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Clinical Immunology

Colonic Immunopathogenesis of Clostridium difficile Infections

Charles Darkoh, Bradley P. Turnwald, Hoonmo L. Koo, Kevin W. Garey, Zhi-Dong Jiang, Samuel L. Aitken, Herbert L. DuPont
M. F. Pasetti, Editor
Charles Darkoh
aThe University of Texas Health Science Center, School of Public Health, Center for Infectious Diseases, Houston, Texas, USA
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Bradley P. Turnwald
eOhio Wesleyan University, Delaware, Ohio, USA
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Hoonmo L. Koo
dBaylor College of Medicine, Department of Medicine, Houston, Texas, USA
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Kevin W. Garey
aThe University of Texas Health Science Center, School of Public Health, Center for Infectious Diseases, Houston, Texas, USA
cSt. Luke's Medical Center, Internal Medicine, Houston, Texas, USA
fUniversity of Houston College of Pharmacy, Houston, Texas, USA
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Zhi-Dong Jiang
aThe University of Texas Health Science Center, School of Public Health, Center for Infectious Diseases, Houston, Texas, USA
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Samuel L. Aitken
fUniversity of Houston College of Pharmacy, Houston, Texas, USA
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Herbert L. DuPont
aThe University of Texas Health Science Center, School of Public Health, Center for Infectious Diseases, Houston, Texas, USA
bThe University of Texas Medical School, Houston, Texas, USA
cSt. Luke's Medical Center, Internal Medicine, Houston, Texas, USA
dBaylor College of Medicine, Department of Medicine, Houston, Texas, USA
fUniversity of Houston College of Pharmacy, Houston, Texas, USA
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M. F. Pasetti
Roles: Editor
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DOI: 10.1128/CVI.00770-13
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  • FIG 1
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    FIG 1

    Different inflammatory biomarkers detected in the clinical stool samples examined. Stools (300 mg) from 100 antibiotic-associated diarrheal patients (50 CDI positive and 50 CDI negative) were evaluated for the presence of 36 inflammatory-associated proteins using the Proteome Profiler human cytokine array panel A kit (R&D Systems, Minneapolis, MN). Abbreviations: Pos. Ctl, positive control; Neg. Ctl, negative control; CD40L, CD40 ligand; IFN-γ, gamma interferon, IL-1α, interleukin-1α; IL-1β, interleukin-1β; IL-1ra, interleukin-1 receptor antagonist; IL-8, interleukin-8, IL-23; interleukin-23; MIF, macrophage migration inhibitory factor; PAI-1, plasminogen activator inhibitor 1.

  • FIG 2
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    Fold change in the amount of inflammatory markers detected in CDI-positive and CDI-negative stools. Stools (300 mg) from 100 antibiotic-associated diarrheal patients (50 CDI positive and 50 CDI negative) were evaluated for the presence of 36 inflammatory biomarkers using a Proteome Profiler human cytokine array panel A kit (R&D Systems, Minneapolis, MN). Band intensities were determined and converted into pixel densities using ImageJ (National Institutes of Health, Bethesda, MD). Error bars represent the standard deviations from the mean values for each inflammatory biomarker. Significant differences between CDI-positive and CDI-negative stools are denoted by asterisks. The P values, based on a nonparametric t test, were 0.011 for C5a, 0.042 for CD40L, 0.045 for G-CSF, 0.030 for I-309, 0.001 for IL-13; 0.031 for IL-16, 0.027 for IL-27, 0.013 for MCP-1, 0.021 for TNF-α, 0.004 for IL-8, and 0.002 for IL-23. Abbreviations: GM-CSF, granulocyte colony-stimulating factor; GRO-α, growth-regulated oncogene-alpha; sICAM-1, soluble intercellular adhesion molecule 1; IP-10, interferon gamma-induced protein 10; I-TAC, interferon-inducible T cell alpha chemoattractant; MIP-1α and MIP-1β, macrophage inflammatory proteins alpha and beta, respectively; SDF-1, stromal cell-derived factor 1; sTREM-1, soluble triggering receptor expressed on myeloid cells 1; MIF, macrophage migration inhibitory factor; PAI-1, plasminogen activator inhibitor 1. The other abbreviations are defined in the text.

  • FIG 3
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    IL-8 and IL-23 were present in the majority of CDI-positive and CDI-negative stools. (A) IL-8 and IL-23 were detected in a greater number of CDI-positive stools than CDI-negative stools. Stools (300 mg) from 100 antibiotic-associated diarrheal patients (50 CDI positive and 50 CDI negative) were evaluated for the presence of 36 inflammation-associated proteins using a Proteome Profiler human cytokine array panel A kit (R&D Systems, Minneapolis, MN). Stools from the hospitalized patients (controls) without diarrhea were not evaluated by this initial assay but were included retrospectively in the quantitative ELISA for comparison. (B) CDI-positive stools contain large amounts of IL-8 and relatively small amounts of IL-23 compared to the amounts in stools from CDI-negative diarrheal patients and hospitalized patients without diarrhea. The concentrations of IL-8 and IL-23 were determined in stools from 50 CDI-positive patients, 50 CDI-negative patients, and 45 nondiarrheal controls by quantitative ELISA (R&D Systems, Minneapolis, MN). A Mann-Whitney two-tailed test showed significant differences between CDI-positive patients and nondiarrheal controls (P = 0.0001), CDI-positive patients and CDI-negative patients with diarrhea (P = 0.002), and CDI-negative patients and nondiarrheal controls (P = 0.006) for IL-8 and CDI-positive patients and nondiarrheal controls (P = 0.001), CDI-positive patients and CDI-negative patients with diarrhea (P = 0.003), and CDI-negative patients and nondiarrheal controls (P = 0.0001) for IL-23. Horizontal bars, mean concentrations.

  • FIG 4
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    FIG 4

    Comparison of Th1 and Th2 cytokines in CDI-positive and CDI-negative stools. (A) Fold change in amounts of Th1 cytokines (IFN-γ, IL-2, IL-12, TNF-α) and Th2 cytokines (IL-4, IL-5, IL-6, IL-10, IL-13) obtained from the initial Proteome Profiler human cytokine array assay. Stools (300 mg) from 100 antibiotic-associated diarrheal patients (50 CDI positive and 50 CDI negative) were evaluated for the presence of 36 inflammatory proteins using a Proteome Profiler human cytokine array panel A kit (R&D Systems, Minneapolis, MN). Data are expressed as the mean of the relative band intensity of each cytokine. Stools from the hospitalized patients (controls) without diarrhea were not evaluated by this initial assay but were included retrospectively in the quantitative ELISA for comparison. Error bars represent the standard error of measurement between two replicates per sample. *, P < 0.05. (B) Concentrations of IFN-γ, TNF-α, and IL-13 in CDI-positive stools and CDI-negative stools from diarrheal patients and stools from hospitalized controls without diarrhea determined by quantitative ELISA (R&D Systems, Minneapolis, MN). The Kruskal-Wallis test showed significant differences between the means (P < 0.0001). Horizontal bars, mean concentrations.

  • FIG 5
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    FIG 5

    CDI-positive stools contain larger amounts of lactoferrin and calprotectin than CDI-negative diarrheal stools and stools from hospitalized patients (controls) without diarrhea. The concentrations of lactoferrin and calprotectin were measured in stools from 50 CDI-positive and CDI-negative patients and hospitalized patients without diarrhea. Fecal lactoferrin and calprotectin concentrations were determined using an IBD-SCAN test (Techlab, Blacksburg, VA) and an HK325 human calprotectin ELISA kit (Hycult Biotech, Plymouth Meeting, PA), respectively. Median lactoferrin concentrations were 31.4 μg/ml (CDI-positive patient stools), 6.3 μg/ml (CDI-negative patient stools), and 5.6 μg/ml (stools from hospitalized patients without diarrhea). Median calprotectin concentrations were 18.0 μg/ml (CDI-positive patient stools), 6.5 μg/ml (CDI-negative patient stools), and 8.7 μg/ml (stools from hospitalized patients without diarrhea). One-way analysis of variance showed significant differences between the means of the CDI-positive patients, CDI-negative patients, and nondiarrheal controls for both lactoferrin and calprotectin (P < 0.0001).

Tables

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  • TABLE 1

    Characteristics of study populationa

    CharacteristicCDI-positive patients (n = 50)CDI-negative patients (n = 50)Control patients with no diarrhea (n = 45)
    Avg (range) age (yr)58 (2–91)56 (21–83)63 (22–85)
    No. of patients by:
        Ethnicity
            Asian110
            B/AA10811
            H/L469
            W/C282925
            Other76
        Gender
            Female272419
            Male232626
    • ↵a CDI, patients with C. difficile infection; B/AA, black/African-American; H/L, Hispanic/Latino; W/C, white/Caucasian.

  • TABLE 2

    Fecal concentrations of IL-13, IL-8, IL-23, TNF-α, IFN-γ, lactoferrin, and calprotectin from the CDI-positive and CDI-negative diarrheal stools and nondiarrheal stools evaluateda

    Patient groupConcn (pg/ml)Concn (μg/ml)
    IL-13IL-8IL-23TNF-αIFN-γLactoferrinCalprotectin
    CDI positive (n = 50)
        Mean323.8318.272259.869.743.423.8
        Median277.4242390.533.75831.418
        Range35.7–1,15013.1–1,529110.0–7,0692.7–163.68.7–225.73.0–155.22.8–70.2
        P value0.010.0220.0010.0780.0670.0190.029
    CDI negative (n = 50)
        Mean141.184.7946.731.248.324.88.8
        Median138.883.3932.625.731.56.36.5
        Range14.3–319.38.5–191.6185.5–2,0160.6–177.70.04–204.30.6–140.32.0–31.0
        P value0.0240.0340.00320.0550.0880.0280.054
    Nondiarrheal control (n = 45)
        Mean234.379.81,61722.357.66.810.2
        Median203.5527681850.25.68.7
        Range19.2–701.721.4–295.7489.0–6,8100.3–83.310.9–143.30.5–35.01.8–33.2
        P value0.060.010.0410.0920.0020.0690.073
    • ↵a Concentrations were determined by quantitative ELISA (R&D Systems, Minneapolis, MN).

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Colonic Immunopathogenesis of Clostridium difficile Infections
Charles Darkoh, Bradley P. Turnwald, Hoonmo L. Koo, Kevin W. Garey, Zhi-Dong Jiang, Samuel L. Aitken, Herbert L. DuPont
Clinical and Vaccine Immunology Mar 2014, 21 (4) 509-517; DOI: 10.1128/CVI.00770-13

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Colonic Immunopathogenesis of Clostridium difficile Infections
Charles Darkoh, Bradley P. Turnwald, Hoonmo L. Koo, Kevin W. Garey, Zhi-Dong Jiang, Samuel L. Aitken, Herbert L. DuPont
Clinical and Vaccine Immunology Mar 2014, 21 (4) 509-517; DOI: 10.1128/CVI.00770-13
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