ROLE OF STREPTOCOCCAL INFECTION I N THE ACUTE PATHOLOGY OF LYMPHATIC FILARIASIS
ESTERRE P.*, PLICHART C.*, HUIN-BLONDEY M.O.** & NGUYEN L.**
Summary:
Growing evidence suggest that secondary bacterial, mainly streptococcal, infections contribute significantly to recurrent episodes of acute adenolymphangitis (ADL| of filarial origin. We examined the role of group A streptococci in the progression of lymphedema in Polynesian patients with filariasis-related ADL (22 cases) or chronic pathology (10 cases), or with erysipela (10 patients) and, as controls, in 20 healthy adults. Antistreptolysin O (ASLO) and anti-streptodornase B (ASDB) titers were
systematically determined in parallel to parasitological and biochemical tests. ASLO and ASDB assays were positive in 100 % of erysipela, 75 % of filarial ADL as compared to 50 % of chronic pathology and 39 % of healthy controls. Interestingly, by opposition to ASLO titers which were not significantly different between the four groups, ASDB titers were higher in ADL (p = 0.019) and erysipela (p = 0.002) than in controls. These results support the hypothesis that recurrent streptococcal infections may have an important role in the pathogenesis of ADL in lymphatic filariasis.
KEY WORDS :
lymphatic filariasis, Wuchereria bancrofti, group A streptococci, acute adenolymphangitis, French Polynesia.MOTS CLES : filariose lymphatique, Wuchereria bancrofti, streptocoques du groupe A, adénolymphongite aigüe, Polynésie Française.
Résumé : RÔLE DES INFECTIONS STREPTOCOCCIQUES DANS LA PATHOLOGIE AIGUË D'ORIGINE FILARIENNE
Les évidences s'accumulent quant à un rôle important des infections bactériennes secondaires, notamment d'origine streptococcique, dans la pathogénèse des adénolymphangites (ADL) aiguës d'origine filarienne. Nous avons recherché l'intervention de streptocoques du groupe A dans la progression des lymphoedèmes de malades, d'origine polynésienne, présentant une ADL (22 patients) ou une pathologie chronique ( 10 cas) d'origine filarienne, un érysipèle (10 patients) et, à titre de contrôle, 20 adultes sains. Des épreuves sérologiques de détermination des anticorps anti-streptolysine O (ASLO) ou anti- streptodornase 6 IASDBI ont été pratiquées, en parallèle aux investigations parasitologiques et biochimiques classiques, les tests ASIO et ASDB se sont révélés positifs pour 100 % des érysipèles, 75 % des ADL filariennes et encore 50 % des filariens à
pathologie chronique et 39 % des contrôles sains. Si les titres en ASLO ne sont pas significativement différents entres ces quatre groupes analysés, il est intéressant de noter que les titres en ASDB sont statistiquement plus élevés, pour les ADL filariennes
(p = 0,019) et les érysipèles (p = 0,002), que la normale. Ces résultats semblent confirmer l'hypothèse selon laquelle des infections streptococciques récurrentes, fréquentes en zone tropicale humide comme la Polynésie, jouent un rôle important dans la pathogénèse des ADL associées à la filariose lymphatique.
H
u m a n lymphatic filariasis is c a u s e d by lym- phatic-dwelling parasites, mainly the s p e c i e sWuchereria bancrofti ( m o r e than 9 0 % o f i n d e x e d c a s e s ) , a n d is characterized b y a w i d e range o f clinical manifestations affecting the limbs, genitals, breasts and other parts o f the b o d y (Partono, 1 9 8 7 ) . Acute and c h r o n i c disease manifestations result in a worldwide annual morbidity estimated to reach four million disably-ajusted life years, making this disease as the s e c o n d leading c a u s e o f disability to mankind (Bradley, 1 9 9 7 ) . In order to interrupt the transmission b y vectors, and doing s o trying to prevent disease,
* Immunology Unit and
** Clinical Research Unit,
Institut Territorial de Recherches Médicales Louis Malardé, BP 30, Papeete, 98713 Tahiti (French Polynesia).
Correspondence: Dr Philippe Esterre, Head of Immunology Unit, Ins- titut Territorial de Recherches Médicales Louis Malardé, BP 30, Papeete, 98713 Tahiti (Polynésie Française).
Fax: 689 43 15 90 - E-mail: esterre@malarde.pf
national control programs have been implemented. But e v e n w h e n transmission is eliminated, c h r o n i c and acute s y m p t o m s can continue to b e important public health p r o b l e m (Fan et al., 1 9 9 5 ) .
T h e acute form o f bancroftian filariasis involves lym- phadenitis and lymphangitis, generally called a d e n o - lymphangitis (ADL) and is s u p p o s e d to b e , at least partly, a local immunological r esp onse to adult w o r m s associated to mechanical damages o f the lymphatic ves- sels m a d e by t h e s e motile parasites. Repeated lym- phatic d a m a g e s related to adult w o r m s activity is sup- p o s e d to result in increased susceptibility to secondary bacterial infections, leading to progression o f lym- p h o e d e m a and elephantiasis (Olszewski et al., 1 9 9 3 , 1 9 9 4 ; S c h a c h e r & Sahyoun, 1967; S h e n o y et al, 1 9 9 5 ) . T h e relative contribution o f these immunological, para- sitological and bacterial c o m p o n e n t s is poorly defined.
B a s e d o n serological results, streptococcal infection have b e e n recently considered as a precipitating factor o f ADL in Brugia malayi- (Suma et al, 1 9 9 7 ) and
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Article available athttp://www.parasite-journal.orgorhttp://dx.doi.org/10.1051/parasite/2000072091
ESTERRE P., PLICHART С , HUIN-BLONDEY M.O. & NGUYEN L.
W. bancrofti- (Vincent et al, 1 9 9 8 ) associated morbi
dity. T h e present study e x a m i n e d serologically infec
tions with group AB hemolytic streptococci, o n e o f the main c o m m o n p a t h o g e n i c bacteria in tropical areas with a marked affinity for the lymphatics, in ADL o f filarial and bacterial (erysipela, s e e clinical definition in Chattier & G r o s s h a n s , 1 9 9 0 , and V i n c e n t et al, 1 9 9 8 ) origins, c o m p a r e d to controls with the s a m e eth
nological and social conditions.
MATERIAL AND METHODS
SERUM SAMPLES
P
rospective patients, e x a m i n e d b y an e x p e r i e n c e d m e d i c a l staff (Clinical R e s e a r c h Unit, Institut Malarde, P a p e e t e , F r e n c h Polynesia), w e r e carefully q u e s t i o n e d for a clinical history o f recurrent epi
s o d e s o f ADL ( S u m a et al, 1997; Vincent et al, 1 9 9 8 ) . T h e s e l e c t e d population consisted o f 22 patients with filarial ADL, 10 patients with c h r o n i c pathology (six hydroceles, t w o elephantiasis and t w o chyluria) and 10 with typical erysipelas and 20 e n d e m i c healthy controls o f the s a m e ethnological ( P o l y n e s i a n ) and social (life-long residents o f Tahiti island, Society archi
p e l a g o ) conditions. After informed consent, diligent cli
nical and laboratory investigations ( c o m p l e t e h e m o - gram, serum biochemistry and detection o f microfilariae b y Nucleopore® m e m b r a n e filtration) w e r e carried in all the subjects enrolled in the study. T h e 20 healthy adults, negative for the specific criteria, w e r e carefully e x a m i n e d for skin or lymphatic diseases w h i c h could interfere with the present study.
METHODS
In addition to the previously cited laboratory investi
gations, detection o f filaria-specific immunoglobulins ( I g G ) w a s m e s u r e d b y ELISA using a soluble antigen extract from B. malayi w o r m and antigenemia (Chan- teau et al, 1 9 9 4 ; Nicolas et al, 1997; Ottesen et al, 1997) w e r e tested with a quick immunochromatogra- phic test (ICT Filariasis®, ICT Diagnostics Ltd, B r o o k - vale, Australia) recently validated. In c a s e o f positive results with the ICT assay, a reference ELISA-based tech
nique ( O g 4 c 3 kit, J C U Tropical Biotech Ltd., Townsville, Australia) w a s used for confirmation (Nguyen et al, 1 9 9 9 ) . W e also studied the antistreptococcal antibody r e s p o n s e s b y estimating the anti-streptolysin O (ASLO) titers with an immunoturbidimetric assay (Tina-Quant®
ASLO, using an Hitachi 7 1 7 instrument, B o e h r i n g e r - Mannheim, Mannheim, G e r m a n y ) , and the anti-strep- t o d o r n a s e B ( A S D B ) with an e n z y m a t i c inhibition (ADNase B®, D a d e Behring, Paris La Defense, F r a n c e ) . W h e n using both ASLO and A S D B tests, nearly all g r o u p A s t r e p t o c o c c a l i n f e c t i o n s c a n b e d e t e c t e d
(Ayoub, 1 9 9 1 ) . In ten patients studied t w o or three times during the o n e - y e a r follow-up period, the e l e vated titers w e r e persistent (data not s h o w n ) . G i v e n a suggestive clinical history o f recurrent ADL, elevation o f either the ASLO or A S D B titers is c o n s i d e r e d as evi
d e n c e o f an antecedent streptococcal infection (Ayoub, 1 9 9 1 ; Vincent et al, 1 9 9 8 ) . ASLO titers are considering to rise about o n e w e e k after the initial infection, with a m a x i m u m after three to five w e e k s , and to return to normal in six to 12 months, e x c e p t in c a s e o f rein
fection b y streptococci (Chartier & Grosshans 1 9 9 0 ; Suma etal, 1 9 9 7 ) . T h u s ASLO are considered to repre
sent a marker o f recent s tr e p t oc oc c a l infection. A S D B r e s p o n s e s e e m to b e m o r e stable than ASLO r é p o n s e , independantly o f the demonstration o f a specific site o f s t r e p t o c o c c u s infection, and r e a c h its m a x i m u m after only six to nine w e e k s with a s l o w e r return to normal levels (Kaplan etal., 1970; Vincent etal, 1 9 9 8 ) : thus they represent an indicator o f m o r e c h r o n i c strep
t o c o c c a l infection.
STATISTICAL ANALYSIS
ASLO and A S D B titers w e r e indifferently u s e d as such or transformed to 10-based log b e f o r e applying /-tests for indépendant samples. P values l o we r than 0.05 w e r e considered significant. W e used statistical analysis softwares (Stamed, Medical C o m p u t e r lab., Faculty o f Medicine, Nancy, France and Statistica 5, StatSoft, Tulsa, USA) for performing the calculations.
RESULTS
CLINICAL PRESENTATION AND FILARIA-SPECIFIC I G G
T
h e g r o u p o f 22 patients with filariasis-related ADL w e r e e x a m i n e d o n the o c c a s i o n o f an acute attack o f lymphangitis with e d e m a , but n o n e o f them s h o w e d a site o f entry for bacteria. Most o f t h e m ( 9 5 . 5 % ) w e r e amicrofilaremic with n o antig e n e m i a ( 9 1 % ) , and specific IgG w e r e only detected in 4 1 % o f this sample. T h e s e c o n d g r o u p o f patients had c h r o n i c lymphatic filariasis pathology (six hydro
celes, two elephantiasis and two recurrent chyluria) without any ADL e p i s o d e during the previous year.
E x c e p t the t w o c a s e s o f chyluria, all patients w e r e negative for microfilaremia and antigenemia, these last result b e i n g confirmed b y an ELISA reference assay.
Specific IgG w e r e identified in 5 0 % o f the sample, including the t w o chyluria. T h e 10 patients with a typical acute erysipela ( V i n c e n t et al, 1 9 9 8 ) , most o f them with irreversible e d e m a and skin thickening, wera all negative for microfilaremia, antigenemia and, e x c e p t o n e (at the l o w e r limit o f positivity), for filaria specific IgG.
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' - . .
S T R E P T O C O C C I A N D L Y M P H A T I C F I L A R I A S I S
Anti- genemia Microfilar. (ITC
prevalence card test) ASLO ASDB (%) (%) (I I/ml) titers Erysipelas 0.0 0.0 193.2± 75.7 693.6 ±535.9 (n-10)
AOL 4.5 9.0 223.3± 164.9 807.0 ±879.7 (n = 22)
Chronic. Pathol. 20* 20* 335.6 ±405.9 402.1 ±532.0 (n-10)
Controls (n-20)
0.0 0.0 212.5±101.3 249.0 ±148.5
The two cases of chyluria were both microfilaremic and positive with F.LISA- and ICT-based detection assays for circulating worm antigens.
Table I. - Laboratory results of the detection of microfilaria, anti- genemia and antistreptococcal antibodies in erysipelas, Wuchereria
bancrofti-assocuited adenolymphangitis (ADD or chronic pathology and healthy controls, from French Polynesia.
ANTISTREPTOCOCCAL ANTIBODY RESPONSES
ASLO a n d / o r A S D B antibodies w e r e positive in 100 % o f erysipela ( p = 0 . 0 0 1 , b y c o m p a r i s o n with controls), 75 % o f o f filarial ADL ( p = 0.04), 50 % o f chronic patho
logy ( p > 0.05, but not with the t w o chyluria), and 3 9 % o f healthy controls ( T a b l e I ) . T h e ASLO titers w e r e n o t significantly different b e t w e e n the four groups, but A S D B titers w e r e higher in erysipela ( p = 0 . 0 0 2 ) a n d ADL ( p = 0.019), but not in patients with chronic patho
logy ( p > 0 . 0 5 ) , than in controls.
DISCUSSION
A
large proportion o f residents affected b y acute lymphatic filariasis involves g r o u p A B h e m o lytic streptococci. About 7 5 % o f the studied s a m p l e with filarial ADL h a s positive levels o f ASLO a n d / o r A S D B antibodies, a result t o b e c o m p a r e d t o the 5 0 % a n d 9 0 % p e r c e n t a g e s o b s e r v e d in a b a n - croftian (Vincent et al, 1 9 9 8 ) a n d a brugian (Suma et al., 1 9 9 7 ) lymphatic filariasis focus, respectively.T h e s e results, a n d previous bacteriological investiga
tions ( O l s z e w s k i et al., 1 9 9 4 ; S h e n o y et al, 1 9 9 5 ) , c o n v i n c i n g l y d e m o n s t r a t e that s t r e p t o c o c c i h a v e a significant role, e v e n if not exclusive, in the pathology o f acute ADL associated to lymphatic filariasis. In addi
tion, half o f the patients with c h r o n i c pathology ( b u t interestingly n o t with chyluria) have also antistrepto
c o c c a l antibodies. This confirms t h e propensity o f streptococci for invading poorly vascularized tissues, as previoulsy noted for elephantiasis (Nutman & Weller, 1 9 9 4 ) . It is noted that 3 9 % o f healthy residents o f Tahiti island, as c o m p a r e d to 2 4 % in the D o m i n i c a n republic (Vincent et al, 1 9 9 8 ) , h a v e past o r present s t r e p t o c o c c a l infections always ignored ( o r n e g l e c t e d )
o n a clinical point o f view. This last result c a n easely be explained b y t h e fact that most o f our controls a n d patients are presently, o r w e r e in the past, barefoot agricultural workers at least for a part o f their life.
Under this h o t a n d humid tropical climate, skin-mace
rating conditions are frequently o b s e r v e d a n d favour recurrent streptococcal invasion o f the skin and the lymphatics, amplifying t h e l y m p h e d e m a - a s s o c i a t e d morbidity o b s e r v e d in lymphatic filariasis. Moreover a role for these streptococcal skin infections has recently b e e n p r o p o s e d for explaining t h e high level o f rheu
matoid arthritis o b s e r v e d in Polynesia. T h e s e data confirm the interest o f rapidly initiating long-term anti
biotic therapy, in ADL as for erysipela, in order to m a n a g e t h e progression o f the disease process.
ACKNOWLEDGEMENTS
W
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Reçu le 4 novembre 1999 Accepté le 31 mars 2000
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