Rickettsia conorii infection with fatal complication

Rickettsial diseases (RD) are a group of endotheliotropic infectious diseases caused by different species of genera Rickettsia. RD are not an uncommon disease and may be misdiagnosed during the evaluation of acute febrile illness due to a lack of reliable serological marker and diagnostic culture methods. Clinical manifestation of RD varies from febrile illness with rashes and myalgia to fatal complications such as shock and respiratory failure. We describe a case of a young male who presented initially with acute febrile illness, followed by shock and respiratory failure, and unfortunately succumbed to death. A post-mortem examination showed histological features of endotheliotropic infection, such as interstitial / perivascular edema in various organs and noncardiogenic pulmonary edema (suggesting increased vascular permeability) and evidence of vasculitis in the lung, liver, and intestines. Molecular studies performed from lung, liver, and kidney tissue confirm the diagnosis of spotted fever group rickettsial disease due to Rickettsia conorii

Are there any factors affecting the outcome of endoscopic sclerotherapy in filarial chyluria? A prospective study

Introduction: Filarial chyluria is a frequent problem in India. While endoscopic therapy is the mainstay of treatment, it is not always successful. We aimed to determine parameters that affect outcomes of endoscopic sclerotherapy for filarial chyluria (FC). Methods: Prospectively maintained data of FC patients who received endoscopic sclerotherapy between June 2011 and March 2015 were analyzed. Sclerotherapy included either povidone-iodine (0.1%) or silver nitrate (1%). The parameters recorded included clinical evaluation, urinary triglyceride (TG)/cholesterol, sclerotherapy treatment, and follow-up. Results: One hundred and fifty-seven patients (male: female, 104:53) with a mean age (± standard deviation [SD]) 41.12 ± 13.68 years underwent endoscopic sclerotherapy. Grade II (68.88%) chyluria was a most common presentation followed by Grade III (25.69%). One hundred and forty-four patients responded whereas six patients failed to respond; another seven were lost to follow up, and twenty patients had recurrence. Overall success rate was 86.11%. Baseline urinary TG (mean ± SD) between success and recurrence group was 195.51 ± 164.73 mg/dl and 652.65 ± 62.55 mg/dl and cholesterol (mean ± SD) was 16.99 ± 10.08 mg/dl and 89.07 ± 39.87 mg/dl, respectively. Patient with urinary TGs >300 mg/dl and urinary cholesterol >30 mg/dl had 3.2 and 1.3 times higher chance to have recurrence after endoscopic sclerotherapy, respectively. Choice of sclerosing agent (silver nitrate 1% versus povidone-iodine 0.1%) had no difference in success rate, but silver nitrate had slightly higher complications rate (25% vs. 20%). A higher number of instillations (>3) was associated with better success rate. Majority of the complications were either Clavien Grade 1 or 2. Conclusions: The factors predicting recurrence were higher clinical grade, higher number of pretreatment courses, and high urinary TG and cholesterol

Classical Photoreceptors Are Primarily Responsible for the Pupillary Light Reflex in Mouse.

Pupillary light reflex (PLR) is an important clinical tool to assess the integrity of visual pathways. The available evidence suggests that melanopsin-expressing retinal ganglion cells (mRGCs) mediate PLR-driven by the classical photoreceptors (rods and cones) at low irradiances and by melanopsin activation at high irradiances. However, genetic or pharmacological elimination of melanopsin does not completely abolish PLR at high irradiances, raising the possibility that classical photoreceptors may have a role even at high irradiances. Using an inducible mouse model of photoreceptor degeneration, we asked whether classical photoreceptors are responsible for PLR at all irradiances, and found that the PLR was severely attenuated at all irradiances. Using multiple approaches, we show that the residual PLR at high irradiances in this mouse was primarily from the remnant rods and cones, with a minor contribution from melanopsin activation. In contrast, in rd1 mouse where classical photoreceptor degeneration occurs during development, the PLR was absent at low irradiances but intact at high irradiances, as reported previously. Since mRGCs receive inputs from classical photoreceptors, we also asked whether developmental loss of classical photoreceptors as in rd1 mouse leads to compensatory takeover of the high-irradiance PLR by mRGCs. Specifically, we looked at a distinct subpopulation of mRGCs that express Brn3b transcription factor, which has been shown to mediate PLR. We found that rd1 mouse had a significantly higher proportion of Brn3b-expressing M1 type of mRGCs than in the inducible model. Interestingly, inducing classical photoreceptor degeneration during development also resulted in a higher proportion of Brn3b-expressing M1 cells and partially rescued PLR at high irradiances. These results suggest that classical photoreceptors are primarily responsible for PLR at all irradiances, while melanopsin activation makes a minor contribution at very high irradiances

List of primary antibodies.

<p>List of primary antibodies.</p

PLR was severely attenuated at all irradiances in mice in which photoreceptor loss was induced with MNU during adulthood.

<p><b>A)</b> Representative pupil images from three groups of mice, showing sustained pupil response in dark, and at low (0.1 μW/cm²), medium (10 μW/cm²), and high (2.8 X 10⁴ μW/cm²) irradiances. <b>B)</b> Percent pupil constriction (mean ± SE) as a function of irradiance. A mixed design ANOVA with repeated measures on irradiance showed significant differences among the three groups (F_2,21 = 97.6; <i>P</i> <<0.0001). A Bonferroni post hoc test showed all three groups were different from each other at <i>P</i> <<0.0001. A pairwise comparison at each irradiance revealed that PLR in MNU-injected mouse was significantly lower than wild-type at all irradiances used here (<i>P</i> = 0.0005 at 4x10^-3 μW/cm² and <i>P</i> << 0.0001 at higher irradiances), while it was lower than rd1 mice at 10 μW/cm² (<i>P</i> <0.05) and higher irradiances (<i>P</i> <<0.0001). The PLR in rd1 mouse was similar to wild-type at irradiances >10³ μW/cm² (<i>P</i> >0.05) (n = 8 mice for all groups).</p

Photoreceptor loss induced during development resulted in partial rescue of PLR at higher irradiances.

<p><b>A)</b> PLR in adult (P-72) mice that were injected with MNU prenatally (5 mg/kg i/p at embryonic day 16; n = 5 mice). The 2 parentheses in the label show animal ages when the drug was injected and PLR was recorded, respectively. PLRs of mice injected with MNU during adulthood and of adult rd1 mice are replotted from <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g001" target="_blank">Fig 1B</a> for comparison. A mixed ANOVA with repeated measures on irradiance showed significant differences among the 3 groups (F_2,18 = 60.7, <i>P</i> <<0.0001). A post hoc test using Bonferroni correction showed that the PLR in MNU (prenatal)(P-72) animals was significantly higher than in MNU (adult)(adult) animals (<i>P</i> = 0.0002), but significantly lower than the adult rd1 mice (<i>P</i> = 0.001). A pairwise comparison at each irradiance revealed that the PLR in MNU (prenatal)(P-72) mice was similar to that in MNU (adult)(adult) at <1 μW/cm², but significantly higher at irradiances >1 μW/cm². The PLR in MNU (prenatal)(P-72) mice was similar to that in adult rd1 mice at <10³ μW/cm², but significantly lower at irradiances >10³ μW/cm². * <i>P</i> ≤0.005 for MNU (prenatal) versus MNU (adult); ^†<i>P</i> <0.0001 for MNU (prenatal) versus adult rd1. <b>B)</b> PLR in adult (P-70) mice that were injected with NaIO₃ at P-8 (60 mg/kg; i/p; n = 6 mice). PLRs of mice injected with NaIO₃ during adulthood and of adult rd1 mice are replotted from Figs <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g002" target="_blank">2A</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g001" target="_blank">1B</a>, respectively, for comparison. A mixed ANOVA with repeated measures on irradiance showed significant differences among the 3 groups (F_2,17 = 14.3; <i>P</i> = 0.0003). A post hoc test using Bonferroni correction showed that the PLR in both rd1 and NaIO₃ (P-8)(P-70) mice was significantly higher than the NaIO₃ (adult)(adult) mice (<i>P</i> = 0.0002 and 0.038, respectively), while the PLR in rd1 mice was similar to that in NaIO₃ (P-8)(P-70) mice (<i>P</i> = 0.098). Pairwise comparisons at individual irradiances revealed that PLR was similar in all 3 groups at irradiances <10³ μW/cm². However, at >10³ μW/cm², the PLR in NaIO₃ (P-8)(P-70) mice was significantly higher than in NaIO₃ (adult)(adult) mice (<i>P</i> = 0.012 at 10³ μW/cm² to <i>P</i> = 0.002 at the highest irradiance) but significantly lower than in rd1 mice (<i>P</i> = 0.006 at 10³ μW/cm² to <i>P</i> = 0.00001 at the highest irradiance). * <i>P</i> ≤0.05 for NaIO₃ (P-8)(P-70) versus NaIO₃ (adult)(adult); ^†<i>P</i> <0.005 for NaIO₃ (P-8)(P-70) versus rd1 mice. <b>C)</b> In mice injected prenatally with MNU, the PLR recorded during adulthood (P-64 or P-72) was significantly higher than during development (P-40, P-49, or P-56) (F_1,8 = 12.6, <i>P</i> = 0.008, n = 5 mice; two-way ANOVA with repeated measures). A pairwise comparison revealed significant differences at irradiances ≥0.1 μW/cm². *<i>P</i> <0.05. <b>D)</b> In mice injected at P-8 with NaIO₃, the PLR recorded during adulthood (P-70) was significantly higher than during development (P-40) (F_1,10 = 18.02, <i>P</i> = 0.002; n = 6 mice; two-way ANOVA with repeated measures). A pairwise comparison revealed significant differences at all irradiances. *<i>P</i> <0.05; ^†<i>P</i> <0.01.</p

Melanopsin made a minor contribution to PLR at high irradiances.

<p>Three of the 6 mice shown in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g003" target="_blank">Fig 3D</a>, which had both MNU and NaIO₃ injected, were administered a melanopsin antagonist (AA41612). This resulted in further reduction in PLR at high irradiances. A two-way ANOVA with repeated measures showed a significant difference between the three groups (F_2,24 = 31.3; <i>P</i> = 0.004). A post hoc Holm-Sidak test showed that injecting AA41612 resulted in significantly lower PLR at irradiances >10³ μW/cm² compared with mice injected with MNU and NaIO₃. PLR data for wild-type mice is replotted from <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g001" target="_blank">Fig 1B</a> for comparison.*<i>P</i> <0.05.</p

Residual PLR in MNU-injected mice was attributable primarily to remnant photoreceptors.

<p><b>A)</b> Temporal profile of PLR (mean ± SE; n = 5 mice) at a high irradiance (6x10³ μW/cm²) for three groups of mice. MNU-injected (7 dpi) mice showed transient response ~2 sec after the stimulus onset (<i>arrow</i>), which was qualitatively similar to that in wild-type mice, whereas rd1 mice did not show any such transient response. <b>B)</b> Representative images of flatmounted rd1 (<i>left column</i>) and MNU-injected (<i>right</i>) mouse peripheral retinas, showing immunolabeling for s-opsin (<i>top row</i>; inferior retina), m-opsin (<i>middle</i>; superior retina) and rhodopsin (<i>bottom</i>; superior retina). S-opsin labeling was present as bright puncta (<i>arrows</i>), possibly representing remnant s-cone outer segments. M-opsin and rhodopsin labeling was present as puncta (<i>arrows</i>), as well as in cell somas (<i>arrowheads</i>). Scale bar: 20 μm. <b>C)</b> Schematics or montages of wholemount retinas labeled for s-opsin (<i>top row</i>), m-opsin (<i>middle</i>) and rhodopsin (<i>bottom</i>) showing the extent and pattern of photoreceptor loss in rd1 (<i>left</i>) and MNU-injected (<i>right</i>) mice. Each black dot in the schematics (top 2 rows) represents a remnant cone. To ensure that cones could be seen as distinctly as possible, we used smaller dot sizes where their density was too high. The number of rods in the MNU-injected sample was so high, especially in peripheral retina that we could not generate a schematic, and therefore show here the images of the montage from both rd1 and MNU-injected mice. Scale bar: 1 mm. <b>D)</b> Administration of NaIO₃ in MNU-injected mice resulted in further reduction in PLR at high irradiances at 7 dpi. A two-way ANOVA with repeated measures on irradiance showed a significant difference between the two groups (F_1,45 = 8.7; <i>P</i> = 0.032; n = 6 mice). A pairwise comparison using post hoc Holm-Sidak test revealed significant differences at irradiances ≥10 μW/cm². *<i>P</i> <0.05.</p

Melanopsin expression levels in retina were unaltered following photoreceptor loss in both rd1 and MNU-injected mice.

<p>(A) Representative immunoblots for melanopsin and the corresponding β-tubulin for wild-type, rd1 and MNU-injected mice. Melanopsin immunoblot produced two bands: glycosylated protein at 85 kDa and unglycosylated protein at 53 kDa. (B) Optical density ratio (melanopsin to β-tubulin) for glycosylated and unglycosylated melanopsin (mean±SE). The levels of glycosylated and unglycosylated melanopsin in rd1 (0.54 ± 0.08 and 0.72 ± 0.07, respectively) and MNU-injected mice (0.84 ± 0.15 and 0.8 ± 0.11) were statistically similar to those in wild-type (0.82 ± 0.13 and 0.86 ± 0.16) (F_2,9 = 1.8, <i>P</i> = 0.22 and F_2,9 = 0.36, <i>P</i> = 0.7, respectively; one-way ANOVA; n = 4 mice). (C) Relative levels of melanopsin mRNA in rd1 (0.83 ± 0.09) and MNU-injected mice (0.92 ± 0.1) were statistically similar to those in wild-type (1.01 ± 0.04) (F_2,30 = 1.25, <i>P</i> = 0.3; one-way ANOVA; n = 11 mice).</p

Attenuation of PLR in MNU-injected mice was attributable to loss of photoreceptors.

<p><b>A)</b> NaIO₃-induced photoreceptor loss led to severely attenuated PLR at all irradiances used here. At 7 days after NaIO₃ injection, pupil constriction at the highest irradiance was ~35% (n = 6 mice). PLR data for wild-type and MNU-injected animals are replotted from <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0157226#pone.0157226.g001" target="_blank">Fig 1B</a> for comparison. <b>B)</b> MNU did not affect PLR in rd1 mouse. PLR was recorded before and 7 days after MNU injection (two-way ANOVA with repeated measures; F_1,8 = 0.02, <i>P</i> = 0.9; n = 5 mice).</p