Aim: To examine three lineages of Toxoplasma gondii RH strain in terms of performance in the dye test, culture, and gene expression.
Methods: Historical data (culture growth and performance in the dye test) from three lineages of RH strain tachyzoites (B, J, and Q) that had been continuously cultured in HeLa cells was assessed. Tachyzoite harvests obtained during continuous cell culture were retrieved from liquid nitrogen and cultured in HeLa cells, providing mRNA that was extracted and used to study gene expression using random amplified polymorphic DNA analysis at different stages of lineage adaptation to continuous culture.
Results: The B and Q lineages consistently produced tachyzoites that were successfully used in the dye test and their gene expression was stable after multiple passages. The J lineage had unpredictable growth, tachyzoites unsuitable for use in the dye test, and changing gene expression with multiple passage.
Conclusion: This study has explained some anomalies in the performance of different stocks of T gondii, and suggests that lineages that are still evolving in cell culture should be avoided.
random amplified polymorphic DNA analysis; RH strain; Toxoplasma gondii; continuous cell culture; gene expression
Cerebrospinal fluid from 100 patients with clinically diagnosed meningitis was examined for alpha-interferon. In the laboratory four patient groups were identified: bacterial meningitis (n = 12), viral meningitis (n = 15), normal cerebrospinal fluid (n = 57) and abnormal cerebrospinal fluid (n = 16). A further 14 patients with cerebrospinal fluid shunts but no abnormality in the cerebrospinal fluid provided a control group for alpha-interferon determinations. The group with viral meningitis and the group with abnormal cerebrospinal fluid had significantly higher alpha-interferon concentrations (p less than 0.001) when compared with those of the three other groups. This assay had great predictive value in determining those patients with abnormal cerebrospinal fluid who did not have a bacterial cause of meningitis. As the groups with abnormal cerebrospinal fluid and viral meningitis had a similar spread in alpha-interferon values it is likely that both reflect viral infection of the central nervous system.
Pseudohyperkalaemia is described from a patient with infectious mononucleosis. The in vitro release of potassium was associated with clotting and all the blood cells may have been involved.
Aims: Previous studies investigating the link between infection with Borrelia burgdorferi and morphoea have produced conflicting results. Often, these studies have been undertaken in patients from different regions or countries, and using methods of varying sensitivity for detecting Borrelia burgdorferi infection. This study aimed to establish whether a relation could be demonstrated in the Highlands of Scotland, an area with endemic Lyme disease, with the use of a sensitive method for detecting the organism.
Methods: The study was performed on biopsies of lesional skin taken from 16 patients from the Highlands of Scotland with typical clinical features of morphoea. After histological confirmation of the diagnosis, a nested polymerase chain reaction (PCR) using primers to a unique conserved region of the Borrelia burgdorferi flagellin gene was performed on DNA extracts from each biopsy. A literature search was also performed for comparable studies.
Results: None of the 16 patients had documented clinical evidence of previous infection with B burgdorferi. DNA was successfully extracted from 14 of the 16 cases but all of these were negative using PCR for B burgdorferi specific DNA, despite successful amplification of appropriate positive controls in every test. The results were compared with those of other documented studies.
Conclusions: Examination of the literature suggests that there is a strong geographical relation between B burgdorferi and morphoea. These results, in which no such association was found, indicate that morphoea may not be associated with the subspecies of B burgdorferi found in the Highlands of Scotland.
morphoea; Borrelia burgdorferi; polymerase chain reaction
Aims—To determine whether IgG immunoblotting can improve the diagnosis of ocular toxoplasmosis.
Methods—Samples of serum were tested from patients with ocular lesions that could be caused by toxoplasmosis. All such samples from Scotland and Northern Ireland are usually referred to the Scottish Toxoplasma Reference Laboratory. From questionnaires filled out by the clinicians, two groups of sera were identified: ocular toxoplasmosis (active and quiescent), n = 54 (group 1); and eye disease as a result of other causes, n = 36 (group 2). Control groups were made up of sera from patients with no eye disease and a normal dye test result (≤ 125 IU/ml), n = 16 (group 3); and toxoplasma seronegative, cytomegalovirus (CMV) positive, and herpes simplex virus (HSV) positive sera (group 4), n = 18.
Results—Immunoblots with an active pattern could be identified (IgG antibodies against at least four antigens with molecular weight of 6, 20, 22, 23, 25, and 36 kDa). Significantly more of this pattern was found in group 1 (33 of 54; 61.1%) compared with group 2 (nine of 36; 25%) or group 3 (six of 16; 37.5%). Within group 1, significantly more sera with an active pattern had dye test results ≥ 65 IU/ml compared with those without. More sera from patients < 30 years of age were found with the active pattern in group 1 compared with group 2. No group 4 sera had active immunoblot patterns.
Conclusions—The immunoblot result adds more support to the diagnosis of ocular toxoplasmosis. In cases where the clinical diagnosis is difficult, immunoblots are particularly indicated; if negative, other causes of eye disease should be sought.
ocular toxoplasmosis; IgG immunoblotting; dye test
Aim—To characterise 12 Borrelia burgdorferi sensu lato isolates cultured from ticks collected in the Highlands of Scotland.
Methods—Three molecular methods were used: an outer surface membrane protein A (OSP A) gene polymerase chain reaction (PCR) designed to give different molecular weight products with different genomic groups, randomly amplified polymorphic DNA (RAPD) analysis, and ribosomal RNA (rRNA) gene PCRs using genomic group specific primers.
Results—All of the molecular methods used were quick and easy to perform and capable of differentiating between the different genomic groups of B burgdorferi sensu lato. All 12 tick isolates were characterised successfully with each method: five were characterised as B afzelii and seven were characterised as B burgdorferi sensu stricto. RAPD also identified differences within these genomic groups.
Conclusions—From this study, it is now known that at least two different B burgdorferi sensu lato genomic groups are present in the Highlands of Scotland: B afzelii and B burgdorferi sensu stricto. This information can now be used to develop appropriate serological tests, which should improve the diagnosis and management of patients with Lyme disease in Scotland. The molecular methods chosen were found to be useful typing tools and will allow rapid identification of any future isolates.
Borrelia burgdorferi; randomly amplified polymorphic DNA analysis; ribosomal RNA gene polymerase chain reaction
AIMS: To identify antigens detected by western blotting in primary Toxoplasma gondii infection and determine their role in diagnosis of reactivated toxoplasmosis. METHODS: Twenty three immunocompromised patients were tested by IgG western blotting. Patients were grouped retrospectively. Group 1 comprised 15 human immunodeficiency (HIV)/AIDS patients and included: group 1A (six patients with clinical and/or serological evidence of reactivation), group 1B (five patients with clinical evidence only), and group 1C (four asymptomatic patients). Group 2 comprised eight non-HIV/AIDS immunocompromised patients with clinical and/or serological evidence of reactivation. Immunocompetent patients (n = 23) with primary toxoplasmosis were a control group used to determine the progression of the antigens detected. RESULTS: In primary toxoplasmosis, antibodies against 6, 20, 22, 23, 25, 28, 29, and 36 kDa antigens predominated. Detection of four or more of the 6, 20, 22, 23, 25, and 36 kDa antigens was considered to be western blot positive. In two group 1A patients, western blotting indicated past infection. During reactivation, this reverted to being western blot positive. Three other group 1A patients were western blot positive. In three of five group 1B patients, western blot positive results improved serological diagnosis of reactivated toxoplasmosis (p < 0.05). In two of five group 1B patients and all four group 1C patients, western blot indicated past infection. In group 2, two of eight patients reverted from a pattern of past infection to western blot positive. Five other patients from group 2 were western blot positive. CONCLUSIONS: Detection of some low molecular weight antigens is diagnostic of reactivated toxoplasmosis. These antigens can be detected even with normal dye test titres and their detection improves the diagnosis of reactivated toxoplasmosis. They might be the result of the release of bradyzoites from ruptured tissue cysts.
AIM: To determine the value of tests for specific IgA, IgE, and IgG avidity in diagnosing Toxoplasma gondii infection during pregnancy. METHODS: In a retrospective study, current serological tests (dye test and three IgM assays with different sensitivities) were compared with immunosorbent agglutination assays (ISAGA) for specific IgA and IgE and an IgG avidity enzyme linked immunosorbent assay (ELISA). Patient group 1 comprised six women with definite or probable infection during pregnancy determined by congenital toxoplasmosis or laboratory results. Group 2 comprised seven women infected during or before 11 pregnancies (two consecutive pregnancies in two patients and three in a third). RESULTS: One patient in group 1 seroconverted during pregnancy. IgA ISAGA and avidity confirmed acute infection when confirmatory IgM ELISA remained negative. In five of six patients from group 1, IgA and IgE ISAGA and avidity confirmed acute infection. In group 2, the dye test titre was raised in seven of 11 pregnancies (six of seven patients). Specific IgM and IgA were positive during all 11 pregnancies. IgE ISAGA was positive in only four of 11 pregnancies (three of seven patients), but negative results in the remainder may exclude acute infection. High avidity antibodies indicative of past infection were found in four of 11 pregnancies (two of seven patients). CONCLUSIONS: Each test improved diagnosis or timing of infection but no single test was ideal. The IgA ISAGA was sensitive and detected seroconversion. Positive IgE ISAGA and low avidity both confirmed infection, whereas negative IgE may exclude acute infection. High avidity diagnosed past infection but persistence of low avidity reduced its value to differentiate acute and past infection. Further studies with larger patient groups are needed to determine the optimum diagnostic strategy. These techniques are valuable in complementing existing tests.
Aims—To determine whether enzyme linked immunosorbent assay (ELISA) results for Borrelia burgdorferi require confirmation by immunoblotting and how immunoblotting may best be used in the diagnosis of Lyme disease.
Methods—Over one year, all referrals for Lyme disease to a district general hospital with a large tick population in its catchment area were tested by ELISA. Positive, low positive and negative serum samples were subjected to immunoblotting and the reactive bands analysed.
Results—In total, 633 samples were received; 38 were ELISA positive and 97 low positive. More serum samples were from rural (n = 356) than from urban (n = 277) areas but a higher percentage of serum samples from urban areas were ELISA positive. The ELISA results were confirmed by immunoblotting in 15/38 positive samples but in only four of 37 with a low positive titre. An IgM positive blot required a 41 kDa band plus ≥1 specific band; for IgG a 41 kDa band plus ≥2 specific bands were necessary. Five serum samples were IgM positive with a 41 kDa plus one or more other specific bands. For IgG blots, the best discrimination was seen with the 21, 31, 46, and 92 kDa bands. Nonspecific, weakly reacting bands at 55, 60 and 67 kDa were frequently seen. Infection was confirmed in four of six patients with arthritis, but in only one of 10 patients with erythema chronicum migrans.
Conclusions—ELISA alone is insufficient for diagnosis. All positive and low positive or negative serum samples with a good clinical history should be examined by immunoblotting. A higher percentage of modified ELISA positive than low positive results were confirmed. There are significant differences between European and American immunoblotting patterns. Local results show similarity to American results, highlighting the need for a local Borrelia isolate.
Lyme disease; ELISA; immunoblotting; Borrelia burgdorferi
Aim—To compare the techniques and results of a nested PCR and an immunofluorescence assay (IFA) for the detection of Pneumocystis carinii infection; to consider the role of the nested PCR in the diagnosis of P carinii pneumonia (PCP).
Methods—Serial dilutions of two known P carinii positive samples were tested by IFA and PCR to determine their relative sensitivities. Seventy eight respiratory samples (15 from 11 patients with HIV infection/acquired immunodeficiency syndrome (AIDS) and 63 from 42 patients with other forms of immunodeficiency) were tested using both assays, and the costs and technical requirements of each assay were assessed.
Results—The PCR had a greater relative sensitivity over the IFA of 2 × 101 to 2 × 103 fold in a postmortem lung sample and 2 × 105 to 2 × 106 fold in a bronchoalveolar lavage sample from a patient with PCP. P carinii was detected in all 15 samples from the patients with HIV/AIDS by both IFA and PCR. Of the 63 samples from the patients with immunodeficiencies other than HIV/AIDS, the PCR was more sensitive than IFA.
Conclusions—The nested PCR is a more sensitive assay than the IFA. It may be useful in the diagnosis of PCP in patients with immunodeficiencies other than HIV/AIDS. Similarly, PCR may be of benefit for this patient group as less invasive specimens are needed. PCR has an increasing role to play in the diagnosis of PCP in the routine laboratory.
Pneumocystis carinii; PCR; immunofluorescence assay; acquired immunodeficiency syndrome
AIMS: To assess the value of detecting Toxoplasma gondii in human blood samples using the polymerase chain reaction (PCR). METHODS: Blood samples in lithium heparin were examined from 34 patients with suspected toxoplasmosis, and six healthy volunteers with or without the addition of doubling dilutions of toxoplasma tachyzoites. Products of a nested PCR, using oligonucleotide primers of the B1 gene, were analysed by electrophoresis and stained by ethidium bromide. The primary product was 194 base pairs in length; the nested products were 160 or 97 base pairs. RESULTS: When toxoplasma tachyzoites were added to the leucocytes of six different volunteers, eight to 16 parasites were detected by nested PCR in one experiment and one to four parasites in eight experiments. All nine experiments were negative in samples without added tachyzoites. Of 34 patients, PCR was negative in 13 with recent lymphadenopathy; nine with persisting IgM, including two pregnant patients; four with reactivated infection due to immunodeficiency; and five with no evidence of active infection. Positive PCR results were found in three patients with reactivated infection. There was only one discrepancy between PCR and animal culture results; this was in an immunocompromised patient with a positive PCR and negative culture. CONCLUSIONS: The PCR technique was rapid, sensitive, and specific in human blood samples. Negative PCR results in patients with persisting IgM suggested that the fetus was not at risk, or that treatment was not indicated in myalgic encephalomyelitis-like illness. PCR results in immunocompromised patients permitted appropriate management--no treatment if negative, treatment if positive.
AIMS: To compare the sensitivity and user friendliness of seven commercially available enzyme linked immunoabsorbent assay (ELISA) kits for toxoplasma specific IgM. METHODS: Five antibody capture assays supplied by Abbott, Mercia, Northumbria, Organon and Sorin, and two indirect ELISA assays from Biostat and Mast, were assessed. Using defined dilutions of Toxoplasma gondii specific IgM, the performance and sensitivity of each assay was established. They were further assessed on a panel of 27 sera with a range of dye test and IgM results (as determined by the Scottish Toxoplasma Reference Laboratory). All of the assays were performed by three experienced operators and assessed for user satisfaction. RESULTS: The Mast, Organon, and Abbott assays were of low sensitivity; the Mercia and Northumbria were of high sensitivity; and the Biostat and Sorin assays produced too many false positive results. The Mercia kit provided most user satisfaction; the Mast and Abbott assays were most difficult to use. CONCLUSIONS: Local laboratories investigating toxoplasma infection should have three tests: one IgG and two IgM (high and low sensitivity) to help in the timing of infection. Alternatively, one sensitive IgM assay, such as that of Mercia, could be used by selecting appropriate high and low thresholds.
The IgG antibody profile to Toxoplasma gondii proteins of less than 37 kilodaltons in sera from patients with acute and previous infection was studied by immunoblotting. Bands at 28, 29, and 36 kilodaltons were more common in acute infection (10 out of 10, nine out of 10, and nine out of 10, respectively) compared with previous infection (five out of 10, four out of 10, and one out of 10, respectively). The 6 kilodalton band was present in 10 out of 10 sera from patients with acute infection and five out of 10 sera from those with previous infection. A new observation is a doublet of bands of 22-25 kilodaltons present only in sera from patients with acute infection. This doublet may be a more reliable indicator of acute infection than the 6 kilodalton band.
A rapid test for the detection of IgM and IgG Epstein-Barr nuclear antigen (EBNA-1) has been extensively marketed. If IgM to Epstein-Barr viral capsid antigen (EBV VCA) is taken as evidence of current EBV infection, one observer detected 17 of 38 such samples and the other 22 of 38 as acute. The positive predictive value of the test was 63%, and the greatest difficulty was posed by the detection of IgM EBV VCA positive, heterophile antibody negative samples. Significant false positive results were obtained in sera with evidence of current Toxoplasma gondii, cytomegalovirus, and adenovirus infection. Rheumatoid factor was not a problem. Modification of the test protocol improved its performance: the positive predictive value rose to 87% and the negative predictive value to 81%. Although our modifications did not increase the speed of the test, there was reliable information on the EBNA-1 state. The test is best used as an adjunct to other EBV serology, and laboratories should be aware of the limitations of the rapid test.
In order to examine the prevalence of patients with symptoms fulfilling the criteria for the chronic fatigue syndrome an extensive survey was carried out of general practitioners on 10 local government lists in two health boards (91% response rate). At the same time practitioners' attitudes to the syndrome and their experience in terms of workload and the characteristics of patients affected were documented. The majority of general practitioners (71%) accepted the existence of chronic fatigue syndrome, but 22% were undecided. The doctors reported a prevalence among their patients of 1.3 per 1000 patients (range 0.3-2.7 for the 10 areas) with a peak in the 30-44 years age group. Female patients were more commonly affected than males (sex ratio 1.8:1.0), but the severity of illness and the use of general practitioner's time was the same among male and female patients. Patients in occupations where they were exposed to infection were affected (teachers and students, 22% of sample; hospital workers, 7%), but many patients were unskilled (8%) and skilled workers (9%). Patients suffering from the chronic fatigue syndrome appear to be a real and distinct group for general practitioners and may represent a substantial part of the workload of doctors in particular areas.
A case definition for post-viral fatigue syndrome is proposed within which various subgroups of patients exist. Any one treatment may not apply to all the subgroups. In particular, patients' experiences do not show that avoidance of exercise is maladaptive. It is proposed that the recently ill often try to exercise to fitness whereas the chronically ill have learnt to avoid exercise. Recovery is more likely to be achieved if patients learn about their illness and do not exhaust their available energy.