Acute large-vessel occlusion due to an infected thrombus formation induced by invasive sphenoid sinus aspergillosis: illustrative case.

BACKGROUND: The authors describe a rare case of acute large-vessel occlusion due to an infected thrombus formation that was induced by invasive sphenoid sinus aspergillosis. OBSERVATIONS: An 82-year-old man with a history of immunoglobulin G4-related disease and long-term use of steroids and immunosuppressants was admitted to the authors' hospital with severe right hemiparesis. Cerebral angiography revealed occlusion of the left internal carotid artery (ICA). He underwent thrombectomy, resulting in successful recanalization. However, severe stenosis was evident in the left ICA cavernous segment. Pathological analysis of the retrieved thrombus identified Aspergillus. Postoperative magnetic resonance imaging revealed sinusitis in the left sphenoid sinus as a possible source of the infection. The patient's general condition deteriorated during the course of hospitalization due to refractory aspiration pneumonia, and he died 46 days after thrombectomy. Pathological autopsy and histopathological investigation of the left ICA and the left sphenoid sinus showed that Aspergillus had invaded the wall of the left ICA from the adjacent sphenoid sinus. These findings indicate a diagnosis of acute large-vessel occlusion due to infected thrombus formation induced by invasive sphenoid sinus aspergillosis. LESSONS: Pathological analysis of a retrieved thrombus appears useful for identifying rare stroke etiologies such as fungal infection.

Feasibility of Diffusion-weighted Imaging (DWI) for Assessing Cerebrospinal Fluid Dynamics: DWI-fluidography in the Brains of Healthy Subjects.

PURPOSE: The present study aimed to investigate whether diffusion-weighted imaging (DWI) can qualify and quantify cerebrospinal fluid (CSF) dynamics in the brains of healthy subjects. For this purpose, we developed new DWI-based fluidography and compared the CSF dynamics seen on the fluidography with two apparent diffusion coefficients obtained with different DWI signal models at anatomical spaces filled by CSF. METHODS: DWI with multiple b values was performed for 10 subjects using a 7T MRI scanner. DWI-fluidography based on the DWI signal variations in different motion probing gradient directions was developed for visualizing the CSF dynamics voxel-by-voxel. DWI signals were measured using an ROI in the representative CSF-filled anatomical spaces in the brain. For the multiple DWI signals, the mono-exponential and kurtosis models were fitted and two kinds of apparent diffusion coefficients (ADCC and ADCK) were estimated in each space using the Gaussian and non-Gaussian diffusion models, respectively. RESULTS: DWI-fluidography could qualitatively represent the features of CSF dynamics in each anatomical space. ADCs indicated that the motions at the foramen of Monro, the cistern of the velum interpositum, the quadrigeminal cistern, the Sylvian cisterns, and the fourth ventricle were more drastic than those at the subarachnoid space and anterior horns of the lateral ventricle. Those results seen in ADCs were identical to the findings on DWI-fluidography. CONCLUSION: DWI-fluidography based on the features of DWI signals could show differences of CSF dynamics among anatomical spaces.

Successful carotid stenting of a carotid arterial dissection after straightening the tortuosity using an inflated balloon guiding catheter and the delivery wire of an anchored stent retriever.

The authors present a patient with carotid dissection in a tortuous arterial segment who successfully underwent carotid artery stenting (CAS) by straightening the tortuosity using an inflated balloon guiding catheter (BGC) and a stent retriever (SR). A 56-year-old man was transferred to our institute with right hemiparesis and a National Institutes of Health Stroke Scale score of 9. Magnetic resonance imaging showed left internal carotid artery (ICA) occlusion and ischemic change in the parietal lobe. Emergent angiography revealed tapered extracranial ICA occlusion sugg carotid artery dissection (CAD). CAS was attempted for CAD due to a mismatch of the motor area on clinical imaging. However, several attempts to navigate the stent delivery system over a guidewire failed. Therefore, we deployed a Trevo NXT ProVue SR (3 × 32 mm) in the middle cerebral artery, inflated a BGC, and then pulled on both to straighten the tortuous carotid artery, which resulted in successful navigation of the stent delivery system. The patient's symptoms improved after the recanalization. This case demonstrates the utility of a technique for navigation of a stent delivery system through a tortuous carotid artery in which the tortuosity is straightened by pulling on an inflated BGC and the delivery wire of the SR.

Identification of a new oligomycin derivative as a specific inhibitor of the alternative peptidoglycan biosynthetic pathway.

Peptidoglycan is an important macromolecule in bacterial cell walls to maintain cell integrity, and its biosynthetic pathway has been well studied. Recently, we demonstrated that some bacteria such as Xanthomonas oryzae, a pathogen causing bacterial blight of rice, used an alternative pathway for peptidoglycan biosynthesis. In this pathway, MurD2, a MurD homolog, catalyzed the attachment of L-Glu to UDP-MurNAc-L-Ala and MurL, which did not show homology to any known protein, catalyzed epimerization of the terminal L-Glu of the MurD2 product to generate UDP-MurNAc-L-Ala-D-Glu. Because the alternative pathway also operates in some other plant pathogens and opportunistic pathogens, specific inhibitors of the alternative pathway could function as pesticides and antibiotics for these pathogens. In this study, we searched for specific inhibitors of the alternative pathway from metabolites produced by actinomycetes and identified a new oligomycin-class polyketide, which was revealed to inhibit the MurD2 reaction, in culture broth of Micromonospora sp. K18-0097.

Peptide Epimerase Responsible for d-Amino Acid Introduction in Poly-γ-glutamic Acid Biosynthesis.

Poly-γ-glutamic acid (PGA) is a natural polymer of d- and/or l-glutamic acid (Glu) linked by isopeptide bonds. We recently showed that PGA synthetase, an enzyme complex composed of PgsB, PgsC, and PgsA, uses only l-Glu for polymerization, and d-Glu residues are introduced by peptide epimerization. However, it remains unclear which of the three enzymes is responsible for epimerization because in vitro functional characterization of the membrane-associated PgsBCA complex has never been successful. Here, we performed gene exchange experiments and showed that PgsA is responsible for the epimerization. Additionally, we identified a region in PgsA that modulates epimerization activity based on homology modeling from the recently solved structure of MslH, which showed 53% identity to PgsA. Our results suggested that d/l-ratios of the PGA product can be altered by introducing amino acid substitutions in this region, which will be useful for the production of PGA with controlled d/l-ratios.

Optimization of tyrosol-producing pathway with tyrosine decarboxylase and tyramine oxidase in high-tyrosine-producing Escherichia coli.

Tyrosol (4-hydroxyphenylethanol) is a phenolic compound used in the pharmaceutical and chemical industries. However, current supply methods, such as extraction from natural resources and chemical synthesis, have disadvantages from the viewpoint of cost and environmental protection. Here, we developed a tyrosol-producing Escherichia coli cell factory from a high-tyrosine-producing strain by expressing selected tyrosine decarboxylase-, tyramine oxidase (TYO)-, and medium-chain dehydrogenase/reductase (YahK)-encoding genes. The genes were controlled by the strong T7 promoter and integrated into the chromosome because of the advantages over plasmid-based systems. The strain produced a melanin-like pigment as a by-product, which is suggested to be formed from 4-hydroxyphenylacetaldehyde (a TYO product/YahK substrate). By using a culture medium containing a high concentration of glycerol, which was reported to enhance NADH supply required for YahK activity, the final titer of tyrosol reached 2.42 g/L in test tube-scale cultivation with a concomitant decrease in the amount of pigment. These results indicate that chromosomally integrated and T7 promoter-controlled gene expression system in E. coli is useful for high production of heterologous enzymes and might be applied for industrial production of useful compounds including tyrosine and tyrosol.

Peptide epimerase-dehydratase complex responsible for biosynthesis of the linaridin class ribosomal peptides.

Grisemycin, salinipeptin, and cypemycin belong to the linaridin class of ribosomally synthesized and posttranslationally modified peptides that contain multiple dehydrobutyrine and D-amino acid residues. The biosynthetic gene clusters of these linaridins lack obvious candidate genes for the dehydratase and epimerase required to introduce dehydrobutyrine and D-amino acid residues, respectively. However, we previously demonstrated that the grisemycin (grm) cluster contained cryptic dehydratase and epimerase genes by heterologous expression of this biosynthetic gene cluster in Streptomyces lividans and proposed that two genes (grmH and grmL) with unknown functions catalyze dehydration and epimerization reactions. In this study, we confirmed that both GrmH and GrmL, which were shown to constitute a protein complex by a co-purification experiment, were required to catalyze the dehydration, epimerization, and proteolytic cleavage of a precursor peptide GrmA by in vivo experiments. Furthermore, we demonstrated that GrmH/GrmL complex accepted salinipeptin and cypemycin precursor peptides, which possess three additional amino acids.

Structure of lasso peptide epimerase MslH reveals metal-dependent acid/base catalytic mechanism.

The lasso peptide MS-271 is a ribosomally synthesized and post-translationally modified peptide (RiPP) consisting of 21 amino acids with D-tryptophan at the C-terminus, and is derived from the precursor peptide MslA. MslH, encoded in the MS-271 biosynthetic gene cluster (msl), catalyzes the epimerization at the Cα center of the MslA C-terminal Trp21, leading to epi-MslA. The detailed catalytic process, including the catalytic site and cofactors, has remained enigmatic. Herein, based on X-ray crystallographic studies in association with MslA core peptide analogues, we show that MslH is a metallo-dependent peptide epimerase with a calcineurin-like fold. The crystal structure analysis, followed by site-directed mutagenesis, docking simulation, and ICP-MS studies demonstrate that MslH employs acid/base chemistry to facilitate the reversible epimerization of the C-terminal Trp21 of MslA, by utilizing two pairs of His/Asp catalytic residues that are electrostatically tethered to a six-coordination motif with a Ca(II) ion via water molecules.

Using a low-metal-density stent for thrombectomy-resistant vertebrobasilar occlusion due to thrombus migration from a thrombosed vertebral artery aneurysm: illustrative case.

BACKGROUND: Thrombosed intracranial aneurysms can lead to large vessel occlusion as a result of spontaneous thrombosis. Although mechanical thrombectomy is likely effective, recurrent thromboembolism can occur if the thrombotic source remains untreated. The authors describe a case of recurrent vertebrobasilar artery occlusion due to thrombus migration from a large thrombosed vertebral artery (VA) aneurysm that was successfully treated with mechanical thrombectomy followed by stenting. OBSERVATIONS: A 61-year-old male previously diagnosed with a large, thrombosed VA aneurysm presented with right hypoesthesia. Imaging on admission showed left VA occlusion and an acute ischemic lesion in the left medial medulla. His symptoms worsened, with complete right hemiparesis and tongue deviation occurring 3 hours after admission, and mechanical thrombectomy was performed to recanalize the left-dominant VA. Despite several attempts, reocclusion of the vertebrobasilar system occurred after each mechanical thrombectomy because of repeated thrombus formation in the thrombosed aneurysm. Therefore, a low-metal-density stent was deployed to prevent thrombus migration into the parent artery, which resulted in complete recanalization and rapid improvement of the symptoms. LESSONS: Stenting with a low-metal-density stent for recurrent embolism secondary to thrombus migration from a large thrombosed aneurysm was feasible in the acute stroke setting.

N-Formimidoylation/-iminoacetylation modification in aminoglycosides requires FAD-dependent and ligand-protein NOS bridge dual chemistry.

Oxidized cysteine residues are highly reactive and can form functional covalent conjugates, of which the allosteric redox switch formed by the lysine-cysteine NOS bridge is an example. Here, we report a noncanonical FAD-dependent enzyme Orf1 that adds a glycine-derived N-formimidoyl group to glycinothricin to form the antibiotic BD-12. X-ray crystallography was used to investigate this complex enzymatic process, which showed Orf1 has two substrate-binding sites that sit 13.5 Å apart unlike canonical FAD-dependent oxidoreductases. One site could accommodate glycine and the other glycinothricin or glycylthricin. Moreover, an intermediate-enzyme adduct with a NOS-covalent linkage was observed in the later site, where it acts as a two-scissile-bond linkage facilitating nucleophilic addition and cofactor-free decarboxylation. The chain length of nucleophilic acceptors vies with bond cleavage sites at either N-O or O-S accounting for N-formimidoylation or N-iminoacetylation. The resultant product is no longer sensitive to aminoglycoside-modifying enzymes, a strategy that antibiotic-producing species employ to counter drug resistance in competing species.

First direct evidence for direct cell-membrane penetrations of polycationic homopoly(amino acid)s produced by bacteria.

Bacteria produce polycationic homopoly(amino acid)s, which are characterized by isopeptide backbones. Although the biological significance of polycationic homopoly(amino acid)s remains unclear, increasing attention has recently been focused on their potential use to achieve cellular internalization. Here, for the first time, we provide direct evidence that two representative bacterial polycationic isopeptides, ε-poly-L-α-lysine (ε-PαL) and ε-oligo-L-ß-lysine (ε-OßL), were internalized into mammalian cells by direct cell-membrane penetration and then diffused throughout the cytosol. In this study, we used clickable ε-PαL and ε-OßL derivatives carrying a C-terminal azide group, which were enzymatically produced and then conjugated with a fluorescent dye to analyze subcellular localization. Interestingly, fluorescent proteins conjugated with the clickable ε-PαL or ε-OßL were also internalized into cells and diffused throughout the cytosol. Notably, a Cre recombinase conjugate with ε-PαL entered cells and mediated the Cre/loxP recombination, and ε-PαL was found to deliver a full-length IgG antibody to the cytosol and nucleus.

Transfemoral subclavian artery stenting through a shaped guiding catheter without pull-through technique: A case report.

Transfemoral subclavian artery stenting can be challenging unless the placement of the guiding catheter is secured. Herein, we present a patient with subclavian artery stenosis treated with endovascular stenting using a shaped guiding catheter. A 79-year-old woman was admitted to our department because of a cold sensation and numbness of her left arm. Computed tomography revealed stenosis of the left subclavian artery (SA), located just proximal to the ostium of the left vertebral artery (VA). Doppler ultrasound showed reverse flow in the left VA. We planned to stent for the SA stenosis under the balloon protection of the left VA. The balloon protection device was easily navigated into the left VA through brachial access. After that, a self-expandable stent was successfully placed from just proximal to the VA origin to the ostium of the SA using a highly stable shaped guiding catheter. The patient recovered from the symptoms and was discharged 4 days after the procedure. The high stability of the shaped guiding catheter is advantageous during endovascular treatment of the subclavian artery.

Balloon-hooking technique for stabilizing a guiding catheter in tortuous supra-aortic vessel: A case report.

Objective: When performing endovascular interventions for supra-aortic vessels, the tortuous vascular anatomy observed in patients with atherosclerotic lesions often limits the ability to maintain a stable guiding catheter position. Here, we report a case of right vertebral artery (VA) stenosis treated with transfemoral stenting and discuss the utility of balloon-hooking technique using partially inflated balloon for stabilizing the balloon guiding catheter (BCG) in the supra-aortic vessel. Case presentation: A 74-year-old man who underwent right carotid artery stenting, coronary artery bypass grafting, and bilateral iliac artery stenting was admitted to our emergency department because of dizziness related to head movement. Computed tomography angiography revealed right VA origin stenosis and left subclavian artery (SA) occlusion. The patient underwent stenting of the right VA. After several unsuccessful cannulation attempts into the right VA through transradial access, transfemoral access was obtained through the left iliac stent. A 9-Fr BGC was navigated into the right SA. The balloon was partially inflated just distal to the first curve of the right SA and used as hook by pulling back until the proximal edge of the balloon was pushed distally by the lesser curvature of the SA, resulting in stabilization of the BGC and successful angioplasty and stent deployment at the VA stenosis. The patient's symptoms resolved completely, without any neurological deficits. Conclusions: Balloon-hooking technique using a partially inflated BGC is feasible for stabilizing the guiding catheter in tortuous supra-aortic vessel.

Rupture of Vertebral Artery Dissecting Aneurysm after mRNA Anti-COVID-19 Vaccination: A Report of Two Cases.

The coronavirus disease 2019 (COVID-19) pandemic continues to spread around the world, and widespread vaccination is considered the most effective way to end it. Although the efficacy of COVID-19 vaccines has been confirmed, their safety remains a concern. In this paper, we report two cases of ruptured vertebral artery dissecting aneurysm (VADA) immediately after messenger RNA (mRNA) anti-COVID-19 vaccination. In Case 1, a 60-year-old woman experienced sudden headache 3 weeks before her first dose of the Moderna mRNA-1273 COVID-19 vaccine. Magnetic resonance imaging showed dilatation of the right vertebral artery (VA) without intracranial hemorrhage. A day after the vaccination, she developed subarachnoid hemorrhage with pulmonary effusion due to a ruptured right VADA. She underwent endovascular internal trapping and parent artery occlusion under general anesthesia. In Case 2, a 72-year-old woman with a previous history of the left VA occlusion due to arterial dissection developed subarachnoid hemorrhage 7 days after the first dose of the Pfizer-BioNTech BNT162b2 COVID-19 mRNA vaccine due to a ruptured right VADA and underwent stent-assisted coil embolization under general anesthesia. The postoperative courses of these two cases were uneventful. The accumulation of more cases and further study are warranted to clarify the relationship between COVID-19 mRNA vaccination and ruptured intracranial dissecting aneurysms.

Biosynthetic Gene Cluster of Linaridin Peptides Contains Epimerase Gene.

Salinipeptins belong to the type-A linaridin class of ribosomally synthesized and post-translationally modified peptides (RiPPs) comprising 22 amino acid residues with multiple D-amino acids. Although chirality of other type-A linaridins, such as grisemycin and cypemycin, has not been reported, the biosynthetic gene clusters of type-A linaridins have identical gene organization. Here, we report heterologous expression of grisemycin biosynthetic gene cluster (grm) and show that grisemycin contains multiple D-amino acids, similar to salinipeptins. The heterologous expression experiments also confirm the involvement of a novel peptide epimerase in grisemycin biosynthesis. Gene-deletion experiments indicate that grmL, a single gene with unknown function, is indispensable for grisemycin production. We also show that the presence of D-amino acids is likely a common feature of linaridin natural products by analyzing two other type-A linaridin clusters.

Identification of Cyclopropane Formation in the Biosyntheses of Hormaomycins and Belactosins: Sequential Nitration and Cyclopropanation by Metalloenzymes.

Hormaomycins and belactosins are peptide natural products that contain unusual cyclopropane moieties. Bioinformatics analysis of the corresponding biosynthetic gene clusters showed that two conserved genes, hrmI/belK and hrmJ/belL, were potential candidates for catalyzing cyclopropanation. Using in vivo and in vitro assays, the functions of HrmI/BelK and HrmJ/BelL were established. HrmI and BelK, which are heme oxygenase-like dinuclear iron enzymes, catalyze oxidation of the ϵ-amino group of l-lysine to afford l-6-nitronorleucine. Subsequently, HrmJ and BelL, which are iron- and α-ketoglutarate-dependent oxygenases, effectively convert l-6-nitronorleucine into 3-(trans-2-nitrocyclopropyl)-alanine through C4-C6 bond installation. These observations disclose a novel pathway of cyclopropane ring construction and exemplify the new chemistry involving metalloenzymes in natural product biosynthesis.

Identification of pulvomycin as an inhibitor of the futalosine pathway.

Menaquinone is an essential cofactor in the electron-transfer pathway for bacteria. Menaquinone is biosynthesized from chorismate using either the well-known canonical pathway established by pioneering studies in model microorganisms or the futalosine pathway, which we discovered in Streptomyces. Because Helicobacter pylori, which causes stomach cancer, uses the futalosine pathway and most beneficial intestinal bacteria including lactobacilli use the canonical pathway, the futalosine pathway will be a great target to develop antibiotics specific for H. pylori. Here, we searched for such compounds from metabolites produced by actinomycetes and identified pulvomycin from culture broth of Streptomyces sp. K18-0194 as a specific inhibitor of the futalosine pathway.

Discovery of an alternative pathway of peptidoglycan biosynthesis: A new target for pathway specific inhibitors.

Peptidoglycan in bacterial cell walls is a biopolymer consisting of sugars and amino acids and plays important role in maintaining cell integrity from the environment. Its biosynthesis is a major target for antibiotics and the genes and enzymes involved in the biosynthetic pathway have been well studied. However, we recently identified an alternative pathway in the early stage of peptidoglycan biosynthesis in Xanthomonas oryzae, a plant pathogen causing bacterial blight disease of rice. The distribution of the alternative pathway is limited to relatively few bacterial genera that contain many pathogenic species, including Xylella and Stenotrophomonas, besides Xanthomonas. Thus, the alternative pathway is an attractive target for the development of narrow-spectrum antibiotics specific to pathogens. In this minireview, we summarize the discovery of the alternative pathway and identification of its specific inhibitors.

High Production of Ergothioneine in Escherichia coli using the Sulfoxide Synthase from Methylobacterium strains.

We previously constructed a heterologous production system for ergothioneine (ERG) in Escherichia coli using five ERG biosynthesis genes (egtABCDE) from Mycobacterium smegmatis. However, significant amounts of hercynine (HER), an intermediate of ERG, as ERG were accumulated, suggesting that the reaction of EgtB catalyzing the attachment of γ-glutamylcysteine (γGC) to HER to yield hercynyl-γ-glutamylcysteine sulfoxide was a bottleneck. In this study, we searched for other EgtBs and found many egtB orthologs in diverse microorganisms. Among these, Methylobacterium strains possessed EgtBs that catalyze the direct conversion of HER into hercynylcysteine sulfoxide with l-cysteine (l-Cys) as a sulfur donor, in a manner similar to those of acidobacterial CthEgtB and fungal Egt1. An in vitro study with recombinant EgtBs from Methylobacterium brachiatum and Methylobacterium pseudosasicola clearly showed that both enzymes accepted l-Cys but not γGC. We reconstituted the ERG production system in E. coli with egtB from M. pseudosasicola; ERG productivity reached 657 mg L-1.

Recent advances in functional analysis of polyunsaturated fatty acid synthases.

Polyunsaturated fatty acids (PUFAs) such as docosahexaenoic acid, eicosapentaenoic acid, and arachidonic acid are essential fatty acids for humans. PUFAs are biosynthesized by either desaturases/elongases from oleic acid or PUFA synthases from acetyl units. PUFA synthases are composed of three or four subunits, and each creates a specific PUFA even though the multiple catalytic domains in each subunit are very similar. We recently dissected these PUFA synthases by in vivo and in vitro experiments and elucidated how the enzymes control PUFA profiles. Moreover, for the first time, we converted a practical microalgal docosahexaenoic acid synthase into an eicosapentaenoic acid synthase based on the results.