dgkh000161
10.3205/dgkh000161
urn:nbn:de:0183-dgkh0001611
Research Article
Persistently elevated IgA antibodies to Mycoplasma pneumoniae in patients with internal carotid artery stenosis
Persistent erhöhte IgA Antikörper gegen Mycoplasma pneumoniae bei Patienten mit Stenose der A. carotis interna
Daxböck
Daxböck
Florian
F
Dr. med.
Mödling, Austria
author
Assadian
Assadian
Afshin
A
Department for Vascular and Endovascular Surgery, Wilhelminenspital Vienna, Vienna, Austria
author
Watkins-Riedel
Watkins-Riedel
Thomas
T
Clinical Institute for Laboratory Medicine, Medical University Vienna, Vienna General Hospital, Vienna, Austria
author
Assadian
Assadian
Ojan
O
Prof. Dr.
DTMH
Clinical Institute for Hospital Hygiene, Medical University Vienna, Vienna General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria, Phone: +43-1-40400-1904, Fax: +43-1-40400-1907Clinical Institute for Hospital Hygiene, Medical University Vienna, Vienna General Hospital, Vienna, Austria
ojan.assadian@meduniwien.ac.at
author
German Medical Science GMS Publishing House
Düsseldorf
610
Mycoplasma pneumonia
IgA
atherosclerosis
stenosis
elevated antibodies
A. carotis interna
Mycoplasma pneumonia
IgA
Arteriosklerose
Stenose
erhöhte Antikörper
A. carotis interna
20111215
engl
1863-5245
6
1
GMS Krankenhaushygiene Interdisziplinär
GMS Krankenhaushyg Interdiszip
Prevention and therapy of nosocomial infections
04
Hintergrund: Mycoplasma pneumoniae wurde mit der Pathogenese der Arteriosklerose in Verbindung gebracht. Bis heute konnte dieser mögl<![CDATA[ich</PlainText></TextGroup>e Zusammenhang jedoch nicht endgültig bestätigt oder verworfen werden und bleibt daher Gegenstand kontroverser Diskussion. </Pgraph><Pgraph><Mark1>Methoden:</Mark1> Wir untersuchten den spezifischen IgA Antikörper-Wert von 91 Patienten mit Stenose der A. carotis interna mittels eines kommerziellen Kits (SeroMP™ IgA; Savyon Diagnostics, Israel; cut-off Wert: 20 B.E.). Alle Patienten durchliefen eine gefäßchirurgische Operation der A. carotis interna. Von jedem Patienten wurden die erste Serumprobe (S1) vor der Operation und eine zweite Serumprobe (S2) 6 Monate nach der Operation abgenommen.</Pgraph><Pgraph><Mark1>Ergebnisse:</Mark1> Die S1 Seroprävalenz betrug 18,7% (17/91). 13 der 17 Patienten mit positivem S1 IgA Wert blieben auch 6 Monaten nach der operativen Sanierung der Stenose positiv, wobei kein Abfall der IgA-Werte zu verzeichnen war (Medianer S1 Wert: 34 BU, Range: 22–65 BU; Medianer S2 Wert: 37 BU, Range: 22–58 BU). Sechs dieser Patienten zeigten eine Erhöhung der Werte nach 6 Monaten und 6 weitere Patienten verstarben. Bei einem Patienten blieben die Werte konstant. Im Gegenzug dazu wurden nur 3 der 74 S1-negativen Patienten nach 6 Monaten Kontrolle positiv für anti-<Mark2>M. pneumoniae</Mark2> IgA Antikörper (p<0,01). Keine der untersuchten demographischen Risikofaktoren für Arteriosklerose, Grad der CAVK oder der Stenose korrelierten mit der IgA-Seropositivität.</Pgraph><Pgraph><Mark1>Schlussfolgerungen:</Mark1> Diese Ergebnisse können nicht durch die allgemein hohe Durchseuchung der Bevölkerung oder vergangener respiratorischer Infektionen mit <Mark2>M. pneumonia</Mark2> erklärt werden, womit eine mögliche Rolle von <Mark2>M. pneumoniae</Mark2> im Zusammenhang mit der Pathogenese der Arteriosklerose nicht ausgeschlossen werden kann, da eine chronische Infektion vermutet werden muss. </Pgraph></Abstract>
<Abstract language="en" linked="yes"><Pgraph><Mark1>Background:</Mark1> It has been suggested that <Mark2>Mycoplasma pneumoniae</Mark2> may play a role in the development of atherosclerosis, but to date this association is still a matter of debate due to conflicting findings.</Pgraph><Pgraph><Mark1>Methods:</Mark1> We have investigated the levels of specific IgA antibodies to <Mark2>M. pneumoniae</Mark2> in 91 patients with internal carotid artery (ICA) stenosis using a commercial kit (SeroMP™ IgA; Savyon Diagnostics, Israel; cut-off value: 20 binding units; BU). All patients underwent surgery for ICA stenosis. From each patient, the first serum sample (S1) was taken before surgery, and the second after an interval of 6 month (S2).</Pgraph><Pgraph><Mark1>Results:</Mark1> The S1 seroprevalence was 18.7% (17/91). Thirteen of the 17 patients with positive S1 levels also remained positive after six month, whereby no decrease of IgA level was seen (median S1 level: 34 BU, range: 22–65 BU; median S2 level: 37 BU, range: 22–58 BU). Specifically, six of the patients showed an increased level after 6 months, and six a decrease, with the level remaining constant in one patient. In contrast, only 3 of the 74 S1 negative patients became positive for anti-<Mark2>M. pneumoniae</Mark2> IgA between the taking of the first and the second serum specimen (p<0.01). None of the assessed demographic factors or risk factors for atherosclerosis was associated with IgA seropositivity, neither were the degree CAVK or the degree of stenosis.</Pgraph><Pgraph><Mark1>Conclusion:</Mark1> These findings cannot be explained throughout by the general seroprevalence, or by past respiratory tract infections with the pathogen, and therefore may suggest a role for <Mark2>M. pneumoniae</Mark2> in the development of atherosclerosis, since a chronic infection must be assumed.</Pgraph></Abstract>
<TextBlock linked="yes" name="Introduction">
<MainHeadline>Introduction</MainHeadline><Pgraph><Mark2>Mycoplasma pneumoniae</Mark2> is an important cause of res<TextGroup><PlainText>pirato</PlainText></TextGroup>ry tract infections including community-acquired pneumonia <TextLink reference="1"></TextLink>. It has been suggested that the pathogen may also play a role in the development of atherosclerosis. This hypothesis is supported by the ability of <TextGroup><Mark2>M. pneumoniae</Mark2></TextGroup> to cause extrapulmonary manifestations affecting the blood vessels <TextLink reference="2"></TextLink>, <TextLink reference="3"></TextLink>, <TextLink reference="4"></TextLink>. Some recent studies found an association between <Mark2>M. pneumoniae</Mark2> infection and atherosclerosis <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>, <TextLink reference="7"></TextLink>. However, others have presented discordant results, so that the role of <TextGroup><Mark2>M. pneumoniae</Mark2></TextGroup> in the pathogenesis of atherosclerosis must still be regarded as unknown <TextLink reference="8"></TextLink>, <TextLink reference="9"></TextLink>.</Pgraph><Pgraph>Serum IgA antibodies are a more reliable indicator for acute <Mark2>M. pneumoniae</Mark2> infection than IgM, because specific IgM are not mounted regularly in elderly patients <TextLink reference="10"></TextLink>, <TextLink reference="11"></TextLink>. Importantly, the serum level of specific IgA declines to normal values earlier after acute infection than the level of specific IgM, with a significant decrease 60 days after the onset of disease <TextLink reference="12"></TextLink>. Therefore, persistently elevated IgA serum levels may indicate chronic infection. The aim of this study was to investigate the role of <TextGroup><Mark2>M. pneumoniae</Mark2></TextGroup> in the development atherosclerosis by repeated testing of specific IgA over a period of 6 month. </Pgraph></TextBlock>
<TextBlock linked="yes" name="Material and methods">
<MainHeadline>Material and methods</MainHeadline><Pgraph>Ninety-one consecutive patients with symptomatic and asymptomatic internal carotid artery (ICA) stenosis >70%, who were admitted for surgery March and July 2004 were enrolled in this study. Fifty-three patients were male and 38 were female. The age ranged from 41 to 86 years (median: 69 years). Thirty-nine patients (43%) had asymptomatic ICA stenosis, 32 patients (35%) had transient ischaemic episodes and 20 patients (22%) were operated on for non-disabling stroke.</Pgraph><Pgraph>All patients were planned for routine eversion endarterectomy (EEA) of the ICA under regional anaesthesia. As anaesthetic agent 1% lidocaine was used for a combined superficial and deep cervical block. Symptomatic patients with stroke had an interval of less than 6 weeks prior to surgery; symptomatic patients with transient hemispheric and non-hemispheric symptoms were all operated on within 3 weeks after presentation. For all patients, the following data were assessed: Age, sex, clinical stage of carotid artery disease (CAD) (right/left), degree of stenosis (right/left), body mass index (BMI), alcohol consumption (gram/week), nicotine (cigarettes/day), diabetes mellitus, cholesterol, triglycerides and homocysteine.</Pgraph><Pgraph>Patients on antihypertensive medication or a blood pressure of ≥140/75 mmHg on repeat measurements were characterized hypertensive.</Pgraph><Pgraph>Maximum ICA stenosis was assessed by magnetic resonance angiography and Duplex and stenosis of ≥70% were an indication for surgery.</Pgraph><Pgraph>Serum was obtained by venipuncture of the antecubital vein using standard tubes (Vacuette EDTA Tubes, Greiner Bio-One, Kremsmuenster, Austria) and centrifugation 10 minutes at 2,000 G. Serum was stored at –80°C until use. The first serum specimen (S1) was taken before surgery, and the second after an interval of 6 months (S2). Specific IgA were measured by the SeroMP™ IgA kit (Savyon Diagnostics, Ashdod, Israel) according to the manufacturer’s recommendations. As indicated by the manufacturer values >20 BU (Binding Units) were considered positive.</Pgraph><Pgraph>All patients gave written informed consent. The study was approved by the local ethics committee.</Pgraph><Pgraph>Statistical analysis was performed by Chi squared test (Yates correction), using EpiInfo 2002™ (CDC, Atlanta, GA, USA). A p-value of <0.05 was considered significant.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Results">
<MainHeadline>Results</MainHeadline><Pgraph>The IgA seroprevalence at admission (S1) was 18.7% (17 of 91 patients). In these patients, the median S1 value was 35 BU (range: 22–58 BU). Thirteen of these 17 patients were also tested positive for anti-<Mark2>M. pneumoniae</Mark2> IgA after a period of 6 month (median: 36 BU; range: 22–57 BU). Among the 74 patients with negative S1 results, only 3 showed a positive result after 6 months (p<0.01). The ELISA results and basic clinical data of the 18 patients with ≥1 result >20 BU are shown by Table 1 <ImgLink imgNo="1" imgType="table"/>.</Pgraph><Pgraph>None of the assessed demographic factors or risk factors for atherosclerosis was associated with IgA seropositivity, neither were the degree CAVK or the degree of stenosis.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Discussion">
<MainHeadline>Discussion</MainHeadline><Pgraph>In this study we found a considerable seroprevalence of IgA antibodies to <Mark2>M. pneumoniae</Mark2> in patients with internal carotid artery stenosis. However, the more remarkable finding was that in the majority of our patients IgA remained elevated at essentially constant levels through a period of at least 6 month. In contrast, few patients (3) developed specific IgA between the taking of the first and the second serum specimen.</Pgraph><Pgraph>We have focused on IgA determination in the present study, because specific IgM formation may be lacking in the elderly <TextLink reference="10"></TextLink>. IgG antibodies, on the other hand, remain elevated for longtime after infection, which results in a high IgG seroprevalence, that can cause interpretation difficulties <TextLink reference="1"></TextLink>.</Pgraph><Pgraph>Determination of specific IgA is a suitable tool for the diagnosis of <Mark2>M. pneumoniae</Mark2> infection <TextLink reference="11"></TextLink>. It has been shown that after infection specific IgA decline to normal values (i.e. levels below the cut-off value of commercially available tests) earlier than specific IgM <TextLink reference="12"></TextLink>. However, IgA-based diagnosis is less established than IgM- or IgG-based diagnosis, and persistently elevated IgA as indicator of chronic infection, although biologically plausible, has to be interpreted with caution. It has to be mentioned that differing figures concerning the seroprevalence of IgA antibodies to <Mark2>M. pneumoniae</Mark2> in elderly patients have been published, with seroprevalences up to 79% <TextLink reference="8"></TextLink>, <TextLink reference="13"></TextLink>. However, the applied assay and the respective cut-off level for positivity is obviously important in this context. By the assay applied in the present study, we have found a seroprevalence of 13% (>20 BU) and no value >30 BU among 46 healthy subjects <TextLink reference="11"></TextLink>.</Pgraph><Pgraph>A certain variance of ELISA results has to be considered. Nevertheless, a significant trend to a decrease in antibody level would be expected if the elevated IgA levels in our patients should simply reflect past respiratory tract infection. It is notable that in the 13 patients with persistently high IgA levels, 6 showed an increasing and 6 a decreasing IgA level, with the level in one patient remaining constant (Table 1 <ImgLink imgNo="1" imgType="table"/>).</Pgraph><Pgraph>An important study negotiating a potential role of <TextGroup><Mark2>M. pneumoniae</Mark2></TextGroup> in the development of atherosclerosis has been provided by Maraha et al., who failed to detect the pathogen in the great majority of 103 atherectomy specimens and degenerative heart valve specimens <TextLink reference="9"></TextLink>. However, it should be considered that some mycoplasma-a<TextGroup><PlainText>ssociat</PlainText></TextGroup>ed diseases, including severe pneumonia and neurological manifestations, are immunologically mediated and require the presence of the pathogen only in an early stage of the disease <TextLink reference="14"></TextLink>, <TextLink reference="15"></TextLink>, <TextLink reference="16"></TextLink>. Therefore, serological methods may be advantageous to explore the association between <Mark2>M. pneumoniae</Mark2> infection and athe<TextGroup><PlainText>rosclero</PlainText></TextGroup>sis.</Pgraph><Pgraph>In conclusion, we have applied a new serological approach to investigate the role of <Mark2>M. pneumoniae</Mark2> in the development of atherosclerosis. The results can not be explained throughout by the general seroprevalence, or by past respiratory tract infections with the pathogen, so that they suggest a role for <Mark2>M. pneumoniae</Mark2> in the development of atherosclerosis. However, it has to be considered that the association between chronic mycoplasma infection and persistently elevated IgA antibodies is not yet proven by large-scale epidemiological investigations. Future studies on the potential role of <Mark2>M. pneumoniae</Mark2> in the development of atherosclerosis are warranted.</Pgraph></TextBlock>
<TextBlock linked="yes" name="Notes">
<MainHeadline>Notes</MainHeadline><SubHeadline>Conflicts of interest</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock>
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<Caption><Pgraph><Mark1>Table 1: Results of IgA ELISA and clinical data in 18 patients who were tested positive (>20 binding units; BU) on at least one occasion</Mark1></Pgraph></Caption>
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