis of CD8 T cells during chronic HIV-1 infection.

Chronic HIV-1 infection can induce a significant decrease in CD127 expression on CD8 T cells, but the underlying mechanisms and immunological consequences are unclear. In this study, we investigated CD127 expression on CD8 T cells from a total of 51 HIV-1-infected subjects and 16 healthy individuals and analyzed the association between CD127 expression and CD8 T-cell apoptosis in these HIV-1-infected subjects. We found that CD127 expression on total CD8 T cells was significantly down-regulated, which was correlated with the increased CD8 T-cell apoptosis and disease progression of chronic HIV-1 infection. The in vitro addition of IL-7 efficiently rescued the spontaneous apoptosis of CD8 T cells from HIV-1-infected individuals. IL-7 stimulation also transiently down-regulated CD127 expression, whereas some of the CD127(-) CD8 T cells regained CD127 expression soon after IL-7 was retracted from the incubation medium. Thus, IL-7 stimulation reduced apoptosis of both CD127(+) and CD127(-)CD8 T cells to some degree. These data indicate that CD127 loss might impair IL-7 signaling and increase CD8 T-cell apoptosis during HIV-1 infection. This study, therefore, will extend the notion that IL-7 could be a good candidate for immunotherapy in HIV-1-infected patients.

[Serial analyses of viral levels and immunocytes during in vitro incubation of peripheral blood mononuclear cells from HIV-infected individuals].

OBJECTIVE: To investigate the dynamic changes of viral loads and immunocytes during the in vitro culture of peripheral blood mononuclear cells (PBMC) from HIV carriers. METHODS: The PBMCs from 14 HIV-infected individuals and 6 healthy persons were incubated in serum-free AIM-V medium containing cocktail cytokines. The phenotype of CD3, CD4, CD8, CD3CD56 and CD25 was identified by flow cytometric analysis every two days. The production of cytokines in the supernatants, including IL-1alpha, IL-12, TNF-alpha and IL-10 was measured by ELISA. The supernatant HIV-1 RNA load was also determined by Real-time fluorescent PCR. RESULTS: During a 21-day incubation period, The PBMCs multiplied approximately 60.7-fold and 16.8-fold respectively in the healthy controls and 7 out of the 14 HIV-infected subjects, however failed to multiply in the remaining 7 HIV-infected subjects. The expanded cells were phenotypically shown a heterogeneous cellular population with 23.3%-35% for CD3(+)CD4(+) T cells and 58.7%-72% for CD3(+)CD8(+) T cells, and approximate 17% CD3(+)CD56(+) cells at 16-day incubation for HIV-infected cases. HIV-1-positive PBMCs were found to produce an elevated ratios (value range 6.01 - 48.04) of IL-12:IL-10 compared to healthy individuals (6.65 - 10.2) at 16-day incubation. Furthermore, serial analyses of HIV-1 RNA levels showed an inverted V type dynamic change during 16 day in vitro incubation period. CONCLUSION: In vitro expansion of functional immunocytes of HIV-1 carrier origin is feasible and may facilitate the autologous antiviral immune therapy for HIV-infected patients.

[Epidemiologic features, clinical diagnosis and therapy of first cluster of patients with severe acute respiratory syndrome in Beijing area].

OBJECTIVE: Investigate the features of outbreak epidemic, clinical disease progression of the first SARS cases in Beijing and evaluate the efficacy of therapeutic regimen. METHODS: Twenty-nine patients (11 men and 18 women, 20 - 74 years old age range) were diagnosed with infectious SARS and admitted in our hospital from the March 5th to April 14th, 2003 in this study. The data of clinical presentation and disease progression of all the patients including index subject as the infectious SARS resource patient, her family infected members and 21 health care workers were abstracted. RESULTS: The first SARA outbreak in Beijing was characterized with the cluster feature of resource patient family members and health care providers. The incubation period ranged from 2 to 14 days. All the patients had a fever (temperature > 38 degrees C for over 24 hours) and other manifestations as reported before. Serial chest radiographs showed progressive pathologic air-space disease. Twenty patients showed the severe syndrome with various time ranged from 1 day to 14 days. Two patients died of progressive acute respiratory distress disease. The histologic analysis of one death patient showed diffuse alveolar damage in the two lungs. Twenty-six patients receiving the combined therapy including use of corticosteroid, antiviral ribavirin agents after the onset of symptoms and showed they had an acute self-limited disease course. The oldest patient (74 year old, male) received the healthy convalescent plasma infusion (50 ml) from recovered SARS subject and completely recovered within 21 days, having a shorter disease course. CONCLUSION: SARS is a kind of new self-limited and acute infectious disease. Early diagnosis, early isolation, early antiviral therapy for patients and efficient prevention for health care providers are urgently recommended. In particular, a combinational therapy of use of antiviral agents, preventive antibacterial antibiotics and pulsed dosage of corticosteroid can efficiently raise the clinical recovery rate and decrease mortality of SARS patients.

[Analysis of severe acute respiratory syndrome in Beijing].

OBJECTIVE: To study the clinical, laboratory, and radiologic features of 34 cases of severe acute respiratory syndrome (SARS) in Beijing. METHODS: All patients were admitted to the isolation wards. Their demographic, clinical, laboratory, and radiologic characteristics were analyzed. Univariate and multivariate analyses were performed. RESULTS: Eight patients came from a family, and 15 patients were medical staff. The mean age of patients was (33.4 +/- 13.4) years. The latent period varied from 2 to 14 days (median 4 days). The most common symptoms were fever (100%), palpitation (91.7%), myalgia (79.2%), headache (70.8%), diarrhea (73.9%) and cough (58.3%). The mean leucocyte count was (4.6 +/- 1.4) x 10(9)/L, and the mean lymphocyte ratio was 0.27 +/- 0.11. 68.4% of the patients had lymphopenia (absolute lymphocyte count < 1.3 x 10(9)/L). Other common findings included elevated levels of serum alanine aminotransferase, lactate dehydrogenase and erythrocyte sedimentation (76.2%, 28.6% and 47.8%, respectively), and decreased levels of serum iron and albumin (63.2% and 47.8%, respectively). Thirty-two cases had abnormal chest radiographs. In 2 cases in whom typical lung opacities could not be found on the initial plain chest radiographs, thoracic CT proved to be useful. Postmortem examination of 1 patient revealed marked edema with foci of hemorrhage and hyaline membrane formation in the lungs, hemorrhage necrosis and a obvious decline of cells in lymph glands. In a multivariate analysis (Stata 7.0), the independent predictor of an adverse outcome was advanced age (odds ratio per decade of life, 1.6; 95% CI, 1.08 to 2.63; P = 0.007). CONCLUSIONS: Fever, lymphopenia, low serum iron and chest radiograph are helpful to diagnose SARS early; age is the independent predictor of an outcome.