Genetically Confirmed Edwardsiella tarda Peritonitis was Associated with Improper Caregiver's Hand Hygiene during Peritoneal Dialysis Bag Exchange.

Edwardsiella tarda is a Gram-negative bacillus and is responsible for waterborne disease. This is the first case report of peritoneal dialysis (PD)-associated peritonitis caused by genetically confirmed E. tarda, which was transmitted from the caregiver's hand during PD bag exchange. Aside from that, the caregiver was a fishmonger and a gastrointestinal carrier of the pathogen. Prior to the onset of peritonitis, the caregiver reported that she did not wash her hands every time when performing the PD bag exchange. Although extraintestinal edwardsiellosis usually poses a poor outcome, PD-associated peritonitis with this species is paradoxical if diagnosed early, and treatment is promptly provided, as presented here. This case emphasizes the importance of hand hygiene in preventing environment-bound infection in patients on PD and demonstrates the unusual route of infection, contamination during PD bag exchange.

Peritoneal Dialysis-Related Peritonitis Due to Melioidosis: A Potentially Devastating Condition.

♦ BACKGROUND: Melioidosis, an infectious disease caused by Burkholderia pseudomallei, is endemic in Southeast Asia and Northern Australia. Although a wide range of clinical manifestations from this organism are known, peritonitis associated with peritoneal dialysis (PD) has rarely been reported. ♦ PATIENTS AND METHODS: Peritoneal dialysis patients from all regions in Thailand were eligible for the study if they had peritonitis and either peritoneal fluid or effluent culture positive for B. pseudomallei. Patient data obtained included baseline characteristics, laboratory investigations, treatments, and clinical outcomes. When possible, PD fluid and removed Tenckhoff (TK) catheters were submitted for analyses of minimal inhibitory concentration (MIC) and microbial biofilm, respectively. ♦ RESULTS: Twenty-six patients were identified who were positive for peritoneal B. pseudomallei infection. The recorded mean age was 50 ± 15 (24 - 75) years, and the majority (58%) were female. Most of the cases were farmers living in Northeastern and Northern Thailand. Almost half of the cases had diabetes. Infections were reported commonly during the monsoon season and winter. The clinical presentations of peritonitis were similar to the manifestations from other microorganisms. Nine patients (41%) died (7 from sepsis), 6 fully recovered, and 7 switched to permanent hemodialysis. The mortality was potentially associated with sepsis (p = 0.007), infection during the monsoon season (p = 0.017), high initial dialysate neutrophils (p = 0.045), and high hematocrit (p = 0.045). Although no antibiotic resistance to ceftazidime and carbapenems was detected, approximately 50% of patients died with this treatment. Microbial biofilms were identified on the luminal surface of 4 out of 5 TK catheters, but the removal of the catheter did not alter the outcomes. ♦ CONCLUSION: Peritoneal dialysis-related peritonitis due to melioidosis is uncommon but highly fatal. Increased awareness, early diagnosis, and optimal management are mandatory.

Intermedin (adrenomedullin-2): a potential protective role in human aortic endothelial cells.

BACKGROUND/AIMS: Intermedin (IMD) is a novel peptide with significant vasodilator and cardiac protective actions similar to the related peptide adrenomedullin (ADM). Unlike those of ADM the actions and expression of IMD in endothelial cells are poorly characterised. ADM expression can be increased during cardiovascular disease/stress in vitro and in vivo where it may have a role in several cardiovascular protective actions. To characterise IMD mRNA expression cultured human aortic endothelial cells (HAEC) were stressed by removing serum and bicarbonate, and the addition of hydrogen peroxide. The responses were compared to those of ADM mRNA. We also compared the effects of ADM and IMD on caspase activity and cell viability, and investigated if IMD actions could be altered by a CGRP receptor antagonist. METHODS/RESULTS: Using the cell immunoblot assay, immunoreactive IMD was shown to be secreted by HAEC. IMD mRNA expression was also detected in HAEC grown in endothelial growth media (but at markedly lower levels than that of ADM). Absence of bicarbonate, a redox-mediated regulator of endothelial response to various stresses, increased IMD mRNA and ADM mRNA expression. However IMD mRNA, but not ADM mRNA, was markedly increased over time in HAEC in conditions of cell stress including incubation with serum-free Dulbecco's modified Eagle's medium (DMEM) and in response to hydrogen peroxide (H2O2). These vigorous responses in IMD mRNA expression were further enhanced by incubation in 5% serum in DMEM without bicarbonate, but in a selective manner since ADM expression was suppressed by serum. We also observed that IMD mRNA was markedly increased and ADM mRNA suppressed in HAEC following a period of suspension and replating. Finally, we observed that IMD, like ADM, increased cell viability in HAEC in DMEM without serum but only IMD reduced caspase activity, perhaps via and a yet to be defined receptor system. CONCLUSION: HAECs express IMD mRNA and secrete IMD peptide. IMD mRNA expression is markedly dependent on metabolic conditions and is selectively regulated in a contrary fashion to ADM mRNA. IMD mRNA expression in endothelial cells is markedly sensitive to oxidative stress, and IMD peptide itself has antiapoptotic activity in human endothelial cells. Our data suggest that IMD has a different role to ADM and may perform a protective function in humans.

Regulation of endothelin-1 release from human endothelial cells by sex steroids and angiotensin-II.

It is well documented that there are gender differences in the incidence and patterns of cardiovascular disease; males have a higher incidence of cardiovascular disease than premenopausal women. We have therefore investigated whether the sex hormones, estradiol and testosterone, could directly influence the secretion of vascular peptides from human aortic endothelial cells (HAEC). Previously we have shown that testosterone can increase the number of HAECs that secrete adrenomedullin. In this study we investigated sex hormone regulation of endothelin-1 in HAEC. Several studies have observed a reduction in endothelin-1 secretion from endothelial cells in the presence of estradiol, the effect being more marked for stimulated cells. Studies on the actions of testosterone are much fewer and inconclusive. In this study we observed that estradiol did not change the number of cells secreting endothelin-1 during 4h incubation under basal conditions but decreased the number of secreting cells stimulated with angiotensin-II. Testosterone induced an increase in the number of cells secreting endothelin-1 (p=0.03). Complementary incubations revealed that testosterone up-regulated endothelin-1 mRNA at 1-3h (p<0.05). These results, together with our previous observations, indicate that angiotensin-II, testosterone and estradiol have parallel effects on the production of endothelin-1 as on adrenomedullin in HAEC. We conclude that there is potential for coordinated modulation by sex steroids and angiotensin-II of vasoactive peptide production in human endothelial cells.

Regulation of adrenomedullin release from human endothelial cells by sex steroids and angiotensin-II.

It is well documented that there are gender differences in the incidence and patterns of cardiovascular diseases but the reasons are unclear. Sex steroids may modulate the behaviour of vascular endothelial cells, which in turn act by paracrine processes to alter adjacent vascular smooth muscle activity. We hypothesised that the sex steroids alter the percentage of vascular endothelial cells that secrete the vasodilator peptide, adrenomedullin and modify the adrenomedullin-stimulating action of angiotensin-II. The percentage of adrenomedullin-secreting human aortic endothelial cells was determined using the cell immunoblot method. Cells were incubated with selected concentrations of angiotensin-II, oestradiol and testosterone alone and sex steroids in combination with angiotensin-II. Adrenomedullin mRNA expression in endothelial cells was quantified by real-time PCR. It was observed that at 4 h, angiotensin-II increased the percentage of adrenomedullin-secreting cells in a concentration-dependent manner. Testosterone at physiological concentrations was observed to increase the number of adrenomedullin-secreting cells whilst oestradiol had no effect. Addition of testosterone to angiotensin-II resulted in less than additive increases in the number of cells secreting adrenomedullin. Oestradiol reduced the angiotensin-II-induced increase in adrenomedullin-secreting cells. Adrenomedullin mRNA expression was significantly increased by testosterone and there was also a trend for an increase in adrenomedullin mRNA expression, which occurred when cells were incubated with angiotensin-II. Our results point to a complex interplay between the sex steroids and angiotensin-II in regulating adrenomedullin production by human endothelial cells, which may contribute to gender-related differences in vascular disease in humans.