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Background Mycoplasma pneumoniae and Chlamydia pneumoniae are atypical pathogens responsible for pneumonia and a leading cause of morbidity and mortality in low income countries. The study objective is to determine the prevalence of this pathogens in Peruvian children with acute respiratory infections. Methods A consecutive cross-sectional study was conducted in Lima, Peru from May 2009 to September 2010. A total of 675 children admitted with clinical diagnoses of acute respiratory infections were tested for Mycoplasma pneumoniae and Chlamydia pneumoniae detection by polymerase chain reaction (PCR), and clinical symptoms were registered by the attending physician. Results Mycoplasma pneumonia was detected in 25.19% (170/675) of nasopharyngeal samples and Chlamydia pneumonia in 10.52% (71/675). The most common symptoms in patients with these atypical pathogens were rhinorrhea, cough and fever. A higher prevalence of Mycoplasma pneumoniae cases were registered in summer, between December 2009 and March 2010. Conclusions Mycoplasma pneumoniae and Chlamydia pneumonia are a significant cause of morbidity in Peruvian children with acute respiratory infections (ARI). Further studies should evaluate the use of reliable techniques such as PCR in Peru in order to avoid underdiagnoses of these atypical pathogens.

Abdominal aortic aneurysm (AAA) is a common disease that develops gradually over several years and is characterised by weakening and dilatation of the aortic wall. AAAs also demonstrates a marked inflammatory infiltrate throughout the aortic wall. Chlamydophila pneumoniae (C. pneumoniae), is a common bacterium. About 50% of the population has been infected in adolescence. Thirteen studies report the presence of either C. pneumoniae or its antigens in 35-100% of AAA specimens. The overall aim of this thesis was to evaluate the possible role of C. pneumoniae in inflammatory response and expansion of AAA from a clinical point of view. In paper I, viable C. pneumoniae was detected in a majority of 26 patients with AAA having open surgery. Patients operated for AAA had higher C. pneumoniae antibodies titers than controls. In paper II, 247 patients were randomised in a double-blind trial, to evaluate the effect of azithromycin on the expansion of small AAAs. No such effect was seen and there was no correlation between C. pneumoniae antibody titers and AAA expansion. In paper III, 42 patients with AAA were compared to 100 age- and sex matched controls with normal aortas. C. pneumoniae antibodies were analysed in plasma samples obtained at screening, and in samples from a study conducted 5-15 (mean 12) years previously on the same population. There was no significant difference between the groups. In paper IV, were 211 patients were analysed, we could not find an association between levels in plasma of three markers of inflammation (IL-6, MMP-9 and CRP) and AAA expansion. A significant reduction in AAA expansion rate was found in patients treated with a combination of ASA and statins. In conclusion, viable C. pneumoniae is found at the scene of the crime, but we were unable to reverse or halt expansion of AAA with antibiotic treatment. C. pneumoniae antibody titers cannot be used, to detect small AAA, or to evaluate AAA expansion. From a clinical point of view, based on the methods and analyses used in this thesis, the role of C. pneumoniae in the inflammatory response and expansion of abdominal aortic aneurysms is limited.

Diss. (sammanfattning) Uppsala : Univ., 2002. / Härtill 5 uppsatser.

Diss. (sammanfattning) Stockholm : Karol inst., 2004. / Härtill 6 uppsatser.

Diss. (sammanfattning) Stockholm : Karol. Inst., 2002. / Härtill 4 uppsatser.

Thesis (Ph.D. )--University of Tennessee Health Science Center, 2007. / Title from title page screen (viewed on May 16, 2008 ). Research advisor: Gerald I. Byrne, Ph.D. Document formatted into pages (xi, 114 p. : ill.). Vita. Abstract. Includes bibliographical references (p. 65-107).

Introdução: Aneurisma de aorta é considerado uma doença inflamatória crônica, mas ainda é controverso se está relacionado a aterosclerose aos agentes infecciosos. Antígenos de Chlamydophila pneumoniae (CP) e Mycoplasma pneumoniae (MP) foram encontrados em grande quantidade nas placas instáveis que usualmente estão associadas a remodelamento positivo e inflamação do vaso. Metaloproteinase da matriz 9 (MMP-9) está implicada na fragilidade da parede vascular e na formação dos aneurismas. Os efeitos imunomodulatórios dos receptores ativados por proliferador de peroxissomo (PPARs) têm sido relacionados à aterosclerose. Objetivos: Comparar lesões ateroscleróticas graves com e sem aneurisma do ponto de vista inflamatório e infeccioso, analisando antígenos de MP e CP e expressão de MMP-9, TIMP-1 e PPARs. Métodos: No presente estudo quantificamos, através da técnica de imunoistoquímica, antígenos de MMP- 9, TIMP-1, PPARs a e , e dos agentes infecciosos CP e MP em fragmentos de aorta ateroscleróticos com aneurisma (n=14) e sem aneurisma (n=14). Resultados: A adventícia e o tecido adiposo periadventicial (TAP) dos aneurismas apresentaram intensa inflamação. Expressão de MMP-9 esteve aumentada no TAP e agentes infecciosos, TIMP-1 e PPAR a estiveram aumentados na adventícia e no TAP, sem diferença em relação a expressão de PPAR . Colágeno, TIMP-1 e PPARs estiveram positivamente correlacionados no grupo com aterosclerose, mas não no grupo com aneurisma. Conclusão: Nossos achados sugerem que aneurisma de aorta é uma complicação das lesões ateroscleróticas. Quantidade aumentada de Chlamydophila pneumoniae e Mycoplasma pneumoniae na adventícia e PAT sem correlação da resposta de TIMP-1 e PPARs são achados que estão associados com a presença de aneurisma nos segmentos de aorta ateroscleróticos / Introduction: Aortic aneurysm is considered a chronic inflammatory disease, but remains a controversial matter if it is related to atherosclerosis and infectious agents. Chlamydophila pneumoniae (CP) and Mycoplasma pneumoniae (MP) antigens were found in higher amount in unstable plaques that are usually associated to positive remodeling and vessel inflammation. Matrix metalloproteinase 9 (MMP-9) has been implicated in vascular wall fragility and aneurysm development. The immunemodulator effects of peroxisome proliferators - activated receptor (PPARs) have been related to atherosclerosis. Objectives: To compare severe atherosclerotic lesions with and without aneurysms by inflammatory and infectious point of view, analyzing MP and CP, MMP-9, TIMP-1 and PPARs antigens. Methods: In the present study we quantified, using immunohistochemistry technique, MMP-9, TIMP-1, PPAR a and and infectious agents CP and MP antigens in aortic atherosclerotic fragments with aneurysms. (n=14) and without aneurysms (n=14). Results: Adventitia and periadventitial adipose tissue (PAT) from aneurysms showed intense inflammation. MMP-9 expression has increased in PAT and the infectious agents, TIMP-1 and PPAR a were increased in adventitia and PAT in aneurysmatic group, without difference related to PPAR expression. Collagen, TIMP-1 and PPARs were positively correlated in atherosclerotic group, but it was not observed in aneurysmatic group. Conclusion: Our data have suggested that aortic aneurysm is a complication of aortic atherosclerotic lesions. Increased amount of Chlamydophila pneumoniae and Mycoplasma pneumoniae in the adventitia and PAT without a correlated TIMP-1 and PPARs response are findings that were associated with the presence of aneurysm in atherosclerotic aortic segments

Introdução e Objetivo: A doença mixomatosa da valva mitral leva ao comprometimento de sua matriz devido à alteração em sua composição tecidual provocada pelo desequilíbrio na quantidade de ácidos mucopolissacarídeos ou glicosaminoglicanos. Sua etiologia ainda não está totalmente esclarecida, podendo ocorrer em formas familiares com transmissão autossômica dominante de penetrância variável, que pode ser dependente do tempo ou de prováveis fatores ambientais, situações em que a interação de agentes infecciosos necessita de maiores esclarecimentos. O objetivo deste estudo é a análise dos produtos dos patógenos da Chlamydophila pneumoniae, Mycoplasma pneumoniae e Borrelia burgdorferi em segmentos de cúspide retirados da valva mitral com degeneração mixomatosa, comparada ao grupo controle e a relação dos produtos bacterianos com aumento de marcadores inflamatórios (CD20, CD48, CD68) e de metaloproteinase (MMP9) na etiopatogenia da degeneração mixomatosa da valva mitral. Método: Estudo observacional, analítico, tipo caso-controle, que analisou 2 grupos contendo 20 pacientes cada e divididos em grupo 1, composto por fragmentos de tecido valvar mitral com diagnóstico de degeneração mixomatosa extraídos em procedimentos de troca ou plásticas valvares mitrais; e grupo 2, formado por segmentos de valvas mitrais sem valvopatia retirados no serviço de verificação de óbito. Foram realizadas colorações de hematoxilina e eosina e Movat para diagnóstico histológico da degeneração mixomatosa e técnica de imunohistoquímica para detecção de antígenos da Borrelia burgdorferi, Mycoplasma pneumoniae, mediadores inflamatórios (CD20, CD45, CD68) e marcadores de metaloproteinase (MMP9). A presença de antígenos da Chlamydophila pneumonia e foi pesquisada pela técnica de hibridização in situ. A análise quantitativa dos aspectos microscópicos foi realizada com o analisador de imagens Aperio. A pesquisa de elementos bacterianos foi feita através de microscopia eletrônica de transmissão. Resultados: No grupo 1, 14 (70%) pacientes são do gênero masculino e 6 (30%) do gênero feminino. A idade média é de 67,4 anos (51 a 79 anos, dp = 9,2). No grupo 2, 11 (55%) pacientes são do gênero masculino e 9 (45%) do gênero feminino. A idade média é de 67,6 anos (42 a 84 anos, dp= 12,0). Na análise da porcentagem de degeneração mixomatosa pela coloração Movat, houve diferença com significância estatística entre os grupos DM (G1), com média de 54,6 % ± 23,7 e grupo controle (G2) com média de 35,5 % ± 22,5 com valor de p = 0,013. Houve um maior número de células CD20 positivas/mm2 no grupo com DM com mediana igual a 17,8 (6,7 - 27,9) x 4,6 (3,6 - 9,8) com p = 0,007 para a área 1. Houve maior número de células CD45 positivas/mm2 no grupo com DM com mediana igual a 17,3 (3,4 - 92,5) x 2,8 (1,4 - 10,1) com p = 0,008 para a área 1. Houve maior número de células CD68 positivas/mm2 no grupo controle (G2), porém sem significância estatística com mediana igual a 38,7 (26,6 - 81,8) x 70 (42,7 - 120,4) com p = 0,098 para a área 1. Em relação à presença de antígenos de Mycoplasma pneumoniae, houve uma maior área (?m2) de antígenos detectados no grupo 1, quando comparadas com o grupo 2 com diferença estatisticamente significante para as duas áreas. Na área 1, mediana de 180.993 (24.856 - 387.477) x 7.970 (2.736 - 15.992) com p < 0,001 e na área 2, mediana igual a 105.968 (2.503 - 416.585) x 7.190 (3.314 - 17.833) com p = 0,02 A análise da presença de antígenos de Chlamydophila pneumoniae demonstrou que em ambas as áreas, houve uma maior área (?m2) de antígenos detectados no grupo de valvas com degeneração mixomatosa, quando comparadas com o grupo controle, porém sem diferença estatística com mediana para o G1 de 9.905 (4.716 - 16.912) x 5.864 (2.382 - 8.692) com p = 0,2 e para o G2, mediana de 3.199 (1.791 - 10.746) x 2.536 (683 - 6.125) com p = 0,3. Em relação à presença de antígenos de Borrelia burgdorferi, houve uma maior área (um2) de antígenos detectados no grupo 2 em relação ao grupo 1, em ambas as áreas. Na área 1, mediana de 7.596 (3.203 - 13.519) x 10.584 (7.223 - 15.974) com p = 0,14 e na área 2, mediana igual a 5.991 (3.009 - 8.475) x 8.403 (1.626 - 27.887) com p = 0,47. Em relação à presença da metaloproteinase MMP9, observamos maior área (um2) de antígeno marcado de MMP9 no grupo com degeneração mixomatosa tanto na área 1 quanto na área 2, com diferença estatística significante. Na área 1, mediana de 503.894 (202.428 - 938.072) x 269.244 (111.953 - 354.022) com p = 0,03. Na área 2, houve diferença estatística representada pela mediana de 389.844 (214.459 - 679.711) x 144.397 (29.894 - 247.453) com p < 0,001. No grupo DM houve correlação positiva entre Borrelia burgdorferi e porcentagem de DM com R = 0,52 e p = 0,018. Em relação às células inflamatórias, houve correlação positiva entre CD45 e Mycoplasma pneumoniae com R = 0,51 e p = 0,02. A presença de MMP9 se correlacionou positivamente com a presença de Mycoplasma pneumoniae com R = 0,45 e p = 0,04. Estas correlações estiveram ausentes no grupo controle. Conclusões: Houve associação de agentes infecciosos Mycoplasma pneumoniae e Borrelia burgdorferi na etiopatiopatogenia da degeneração mixomatosa da valva mitral. Na análise da relação dos produtos bacterianos com os marcadores inflamatórios e com a metaloproteinase, houve relação positiva entre o marcador inflamatório CD45 e a metaloproteinase (MMP9) apenas com a Mycoplasma pneumoniae, nas valvas com degeneração mixomatosa. O marcador inflamatório CD68 foi encontrado em maior número no grupo controle / Background: The myxomatous mitral valve disease leads to impairment due to changes in their tissue composition caused by the imbalance in the amount of acid mucopolysaccharides or glycosaminoglycans. Its etiology is not yet fully understood and may occur in familial forms of autosomal dominant trait with variable penetrance that can be time-dependent or probable environmental factors, where the interaction of infectious agents requires further elucidation. The purpose of this study is the analysis of the pathogens products of Chlamydophila pneumoniae, Mycoplasma pneumoniae and Borrelia burgdorferi in removed cusp segments of the mitral valve with myxoid degeneration, compared to the control group and the ratio of bacterial products with increased inflammatory markers (CD20, CD48, CD68) and metalloproteinase (MMP9) in the pathogenesis of myxomatous degeneration of the mitral valve. Method: Observational, analytical, case-control study which analyzed 2 groups of 20 patients each and divided in group 1, consisting of fragments of mitral valve tissue with diagnosis of myxomatous degeneration extracted in replacement procedures or mitral valve repair; group 2, formed by segments of mitral valves without valvolpaty clinial disease removed in the coroner service. Hematoxylin and eosin and Movat stains were done for histological diagnosis of myxoid degeneration and immunohistochemical technique for the detection of Borrelia burgdorferi, Mycoplasma pneumonia antigens, inflammatory mediators (CD20, CD45, CD68) and markers of metalloproteinase (MMP9). The presence of Chlamydophila pneumonia antigens was verified through an in situ hybridization technique. The quantitative analysis of the microscopic aspects was performed with the Aperio image analyzer. The research of bacterial elements was performed by a transmission electron microscopy. Results: In group 1, 14 (70%) patients were male and 6 (30%) were female. The mean age was (51 to 79 years, sd = 9.2). In group 2, 11 (55%) patients were male gender and 9 (45%) were female. The mean age was 67,6 years (42 to 84 years, sd= 12). In the analysis percentage of myxomatous tissue by Movat staining, there was a significant difference between the DM (G1) groups, with a media of 54.6 % ± 23,7 and control group (G2) with a media of 35.5 % ± 22.5 with p = 0.013. There was an increased number of CD20 cells/mm2 in myxomatous degeneration group (G1) with a median of 17.8 (6.7 - 27.9) x 4.6 (3.6 - 9.8) with p = 0.007 for the area 1. There was a higher number of CD45 cells/mm2 in myxomatous degeneration group (G1) with a median of 17.3 (3.4 - 92.5) x 2.8 (1.4 - 10.1) with p = 0.008 for the area 1. There was a higher number of CD68 cells/mm2 in control group (G2) without a statistically significant difference, with a median of 38.7 (26.6 - 81.8) x 70 (42.7 - 120.4) with p = 0,098 for the area 1. In quantifying Mycoplasma pneumoniae we observed a higher area (um2) antigen marked by, there was a higher amount of antigen detected in myxomatous degeneration group. In area 1, a median of 180,993 (24,856 - 387,477) x 7,970 (2,736 - 15,992) with p < 0.001 and in area 2, a median of 105,968 (2,503 - 416,585) x 7,190 (3,314 - 17,833) with p = 0.02. The analysis of the presence of Chlamydophila pneumoniae antigens showed that in both area, there was a larger area (?m2) antigens detected in the group of valves with MD when compared with the control group, but without significant differences with median for the G1 of 9,905 (4,716 - 16,912) x 5,864 (2,382 - 8,692), with p = 0.2 and the G2, median 3,199 (1,791 - 10,746) x 2,536 (683 - 6,125) with p = 0.3. Regarding the presence of Borrelia burgdorferi antigens, there was a greater area (?m2) antigens detected in group 2 than in group 1, in both areas. In one area, median 7,596 (3,203 - 13,519) x 10,584 (7,223 - 15,974), with p = 0.14 and in area 2, a median of 5,991 (3,009 - 8,475) x 8,403 (1,626 - 27,887) with p = 0.47. Regarding the presence of metalloproteinase MMP9, we observed a higher area (um2) antigen marked by MMP9 in the group with MD both in area 1and area 2, with statistically significant difference. In area 1, median of 503,894 (202,428 - 938,072) x 269,244 (111,953 - 354,022), p = 0.03. In area 2, median 389,844 (214,459 - 679,711) x 144,397 (29,894 - 247,453) with p < 0.001. In the DM group there was a positive correlation between Borrelia burgdorferi and the percentage of MD with R = 0.52 and p = 0.018. Regarding inflammatory cells, there was a positive correlation between CD45 and Mycoplasma pneumoniae with R = 0.51 and p = 0.02. The presence of MMP9 was positively correlated with the presence of Mycoplasma pneumoniae with R = 0.45 and p = 0.04. These correlations were absent in the control group. Conclusions: There was an association of infectious agents Mycoplasma pneumoniae and Borrelia burgdorferi in etiopathogeny of myxoid degeneration of the mitral valve. In the analysis of the relationship of bacterial products with the inflammatory markers and the metalloproteinase, there was a positive relationship between the inflammatory marker CD45 and metalloproteinase (MMP9) only with Mycoplasma pneumoniae. The inflammatory marker CD68 was found in greater numbers in the control group

INTRODUÇÃO: A inflamação das vias aéreas na asma envolve respostas imunes inatas. Os receptores do tipo Toll (Toll-like receptors, TLRs) e a citocina linfopoetina do estroma tímico (thymic stromal lymphopoietin, TSLP) estão envolvidos na inflamação brônquica da asma, mas a expressão destas proteínas em vias aéreas grandes e pequenas de asmáticos ainda não foi investigada. Os objetivos deste estudo foram analisar a expressão protéica de TLR2, TLR3, TLR4 e TSLP em vias aéreas grandes e pequenas de asmáticos, comparar sua expressão entre asmáticos tabagistas e não tabagistas e investigar se a expressão dos TLRs está associada à infecção por Chlamydophila pneumoniae e Mycoplasma pneumoniae. MÉTODOS: Foram analisadas por método imuno-histoquímico e análise de imagens as expressões de TLR2, TLR3, TLR4 e TSLP em vias aéreas grandes e pequenas de 24 indivíduos falecidos por asma (13 não tabagistas e 11 tabagistas) e 9 controles não asmáticos. A análise das proteínas foi realizada em quatro regiões das vias aéreas: camadas epitelial, interna, muscular e externa. A presença de C. pneumoniae e M. pneumoniae no tecido pulmonar foi investigada por meio de reação em cadeia da polimerase em tempo real. RESULTADOS: Os indivíduos asmáticos apresentaram maior expressão de TLR2 nas camadas epitelial e externa de vias aéreas grandes e pequenas, e maior TLR2 na camada muscular de vias aéreas pequenas. Asmáticos tabagistas tiveram menor expressão de TLR2 nas camadas interna e externa de vias aéreas pequenas do que asmáticos não tabagistas. Indivíduos asmáticos tiveram maior expressão de TSLP na camada epitelial e externa de vias aéreas grandes, aumento de TLR3 na camada externa de vias aéreas grandes e aumento de TLR4 na camada externa de vias aéreas pequenas. O DNA de C. pneumoniae e M. pneumoniae não foi detectado em nenhum indivíduo asmático ou controle. CONCLUSÕES: Os receptores da imunidade inata TLR2, 3 e 4 e a citocina TSLP estão aumentados nas vias aéreas de pacientes falecidos por asma, e a expressão dos TLRs não está associada à presença de Chlamydophila pneumoniae e Mycoplasma pneumoniae nos pulmões. O tabagismo em asmáticos parece reduzir a expressão de TLR2 em vias aéreas pequenas. Estes resultados sugerem que os TLRs 2, 3 e 4 e a TSLP podem contribuir com a inflamação brônquica presente em exacerbações graves de asma e que as bactérias C. pneumoniae e M. pneumoniae não estão envolvidas em óbitos por asma / INTRODUCTION: Airway inflammation in asthma involves innate immune responses. Toll-like receptors (TLRs) and the cytokine thymic stromal lymphopoietin (TSLP) are involved in bronchial inflammation in asthma, but the expression of these proteins in large and small airways of asthmatics has not been investigated. The aims of this study were to analyze the protein expression of TLR2, TLR3, TLR4 and TSLP in large and small airways of asthmatics, to compare their expression in smoking and nonsmoking asthmatics and to investigate if TLR expression in associated with infection by Chlamydophila pneumoniae and Mycoplasma pneumoniae. METHODS: Using immunohistochemistry and image analysis, we investigated the expression of TLR2, TLR3, TLR4 and TSLP in large and small airways of 24 fatal asthma patients (13 nonsmokers and 11 smokers) and 9 nonasthmatic controls. The protein expression was analyzed in four regions of the airways: epithelial, internal, airway smooth muscle and outer layers. C. pneumoniae and M. pneumoniae presence in lung tissue was analyzed by real-time polymerase chain reaction. RESULTS: Fatal asthma patients had increased expression of TLR2 in the epithelial and outer layers of large and small airways, and also higher TLR2 in the muscle layer of small airways. Smoking asthmatics had lower TLR2 in the inner and outer layers of small airways than nonsmoking asthmatics. TSLP was increased in the epithelial and outer layers of large airways. Asthmatics also had greater TLR3 in the outer layer of large airways and greater TLR4 in the outer layer of small airways. C. pneumoniae and M. pneumoniae DNA was not detected in asthmatics or controls. CONCLUSIONS: Innate immunity receptors TLR2, 3 and 4 and innate cytokine TSLP are increased in the airways of fatal asthma patients, and TLRs expression is not associated with the presence of Mycoplasma pneumoniae and Chlamydophila pneumoniae in the lungs. Smoking may reduce TLR2 expression in the small airways of asthmatics. These results suggest that TLR2, 3, 4 and TSLP may contribute to the bronchial inflammation seen in severe exacerbations of asthma and that M. pneumoniae and C. pneumoniae are not involved in fatal asthma exacerbations