Evidence linking Chlamydia pneumoniae infection to atherosclerosis and to atherothrombotic events has recently emerged. A primary candidate implicated in these pathogenetic events is the 60-kDa chlamydial heat shock protein (HSP60). Another putative candidate to activate a potential proinflammatory mechanism is the chlamydial outer membrane protein 2 (OMP2). We have generated both HSP60 and OMP2 recombinant antigens in a nondenatured form and shown that (i) the two antigens were highly immunogenic in mice and (ii) murine antisera thus generated recognized the native C. pneumoniae proteins. We measured by enzyme linked immunosorbent assay (ELISA) and immunoblot assay antibody titers to the recombinant antigens in samples from 219 patients with coronary heart disease (CHD), 179 patients with unstable angina (UA), 40 patients with acute myocardial infarction (AMI), and 100 age-, sex-, and risk factor-matched healthy controls. We also examined whether anti-HSP60 and/or anti-OMP2 antibodies correlated with anti-C. pneumoniae antibodies assessed by a commercial microimmunofluorescence (MIF) assay. Immunoglobulin G (IgG), but neither IgA nor IgM, antibodies against the two recombinant proteins were detected by ELISA. In particular, anti-HSP60 antibodies were detected in >99% of CHD patients versus 0% of the controls, whereas the proportions of anti-OMP2 positive subjects were >70 and 27%, respectively. Nonetheless, among CHD patients, similar frequencies of positive subjects and titers of anti-HSP60 or anti-OMP2 antibodies were present in UA and AMI subjects. The anti-OMP2, but not the anti-HSP60, antibodies showed high specificity. Consistently, high serological correlation was observed between IgG MIF titers and IgG ELISA reactivity to OMP2 but not to HSP60. Overall, the results of this study demonstrate a strong correlation between CHD and anti-HSP60 IgG levels, as measured by our in-house ELISA. They also suggest that recombinant OMP2 ELISA, because of its high specificity and strong correlation with MIF assay, could be a candidate diagnostic marker for C. pneumoniae infection, which would be of potential usefulness for its specificity and nonsubjective nature.

Antibodies to 60-kilodalton heat shock protein and outer membrane protein 2 of Chlamydia pneumoniae in patients with coronary heart disease.

Most publications on the relationship between infection with Chlamydia pneumoniae and coronary heart disease (CHD) propose an association, but negative studies are also reported. Seroepidemiological studies vary in the use of different serological methods, different cutoff limits, different sampling times in relation to acute cardiac events, and different clinical stages of CHD. We wanted to compare three different commercially available methods for measuring Chlamydia antibodies to see how the choice of method influenced the prevalence of seropositive individuals in CHD patients and in healthy individuals and to see if sampling time in relation to an acute cardiac event or the stage of atherothrombotic disease influenced the results. Blood samples from 197 CHD patients and 197 individually matched healthy control individuals were tested at baseline and after 6 months; the mean age was 55 years in both groups, and 18% were women. Among the CHD patients, 166 were included at a median of 16 days after an acute cardiac event and 31 had chronic disease with the latest acute event being >3 months earlier. The difference in prevalence of antibodies between the CHD patients and the healthy controls was significant when Chlamydia lipopolysaccharide antibodies were measured, while no significant differences between the study groups were observed by the two methods detecting Chlamydia pneumoniae major outer membrane protein antibodies. The number of seropositive individuals was quite similar at inclusion and 6 months later, and no significant differences were observed between patients with a recent cardiac event and those with a more remote cardiac event. We conclude that the choice of serological method is of major importance when evaluating a possible relationship between C. pneumoniae and CHD.

Chlamydia pneumoniae Serology: Importance of Methodology in Patients with Coronary Heart Disease and Healthy Individuals

https://scholarlypublications.universiteitleiden.nl/access/item%3A3138648/view

Chlamydia pneumoniae, Helicobacter pylori and cytomegalovirus infections and the risk of peripheral arterial disease in young women

Detection of Chlamydia pneumoniae antigenin PBMNCs of healthy blood donors.

Cardiovascular disease (CVD) is rapidly becoming an important public health problem in sub-Saharan Africa, yet the response so far is often minimal and inadequate. While there is, undoubtedly, a 'double burden of disease' (persisting infectious diseases co-existing with emerging non-communicable disease), this is hardly reflected in current health planning, possibly due to a limited appreciation of the changing pattern of CVD and CVD risk factor exposure. In a situation where there are also considerable budget constraints and well-established infectious disease priorities, it is difficult to implement effective interventions for prevention or treatment of CVD. Yet such planning is urgently needed and a template for a comprehensive programme, adaptable to local situations, is presented here. The first step is to raise awareness and create evidence-based commitment among policy-makers, which could lead to the establishment of a multi-sectoral CVD unit at national level. Programmes need to focus on prevention of modifiable risk factors at population level, involving a wide range of institutions and individuals. Recommended strategies include decentralizing the design and implementation of programmes, with appropriate standardized surveillance of major risk factors, all complemented by operational, epidemiological and basic research.

A template for improved prevention and control of cardiovascular disease in sub-Saharan Africa

Background: The role of Chlamydia pneumoniae in the pathogenesis ofatherosclerosis has so far mainly been investigated in patients suffering from coronary heart disease; the other vascular regions have virtually been ignored. The aim of this study was to carry out a statistical survey of serological markers of a C. pneumoniae infection in patients with different patterns ofatherosclerosis manifestation. Patients and methods: 340 patients were examined for the atherosclerotic alteration of peripheral arteries of the lower limbs, carotid arteries and coronary arteries by ultrasound scan and/or angiography. Immunoglobulin(Ig)G and IgA-rELISA were used to measure chlamydial lipopolysaccharide antibodies. Species determination was performed using the IgG micro-immunofluorescence test. Results: 24.0% of atherosclerotic cases (A) and 52.3% of controls (C) were negative for C. pneumoniae lipopolysaccharide antibodies (p = 0.00002). By contrast, 45.1% of atherosclerotic cases and 16.9% of controls were positive for both IgG and IgA (p = 0.00002). The mean antibody titers of the atherosclerosis group were higher than in the control group (IgG positive x A IgG = 344, x C IgG = 272; IgG and IgA positive x A IgG = 576, x C IgG = 486 and x A IgA = 120, x C I-gA = 91). Concerning atherosclerosis manifestation in various vascular regions, no significant differences were found between IgG and IgA antibody titers and prevalence. Conclusions: The results show that a persistent C. pneumoniae infection with evidence of lipopolysaccharide immunoglobulin G and A is equally associated with the atherosclerotic alteration of coronary arteries, carotid arteries and peripheral arterial occlusive disease, irrespective of the severity of atherosclerosis and with no predisposition to any particular vascular region.

Serological evidence of Chlamydia pneumoniae lipopolysaccharide antibodies in atherosclerosis of various vascular regions.

HISTORY AND CLINICAL FINDINGS A 41-year-old man was admitted to hospital for acute pain in the right flank. At first urolithiasis was suspected but excluded by sonography and excretion urography. Computed tomography (CT) was performed because of increasing pain and swelling of the left leg. It showed bilateral thrombosis of the deep leg and pelvic veins as well as of the infrarenal inferior vena cava (IVC) and the right renal vein. The patient's general condition was impaired. The circumference of the left leg was greater than that of the right by 5 cm 15 cm above the knee joint space and both legs had marked varicosities with congestive dermatitis. INVESTIGATIONS The concentration of the thrombin-antithrombin complex was 13.4 micrograms/l, D-dimer 124 micrograms/l, prothrombin fragment F1+2 3,5 nmol/l and fibrin monomere 27.7 micrograms/ml, as expression of a manifest thrombosis. CT with contrast medium demonstrated the previously sonographically shown extent of the thrombosis. In addition the hepatic IVC segment was absent. The azygos vein was enlarged and there was an extensive collateral circulation. TREATMENT AND COURSE Systemic thrombolysis (streptokinase for 3 days, then urokinase) for 11 days dissolved the thrombi and CT now demonstrated complete recanalization of the caudal deep vein system and the IVC abnormality (absence of hepatic segment). After intravenous thrombolysis oral anticoagulation with phenprocoumon was started and will be continued all the patient's life.

Thrombolyse einer ausgedehnten Venenthrombose der unteren Körperhälfte bei Anomalie der Vena cava inferior

History and clinical findings A 42-year-old man was admitted for treatment of peripheral vascular disease in the left leg (stage III of Fontaine). A year before he had undergone a right aortofemoral bypass operation. On admission there was stenosis of the left pelvic axis and bilateral femoral artery occlusion. In addition there were changes in the skin with abnormal folds, loss of elasticity and yellowish spots over the sides of the neck and the flexor surfaces of all large joints. In addition vision in the left eye was impaired. These findings suggested connective tissue disease involving the skin, eye and arterial system. Investigations Routine haematological tests were normal as were clotting parameters. Serum concentration of GOT, GPT, gamma-GT were slightly increased. There was a dysproteinaemia with raised HDL and LDL levels. Resting electrocardiogram was normal, showing sinus rhythm and left axis deviation. The crurobrachial pressure index was clearly abnormal: 0.6 on the right and 0.5 on the left. Angiography of the pelvic and left arteries revealed long-segment femoral and partial lower-leg occlusions bilaterally. Abdominal sonography indicated diffuse parenchymal calcifications in both kidneys and angioid streaks on bilateral fundoscopy. Skin biopsy showed defects of elastic fibres and perivascular inflammatory infiltration, while capillary microscopy revealed twisting of the capillaries, most of them with normal lumen. These findings taken together indicated pseudoxanthoma elasticum (PXE) or Gronblad-Strandberg syndrome. Treatment and course A thrombendarterectomy was performed on the left superficial femoral artery, after which the left popliteal artery became palpable, the pressure indices for the left leg were slightly better, and the patient was discharged home without further complications and improved leg perfusion. Conclusion Possible cardiovascular involvement had to be taken into account in patients with PXE, and long-term angiological monitoring is indicated.

[Grönblad-Strandberg syndrome from the angiological viewpoint].

Coumarin necrosis is a rare but clinical very important complication of therapy with coumarin derivatives. We report a patient with congenital protein S deficiency type II, who developed coumarin necrosis during stabilization of phenprocoumon. Diagnostic problems and therapeutic alternatives are discussed considering the recent literature.

Recurrent coumarin necrosis in type II protein S deficiency

HISTORY AND CLINICAL FINDINGS On the day before admission a 68-year-old woman had an acute episode of incomplete ischaemia of the left lower arm. She had no known heart disease and her general condition was unchanged. There were no palpable pulses in the cold and pale lower arm. Sensory and motor functions of the left hand were slightly impaired. Arterial embolisation was suspected. INVESTIGATIONS The blood picture was normal, erythrocyte sedimentation rate 20/50 mm, C-reactive protein elevated to 7.0 mg/l. There was no evidence of clotting abnormality. The resting ECG showed normal sinus rhythm. Doppler ultrasound gave a systolic pressure of 80 mm Hg over the radial artery and 50 mm Hg over the ulnar artery, with a systemic systolic pressure of 140 mm Hg. No intracardiac thrombi were seen on echocardiography. Transoesophageal echocardiography revealed a 2 x 3 cm hypermobile mass in the distal aortic arch, most likely a thrombus as the source of the embolus. Contrast computed tomography and digital subtraction angiography also demonstrated the mass. TREATMENT AND COURSE At first heparin (bolus of 5000 IU, then 1000 IU/h) was infused. One day after the diagnosis had been established thrombectomy of the aortic arch and embolectomy of the left brachial artery were performed without complication. The patient was discharged on the 15th post-operative day on a maintenance dose of phenprocoumon. Histological examination of the surgical specimen from the aorta showed a separating thrombus on an ulcerating atherosclerotic plaque. CONCLUSION The importance of the thoracic aorta as a source of emboli is often underestimated. Transoesophageal echocardiography is a reliable method to demonstrate aortic thrombi.

Der Aortenbogen als Quelle einer peripheren arteriellen Embolie

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