AD-Al68 189 PATHOGENESIS OF CELL INJURY BY RICKETTSIA CONORIICU) A/iNORTH CAROLINA UNIY AT CHARPEL HILL P HN MALKER15 JUN 94 DAINDI-83-C-3122 M

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0_ Report Number 1

to Pathogenesis of Cell Injury byVRickettsia conorii

Annual Summary Report

DTICDavid H. Walker, M.D. ELECTE

JUN 2 MB

June 15, 1984

B

Supported by

U.S. Army Medical Research and Development CommandFort Detrick, Frederick, Maryland 21701

Contract No. DAMD 17-83-C-3122

University of North Carolina at Chapel HillChapel Hill, North Carolina 27514

Approved for public release; distribution unlimited

The findings in this report are not to be construed as anofficial Department of the Army position unless so designated byother authorized documents.

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1. REPORT NUMBER 12 GOVT ACCESSION NO. 3. RECIPIENT'S CATALOG NUMBER 4

Annual Summary Rport -14. TITLE (a Subtitle) S. TYPE OF REPORT & PERIOD COVERED

Pathogenesis of o a..e;a_ interim (annual surary)Pathogenesis o4/11/83-4/10/84

Ifl e 4r; fi-i -1 C IA0 . PERFORMING ORG. REPORT NUMBER

7. AUTHOR(e) I. CONTRACT OR GRANT NUMBER(e)

Dr. David H. Walker DAMD 17-83-C-3122

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AREA & WORK UNIT NUMBERS

University of North Carolina at Chapel HillChapel Hill, NC 27514

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U.S. Army Medical Research and Development 15 June 1984

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rickettsia, rickettsial disease, boutonneuse fever,Rickettsia conorii, ticks, pathology

hb ABSTRACT (,contino enp reee sid it neceeary and IdentifF by block number)

-"This work was undertaken to determine the pathogenic mechanismby which Rickettsia conorii causes disease. R. Conorii, anorganism that has been neglected in spite of its w-despreaddistribution and pathogenic qualities, was studied in humansubjects and in vitro. The purpose of the work is'to elucidatethe pathology-of boutonneuse fever and the pathogenic mechanismswhich might be blocked therapeutically or prophylactically. Human

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fissues were investigated by light microscopy, histochemistry,immunofluorescence, and electron microscopy. In vitro models ofcell injury by R. conorii included parabiotic chambers and theplaque model.

Biopsies of 17 taches noires and 4 liver biopsies frompatients with boutonneuse fever and necropsy tissues from twofatal cases of South African tick bite fever and amputated,gangrenous fingers from another patient with severe Rickettsiaconorii infection were examined. R. conorii were identified in 11taches noires, none of the liver biopies, the endothelium ormacrophages of the kidneys, brain, meninges, liver, spleen,heart, lung, lumph node, skin, and pancreas of the autopsy cases,and the blood vessels of the partially necrotic zone between theviable tissue and the mummified, necrotic tissue of the amputatedfingers, Significant vascular injury and infiltrating smalllymphocytes_and large mononuclear cells were observed in most ofthese locat bs. The lesions where similar to other rickettsiosessuch as typhus"'fever and Rocky Mountain spotted fever. Vasculitiswas more prominent than vascular thrombosis.

In vitro studies employing parabiotic chambers and theplaque model yielded no evidence for an exotoxin or solubleenzyme in cell injury by R. conorii, but did document that cellinjury could be blocked by inhibitors of phospholipase A2 ortrypsin-like protease.

.These results lead us to conclude that a rapid diagnostictest has been achieved, that visceral lesions and rickettsialdistribution occur in fatal cases, and that further studies oftaches noires and protease and phospholipase inhibitors areimportant.

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AD

Report Number 1

Pathogenesis of Cell Injury byRickettsia conorii

Annual Summary Report

David H. Walker, M.D.

June 15, 1984

Supported byU.S. Army Medical Research and Development Command

Fort Detrick, Frederick, Maryland 21701

Contract No. DAMD 17-83-C-3122

University of North Carolina at Chapel HillChapel Hill, North Carolina 27514

I'1

The findings in this report are not to be construed as anofficial Department of the Army position unless so designated byother authorized documents.

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Summary

This work was undertaken to determine the pathogenicmechanism by which Rickettsia conorii causes disease. R. conorii, an organism that has been neglected in spite of its wTdespreaUdistribution and pathogenic qualities, was studied in humansubjects and in vitro. The purpose of the work is to elucidatethe pathology-f boutonneuse fever and the pathogenic mechanismswhich might be blocked therapeutically or prophylactically. Humantissues were investigated by light microscopy, histochemistry,immunofluorescence, and electron microscopy. In vitro models ofcell injury by R. conorii included parabiotic chambers and theplaque model.

Biopsies of 17 taches noire and 4 liver biopsies frompatients with boutonneuse fever and necropsy tissues from twofatal cases of South African tick bite fever and amputated,gangrenous fingers from another patient with severe Rickettsiaconorii infection were examined. R. conorii were identified in 11taEhes-noires, none of the liver Uopsies, the endothelium ormacrophages of the kidneys, brain, meninges, liver, spleen,heart, lung, lymph node, skin, and pancreas of the autopsy cases,and the blood vessels of the partially necrotic zone between theviable tissue and the mummified, necrotic tissue of the amputatedfingers. Significant vascular injury and infiltrating smalllymphocytes and large mononuclear cells were observed in most ofthese locations. The lesions where similar to other rickettsiosessuch as typhus fever and Rocky Mountain spotted fever. Vasculitiswas more prominent than vascular thrombosis.

In vitro studies employing parabiotic chambers and theplaque model yielded no evidence for an exotoxin or solubleenzyme in cell injury by R. conorii, but did document that cellinjury could be blocked by inhibitors of phospholipase A2 ortrypsin-like protease.

These results lead us to conclude that a rapid diagnost .ctest has been achieved, that visceral lesions and rickettsialdistribution occur in fatal cases, and that further studies oftaches noires and protease and phospholipase inhibitors areimportant.

".

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I 7

Foreword

For the protection of human subjects, the investigator hasadhered to policies of applicable Federal Law 45CFR46.

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Table of Contents

Report Documentation . . . . . . . . . . . . . . . . . . . . . 3

Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Summary . . . . . . . . . . . . . . . 0 . . . . . . . . . . . 6

Foreward . . . . . . . . . . . . . . . . . . 7

Table of Contents . . . . . . . . . . . . . . . . . . . . . . 8

Statement of Problem . . . . . . . . . . . . . . . . . . . . . 9

Background . . . . . . . . . . . . . . . * . .. . . . . . . . 9

Approach to Problem . . . . . . . . . . . . . . . . . . . . . 18

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Table I . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

STable 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

L-.Table 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Table 4 . . . . . . . . . . . . . . . . . . . . . . . .. . . 35

Table 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Table 6 . . . . . . .. . . . . . . . . . . . . . . . . .

*Table 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . 40

Recommendations . . . . . . . . . . . . . . . . . . . . . . . 43

Selected Bibliography . . . . . . . . . . . . . . . . . . . . 44

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Statement of Problem

Spotted fever group rickettsiae including Rickettsiaconorii, R. sibirica, and R. akar' are important potentia causesof military health problems. Tn order to meet the challenges ofthese diseases to the health of groups of soldiers who enterzoonotic areas, methods of effective prevention, improveddiagnosis, and optimal treatment are required. Development of aneffective vaccine offers the best hope for prevention ofboutonneuse fever and other spotted fever group rickettsioses. Noeffective vaccine exists for any of these rickettsial diseases.Because most effective vaccines for prokaryotic organisms rely uponinterdiction of the specific pathogenic mechanism of the organism,e.g., diphtheria and tetanus, it is important to elucidate thepathogenic mechanism of cell injury by R. conorii. The failure ofkilled rickettsial and bacterial vaccines, e.g., Rocky Mountainspotted fever, typhoid fever, and cholera, may be a result of alack of stimulation of the immune system to block crucialpathogenic steps. The goal of this research contract is todetermine the pathogenic mechanism for R. conorii. Laboratoryresearch on hypothetical rickettsial pathogenic effects must becompared with observations on the human disease in order to assureas well as possible the relevance and reality of working models ofthe host-parasite interaction. The problems of lack of informationon the pathology of boutonneuse fever, the human ultrastructurallesions for any rickettsiosis, and the composition of the immuneand inflammatory cell populations actually present in foci ofrickettsial infection in humans are addressed in this researchproject. Diagnosis of boutonneuse fever, North Asian tick typhus,and rickettsialpox is an unsure affair with a considerable amountof room for error. Misdiagnosis and delayed diagnosis result inprolonged illness, need for more care often including nursing andhospitalization, and failure to institute epidemiologic preventivemeasures. Diagnosis is a clinical one in the acute stage of theillness. Yet, clinical features are variable and do not always leadto a timely correct diagnosis. There has been no rapid, acutelaboratory diagnostic method. Serologic diagnosis is aretrospective tool employed during convalescence or in the latestage of the illness. There are few facilities in the world forisolation of R. conorii, and the laboratory procedure for isolationis both cumbersome and long. A diagnostic test that can be appliedduring the acute stage of illness is an expected spinoff of thisresearch project.

Background

Rickettsial diseases occur over a wide geographicdistribution, are firmly entrenched ecologically, and pose an

important threat to both military and public health.Members of the genus Rickettsia are classifed into three

groups on the basis of shared group antigens: spotted fever group,typhus group, and scrub typhus group. All are obligateintracellular bacteria which spend at least a portion of their lifein arthropod hosts such as ticks, mites, fleas, or lice. They allaffect man in a similar fashion with hematogenous spread and

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infection of vascular endothelium producing increased vascularpermeability and vasculitis in multiple organ systems. Theserickettsiae include the etiologic agents of diseases that have beendocumented as major military health problems. Rickettsia prowazekiihas affected the outcome of numerous military campaigns forcenturies. R. tsutsugamushi was a severe problem in Asia and thewestern Pacific theaters during World War II and infected soldiersin the Viet Nam War. These rickettsiae have continued to attractresearch support. Although R. conorii has received far lessattention, it too has been documented as an important cause ofillness among troops in South Africa. R. conorii is a member of thespotted fever group of rickettsiae along with other human pathogensincluding R. rickettsii (Rocky Mountain spotted fever), R. akari(rickettsiapox), R. sibirica (North Asian tick typhus),-and W.-australis (Queensland tick typhus). Isolates of spotted fever groupricZets-iae from the Mediterranean basin, where the disease isknown as boutonneuse fever, East Africa (Kenya tick typhus), SouthA rica (South A rican tick typhus), and the Indian subcontinent(India tick typhus), were all shown to be members of the samespecies, R. conorii, by the mouse toxin neutralization test. Datapresented by Myers and Wisseman on DNA hybridizations among thespotted fever group rickettsiae have documented close relationshipsamong various strains of R. conorii including rickettsiaeassociated with the severe disease occurring in Israel and R.rickettsii. Many of these hybridizations were in the range of90-100% homology.

Infection of man with various strains of R. conorii occursin a widespread geographic distribution in the Old World with well-documented disease in the Mediterranean basin, Africa, and theM*ddle East from Israel to India. In the Mediterranean basin, thedisease is endemic in Portugal, Spain, southern France, Italy,Greece, Romania, Turkey, Morocco, Algeria, Tunisia, Libya, andEgypt as well as in the margins of the Black Sea and the Caspianbasin. More recently it has been reported from South Africa, Kenya,India, Pakistan, Togo, Ethiopia, Cameroun, and Israel.

In the majority of the areas where the disease is endemic,"t occurs as sporadic cases during the summer months with littlevariation in the annual numbers of cases reported. Scafidi notesthat there were 107 cases in Israel in 1974, around 30 annual casesin Tunisia from 1961-1975, and 20 annual cases in Marseille from1925-1930. He and Bourgeade et al, however, point out that thesenumbers do not reflect the reality since the great majority ofpatients are treated at home and are not reported. This is also anexplanation for the scarcity of information about the prevalence ofthe disease.

The low endemicity that prevails in the majority of theaffected areas has changed significantly in Italy where, since1975, there was a sharp increase in the incidence of the disease.Indeed, from an average of less than 10 cases per year up to 1972the number of cases in Sicily increased progressively to reach 219cases in 1979. Similar increases were observed in other regions ofItaly as Liguria, Sardinia, and Lazzio; in this last mentionedregion that includes the city of Rome, there were 369 cases

* reported in 1979. Besides Rome, the disease has also been reportedin suburban and urban Marseille, and there are data that it is alsoincreasing in Spain and Portugal.

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The causes for such a rapid increase in the incidence ofboutonneuse fever in Italy are not apparent. The Italians havesuggested several possible explanations: 1) increase in the numberof vectors, 2) introduction of new vectors, and 3) changes in theecosystem. There have been some very interesting observatons on theisle of Ustica where, after the recent introduction of wildrabbits, there was an explosive proliferation of Hyalommaexcavatum, a tick that had rarely been found in theislandpreviously. Gilot, et a' also mention the possibility of adaptationof certain species of ticks, parasites of wild animals, to humandwellings and the potential consequences of the transmission ofboutonneuse fever.

What is happening in Italy may occur in other regions.Weyer, reviewing the subject of rickettsioses in 1978, said"Despite the great successes in control, none of the rickettsiosespathogenic for man have been eradicated. Therefore, it is necessaryto preserve the knowledge about these once devastating andimportant diseases because the present situation could changesuddenly."

Indeed, recent data have demonstrated that several differentspecies of ticks harbor R. conorii not only in the known endemicareas but also in regions where the human disease is not recognizedincluding Pakistan, Armenia, Thailand, areas of France,Czechoslovakia, Austria, and Germany.

Boutonneuse fever is transmitted to man from ticks, mostfrequently by Rhipicephalus sanjuineus. Infected ticks transmit thedisease through their infected salivary secretions during the bite;exceptionally the agents may invade the human host from infectioustick material through abrasions in the skin or through theconjunctivae. There are references that report the disease beingacquired by persons who rubbed their eyes after deticking dogs. Theagent appears innocuous to the tick which also serves as reservoirfor R. conorii which is transmitted transovarially in ticks. Smallwild mammals are the source of blood meals for immature forms of P.sanguineus. Dogs, and on occasion man, are the source of bloodmeals for the adult stage. The following species of ticks, besidesthe common vector Rhipicephalus sanguineus, have been reported toharbor R. conor'i: Ixodes ricznus, R. Texagonus, Dermacentormarginatus, and D. reticulatus in France; Haeraphysalis leachii,Ambloyomma hebraeum, Rhipicephalus aopendiculatus, R. evertsi, andiHaomma magTnatus rufipees in South Africa; Awblommra varieqatum.and Hyalomma albiparamatum in Kenya; Ixodes granulatus in Yalaysia;Rhipicephalus simus, Amblyomma varieqatum, A. cohaerens, and A.gemma in Ethiopia; and Rhipicephalus bursa, Hyallomma marqinatum, H.lusitanicum, and Haemaphysailis punctata in Sicily. Voreover,serological tests in wild and d(omestic animals have shown thatantibodies against R. conorii are present in several species inmany regions, some of then far away from the known endemic areas.In Sicily, 20% of dogs harbor R. sanguineus and 29-71% of them haveantibodies to R. conorii identT-iedh(]yimmunofluorescence test.Serologic tests have identified antibodies against R. conorii inlarge numbers of healthy persons: in Africa, 13% of sera containedantibodies in an investigation in Cameroun and similar results werereported from Niger, Zaire and the Central African republic; inGreece 16% of 560 sera from healthy persons were positive; datarom France indicate that positive serology in healthy persons has

12

been observed in Caen, Nantes, and Lyon. In one endemic area ofSicily 19.3% of healthy subjects had positive immunofluorescenceassay for anti- R. conorii antibodies. Not all of these studiesemployed the same serological tests, and there is variation inspecificity among different tests. Some, however, used specificimmunofluorescence techniques.

All the data above presented confirm the suggestion of Weyerthat the stage is set for an increase in the frequency ofboutonneuse fever and that this may occur in many different areasof the world.

Recently there have been reports of cases of boutonneusefever in German and Swiss tourists who had returned from endemicareas and even of cases in American tourists returning from Africa.Interestingly, a tick was found on one of these patients thatmight, if circumstances had been favorable, have become estahlishedin an American ecological niche. Cases have also been reported inpersons living in Paris.

Human illness caused by R. conorii infection is usually anincapacitating febrile exanthem. Alhough death is rare, somestrains of R. conorii possess the capability of producing severedisease requiring hospitalization and critical medical and nursingcare. The disease usually resolves spontaneously in one or twoweeks, this period being reduced by appropriate antibiotic therapywhich may be given at home. It is necessary to emphasize that evenbeing mild it is incapacitating and in a minority of cases can besevere or even fatal; moreover, in certain regions, as apparentlyis the case in Israel, it can assume a more severe course similarto the picture of Rocky Mountain spotted fever. The minority ofpatients seeking hospital care apparently do not manifest anyspecial features or increased severity of their illness. Men areslightly more frequently affected than females and the diseaseoccurs at all ages being, however, uncommon in the very young andvery old. Most of the patients report contact with dogs, ticks, orrecent visit to endemic areas; others are farmers or hunters. Thencubation period varies from 7 to 14 days, but can be as short as

4 or as long as 22 days. In the majority of the cases the patientremembers being bitten by a tick and from 33% to 92% of them havean eschar (tache noire) at the site of the tick bite. Lessfrequently they have acute unilateral conjunctivitis.

The disease is initiated by a sudden increase in temperatureto levels as high at 40°C; at the same time the patients cornplainof joint and muscle pain and violent, persistent headache that isfrequently retroorbital. There is also congestion of theconjunctivae and mild lymphadenopathy. These manifestationscoincide with the appearance of the eschar. Four to 5 days afterthe beginning of the fever the typical rash appears; it is firstobserved on the limbs but rapidly expands to trunk an, face withpalms and soles being also involved. In some cases even the oralmucosa presents an exanthem. In the beginning the rash appears aserythematous macules that rapidly change to a maculopapular patternand eventually become nodular or button-like, as the namedescribes. The early lesions are light pink, but some of the olderones may become darker or herorrhagic. The rash occurs insuccessive bouts so that lesions in different phases may beobserved side by side.

Fever persists for 7-14 days and during this period 4r' of

13

the patients develop splenomegaly, 20% hepatomegaly, and somepatients, signs of pulmonary congestion. Diarrhea, constipation andvomiting may also occur. Neurological signs of meningeal irritationas nuchal rigidity or Kernig's sign as well as obtundation and evencoma can be observed in a minority of the cases. These more severemanifestations occur mainly in older or debilitated persons; theyare exceptional in children. Recovery is uneventful without anysequelae. Mortality is low, less than 1%. In a few cases, however,complicatons occur; they are rare and, as state(, tend to occur inolder debilitated persons. Scafidi et al describe cases ofhypertoxic, "dermatotifosa" and hemo-rriagic disease, the last formbeing associated with severe gastrointestinal or genital bleeding.They go on to describe cases with atria] fibrillation, myocardialischemia, and renal complications. A series of French publications .describe "atypical rickettsiosis" with pericarditis, pleuritis, andpneumonitis. Some of the cases, however, did not present witheschars and the final diagnosis was made by positivemicroagglutination tests according to the method of Giroud, thusraising doubts concerning the diagnosis. In Israel, however, therehave been some very interesting cases of tick-borne rickettsiosiswith severe renal insufficiency requiring dialysis; in these cases,there are questions about the exact classification of the etiologicagent that did not conform exactly with the antigenic structure oR. conorii. More recently severe and fatal cases have beendescribed in South Africa and France.

The clinical feature that is most significant diagnosticallyin R. conorii infection is the tache no're which develops at thesite of tickbite in approximately 50% of cases. The tache noire, orblack spot, is a zone of dermal and epidermal necrosiswhi~cgenerally appears prior to onset of fever and rash. Conor and Burchdid not describe eschars in the original description of human R.conorii infection in 1910. Tache noire is a French term and wasintroduced in 1925 by Pieri to refer to the tickbite site eschar inboutonneuse fever. Thereafter, the term tache noire seems to havebeen used continuously. Similar eschars are frequently observed inscrub typhus (R. tsutsugamushi), North Asian tick typhus (R.sibirica), rickettsialpox, (R. akari), and Queensland tick typhus(R. australis). Eschars are rareTy observed in Rocky Mountainspotted fever and do not occur in typhus fever and murine typhus.Thus, eschars are seen only in rickettsioses transmitted byinoculation of infected salivary secretions by ticks and mites anoare not observed in rickettsioses transmitted by scratchingrickettsia-containing louse or flea feces into the skin. Patientswho develop boutonneuse fever after accidental introduction ofinfected tick constituents into the conjunctiva do not haveeschars, but manifest conjunctivitis at the portal of entry.

Our laboratory has described the clinical features,brightfield microscopic pathology, and distribution of R.rickettsii in eschars which occurred in two fatal. cases of RockyMountain spotted fever examined at autopsy. These eschars consistedof a 8 x 10 mm oval region of necrotic epidermis and uner'yingdermis. The necrotic zone was surrounded by a zone of blood vesselsthat were injured with extensive thrombosis and intramural andperivascular mononuclear inflammatory cells. Tm-,unohistochemiralexamination revealed very large quantities of R. rickettsi in theendlothelium and vascular wall of these bloo, vessels.

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There is some degree of controversy about the role ofconstituents of tick salivary secretions such as enzymes associatedwith tickbite in the pathogenesis of the tache noirp. Experimentalstudies suggest that the dose of inoculum rather than the tickbiteitself is crucial. Inoculation of a large dose of R. rickettsii, agenerally nonescharogenic rickettsia, into human skin by syrinqeand needle produces eschars. Inoculation of R. conorii into theskin of syphilitic subjects as pyrotherapy produced taches noiresproportional to the quantity of rickettsiae injected. Evennonescharogenic R. mooseri produces eschars in the skin of guineapigs injected intradermally by syringe and needle with a large doseof rickettsiae. Not all monkeys inoculated with R. tsutsugamushidevelop an eschar at the injection site; some develop only papuleswhich do not undergo epidermal necrosis and ulceration. Thus, thetache noire appears to be an accessible lesion that contains thepathogenic mechanisms of R. conorii and the immune and inflammatorymechanisms of the host that Td t healing.

Hypothetical rickettsia! pathogenic mechanisms include boththose that are host-mediated and rickettsia-mediated. Host-mediatedmechanisms of injury which have been proposed includeimmunopathology, blood coagulation, and inflammation.Rickettsia-mediated mechanisms might include an exotoxin,endotoxin, enzymes that destroy host components, metaboliccompetition for the host's intracellular substrates, ATPparasitism, and host cell membrane injury on rickettsialpenetration into and/or release from the target cell.

Experimental evidence indicates that host-mediatedpathogenic mechanisms such as immunopathology, Shwartzmanphenomenon-like blood coagulation, and inflammation are not theprimary mechanisms of injury in infection by R. rickettsii.Localized effects of kallikrein are probably events secondary tothe primary pathogenic mechanism(s). Occlusive vascular thrombosisis infrequent, and has not been demonstrated as a primarypathogenic mechanism.

Among the hypothetical rickettsia-mediated mechanisms ofinjury, currently no toxin of R. rickettsii has been identified,and there is evidence against the existence of a toxin as animportant pathogenic mechanism. The confusion regarding thishypothesis has originated in the so-called mouse toxin phenomenonand in erroneous analogies drawn between endotoxin and rickettsiae.Mouse toxicity depends on viable, metabolically active rickettsiaeand is prevented by heating (600 C for 30 minutes), exposure todilute formalin, rickettsial starvation, ultraviolet irradiation,specific anti-rickettsial antiserum neutralization, and abeta-lipoprotein present in some normal human sera. Thepathogenesis of this phenomenon may be related to thepathophysiology of the rickettsia-host cell interaction, e.g.,massive rickettsial penetration of endothelium. Rickettsiae of boththe typhus and spotted fever groups have been shown to containlipopolysaccharides. However, the enlotoxin activity in ioassaysincluding the Shwartzman phenomenon and Limulus assay wasconsiderably less than that of potent bacterial endotoxins.Moreover, study of the adrenal in fatal RMSF has not demonstrateOthe pathologic lesions expected of eniotoxin-mediated pathoqenesis.Further evidence against the hypothesis of rickettsial toxin hasbeen demonstrated in the plaque model.. Thus, the evidence for a

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rickettsial toxin of pathogenic importance is quite meager.The plaque model has been established as a useful too] for

investigation of pathogenic mechanisms of cell injury by P.rickettsii. Inoculation of confluent monolayers of primary chickembryo cells derived from 12-day old specific pathogen-free,antibiotic-free, embryonated hen's eggs with a defined quantity ofR. rickettsii results in a predictable course of infection and

pathologic alterations in v'tro. Each infectious unit under agarospoverlay produces contiguous centrifugal spread of intracellularinfection and injury to the host cell monolayer. This modelproduces a grossly visible plaque on day 5 after inoculation whenoverlaid with agarose containing the supravital dye neutral red.The plaque provides a temporal and spatial cross-section of therickettsia-host cell interaction including rickettsial penetration,

proliferation and release, and host cell cytopathologic alterationsand necrosis. Morphometric analysis of the plaque and surroundinginfected and uninfected cells has been performed maintaining thetopographic relationships of the cells as a monolayer. The resultshave shown the association of intensity of infection andcytopathology at the microscopic and ultrastructural levels. Thereis a statistically highly significant relationship between theintensity of infection as measured by the quantity of intracellularrickettsiae and the presence of cellular injury as judged bycytopathology and necrosis. This relationship is validindependently of the apparent duration of infection. That is tosay, more heavily parasitized host cells are more likely to exhibitpathologic alterations, even if they are located at the margin ofthe plaque, than those cells which contain fewer rickettsiae andare nearer to the center of th plaque. This study also confirms the -observation of Silverman and Wisseman that the typicalcytopathologic change in chick embryo cells infected with R.rickettsii is distinct dilation of the cisternae of endoplasmicreticulum. This ultrastructural finding is characteristic of theresponse of an injured cell to the influx of water. The utilizationof the technique of maintaining the topography of the monolayerintact enabled us to determine that the uninfected cells of themonolayer even within 1 mm of the intensely infected marginal zoneof the plaque were normal by ultrastructural and supravital dyestaining criteria even though they were exposed to the same milieuof extracellular nutritional factors, nonspecific toxic products ofmetabolism and substances released from injured cells, andsenescence of cultured cells. Thus, the plaque model, which has a0.5% agarose overlay that prevents rapid, distant spread ofrickettsiae and yet allows for diffusion of macroTrolecules,demonstrated that cell injury was limited to the more heavilyparasitized cells and that there was no toxic effect on uninfectedcells, even those immediately adjacent. This is strong evidencethat R. ricketts'" does not elaborate an extracellular toxin whichaffects chick embryo cells. Further studies in our laboratory haveextended this observation and conclusion to Vero cells which are ofprimate origin and to human umbilical vein endothelial cells.

Another strong indication that P. rickettsi" does notproduce an important toxin resulted from observations utilizingparabiotic chambers. Specially designed flasks contained covers pswith monolayers of cells with fluid overlay in separate chamberswhich were separated by an 0.22 mm millipore filter. R. rickettsii

4..

16

was inoculated into one chamber of several flasks; other controlflasks were observed without rickettsiae in either chamber.Inoculated monolayers developed cytopathic effect associated withheavy rickettsial infection. On the other hand, the cells in theopposite chamber remained viable with the same appearnce asmonolayers of unmanipulated parabiotic chambers. No toxicmacromolecules injured the side of the chamber which was protectedfrom rickettsial infection by the 0.22 gm filter. The filteroffered no barrier to the free passage of molecules between theinfected and uninfected chambers. Thus, in an experimental systemin which rickettsiae injured infected host cells, we demonstratedno effect of putative toxin, which would have been in equalconcentration in the extracellular fluid of both chambers if itwere present.

Examination of the hypothesis of competition for metabolicsubstrates has also failed to produce evidence to support it as apathogenic mechanism in plaque model experiments with supplementalglutamate and glutamine. Although rickettsiae are capable ofgenerating ATP for penetration of host cells by oxidation ofglutamate, exogenous ATP from the host cell is utilized forbiosynthesis of proteins and lipids by rickettsiae. This energyparasitism is mediated by an efficient rickettsial ATP/ADPtransport system. No experiment has yet been designed and executedto test the hypothesis of energy parasitism as a pathogenicmechanism.

Experiments reported principally by Winkler and co- workerssuggest that rickettsial penetration-associated phospholipaseactivity injures the host cell membrane. The work of Winkler andassociates on hemolysis by viable R. prowazekii has led to anunderstanding of the rickettsia-host cell membrane interaction

* which probably forms the basis of penetration and a mechanism of"- cell injury. Rickettsial hemolysis may be divided into two steps,-. adsorption and lysis. Hemolysis is inhibited by cyanide (1 mM RCN,

an inhibitor of the electron transport system), low temperature(0°C), and starvation of R. prowazekii for glutamate. Ghosts oferythrocytes exposed to Amphotericin B or digitonin, compoundswhich bind to the cholesterol-containing receptor sites in theerythrocytic membrane, are no longer able to adsorb rickettsiae.Adsorption and hemolysis are inhibited by adenine nucleotides, ADP,ATP, arsenite, which is a Krebs cycle inhibitor, and2,4-dinitrophenol and m-chloro- phenylhydrazone, which areoxidative phosphorylation uncouplers. When rickettsiae are unableto generate ATP by metabolism of glutamate because of cyanide orarsenite inhibition, added ATP restores hemolytic activity of therickettsiae. ATP, however, does not restore hemolytic activityinhibited by uncouplers. Fluoride (10 mM NaF) prevents hemolysis byinhibition of erythrocytic glycolysis without affecting adsorptionor rickettsial metabolism. Recently, rickettsial hemolysis has beenshown to be associated with phospholipase A activity, whichresulted in hydrolysis of fatty acids from the glycerophospholipidsof the red blood cell membrane. Inhibition of either adsorption nrlysis also prevented the release of free fatty acids.

Penetration by rickettsiae has many correlates withrickettsial hemolysis. Inactivation of R. tsutsuqamushi by heat(560 C for 5 minutes), exposure to ultraviolet irradiation, orincubation with 0.1% formalin prevents penetration into host cells.

'.

17

Penetration of L cells by R. powazekii comprises two steps,

adherence and internalization, and requires active participation byboth the rickettsia and the host ceil. Treatment of rickettsiaewith ultraviolet irradiation, 3% formaldehyde, or 1 mM KCN"nhibited adherence to and internalization into L cells. The fewinactivated rickettsiae found associated with L cells were mostlyadherent rather than internalized. Treatment of L cells with NaF(an inhibitor of metabo!isn), N- ethylmaleimide, or cytochalasin Binhibited internalization of rickettsiae. Inoculation of R.prowazekii onto L cells at large multiplicities of infectioninduced immediate cytotoxicity. This cytotoxic effect wasassociated with phospholipase A activity and hydrolysis of fattyacids from host cell phospholipids. Cytotoxicity and phospholipaseactivity were inhibited in a parallel manner by KCN,N-ethylmaleimide, KaF, and low temperature.

Further studies in our laboratory have extendedphospholipase as a pathogenic mechanism to the plaque model, whichmore closely mimics actual infection, and to a member of thespotted fever group, R. rickettsii. Chemical agents which have asound theoretical basis of inhibiting rickettsial penetrationeither at the step of adsorption of the rickettsia to the host cell(Amphotericin B and digitonin) or at the step of internalizationassociated with phospholipase A activity have been demonstrated toreduce plaque formtion. Amphotericin B and digitonin have beenreported to inhibit the attachment of R. prowazekii to erythrocyticcell membre ies by binding to a cholesterol receptor in themembrane. Amphotericin B was introduced in concentrations of 5 and ®IOqg/ml to the overlay after the establishment of infected foci onday 4 after inoculation of R. rickettsii. In order to maintainactive levels of this drug wTich has a decay of 50% per 24 hours at37°C, Amphotericin B was replenished in sequential overlays on Oays5 and 6. On day 6 Amphotericin B caused plaque reduction of 42-45%at both concentrations. More plaques appeared on day 7 with plaquereduction of 16-23%. A similar experiment with digitonin at thesame concentrations resulted in similar plaque reduction on day 6

at both concentrations (38-40%). Plaque reduction was not observedon day 7. These results demonstrate that when the levels of"

cholesterol. receptor-binding drugs are maintained plaque reductioncan be demonstrated. This suggests that inhibition of rickettsiaadsorption delays the cytopathic effect of R. rickettsii in primarychick embryo cells.

Phentermine is a drug which has been shown to havephospholipase A inhibitory activity. A dose response study withthis drug was p~rformed in the plaque model. Plaque reduction was

demonstrated at all doses of phentermine: 69% plaque reduction at

0.5 mg/ml; 54% at 0.1 mg/ml; 25% at 0.05 mg/m]; and 32% at 0.01mg/ml. These results demonstrate that phentermine reduces the

cytopathic effect of R. rickettsii and suggest that phospholipaseactivity may be a pathogenic mechanism for R. rickettsii. These

data extend and support the observations of Winker that

phospholipase activity is associated with hemolysis and immediate

cytotoxicity of a large inoculum of R. prowazek'i.

Previous reports have documented that R. conorii formsdistinct plaques similar to those of R. rck'ttsii in the pioluemodel. fcDade et al produced distinct plaques with R. conorii in

-...... .- - . * . .. ,,*-. .,- .. * ." . .. , " . ..'. *- . , * ., - .- - .- . . -.. . .. . . .. - . -'% ,-,- - .

18

chick embryo cells with a first overlay of medium 199 containing 5calf serum and 0.5% agarose and a later second overlay of medium199, no calf serum, 0.5% agarose, and 0.01% neutral red. Wike et alstudied the critical variables in the plaque assay system forrickettsiae and also showed that R. conorii (Malish strain)produced distinct plaques in the -tandair chick embryo monoJayerwith nutrient overlay containing agarose. Thus, the plaque modeloffers an opportunity to examine quantitatively and predictably thepathogenic mechanisms of R. conorii in an in vitro system that maybe manipulated experimentally to examine hypotheses such asphospholipase-mediated injury.

Because one hypothetical explanation for the apparent rarityof severe visceral involvement in BF as compared with RMSF(encephalitis, hepatitis, pneumonitis) is lower temperaturesensitivity of R. conorii, we are interested in the effects oftemperature on the physiology and pathogenicity of the organism.Oaks and Osterman have investigated the effects of temperature onthe optimal growth of R. conorii. This species of rickettsia has anoptimal range for growth in gamma-irradiated L cells of 32-380 Cwith inhibited proliferation at 400 C. The low rate of proliferationat 400 C might explain the minimal visceral involvement in febrilepatients whose body core temperature is about 380 C and may exceed40°C. An unanswered question is the effect of temperature on thepathogenic mechanism of R. conorii.

Approach to the Problem

Many features of boutonneuse fever have been investigated toa far less degree than typhus fever and Rocky Mountain spottedfever. In particular, pathogenic mechanisms of R. conorii, immunemechanisms against R. conorii, and the laboratory diagnosis ofboutonneuse fever have not been investigated sufficiently.

The localized lesion at the site of the tick bite, theeschar or tache noire, offers an excellent opportunity to extendour knowledgeoIf pathogenic mechanisms, immune mechanisms, andlaboratory diagosis of BF in humans. In contrast to typhus andRocky Mountain spotted fever in which the lesions, althoughnumerous and widespread, are extremely focal, the tache noire issufficiently large and contains a large contiguous network ofseverely injured blood vessels that will allow predictable samplingand qualitative and quantitative analysis of rickettsial infection,host cell injury, and host inflammatory and immune cellularresponse. Thus, alhough the brightf ield microscopic lesions arebetter described in typhus fever, Rocky Mountain spotted fever andscrub typhus than in houtonneuse fever, these reports are notquantitative, often do not demonstrate rickettsiae with theeff iciency and specif icity of immunohistochemical techniques, 7ncdo not evaluate the ultrastructure of the human lesions. Surgicallyexcised, well-fixed eschars should allow these studies inboutonneuse fever.

As yet no significant in vivo Liltrastructural study of thehuman host-rickettsial relationship has been reported. There aretwo major reasons: 1.) the infection in human skin is extremelyfocal, in the exact center of the maculopapular rash of RMSF anrltyphus and, thus, is difficult to f ind by electron microscopy; 2)

19

intensely infected visceral tissues from fatal cases of RMSF andtyphus are not suitable for ultrastructural investigation becauseof portmortem autolysis that occurs prior to performance of thenecropsy. Surgical biopsy of the tache noire of BF should providewell-preserved lesions containing intense R. conorii infection forultrastructural investigation. A report of-the ultrastructuralaspects of an eschar in Rocky Mountain spotted fever describedrickettsiae in the lesion. However, the published electronmicrographs were of poor quality, and no rickettsiae wereidentifiable in them. Correspondence with the authors directly inan attempt to obtain copies of the original electron micrographs orthe EM grids for examination personally has not been answered.

Ultrastructural studies of experimental animals in ourlaboratory and others have shown some of the qualitative aspects ofthe rickettsia-host interaction. Our ultrastructural analysis ofrickettsial infections demonstrated R. rickettsii in enaothelium, vascular smooth muscle, and phagocytes of infected guinea pigs inthree investigations, saline-hydration prolonged survival,antilymphocyte- mediated immunosuppression, andtetracycline-treated rickettsia clearance.

A sample of the tache noire is collected by sterile skinbiopsy technique under local anesthesia after obtaining thepatient's nformed consent. The specimen is divided into threesmall 1 mm blocks and fixed for electron microscopy by immersionin cold buffered glutaraldehyde-formaldehyde solution. The fixedspecimen may be held in this solution for the period of shippingfrom Italy to our laboratory. On arrival at the InfectiousPathogenesis Laboratory in the Department of Pathology of theUniversity of North Caolina, the specimen will be postfixed in 1%osmium tetroxide, dehydrated in graded alcohol concentrations,embedded in a mixture of Epon and Araldite, ultrathin sectioned onan ultramicrotome, and stained with uranyl acetate and leadcitrate. Sections will be examined on a high resolution Zeiss 10 Aelectron microscope. Other electron microscopes includinq a JEMlOOB and a high resolution scanning electron microscope are alsoavailable within the departmental facilities should the need arise.

The remainder of the specimen is fixed in neutralhuffered-4% formaldehyde for routine histology, histochemistry, andimnunohistochemistry. Fixed tissue will be embedded in paraffin an(a ribbon of serial sections will be cut at 4 hm thickness. Adjacentsections will be mounted for staining by hematoxyiin- eosin (H & E)for routine evaluation of pathologic lesions, by phosphotungsticacid-hematoxylin (PTAH) for fibrin thrombi, by Voerhoff-van Giesortechnique (VV) for evaluation of integrity of vascular elastictissue, by modified Brown-Hopps (B1) technique for histoc},emicaldemonstration of rickettsiae, and by Giemsa technique and methylgreen pyronin (MGP) for identification of host immune andinflminatory cells. Among these stains, PTAI and VV yield hiqhysensitive results, BF demonstrates intracellular rickettsiae butwith less sensitivity, consistency, an7 specificity thanimmunofluorescence, and Giemsa and N'GP assist in identification ofeosinophils, basophils, neutrophils, activated lymphocytes, anciplasma cells but leave a large portion of unidentified mononuclearcells which include macrophages and some populations oflymphocytes.

Adjacent sections from the rihbbon are processedl for

.. o. ......... .....................o. .o... .......... . ,.,. ........ o..-.............. ..........

20

immunofluorescent demonstration of R. conorii. Sections are affixedonto clean glass slides with nonautofluorescent LePage Bond Fast

Resin Glue to prevent them from being washed off the slide afterdigestion with trypsin. Sections affixed to slides with glue areheated in an oven at 600 C for 1 hour, deparaffinized in threechanges of xylene for 10 minutes each, and rehydrated throughserial changes of ethanol in concentratons of 100%, 95%, 70%, 501,and 35% and finally in distilled water. Sectons are then incubatedin 0.1% trypsin with 0.1% CaC 2 , pH 7.8, at 370 C or 4 hours. Theslides are washed thoroughly in distilled water, washed for 30minutes in phosphate-buffered saline, and reacted with the specificimmunofluorescent system for R. conorii. We have used anti-SFGrickettsial conjugate in the direct immunofluorescence system andindirect immunofluorescence with guinea pig immune anti- R. conoriiserum followed by anti-guinea pig immunoglobulin conjugate todemonstrate structures which have the expected vascular locationand coccobacillary morphology of rickettsiae.

Studies of pathogenic mechanisms of R. conorii are performedin the plaque model which we have exploited-in i nvestigations ofpathogenic mechanisms of R. rickettsii. Aliquots of R. conoriistock are thawed and diluted in sucrose phosphate buTfer to contain500 pfu per ml. Confluent monolayers of Vero cells are inoculatedwith either 0.1 ml of diluted rickettsial stock containing 50 pfuof R. conorii or uninfected diluent. Rickettsial plaque techniqueis performed according to the method of Wike and Burgdorfer andWike et al. After 30 minutes for absorption to occur andpenetrat'io- to begin, monolayers will be overlaid with 4 ml of 0.5%agarose in minimum essential medium with 5% fetal bovine serum andincubated at 350 C. On day 4 after inoculation, 4 m! of secondoverlay with 1% neutral red is added, and the flasks are allowed toincubate in the dark at 350 C. Flasks are examined daily for plaquesafterwards with observations of monolayers by inverted microscopeand with collection of specimens for examination hyimmunof luorescent and transmission electron microscopy.

The sides of the 25-sq cm Falcon flasks opposite themonolayers are removed by cutting the plastic. Agarose qel overlaysare gently removed by separating the overlay from the sides of theflask with a sharp spatula edge and allowing the gel to detachunder the force of gravity. Exposed monolayers are fixed in 70%ethanol for 20 minutes prior to direct immunofluorescent stainingfor R. conorii with a specific anti- R. conorii conjugate.Follow.,ing incubation of monolayers with con-gte for 30 minutes,they are washed in phosphate-buffered saline for 30 minutes, washe-in distilled water, and mounted with 90% glycerol inphosphate-buffered saline (pH 9) and cover glass. Monolayers areexamined on a Leitz Ortholux ultraviolet microscope equipped withincident beam illumination and barrier and exciter filters forfluorescein isothiocyanate fluorescence microscopy.

Monolayers with overlays removed as described forimmunofluorescence are fixed by covering the cells with a solutionof buffered 2.5% glutaraldehyde for 1 hour. Cells are maintaine ,; onthe plastic surface throughout postfixation in osmium tetroxide,dehydrated through a graded series of ethanol and hydroxypropylmethacrylate solutions, and embeddedI in Mollenhauer's Epon-araldite No. 2. following polymerization in an oven at 370 -451C for24 hours and then 600 C overnight. Embedde(7 monolayers are separ--tel

21

from the plastic flasks. At this point, rickettsia]. plaques may beobserved with the unaided eye as distinct clear zones surrounded bya grey-black carpet of cells. Plaques and adjacent cells are cutout and reembedded in flat molds with the monolayer perpendicularto the plane of sectioning. Ultrathin sections are cut on an LKBultramicrotome using a diamond knife. Observation of the blockduring sectioning reveals the exact relationship of the section tothe plaque. Sections are stained with lead citrate and uranylacetate and examined on a Zeiss 10A transmission electronmicroscope.

Plaque size, time of appearance and phase contrastmorphology are observed. The relationship of R. conorii to plaquess observed by immunofluorescence microscopy. The cytopathology ofinjured cells is described including state of rough endoplasmicreticulum, mitochondria, plasma membrane, and nucleus. For eachplaque zone (center, margin, and periphery), the quantity of R.conorii in cytopathologic and cytologically normal cells will becounted and subjected to statistical analysis for association ornon-association of cytopathology with intensity of intracellularinfection. The cytology of uninfected cells adjacent to the plaquewill be examined.

Plaque model studies of penetration-associated pathogenicmechanism employ the plaque model, Amphotericin B (5 and 10 -(g/ml),and digitonin (5 and 10 Ag/m]), compounds which have been shown tobind to cholesterol-containing membrane receptors, to blockattachment of R. prowazekii to erythrocyte plasma membrane and toreduce plaque Fr6rmation byR. rickettsii which are incorporatedinto the agarose-nutrient me-um overlay. The second overlaycontains the same concentration of the cholesterol-receptor bindingdrug. Plaques are enumerated at the time of appearance of distinctplaques in untreated plaque assays of the same inoculum forstatistical analysis. In a second set of similar experimentsAmphotericin B and digitonin are introduced only in the secondoverlay on day 4 after inoculation, at which time infected fociwill be well established. Significant plaque reduction in thisexperiment indicates blocking of a pathogenic mechanism, not justabortion of initial infection.

Another experiment is designed to inhibit thepenetration-associated mechanism by inhibition of phospholipaseactivity. The approach is to utilize the phospholipase inhibitor,phentermine, in doses which we have shown not to adversely affectthe monolayer yet to cause reduction in R. rickettsii plaques.Concentrations of phentermine of 0.5, 0.1, 0.05, and 0.01 wq/'ml areincorporated in the agarose-nutrient medium overlay. Comparison bystatistical analysis of plaque counts from each (ose and untreatedmonolayers with the same inoculum of R. conorii yield adose-response curve that indicates whether phospholipase activityis necessary for the expression of cell injury by R. conorii.

One hypothesis which can be tested in the plaque modpl isthat the paucity of signs and symptoms pointing to visceralinvolvement is due to a lower threshold of temperature sensitivityof P. conorii. The inability to produce pathogenic effects attemperatures greater than 380 C could explain the relative lack ofseverity of BF when compared with RP'SF despite the 91-94%relatedness of the etiologic agents. The plaquing officiency ofvarious strains of R. conorli and R. rickettsii are co narel at

........ ..... ..-.. .. " *.'.-. • -.- '. " -",.'', ,-" .,. . . . -. ---. .' . .-* .. '.- .--. .. ., .-.. ..--. ". ""-. ' -2

22

320 C, 340 C, 360 C, 380 C, and 400 C. Variation in number of plaquesormed, plaque size (area measured morphometricaly by computer

assisted image analysis), and time of onset are examined. Theseresults reflect the effect of temperature on pathogenic effects.

The hypothesis of secretion of a potent extraceilular toxinby R. conori can be examined in an experiment utilizing parahiotictissue culture chambers. Parabiotic chambers containing cellmonolayers are separated by a filter with 0.22 m pore size. Thisfilter prevents the passage of rickettsiae from one chamber to theadjacent chamber, but allows free passage of macromolecules such asmetabolites, putative toxic products, or enzymes. In some pairs ofchambers, one chamber is inoculated with 10 plaque-forming units ofR. conorii. Other pairs of chambers are maintained with bothchambers uninoculated as controls. On days 3, 5, and 7postinoculation, trypan blue is added to selected pairs ofchambers, and selected chambers are examined by immunofluorescencefor R. conorii. The degree of cell injury in infected chambers,uninf-ected-ricettsial products exposed chambers, and controlchambers is evaluated blindly by estimation of percentage of cellsfailing to exclude trypan blue. Immumofluorescence for R. conoriiconfirms the limitation of infection to inoculated chamF-ers andallows estimation of the percentage of the monolayer that isinfected.

Results

The study of taches noires from patients with boutonneusefever has been performed in collaboration with physicians at theUniversity of Palermo. This collaboration has proven successfulwith opening of several avenues for the continued investigation ofthe pathology, pathophysiology, and clinical aspects of R. conoriinfection in humans. During the period June-August 1983, I spent

six weeks in Sicily as NATO Visiting Professor of Tropical andSubtropical Diseases. My major collaborators were ProfessorMansueto for clinical studies of boutonneuse fever an-1 ProfessorTringali for rickettsial studies. Twenty patients with clinicalboutonneuse fever under the care of Dr. Barba at the GuadagnaInfectious Disease Hospital were investigated. During the visitinqprofessorship, seven biopsies of taches noires were collected. Withfour additional tache noire biopsies collected prior to my arrivaland after my departure, 11 patients' taches noires were biopsied inall during 1983. Some patients with taches noires were not biopsiedprincipally for reasons of location related to cosmetic concern orproximity to vital structures, e.g., carotid artery. Other patientshad boutonneuse fever without a tache noire. Numerous personalcontacts were developed which shou-provid3e the basis for futurenvestigation of the pathology of the tick bites (Professor Tosti,

a ]errnatologist-dermatopathologist) and the role of the tick bitein the pathogenesis of the tache noire. Several clinical stucliesthat are not a part of this contract sFould prove interesting forcorrelation with the tache noire investigation. These includeevaluation of specif ic serum proteins and polypeptides that arerelated to the inflammnatory process (some as acute phase reactants)and hemolysis: alpha-l-antitrypsin, C-reactive protein, C3, C4,

. -.

'7L

23

haptoglobin, and prekallikrein and evaluation of hepatic injury.Rickettsia conorii was isolated from patients by inoculation ofguinea pigs with acutely collected blood or plasma samples.Intradermal inoculation resulted in formation of an eschar at thesite of inoculation in many animals. Guinea pig eschars weredemonstrated to contain R. conorii by direct immunofluorescencewith the anti-spotted fever group rickettsia conjugate obtainedfrom the Centers for Disease Control. The collaborativerelationships with Drs. Mansueto, Tringali, and others is avaluable and productive resource for the study of R. conorij andboutonneuse fever. They are very interested in the-scientificquestions related to the tache noire, boutonneuse fever, and R.conorii. They have mc-1e great efforts to obtain clinical mate-rial,conduct complete patient laboratory diagnosis confirmation andclinical followup, and establish a rickettsiology laboratory.Ongoing and future investigation of pathogenetic mechanisms,diagnostic methods and possibly preventive measures are mutuallyachievable goals. The clinical and professional resources availablein Sicily are valuable; they comprise interdependent personal. andscientific relationships in a setting which offers excellentopportunities for completion of designed investigations. Dr.Mansueto and Dr. Tringali have a strong commitment to thesestudies, and they command an impressive ability to direct theirstaffs and follow their patients in the classic European style thatbrings about a thorough completed study.

Four studies of patients with boutonneuse fever in Sicilywere initiated prior to the beginning of this research contract.They were completed and prepared for publication during the firstyear of this project. In the first study, the method fordemonstration of R. conorii in infected tissues fixed in formalinand embedded in pararffin utilizing the deparaffinization, trypsindigestion method and immunofluorescence was described. T-lymphicytedeficient, nude mice were inoculated cutaneously with 4.8 x 10plaque forming units of R. conorii (strain 7) and were sacrificeOon days 3, 7, and 15 after inoculation. An adult guinea pig wasinoculated intradermally with the same inoculum and sacrificed onday 11. Skin from the inoculation site, spleen, and liver of themice and skin from the inoculation site eschar of the guinea pigwere collected and fixed in 4% neutral buffered formaldehyde. Abiopsy of the rash from a Sicilian patient with boutonneuse "verwas obtained on day 6 after onset of fever and was similarlyprocessed. Sections at 4 Nm thickness were affixed to slides withLePage Bond Fast Resin glue (LePage, Ltd., Montreal, Canada) andwere incubated in an oven at 600C for 1 hr., deparaffinized inthree changes of xylene for 10 min each, rehydrateO through serialchanges of ethanol in concentrations of 100%, 95%, 70%, 50%, 35%,and finally in distilled water. The slides were then incubated for4 hrs in a 0.1% trypsin (Grand Island Biological Co., Grond Island,NY) with 0.1% CaCl, pH 7.8 at 37°C. After incubation slides fronrthe patient and fr m mice were washed thoroughly in distilledwater, washed for 30 min in PBS, and allowed to react (or 30 minwith anti- R. conorii guinea pig serum prepared in our laboratory,washed for 30 min in PBS, and incubated with specific anti-cluinoapig immunoglobulin FITC conjugate (PAKO) for 30 irin, v.ashed in PPSfor 30 min, rinsed in distilled water, mounted in a solution o .

- glycerol in PBS, and examined by ultraviolet microscopy with us of

. ,.. .. .•.. .-- ,..,,.. .... . .......... .....-. ...-....-.. ... . .- .,..-. ,. . ,

* -, ' i - - - -zi - -. . . . -' -,' -i .-.? - - -- .'

24

FITC barrier and exciter filters. For guinea pig tissues we usedanti- R. conorii human serum and an anti-human conjugate from DAKO.

Furthermore, we submitted all the slides to similarprocedures but using direct immunofluorescence with a rabbitimmunoglobulin FITC conjugate prepared against the antigens of R.rickettsii at the Centers for Disease Control, Atlanta, Georgia, asdescribed previously by Walker and Cain.

Organisms with morphology of rickettsiae were observedpredominantly in the vascular walls in the endothelial location inclusters or arranged end-to-end. Only smaller quantities were

*observed away from the vessel walls, apparently associated with thepredominantly macrophagic perivascular cellular reaction. Theseorganisms were demonstrated by both indirect immunofluorescence and

*direct immunofluorescence. An observation deserving comment is thebetter results obtained with the direct reaction using rabbit anti-

R. rickettsii conjugate. Hebert et al have shown that this serum is*specific-for the spotted fever group of rickettsiae. It is a well

known, high-titered, well standardized reagent that givesconsistently excellent results. It reacts with R. conorii and the

-" titer with this agent is only one dilution below the titer with R.rickettsii. In our hands it gives good, clean preparation. TheTndi-ect test was performed with guinea pig or human anti- R.conor: whole serum, both with relatively low titers. It is-"knownthat indirect immunofluorescence gives a certain degree ofnonspecific fluorescence. Indeed, in our preparations there wassome of this nonspecific fluorescence, and sometimes we had to relyon the location, size, and morphology of the fluorescent structuresto consider them to be rickettsiae. In a second publication, thehistologic lesions of the tache noire were described and organismsof R. conorii were demonstrated in 5 of the 6 biopsies using thedepiaaff-inization-trypsinization im.unofluorescent technique.

One of these patients is described in detail in a casereport in the American Journal of Tropical Med'cine and Hgienebecause of the documentation of-the "mild end of the c--l-nicalspectrum of human R. conorii infection that he represents. A sixtyyear old agricultural laborer from Sciacca, Italy noted thepresence of a tick on the lateral aspect of the right lower leg andremoved it on March 10, 1982. Twenty days later he sought medicalattention because of the development of a skin lesion at the siteof tick bite. The cutaneous lesion consisted of a central, blackulcer 2 cm in diameter surrounded by vesicles and a peripheral

*° erythematous zone. Indirect immunofluorescent antibody assayconfirmed the diagnosis of BF with anti- R. conorii IgG titer of1:320 and IgM titer of 1:80.

On April 3, 1982 a biopsy of the tache noire was performed.Brightfield microscopy revealed foci of pseudoepitheliomatoushyperplasia in the epidermis surrounding the necrotic mass ofkaryorrhectic debris, fibrin and keratin, corresponding to theeschar. In the surrounding dermis and underlying subcutaneoustissue, there were perivascular accumulations of macrophages,

* lymphocytes, and numerous eosinophils. The vascular endothelialcells were swollen. Examination of sections by the method ofdeparaffinization and trypsin digestion followed by directimmunofluorescence with a conjugate reactive with spotted fevergroup rickettsiae showed focal clusters of coccobacillary organismsin the lining of the vessel walls in the reticular dermis. The

1" " - - '' " ' .-- "" ''" .-.- - - ,.i-..i-i . " '"'"' ' -i- '""" . '" - / . """ - 4 ' -". -" . . i .-. -

.

25

immunofluorescent conjugate was prepared at the Centers for DiseaseControl using killed R. rickettsii as antigen for immunization ofrabbits. The conjugate of the globulin fraction of rabbit antiserumhas also been demonstrated to react with R. conorii at a titer of1:512.

Reaction of sections of the eschar with guinea pig preserum %by indirect immunofluorescence using a 1:20 dilution of serum and %1:40 dilution of rabbit anti-guinea pig IgG conjugate (DAKO,Accurate Chemical and Scientific Corporation, Westbury, N. Y.)revealed no organisms whereas the same indirect immunofluorescentsystem using convalescent serum collected from the same animal onemonth after inoculation of R. conorii revealed foci of thin bacillicompatible with rickettsiae.

On April 6 the anti- R. conorii titers remained at the samelevel while both the third an- fourth components of complement wereslightly elevated. At no time during his course did the patientreport a fever. He was afebrile and did not have a rash during thisevaluation of the eschar or during the following eight months.

The observation of spotted fever group rickettsiae at thesite of tick bite is strong evidence for inoculation of rickettsiaeinto the skin by tick bite, colonization of vascular endothelium bythe rickettsiae, and stimulation of host defenses without anysystemic signs or symptoms of disease.

The two principal hypotheses that may explain the occurrenceof R. conorii infection manifested only by an eschar are eitherthat the strain of R. conorii-]ike rickettsia was of relatively lowvirulence or that previous spotted fever group rickettsialinfection provided partial immune protection. Investigation ofspotted fever group rickettsiae in North America has revealed agreat diversity of rickettsial species with a spectrum of virulenceas judged by response of guinea pigs to inoculation. At the presenttime the range of virulence of R. conorii and possibly otherspotted fever group rickettsiae-n the Mediterranean basin is not

known. The serologic documentation of infection with R. conoriiamong as many as 20% of persons in western Sicily who are engagedin agricultural activities and give no history of BF suggests thatthere are nonpathogenic strains of R. conorii in Sicily. Thepossibility of a previous infection with R. conorii cannot beexcluded. The serology, in fact, demonstrated a higher level of ^

antibody to R. conorii in the IgG class than the IgM class, aswould be expected in an anamnestic immune response. Bourgeois et alhave shown that in primary infection with R. tsutsuqamushi theantibody response is mainly of the IgM class. In contrast,reinfection scrub typhus stimulates an antibody response mainly ofthe IgG class. We have also observed these two types of antibodyresponse to R. conorii in BF. It may be hypothesized that ourpatient, an agricultural laborer who is at high risk for tick bite

and/or R. conorii infection, had a prior infection with residualimmunity sufficient to contain the subsequently inoculatedorganisms at the portal of entry. Elucidation of thehost-rickettsia relationship between humans and R. conorii willrequire extensive investigation of strains of R. cono'r-lisolatesin Sicily and of the immunology of human host defenses againstrickettsiae. BF offers an excellent opportunity for the advancement

of knowledge concerning rickettsial pathogenesis and immunity.

........-. ..- . .-..-. - .. . - - , . . . .

.w -4 W W

26

The fourth manuscript on R. conorii infection in vivoprepared using data collected prior to the start of this contractpresents a study of infection of genetically immunodeficient micewith R. conorii. In order to determine the definitive importance ofT- and B-lymphocytes in immunity to Rickettsa conor'i, micegenetically deficient in T-cells, B-cells, or both T- and B-cellswere infected experimentally. T-lymphocytes rather than humoralantibodies were crucial to rickettsial clearance and a reducedmortality rate. Mice incapable of an antibody response topolysaccharide capsular antigens effectively controlled rickettsialinfection with no mortality. In contrast, nude mice producedantibody to thymus-independent antigens early in the course ofinfection, yet experienced severe rickettsial infection with deathsoccurring.

These experiments in genetically immunodeficient micedocument the importance of T-lymphocytes in the clearance of R.conorii from the tissues of infected mice. On day 7 the spleens andlivers of T-cell deficient and T- and B-cell deficient micecontained numerous rickettsiae, whereas animals with an intactT-lymphocyte immune system contained very few rickettsiae in theirhepatic and splenic tissues. The only animals that died as a resultof R. conorii infection in these studies were those deficient inT-lymphocytes whether or not they had B-lymphocytes. These resultssupport the conclusion of Kokorin et al that T-lymphocytes conferprotection against R. conorii infecEtion in mice. Moreover, thegeneration of a humoral immune response in our experiments did notcorrelate with clearance of rickettsiae and protection from death.T-lymphocyte deficient nude mice synthesized antibodies to R.conorii detectible on day 7 at which time the visceral organsc-ontained many rickettsiae. Despite the presence of antibodies inthese anaimals, mortality was observed. Nevertheless, B-lymphocytedeficient mice had no antibodies and yet had effectively restrictedrickettsial proliferation in the liver and spleen on day 7;moreover, none of these mice died. These observations conform tothe conclusion of previous studies on immunity to members of thegenus Rickettsia, namely that T-lymphocytes are crucial forimmunity.

The immune response has not been shown in this or previousstudies to be a pathogenic mechanism of tissue injury in infectionsby members of the genus Rickettsia. The cytolytic effect oflymphokines on rickettsia-infected cells in vitro again raises thequestion of an immunopathologic mechanism of tissue and cellularinjury in rickettsial diseases. Although this investigation doesnot exclude a contribution to cell injury by lymphokine-mediatedcytolysis, it does document that in the overall balance in vivo theT-lymphocyte affords protection against R. conorii. Other studiesincluding the in vitro plaque model have 3emonstrated thatrickettsiae possess direct cytopathic activity that appears to bemediated at least in part by the phospholipase- associatedpenetration mechanism and is active in the absence of the immunesystem.

The similarity of the hepatic lesions of these animals tohepatic lesions in boutonneuse fever contributes to understandingof the pathogenesis of the human lesions of multifocalhepatocellular necrosis and associated focal hepatic inflammatoryresponse. The observation of R. conorii in these lesions in mice

_.%

27j

suggests that the rickettsiae play an important role in theirpathogenesis. The immunodeficient mouse model of R. conoriiinfection should be useful in further dissection of pathogenicmechanisms of hepatic injury by R. conorii and in evaluation of theimportance of stimulation of eacH component of the immune system byspecific purified rickettsial antigens in protective immunity andvaccine design. __

The study of Sicilian taches noires has progressedsubstantially (Table i). Eleven taches noires were examined thispast year under the first year of this research contract for atotal of 17 since the beginning of the collaborative study with Dr.Mansueto. The principal features of these biopsies are severe

vasculitis with a predominance of small lymphocytes and largemononuclear cells (compatible with stimulated lymphocytes andmacrophages) and ischemic cutaneous necrosis. Thrombosis is a minorfeature, less impressive than perivascular edema. R. conorii hasbeen identified in 11 of 17 cases, and immunofluorescence of thetache noire appears to be an effective diagnostic test prior to orJurTngt--iifirst 1-2 days of antirickettsial drug treatment.Tissues from seven biopsies have been embedded for electronmicroscopy and will be sectioned and examined soon. Most of thesepatients' diagnoses have been confirmed by indirectimmunofluorescent antibody test or isolation of rickettsiaealthough serologic and rickettsial isolation data have not yet beenreceived from Palermo on a few patients. The prospects of this workproviding answers to questions regarding pathogenesis and immunityto R. conorii appear quite good.

In general visceral involvement is considered to be uncommon inboutonneuse fever. Although moderate elevation in serum lactatedehydrogenase is frequently observed, physical clinical evidencefor important visceral pathology is unusual. Several studies ofselected patients with boutonneuse fever have documented elevatedhepatic enzymes and focal hepatic microscopic lesions. A series ofeight patients from Sicily with boutonneuse fever was examined withserologic documentation of the diagnosis by indirectimmunofluorescent antibody in seven patients, hepatomegaly in fivepatients, and peak SGOT of 50-70 and peak SGPT of 34-123 in fivepatients. The biopsies, which were obtained late in the course ofillness, (day of fever ranged from 7- 23, average 12.8), showed nolesions. Considering the mild involvement, focal nature of thelesions, small sample obtained by needle biopsy, and opportunityfor repair prior to biopsy late in the course, we were notsurprised with the results. In a subsequent study of needle Ibiopsies of four patients observed last summer, lesions wereidentified in all cases. These patients were biopsied during theacute phase of boutonneuse fever (Table 2). The microscopic lesionsare similar:

Patient 1. There was only a small fragment of liver on theslide. It contained fatty change, focal hepatocellular necrosis(pyknotic cells), focal inflammation, ballooning swelling ofhepatocytes, and a mitotic figure. The presence of all threestages: necrosis, inflammatory cell response, and mitoticregeneration suggests an ongoing injury of long enough duration fora host response and host regenerative activity.

Patient 2. There was focal hepatocellular necrosis and focalinflammatory cellular accumulation. Samples of the biopsies from

28

z

CaL

0 0)c .+..+..++.++++ . + +C7

0

0 u)Lc.

L)oo 0

00

-4 c

-4 c CHo) H

C'- a,

co1 d)0))

ca0 E E ++ 0 -Y

co 0 >

.14coU) CO4~- CO E M0 0 aj) 94+

.0 + + )0-)c C D 0 O+ + 0+ + C D++ 0<00 *~

*0 0 + _j

z~0 0ca ** C O.- C

0 = 20 0b 0

>.-E 0 -HC

*LAJ 0) -H d(D 0 E -0 -

0-Y0 0)c

CU - 4

0) 0-coC-) aS~-4 .

C00 )4 Q)L) C'a 2-4

a, ) -- 4

0'-4J 0)O 4)+a

0 ri 0 V) +>

z (U E 4jc cJ C U ) C 3 + ) '-)W )C- -0 02 C 0)4).i-

Q) d) (I) U) CO

0. (-0"4.0 V CU

*u CL .' C .< *.

'\'- Z .' - . -- - , ... . .L .o ,

.. o_. . . . !. . .. - - - - : :

29

Table 2

Patients with Boutonneuse Fever Examined by Hepatic Biopsy in the Acute Phase

,brd

Patient Day of Bx Day of Tick Biteb Tache noireC IFd Lesionse r

I 3 -2 + - +

2 1 0 - - +nf

3 5 unk- - + -

4 7 unk + - +

a Number of days of fever prior to biopsyb - Number of days between observation of attached tick and onset of feverc - Presence (+) or absence (-) of tache noired - Immunofluorescent demonstration of Rickettsia conorii in liver, (-) negativee - Presence of microscopic lesionsf - Unknown

.-

* Wa

"-

NI

30

patients 2, 3, and 4 have been embedded for electron microscopy.Patient 3. There was focal necrosis and inflammatory

cellular response.Patient 4. Multifocal necrosis and inflammatory cellular

response resemble the lesions described by Guardia et al (The liverin boutonneuse fever. Gut 15: 549-551, 1974). These les ons werenot true granulomas. Th-e necrosis apparently preceded the resultingfocal inflammatory reaction.

Samples of the biopsies from patients 2, 3, and 4 have beenembedded for electron microscopy. Examination of needle biopsiesfrom four patients sent by Dr. Faure in Grenoble, France, who hasreported the hepatic histopathology of boutonneuse fever, alsorevealed no immunofluorescent R. conorii.

Severe human R. conorii inf-ections have been reported recentlyin South Africa, France, and Israel. Correspondence with two of theauthors of these reports has resulted in the opportunity toevaluate the pathology of severe and fatal R. conorii infectionincluding two necropsies. The pathology and distribution of R.conorii in fatal cases has not been reported previously. Dr. Gear,an eminant senior rickettsiologist from South Africa, reported twofatal cases and a severe case with digital gangrene. He has shippedto our laboratory material from the gangrenous digits, from thenecropsy of one of the fatal cases, and from the necropsy of asubsequent fatal case, all documented as R. conorii infections. Dr.Raoult from France did not have necropsles on his cases but agreedto send a liver biopsy from a patient with boutonneuse fever.

Paraffin sections of tissues from the three cases of SouthAfrican tick bite fever were stained by routine hematoxylin-eosinmethod, phosphotungstic acid- hematoxylin technique, anddeparaffinization-trypsin digestion- immunofluorescence method witha conjugate reactive with R. conorii as reported in detailpreviously. Tissues examined were cerebrum, cerebellum, kidney,liver, spleen, heart, lung, lymph node, and adrenal gland (case 1);cerebrum, kidney, liver, spleen, heart, lung, and pancreas (case2); and gangrenous fingers (case 3). Positive control tissues forR. conorii immunofluorescence included eschar from guinea piginoculated intradermally with R. conorii (strain 7), eschars frompatients with serologically documented boutonneuse fever, and livertissue from nude mouse inoculated with R. conorii (strain 7).

Thin bright green immunofluorescii-nt bacilli were observedonly in the location of vascular endothelium and of macrophages inhepatic and splenic sinusoids and lymph node sinuses. Nonspecificstaining of host tissues was not seen.

In case 1 the brain contained numerous rickettsiae incerebral and cerebellar blood vessels and foci of rickettsiae inthe subarachnoid location of the leptomeninges. Rickettsiae wereobserved in glomerular arterioles, capillary tufts, intertubularblood vessels, and arterial endothelium. In the liver rickettsiaewere identified only in a few sinusoidal lining cells; norickettsiae were seen in hepatocytes. Splenic rickettsiae appearedto be in macrophages and arteriolar endothelium. Few foci of R.conorii were observed in capillaries between myocardial cells,pulmonary alveolar septa, and macrophages within marginal anddraining sinuses of a lymph node. No rickettsiae were demonstratedin adrenal gland.

In case 2, numerous rickettsiae infected cerebral blood

31

vessels, glomerular arterioles and capillary tufts, renal arterialendothelium, and intertubular blood vessels near thecorticomedullary junction. Few hepatic rickettsiae were observed inscattered sinusoidal lining cells. In spleen, rickettsiae wereidentified in arteriolar endothelium and macrophages in smallquantities and in one medium sized artery in a large amount. In theheart, a few foci of rickettsiae were present in arterialendothelium and capillaries between myocardial fibers. Very fewrickettsiae infected pulmonary alveolar capillaries. Small foci ofrickettsiae were seen in capillaries and septal blood vessels ofthe pancreas and blood vessels in the dermis of skin.

In case 3, several foci containing numerous R. conorii wereidentified in the injured blood vessels at the margi-n Betweenviable and necrotic tissue. Rickettsiae were not observed in themummified necrotic zone or in the zone of healthy tissue.

In case I the cerebrum and cerebellum contained numerousfoci of perivasclar mononuclear cells, some of which infiltratedthe adjacent neuropil. There was widespread enlargement ofendothelial cells, and a diffuse mild increase in microglial cellsinfiltrating neuropil. The subarachnoid space had a mildinfiltration of mononuclear cells and a focal small hemorrhage witherythrophagocytosis by macrophages. The kidney was severelyautolytic, but multiple foci of mononuclear leukocytic vasculitiscould be identified in the outer part of the medulla near thecorticomedullary junction. Hepatic lesions included multifocal,randomly distributed coagulative necrosis of solitary hepatocytes,few polymorphonuclear leukocytes and moderate quantities of smalllymphocytes in portal triads, mild steatosis, moderate congestion,and mild sinusoidal leukocytosis. There were no granulomas, portalvasculitis, or leukocytic accumulation around necrotic hepatocytes.Matching of serial sections by brightfield microscopy andimmunofluorescence demonstrated necrotic hepatocytes adjacent toinfected sinusoidal lining cells and R. conorii within splenicarterioles that contained thrombi and 'aryor-rhectic debris. The red

"* pulp was congested, and no germinal centers were observed. Themyocardium contained a few foci of interstitial leukocytes,predominantly mononuclear cells. Lung lesions included protein-rich

* pulmonary edema, congestion, focal nonocculsive thrombosis, focalacute pneumonia with alveolar polymorphonuclear leukocytic exudate,and foci of fibrosis containing carbon pigment and birrefringentsilica crystals. Lymph node also contained anthrosilicoticFibrosis. There were foci of adrenocortical necrosis withsurrounding leukocytic response, and two periadrenal arteries hadfoci of acute vascular wall necrosis.

In case 2, many foci of vasculitis in the brain consisted ofmononuclear leukocytes infiltrating the blood vessel wall andsurrounding neuropil. There was also a mild mononuclear leukocyticleptomeningitis. Lesions in the severely injured kidney includedkaryorrhexis, thrombosis, and leukocytic infiltration of glomerulararterioles, karyorrhexis in glomerular capillary tufts, corticalvasculitis with perivascular mononuclear leukocytes, plasma cells,and focal hemorrhage, multifocal cortical interstitial edema, andmultifocal severe vasculitis with petechiae at the corticomedullaryjunction and in the outer part of the medulla. The liver containedmultifocal necrosis of solitary hepatocytes, intracanalicularcholestasis, mild steatosis, hepatocellular giant cell

32

transformation, and mitosis. No granulomas, portal vasculitis, orleukocytic response to necrotic hepatocytes were observed. Thespleen had a capsular hemorrhage and polymorphonuclear leukocytesand plasma cells in the red pulp. The lungs were congested withintraalveolar amorphous eosinophilic material compatible withpulmonary edema, scattered intraalveolar erythrocytes, and depositsof carbon pigment. The pancreas was autolyzed, but contained afocus of identifiable perivascular mononuclear cell infiltrate. Theskin showed multifocal dermal and subcutaneous vasculitis withperivascular edema and leukocytes including polymorphonuclearleukocytes. Two dermal blood vessels contained thrombi that did notocclude the lumina.

In vitro experiments on the pathogenic mechanism ormechanisms of R. conorii have employed the parabiotic chamber modeland the plaque model. Parabiotic chambers were employed todetermine whether any soluble rickettsial product would injureuninfected cells sharing the same culture medium with cellsinfected and killed by R. conorii.

The hypothesis t -at cell and tissue injury are mediated by arickettsial toxin has been suggested although an exotoxin has neverbeen demonstrated and rickettsial lipopolysaccharides do not havepotent toxic activity. Much of the confusion concerning rickettsialpathogenesis is the result of the name given to the phenomenon ofthe lethal effect of large doses of viable rickettsiae wheninoculated intravenously into mice. Traditionally, this rickettsiallaboratory assay has been termed the "mouse toxin phenomenon"although it cannot be produced by rickettsiae that are

* metabolically inactive or dead, and this toxicity has never been* produced by a purified component of rickettsiae.

Pairs of sterile parabiotic chambers (Bellco Glass,Vineland, NJ) were separated by 25 mm diameter cellulose triacetatemembrane filters (Gelman Sciences, Ann Arbor, MI) with 0.2i m poresize sealed between the chambers with silicone stopcock grease.Coverslips measuring 10 5 x 35 mm were placed in each chamber andwere seeded with 5 x 10 VERO cells (CDC Tissue Culture Unit,Atlanta, GA). After incubation at 370C in minimum essential mediumwith 5% heat-inactivated fetal calf serum and 10% tryptosephosphate broth for 24-48 hours, monolayers were confluent. Themedium was removed, and 36-360 plaque forming units of R. conorii(strain 7) were inoculated into one chamber of parabiotT-c ciambers.After 30-45 minutes for adsorption of inoculum, 10 ml of the samemedium was added. Control pairs of chambers were not inoculatedwith rickettsiae. Coverslips from adjoining inoculated anduninoculated chambers were examined for evidence of cell death asdetermined by trypan blue staining and for presence anddistribution of R. conorii by direct immunofluorescence.Uninoculated pairs of chambers were examined as controls on day 7after inoculation. For a positive toxin control, one chamber ofeach of two pairs was inoculated with a fresh clinical isolate ofPseudomonas aeruginosa with examination of chambers on day 3 and onday 5 by trypan blue staining. The coverslips were examined on days5 and 6 by phase contrast microscopy after trypan blue staining andthen after acetone fixation by direct immunofluorescence for

- . . *.. .~* ***4 ,* .. . . . . *- .~ . . . . . . . .

I L% .'. '** . . '-a' ~ 7 .----

33

rickettsiae.The monolayers infected with R. conorii showed severe

cytopathic effect but with less necrosis than R. rickettsii-infected monolayers although nearly all of the-cells were

,' infected. In contrast, the adjacent uninoculated monolayersappeared without cytopathic effect. Validation of the parabioticchamber toxin model was provided by demonstration of progressivedestruction of the monolayers in the chamber infected with P.aeruginosa and in the uninfected chamber when examined on d-ys 3and 5.

The plaque model has been useful in the investigation of therole of the phospholipase-associated rickettsial entry mechanism incell injury by R. conorii. We have used VERO cell monolayers and R.conorii (strain 7). Two different drugs that have been reported topossess phospholipase A inhibitory capability, phentermine andindomethacin, were incorporated into the overlay media. Phenterminewas added to both the first and second overlay media in thefollowing final concentrations: 0.1 mg/ml, 0.2 mg/ml, 0.4 mg/ml,0.8 mg/ml, and 1.6 mg/ml. Plaques were counted on day 6 afterinoculation. The results are shown in Table 3. Indomethacin wasincorporatqd in both overlay media in final concentrations of10- M, 10"M, 10-LM, and 10-6 M. Plaques were counted on days 6 and7. The results are presented in Table 4. In an attempt to determinewhether the effect of one of these drugs with phospholipase Ainhibitory activity, phentermine, acts on a rickettsial actvi~y oron a host cell activity, the compound was incubated with either R.

- conorii or VERO cell monolayers pior to inoculation. The 2rickettsiae were then diluted 10 such that the finalconcentration of phentermine at the time of inoculation wasnegligible. The pretreated monolayer was washed with 3 ml ofsterile phosphate buffered saline prior to inoculation to removeunbound phentermine. Plaques were counted on day 7 afterinoculation of R. conorii. The results are shown in Tables 5 and 6.Uninfected monolayers showed no toxicity of phenterminepretreatment over the range of 0.1 - 4.0 mg/ml concentration. Therewas partial toxicity at 10 mg/ml and complete destruction of themonolayer at 20 mg/ml and above.

Because recent studies in our laboratory have shown thatsynthetic diamidine type protease inhibitors have the ability toblock plaque formation by R. rickettsii, we tested the effect ofthe most effective compoungon the R. conorii plaque model.Bis(5-amidino-2-benzimidazolyl)methane, (BABIM), was firstincorporated into bot first and second 6overlay media atconcentrations of 10- M, 10-5M, and 10- M. Plaques were counted on

* day 6 after inoculation. The results demonstrated that thisinhibitor of krypsin-like proteases blocked plaque formation at10- M and 10- M concentrations (Table 7).

R. conorii plaques have been fixed for electron microscopy,". embedded in Epon-Araldite, removed from the flask while the, topography of the plaque was maintained, and reembedded in

Epon-Araldite for sectioning perpendicular to the plane of themonolayer. Ultrathin sectioning, staining, and ultrastructuralanalysis of the host-rickettsia relationship in R. conorii plaquesshould be achieved during the second year of the contract.Additional experiments which have been begun, but have not yieldedsignificant results, include the effect of hemolysate and

[ - *. . . . .-- '*

Ir - - -a -. 11:1

34

Table 3

Effect of Phentermine on Plaque Formation by Rickettsia conorii

Concentration of Phentermine (mg/ml)Inoculum None 0.1 0.2 0.4 0.8 1.6

R. conorii 42.5-5.2' 40.0-4.8 30.3-6.0 16.3-2.5 14.0-2.2 Toxic

None 0 - - - Toxic

a - Number of plaques/flask (mean standard deviation)

* - - " °4 i ' - -

e - - - ' - , - ' - ' ' f ' ' ' - " " , " " ; " , -

WV l-' -w Irr - W- 9--

35

Table 4

Effect of Indomethacin on Plaque Formation by Rickettsia conorii

R. conorii None

Conc. Indomethacin Da 6 Day 7 Day 6 Day 7

None 1 3.5±9.0a 15.3±8.0 0 0

10 M 12.3-9.6 13.5-3.1 - -

-5++10 M 0-0 0-0 -

IO-4M A 00 +

-3d10 M Toxicd Toxic Toxic Toxic

a - Number of plaques/flask (mean standard deviation)b - Plaques smaller than untreated R. conorii plaquesc - Partial destruction of monolayer by toxicity of indomethacin; no plaques in the

intact portions of monolayerd - Indomethacin toxic to monolayer at this concentration

ft.

%'f

-f.

36

Table 5

Effect of Phentermine Pretreatment of Rickettsia conorii on Plaque Formation

Inoculum (Phentermine Concentration) Plaquesa

R. conorii (none) INTC

*R. conorii + phentermine (20 mg/mi) TNT C

*R. conorii + phentermine (40 mg/mi) TNT C

R. conorii + phentermine (80 mg/mi) 15. 8±4.*3

*R. conorii + phentermine (320 mg/mi) 0±0

a -Number of plaques/flask standard deviation

7S

37

* Table 6

Effect of Phentermine Pretreatment of Vero Cells on Subsequent Plaque

Formation by Rickettsia conorii

a

Conc. of Phentermine in Pretreatment Plagues

None 20.8111.5

1 mg/ml 38.8-2.5

4 mg/ml 64.0-14.1

b10 mg/ml

a - Number of plaques/flask standard deviationb - Partial destruction of monolayer by toxicity of phentermine; estimated

adjusted mean of plaque counts, 86.5

38

Table 7

Effect of BABIM on Plaque Formation by Rickettsia conorii

Inoculum Treatment (conc.) Plaques

R. conorii None 21.8-18.1

R. conorii BABIM (10-4M) 21.8-l9.1

R. conorii BABIM (10-5 M) OtO

R. conorii BABIM (10 6M) 0-0

None None 00

None BABIM (10- 4 M) 0+0

None BABIM (+O-SM) 0+-

None BABIM (10 6 M) 0-0

(

4 . . .. . .

39

hemolysate fractions from the glucose-6- phosphate dehydrogenasedeficient cells on R. conorii plaque formation, the effects ofcholesterol recepto-binding compounds such as digitonin andamphotericin B on R. conorii plaque formation, and the effect oftemperature on R. coriTlaqefrain

-. 75

40

Conclusions:

My clinical observations in Sicily convince me that leboutonneuse fever is a potential military problem. The relativeease in finding bona fide cases and the high rates ofseropositivity among the rural population indicate thatcirculation of spotted fever group rickettsiae is very active.Aside from lower mortality rates, the bouton;ieuse fever problemappears analogous to scrub typhus in the Assam-Burma regionduring World War II.

We are in the process of defining the spectrum of illnessassociated with R. conorii. Our documentation of a patient whohad a rickettsia-containing tache noire, but neither fever norrash supplements the known range of disease. Our colleagues inItaly have shown that tnere are many persons who have norecollection of a boutonneuse fever-like illness but do haveantibodies reactive with R. conorii. We have also studied thepathology and distribution of R. conorii in two fatal cases of R.conorii infection in South Afrlca.

The pathologic lesions and pathophysiology of fatal RMSF andSouth African tick bite fever have both similarities and distinctdifferences. In general, the pattern of mononuclearleukocyte-rich infiltration of the infected blood vessel wall andperivascular space is the basic lesion in most affected organs inboth RMSF and these two fatal cases of R. conorii infection. Thelesions in the central nervous system fr-om--th diseases resemblethe classic Frankelos nodules of typhus fever with cellscompatible with macrophages and small and large lymphocytespermeating the perivascular neuropil. A mild leptomeningitis isobserved in both rickettsioses. The cerebrospinal fluid inpatient 1 reflected the rickettsial meningoencephalitis with mildpleocytosis and elevated protein concentration. Other analogouslesions include multifocal perivascular interstitial nephritis,focal interstitial myocarditis, dermal and subcutaneousvasculitis in the skin of the rash, eschar, and peripheralgangrene, and vasculitis in the pancreatic interlobular septa andperiadrenal adipose tissue. Lesions which were observed in fatalR. conorii infection and are not characteristic of RMSF arenecrotizing glomerular arteriolitis and multifocal necrosis ofsingle hepatocytes. Although hepatocellular necrosis other thancentrilobular necrosis was present in 5 of 9 fatal cases of RMSFin one series and in 7 of 16 cases in another series, the majorhepatic lesions of RMSF, portal vasculitis and triaditis, werenot observed in these two patients. The other major difference inpathology is the presence of interstitial pneumonia in RMSF andits absence in South African tick bite fever.

The distribution of lesions correlates with the locations ofrickettsiae in each disease. Thus, the pulmonary capillaries andother small pulmonary blood vessels are infected with numerous R.rickettsii in RMSF, but there were few R. conorii infecting thepulionary microcirculation in these twocases. Conversely, theglomerular arterioles in South African tick bite fever were thesites of intense R. conorii infection and necrotizing vasculitisbut are not a target in RMSF. The locations of R. conorii andlesions correlated well in brain, meninges, live--, kidney, heart,spleen, skin, pancreas, and periadrenal arteries. These general

41

observations were confirmed in specific foci where R. conoriiwere observed in serial sections of vascular injury. ThuFs, thesedata support the theory of direct rickettsial injury of theparasitized cells proposed by Wolbach and supported by recent invitro experiments. ,.-

A discrepancy in the correspondence of the injured cell andparasitized cell is noted in the liver. This description of R.conorii infection of sinusoidal lining cells is the first reportof direct rickettsial infection of the liver in this disease;nevertheless, necrosis occurs in the hepatocyte adjacent to theinfected sinusoidal lining cell. The mechanism by which thisinjury to the hepatocyte is mediated is not apparent. Previousinvestigations of lesions in hepatic biopsies have demonstratedaccumulations of leukocytes in foci of hepatocellular necrosis.We have been unable to demonstrate intact R. conorii in any ofthese inflammatory lesions in humans. Experimental infections ofmice with R. conorii have suggested that immune mechanisms clearthe rickettsiae efficiently from the foci of the hepatocellularnecrosis and inflammation of mice with intact T-lymphocytes whilethese lesions in T-cell deficient mice contain numerousrickettsiae. Moreover, those experiments and the absence oflymphocytes and macrophages in the foci of hepatocellularnecrosis at the stage of development present in these cases wouldmake cell mediated immunopathologic mechanisms seem unlikely.

The other lesions of particular interest are the amputatedfingers. In addition to the expected observations of necrosis andwound repair, there was a zone of severely ischemic tissue inwhich a few viable cells persisted and organisms of R. conoriiwere identified. The observation of persistent rickettsiae in hertissues 36 days after the beginning of treatment withtetracycline is remarkable. Identical findings were present inamputated leg specimens from a patient in North Carolina withRocky Mountain spotted fever who had been treated for three weekswith chloramphenicol. In both cases the spotted fever grouprickettsiae were seen only in the ischemic partially viable zonewhere delivery of effective antirickettsial drug concentrationsand host defenses such as T-lymphocytes, macrophages, andinterferon was probably inadequate. This phenomenon may berelated to the well known capability of spotted fever grouprickettsiae to continue to proliferate in the yolk sac of hen'seggs for 48-72 hours after the death of the embryo. Proof thatthese morphologically intact organisms are truly viable willrequire isolation of rickettsiae from similar amputationspecimens.

This documentation of the pathogenic potential of R. conoriiin its most severe form indicates that further investigailons--fthe renal, hepatic, neurologic, and cutaneous pathophysiology ofthis disease and of the pathogenic mechanisms of R. conoriishould be pursued.

Our studies of the tache noire have shown thatmoderate-to-severe injury to numerous dermal blood vessels is thebasis for the tick-bite site lesion. On the other hand,thrombosis was not as important as in the two previously

investigated eschars in patients with RMSF. Among the 16 biopsies

* .-... ".-* *...' .. . o . .. - ,% .-. .*'.'. * . ° % . .-

. . ... ,. . . . . . . . . . ..

42

of taches noires in which blood vessels could be identified forevaluation; there were no thrombi in 9, mild thrombosis in 5, andmoderate or severe thrombosis in only 2. In contrast, edema wasobserved in all 16 cases in which it could be evaluated. By lightmicroscopy, the predominant immune and inflammatory cell types inthe vascular loci were small lymphocytes and large mononuclearcells. Polymorphonuclear leukocytes and eosninophils weregenerally inconspicuous. This observation will be further testedby ultrastructural examination; however, it supports the conceptof the importance of cell mediated immunity possibly includinglocal interferon production by T-lymphocytes.

Furthermore, this report documents the utility of skinbiopsy immunofluorescence demonstration of R. conorii in thediagnosis of boutonneuse fever. Spotted fever group rickettsiaewere demonstrated in taches noires and the rash and could beidentified by immunofluorescence on either frozen sections ordeparaffinized, trypsin digested sections that had been fixed informalin and embedded in paraffin previously. This techniqueshould be made available on a reference basis to military healthproviders. The specific etiologic diagnosis of a few cases in anarea sounds the olert for increased awareness of the disease andpossible preventive measures directed against tick transmission.

Our human studies have also confirmed that boutonneuse feveraffects the liver. This hepatic injury is important to recognizein understanding the visceral involvement of this illness and asan in vivo model for the pathogenesis of R. conorii injury totissues. In experimental mice, we have documented the importanceof T-lymphocytes rather than B-lymphocytes reactive withcarbohydrate antigens in immunity to R. conorii. Moreover, therewas no apparent contribution of immunopathologic mechanisms totissue injury in vivo.

ParabiotiFc-am6b-r experimentation showed no diffusibleexotoxin or soluble rickettsial enzyme that could injure cells inthe identical milieu excluding the rickettsiae. On the otherhand, two enzyme systems appear to play an important role in cellinjury by R. conorii. Two inhibitors of phospholipase A2 wereable to block plaque formation by R. conorii. Since pretreatmentof the cells with one of the inhibitors (phentermine) resulted inan increase in quantity of plaques, it seems unlikely that thephospholipase is of host cell origin. In contrast, pretreatmentof R. conorii with phentermine inhibited plaque formation. Thisplaque inhibition may have been due to killing of rickettsiae byphentermine or inhibition of a rickettsial phospholipase.

Moreover, there is evidence that BABIM, an inhibitor oftrypsin-like proteases, is highly effective in blocking plaqueformation by R. conorii. Thus a trypsin-like protease appears tobe important in the physiology of and/or cell injury by R.conorii

~ *-..".

43

Recommendations:

1. Offer skin biopsy immunofluorescent demonstration of R.conorii in tache noire as a reference military laboratorydiagnostic test for boutonneuse fever.

, 2. Study the rickettsial hepatitis of boutonneuse fever andexperimental R. conorii infection as models for visceral tissueinjury by R. conorii.

3. Initiate a search for nonpathogenic R. conorii or R. conorii-like isolates in ticks in Sicily.

4. Develop a more rapid, quantifiable assay system for growth ofand cell injury by R. conorii for screening amidine typetrypsin-like protease f"nibitors as potential prophylactic oradjunctive therapeutic agents.

5. Screen amidine type protease inhibitors for inhibition ofcell injury by R. conorii.

6. Continue studies of taches noires for role of thrombosis incell injury and specific identification of local immune celltypes.

* 7. Continue in vitro study of pathogenic mechanisms of cellinjury by R. conorli.

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Selected Bibliography

1. Guardia J, Martinez-Vazquez JM, Moragas A, Rey C, VilasecaJ, Tornos J, Beltran M, Barcardi R: The liver in boutonneusefever. Gut 15:549-551, 1974.

2. Faure J, Escande J-C, Grataloup G, Massot C, Faure H:Hepatite granulomateuse rickettsienne interest de la biopsiehepatique. Nouvelle Presse Medicale 6: 2896, 1977.

3. Raoult D, Gallais H, Ottomani A, Resch JP, Tichadou D,DeMicco Ph., Casanova P: La forme maligne de la fievreboutonneuse mediterraneenne. Six observations. La PresseMedicale 12:2375-2378, 1983.

4. Gear JHS, Miller GB, Martins H, Swanepoel R, Wolstenholme B,Coppin A: Tick-bite fever in South Africa. SA Med J63:807-810, 1983.

5. Torregrossa MV, DiFatta C, Zambito G: Indagini sullapresenza di anticorpi anti R. conori (reazione dimicro-immunofluorescenza) in sieri di soggetti sani viventinella Sicilia Occidentale. Ig Mod. 79: 225-231, 1983.

6. Montenegro MR, Mansueto S, Hegarty B, Walker DH: Thehistology of "taches noires" of boutonneuse fever anddemonstration of Rickettsia conorii in them byimmunofluorescence. Virchows Archiv A 400:309-317, 1983.

7. Walker DH, Firth WT, Ballard JG, Hegarty BC: Role ofPhospholipase- Associated Penetration Mechanism in CellInjury by Rickettsia rickettsii. Infection and Immunity,840-842, 1983.

8. Walker DH, Gay RM, Valdes-Dapena M: The occurrence ofeschars in Rocky Mountain spotted fever. J Am Academy ofDerm, 4:571-576, 1981.

9. Combiesco D: Sur une epidemie de fievre exanthematique:fievre boutonneuse, Arch. roum path exper 2:311, 1932.

10. Pieri J, Mosinger M: Etude anatomo pathologique de la papuleboutonneuse, Presse med. 74:1425, 1935.

11. Gutman A, Schreiber H, Toragan R: An outbreak of tick typhusin the coastal plains of Israel. Trans Royal Sco Trop MedHyg 67:112-121, 1973.

12. Scafidi V: Attuale espansione endemoepidemica della febbrebottonosa in Italia. Minerva Med 72:2063-2070, 1981.

13. Bell, EJ, Stoenner HG: Immunologic relationships among the

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spotted fever group of rickettsias determined by toxinneutralization tests in mice with convalescent animalserums. J. Immunol 84:171-182, 1960.

14. Adams, JS, Walker DH: The liver in Rocky Mountain spottedfever. Am J Clin Path 75:156-161, 1981.

15. Walker DH, Cain BG: A method for specific diagnosis of RockyMountain spotted fever on fixed, paraffin-embedded tissue byimmuofluorescence. J Infect Dis 137:206-209, 1978.

16. Walker DH, Cain BG: The rickettsial plaque. Evidence fordirect cytopathic effect of Rickettsia rickettsii. LabInvest 43:388-396, 1980.

17. Walker DH, Firth WT, Edgell C-JS: Human endothelial cellculture plaques induced by Rickettsia rickettsii. InfectImmun 37:301-306, 1982.

18. Winkler HH: Immediate cytotoxicity and phospholipase A: therole of phospholipase A in the interaction of R. prowazekiand L-cells. In Rickettsiae and Rickettsial Diseases, WBurgdorfer and RL Anacker, eds. New York, Academic Press,1981. pp 327-333.

19. Vigo C, Lewis GP, Piper PJ: Mechanisms of inhibition ofphospholipase A2. Biochem Pharmacol 29:623-627, 1980.

20. Wike DA, Tallent G, Peacock MG, Ormsbee RA: Studies of therickettsial plaque assay technique. Infect Immun 5:715-722,1972.

21. Oaks SC Jr, Osterman JV: The influence of temperature and pHon the growth of Rickettsia conorii in irradiated mammaliancells. Acta virol 23:67-72, 1969.

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