The history of Lyme disease in Italy and its spread in the Italian territory.

Lyme borreliosis (LB) is the most common vector-borne zoonotic inflammatory disease in the Northern Hemisphere. In Italy, the first case was diagnosed in 1985 in a woman in Liguria, while the second, in 1986 in Friuli-Venezia Giulia, documenting the infection in northern Italy. Both diagnoses were confirmed by serological assessment by an indirect immunofluorescence (IFI) technique. Borrelia cultivation from both Ixodes ricinus ticks and human lesions in Trieste (Friuli-Venezia Giulia) identified Borrelia afzelii as the prevalent genospecies; nevertheless, Borrelia garinii, Borrelia burgdorferi (sensu stricto), and Borrelia valaisiana (VS116 Group) were also detected, although less frequently. LB was also documented in other Italian regions: in Tuscany (1991), Trentino-Alto Adige (1995-1996), Emilia-Romagna (1998), Abruzzo (1998), and more recently, Lombardy. Nevertheless, data on LB in other Italian regions, especially in southern Italy and islands, are poor. The aim of this study is to document the spread of LB in Italy through the collection of data from LB patients in eight Italian hospitals located in different Italian regions. Diagnostic criteria for LB diagnosis are as follows: i) the presence of erythema migrans (EM) or ii) a clinical picture suggestive of LB, confirmed by serological tests and/or PCR positivity for Borrelia detection. In addition, data also included the place of residence (town and region) and the place where patients became infected. During the observation period, 1,260 cases were gathered from the participating centers. Although different in extent from northern Italy to central/southern Italy, this study shows that LB is widespread throughout Italy.

Case Report: Lyme Borreliosis and Pregnancy - Our Experience.

Lyme Borreliosis (LB) is an infection transmitted by Ixodes sp. ticks. Its early manifestation includes erythema migrans rash. Since the discovery of LB in 1975, the question arose as to whether this infection could be vertically transmitted from mother to fetus during pregnancy, as transplacental transmission has already been known for other spirochetoses, such as syphilis, relapsing fever and leptospirosis. The first confirmed case with positive Lyme serology was described in 1985 in a 28-year- old mother who had acquired Lyme in the first trimester and then developed an erythema migrans rash. Subsequently, transmission of Borrelia burgdorferi sl. in humans from mother to fetus has been documented through identification of Borrelia spirochetes in fetal tissues/and or placenta by various methods including culture, PCR and indirect immunofluorescence. Adverse birth outcomes, which are limited in case of prompt LB treatment, included spontaneous miscarriage, preterm birth and hyperbilirubinemia, but also cardiac involvement and cutaneous angiomas have been documented although rarely. No significant associations were found between adverse outcomes at birth and the trimester of infection. Patients treated for gestational LB had a lower frequency of miscarriages and premature births, as also the frequency of congenital malformations was similar to that observed in the normal population. The recommended treatment for LB in pregnancy is Amoxicillin, 1 g 3 times a day for 14-21 days. In the present study, we report our case series, which includes 11 pregnant women, 6 of which developed erythema migrans during pregnancy (between week 8 and 34), 3 had myoarticular or neurological symptoms and 2 had positive serology, but did not develop any clinical symptoms. Our data stress on the importance of early antibiotic treatment also in seropositive gestating women without symptoms in order to avoid any possible complication to fetus and newborns.

Borreliae Part 2: Borrelia Relapsing Fever Group and Unclassified Borrelia.

Borreliae of the relapsing fever group (RFG) are heterogenous and can be divided mainly into three groups according to vectors, namely the soft-tick-borne relapsing fever (STBRF) Borreliae, the hard-tick-borne relapsing fever (HTBRF) Borreliae, the louse-borne relapsing fever (LBRF) Borreliae, and the avian relapsing fever ones. With respect to the geographical distribution, the STBRF Borreliae are further subdivided into Old World and New World strains. Except for the Avian relapsing fever group Borreliae, which cause avian spirochetosis, all the others share infectivity in humans. They are indeed the etiological agent of both endemic and epidemic forms of relapsing fever, causing high spirochaetemia and fever. Vectors are primarily soft ticks of Ornithodoros spp. in the STBRF group; hard ticks, notably Ixodes sp., Amblyomma sp., Dermacentor sp., and Rhipicephalus sp., in the HTBRF group; and the louse pediculus humanus humanus in the TBRF one. A recent hypothesis was supported for a common ancestor of RFG Borreliae, transmitted at the beginning by hard-body ticks. Accordingly, STBRF Borreliae switched to use soft-bodied ticks as a vector, which was followed by the use of lice by Borrelia recurrentis. There are also new candidate species of Borreliae, at present unclassified, which are also described in this review.

Borreliae Part 1: Borrelia Lyme Group and Echidna-Reptile Group.

Borreliae are divided into three groups, namely the Lyme group (LG), the Echidna-Reptile group (REPG) and the Relapsing Fever group (RFG). Currently, only Borrelia of the Lyme and RF groups (not all) cause infection in humans. Borreliae of the Echidna-Reptile group represent a new monophyletic group of spirochaetes, which infect amphibians and reptiles. In addition to a general description of the phylum Spirochaetales, including a brief historical digression on spirochaetosis, in the present review Borreliae of Lyme and Echidna-Reptile groups are described, discussing the ecology with vectors and hosts as well as microbiological features and molecular characterization. Furthermore, differences between LG and RFG are discussed with respect to the clinical manifestations. In humans, LG Borreliae are organotropic and cause erythema migrans in the early phase of the disease, while RFG Borreliae give high spirochaetemia with fever, without the development of erythema migrans. With respect of LG Borreliae, recently Borrelia mayonii, with intermediate characteristics between LG and RFG, has been identified. As part of the LG, it gives erythema migrans but also high spirochaetemia with fever. Hard ticks are vectors for both LG and REPG groups, but in LG they are mostly Ixodes sp. ticks, while in REPG vectors do not belong to that genus.

Toll-Like Receptor 1/2 and 5 Ligands Enhance the Expression of Cyclin D1 and D3 and Induce Proliferation in Mantle Cell Lymphoma.

Mantle cell lymphoma (MCL) is an aggressive B-cell non-Hodgkin's lymphoma with a still undefined etiology. Several lines of evidence are consistent with the possible involvement of peculiar microenvironmental stimuli sustaining tumor cell growth and survival, as the activation of Toll-like receptors (TLR) 4 and 9. However, little is known about the contribution of other TLRs of pathogenic relevance in the development of MCL. This study reports evidence that MCL cell lines and primary MCL cells express different levels of TLR2 and TLR5, and that their triggering is able to further activate the Akt, MAPK, and NF-κB signaling cascades, known to be altered in MCL cells. This leads to the enhancement of cyclin D1 and D3 over-expression, occurring at post-translational level through a mechanism that likely involves the Akt/GSK-3α/ß pathway. Interestingly, in primary B cells, TLR1/2 or TLR5 ligands increase protein level of cyclin D1, which is not usually expressed in normal B cells, and cyclin D3 when associated with CD40 ligand (CD40L), IL-4, and anti-human-IgM co-stimulus. Finally, the activation of TLR1/2 and TLR5 results in an increased proliferation of MCL cell lines and, in the presence of co-stimulation with CD40L, IL-4, and anti-human-IgM also of primary MCL cells and normal B lymphocytes. These effects befall together with an enhanced IL-6 production in primary cultures. Overall, our findings suggest that ligands for TLR1/2 or TLR5 may provide critical stimuli able to sustain the growth and the malignant phenotype of MCL cells. Further studies aimed at identifying the natural source of these TLR ligands and their possible pathogenic association with MCL are warranted in order to better understand MCL development, but also to define new therapeutic targets for counteracting the tumor promoting effects of lymphoma microenvironment.

New insights into the pathogenicity of leptospires: evasion of host defences.

Major progress has been made in the basic research of leptospirosis a global zoonotic disease. Recent knowledge on the genome of L. interrogans and the emergence of new genetic tools for comparative genetic studies have further developed research into the genetic pathogenesis of this illness. Many of these studies have compared the putative pathogenicity factors found in L. interrogans, with representative strains of saprophytic leptospires. Leptospires display a rich repertoire of adhesins endowed with multifunctional biological activities such as adhesion to host tissue components, plasminogen activation, resistance to complement. These adhesins are proteins or liproteins located on the outer membrane. Some of them (LenA) escape innate defence such as complement killing and some escape phagocytosis. Much work has to be done to elucidate many other aspects of Leptospira pathogenic factors such as those switched on in chronic infection.

Detection and identification of Rickettsia species in the northeast of Italy.

This study was carried out using Ixodes ricinus ticks collected during 2005 and 2006 from the Friuli Venezia Giulia (FVG) region in the northeastern part of Italy and an area along the Slovenian side of the western border of Italy. The results indicate that Rickettsia spp. is widely distributed throughout these areas, with the greatest prevalence in the central part of the FVG region. The prevalence of Rickettsia spp. was 4.5% during 2005 and 6.1% during 2006. By sequencing the 16S rRNA gene, we show for the first time the presence of Rickettsia helvetica in I. ricinus ticks in the FVG region and the presence of R. monacensis in ticks in both areas. Furthermore, we detected a sequence with a high homology with that of R. limoniae in a tick obtained from the alpine zone.

Evaluation of a genotyping method based on the ospA gene to detect Borrelia burgdorferi sensu lato in multiple samples of lyme borreliosis patients.

In this study we have developed a new Restriction-Fragment-Length-Polymorphism (RFLP) genotyping method for rapid detection and identification of Borrelia genospecies present as unique species or as co-infection in multiple specimens obtained simultaneously from 29 individual patients affected by early or late Lyme borreliosis (LB). The target of the RFLP-genotyping was the heterogeneous plasmid located ospA gene, thus we developed a method able to detect and differentiate between six clinically relevant Borrelia genospecies circulating in Europe, B. burgdorferi sensu stricto, B. garinii, B. afzelii, B. valaisiana, B. bissettii and B. spielmanii. In this study Borrelia DNA could be detected by PCR in at least one specimen of each patient, except in one case of neuroborreliosis (NB); blood samples gave the highest sensitivity in all patient groups. The genotyping indicated that B. afzelii was present in 8 patients with skin involvement, B. garinii in 2 cases of NB and 4 cases with skin involvement, B. burgdorferi sensu stricto was detected in one patient with skin involvement and another with Lyme arthritis. Different Borrelia species in distinct specimens were identified in one patient with EM. The RFLP analysis of 11 patients revealed mixed patterns, which suggested pluri-infection with different Borrelia species.

NF-kB activation and p38 phosphorilation in microglial cells infected with Leptospira or exposed to partially purified leptospiral lipoproteins.

Recently, we have shown a differential susceptibility of non-pathogenic vs. pathogenic leptospires to phagocytosis and killing by microglial cells. Although all ingested to some extent, only the pathogenic strains survived intracellularly while the non-pathogenic ones were killed in a time-dependent manner. By the same infection model, here we demonstrate that microglial cells respond to Leptospira infection with a time- and dose-dependent induction of molecular signals (p38 phosphorilation and NF-kB activation) and the production of soluble factors (cytokines and nitric oxide). Such bio-molecular response is predominantly observed against the pathogenic Leptospira; the phenomenon is reproduced by leptospiral lipoproteins and, to a lower extent, by leptospiral-derived LPS. These data provide initial evidence that Leptospira affects microglial cell response in a different manner depending upon the virulence of the infecting strain; specific bacterial components happen to be involved in the induction of such pathogen-induced immune response.

Interaction of leptospires with murine microglial cells.

Leptospires, the agents of leptospirosis, exert tropism for the central nervous system, in the course of mammal infection. We evaluated the interaction between murine microglial cells and strains of pathogenic L. interrogans leptospires and non-pathogenic L. biflexa leptospires, mainly by flow cytometric assays. In the absence of opsonic conditions microglia are capable of ingesting--even quite slowly--the spirochetes and killing the non-pathogenic strain. The adhesion to microglia, which is quick and relevant for all the strains, does not involve the CR3 integrin receptor. These findings suggest that the murine microglia--in non opsonic conditions in vitro--do not effectively clear the pathogenic leptospires.

Evaluation of the C6 enzyme-linked immunoadsorbent assay for the serodiagnosis of Lyme borreliosis in north-eastern Italy.

A novel antigen preparation--the synthetic C6 peptide, a conserved portion of the variable VlsE antigens of Borrelia burgdorferi--has been evaluated for serodiagnosis of Lyme borreliosis (LB) by an ELISA procedure. Serum specimens were from early and late LB patients, all resident in an endemic area in north-eastern Italy. The specificity of the test approached the 100% and sensitivity was in the order of 63% (early LB) and 100% (late LB); this performance is superior to the preceding generation of Lyme disease tests.

First detection of TBE virus sequences in Ixodes ricinus from Friuli Venezia Giulia (Italy).

We report, for the first time, the presence of tick-borne encephalitis (TBE) virus in the tick Ixodes ricinus collected in the Friuli Venezia Giulia region of north-eastern Italy. Using molecular methods, we demonstrate that the TBE virus carried by ticks from FVG is a western European strain. Sequence analysis of the 5' NCR showed 98.4% identity to the Neudoerfl strain.

Expression of complement factor H binding immunoevasion proteins in Borrelia garinii isolated from patients with neuroborreliosis.

The Lyme disease-pathogen Borrelia burgdorferi binds the complement inhibitor factor H (FH) to its outer surface protein E- (OspE) and BbA68-families of lipoproteins. In earlier studies, only serum-resistant strains of the genospecies B. burgdorferi sensu stricto or B. afzelii, but not serum-sensitive B. garinii strains, have been shown to bind FH. Since B. garinii often causes neuroborreliosis in man, we have readdressed the interactions of B. garinii with FH. B. garinii 50/97 strain did not express FH-binding proteins. By transforming the B. garinii 50/97 strain with an OspE-encoding gene from complement-resistant B. burgdorferi (ospE-297), its resistance to serum killing could be increased. OspE genes were detected and cloned from the B. garinii BITS, Pistoia and 40/97 strains by PCR and sequencing. The deduced amino acid sequences differed in an N-terminal lysine-rich FH-binding region from OspE sequences of resistant strains. Recombinant B. garinii BITS OspE protein was found to have a considerably lower FH-binding activity than the B. burgdorferi sensu stricto 297 OspE protein P21 (P21-297). Unlike bacteria that had been kept in culture for a long time, neurovirulent B. garinii strains from neuroborreliosis patients were found to express approximately 27-kDa FH-binding proteins. These were not recognized by polyclonal anti-OspE or anti-BbA68 antibodies. We conclude that B. garinii strains carry ospE genes but have a decreased expression of OspE proteins and a reduced ability to bind FH, especially when grown for prolonged periods in vitro. Recently isolated neuroinvasive B. garinii strains, however, can express FH-binding proteins, which may contribute to the virulence of neuroborreliosis-causing B. garinii strains.

Regulation of complement activation at the C3-level by serum resistant leptospires.

Leptospires are spirochetes that are transmitted to humans through contacts with wild or domestic animals or via an exposure to contaminated soil or water. In this study we have compared the serum-sensitivity of five pathogenic strains of leptospires (L. interrogans) to an environmental isolate (strain Patoc). Different levels of sensitivities to human serum were seen. Interestingly, the most sensitive strain was the non-pathogenic Patoc strain. The fully and intermediately resistant strains have been isolated from human patients. Testing was performed in the absence of specific antibodies, and killing was found to be dependent on the complement system. The serum sensitive Patoc strain was killed in human serum within minutes, whereas the most resistant strains tolerated serum up to 4h. We also tested the deposition of the complement components C3, C5, C6, C8 and C5b-9 to the surfaces of the sensitive and resistant strains of Leptospira by immunofluorescence microscopy and ELISA. C3 was deposited on both the sensitive and resistant strains, but the terminal complement components were detected only on the surface of the complement-sensitive strain. The complement resistant and intermediate strains were found to bind more factor H from human serum than the complement sensitive strain. Thus, binding of this major alternative complement pathway inhibitor is related to serum resistance in Leptospira spirochetes.

Complement receptor 3 binds the Borrelia burgdorferi outer surface proteins OspA and OspB in an iC3b-independent manner.

Persistence of borreliae within the vertebrate host depends on the fate of interactions between the spirochetes and target cells. The present work demonstrates the direct binding of the Borrelia burgdorferi outer surface proteins OspA and OspB to CR3 and that this binding is independent of iC3b.

New triterpene glycosides from the stems of Anomospermum grandifolium.

Two new dammarane saponins identified as jujubogenin 3-O-alpha-l-arabinofuranosyl(1-->2)-[beta-d-glucopyranosyl(1-->6) beta-d-glucopyranosyl(1-->3)]-alpha-l-arabinopyranoside (2) and jujubogenin 3-O-alpha-l-arabinofuranosyl(1-->2)-[6-O-[3-hydroxy-3-methylglutaryl]-beta-d-glucopyranosyl(1-->3)]-alpha-l-arabinopyranoside (3) and a new lupane saponin, 3beta-hydroxylup-20(29)-en-27,28-dioic acid 28-O-beta-d-glucopyranosyl(1-->2)-[beta-d-xylopyranosyl(1-->3)]-beta-d-xylopyranosyl(1-->2)-beta-d-glucopyranoside ester (5), along with the known jujubogenin 3-O-alpha-l-arabinofuranosyl(1-->2)-[beta-d-glucopyranosyl(1-->3)]-alpha-l-arabinopyranoside (1) and 3beta-hydroxylup-20(29)-ene-27,28-dioic acid (4), were isolated from the methanol extract of the stems of Anomospermum grandifolium. The structures of the new compounds were established by spectral analysis. Antimicrobial activity screening of compounds 1-3 revealed antifungal properties against C. albicans ATCC 3153 for compounds 2 and 3. The antibacterial and antifungal activities of the petroleum ether, chloroform, and methanol extracts of A. grandifolium stems were also evaluated.

Lymphocyte apoptosis co-cultured with Borrelia burgdorferi.

Borrelia burgdorferi is the causative agent of Lyme disease. We investigated whether the in vitro co-cultivation of lymphocytes with spirochetes would induce apoptosis in human lymphocytes. Peripheral blood mononuclear cell were mixed with various ratio of cell/spirochetes (1:10, 1:20, 1:50, 1:100) and incubated in a humified atmosphere of 5% CO(2) at 37 degrees C. Apoptosis was determined at 0, 4, 24 h by Annexin V binding assay and propidium iodide staining, and by CD95 Apo-1 expression. Analysis was performed by multiparametric flow cytometry on CD3, CD4, CD8, CD19 subset of lymphocytes. The binding of Annexin V increased at 24 h in T lymphocytes infected by living spirochetes at ratio 1:50; similar results were obtained with inactivated or sonicated spirochetes and lipidated OspC. The rate of Annexin V binding and pattern of CD95 over-expression were different in CD3, CD4, CD8 and CD19 subset; interleukine-10 (IL-10) was measured in supernatants of cultures after treatment with Borrelia preparations and with OspA and OspC, lipidated or not. Our data suggest that spirochetes were able to induce apoptosis on lymphocytes; the phenomenon appears associated with number of spirochetes, incubation time and the release of IL-10 in co-cultures. Moreover apoptosis was probably Fas-mediated and the cells involved were prevalently CD4.

Human granulocytic ehrlichiosis in Italy: first report on two confirmed cases.

We report here the two first cases of human ehrlichiosis described in Italy. One patient presented symptoms indicative of ehrlichiosis, such as fever, conjunctivitis, and increase of hepatic enzymes; HGE was confirmed by fourfold seroconversion for HGE antigen. The second patient, a forest worker, was affected by Lyme disease, and in this case HGE was suspected because of fever, leukopenia, and seroconversion.