Chlamydia pneumoniae and Chronic Diseases Springer-Verlag Berlin Heidelberg GmbH JOHANNA L'AGE-STEHR (ED.) Chlamydia pneumoniae and Chronic Diseases Proceedings of the State-of-the-Art Workshop held at the Robert Koch-Institut Berlin on 19 and 20 March 1999 Springer Editor: DR. JOHANNA L'AGE-STEHR Robert Koch-Institut Nordufer 20 13353 Berlin ISBN 978-3-540-41136-9 CIP data applied for Chlamydia pneumoniae and chronic diseases : proceedings of the state-of-the-art workshop held at the Robert Koch-Institut Berlin on 19 and 20 March 1999 / Johanna L'age-Stehr (ed.). - Berlin ; Heidelberg ; New York ; Barcelona ; Hong Kong ; London ; Milan ; Paris ; Singapore ; Tokyo : Springer, 2000 ISBN 978-3-540-41136-9 ISBN 978-3-642-57195-4 (eBook) DOI 10.1007/978-3-642-57195-4 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights oi translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. © Springer-Verlag Berlin Heidelberg 2000 Originally published by Springer-Verlag Berlin Heidelberg New York in 2000 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accuracy of any information about the application of operative techniques and medications contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editorial Assistance: Dr. Christiane Cordes Copy-reader and Layout: Ursula Erikli Image Analysis/Processing: Stefan Mertens Typesetting: Camera ready by the editor Cover design: design & production GmbH, Heidelberg SPIN 10785123 18/3130/ag 5 4 3 2 1 0 v Preface J. L 'age-Stehr In March 1999 international experts from many fields gathered in Berlin for a State-of-the-Art Workshop on Chlamydia pneumoniae and chronic diseases. This workshop was the first of its kind initiated and organized by the Robert Koch Institut. The objectives of the workshop were to discuss and enhance interdisciplinary knowledge on the possible etiological role of Chlamydia pneumoniae, a wide spread human respiratory infection, in the pathogenesis of chronic inflammatory diseases with major public health impact such as - atherosclerosis, - cardiovascular disease, - adult-onset asthma bronchiale, - chronic obstructive pulmonary disease, - reactive arthritis, - Morbus Alzheimer and - Multiple Sclerosis. An association of Chlamydia pneumoniae infections and atherosclerosis has been indicated by serological methods and by detection of the agent in vascular tissues. Major goals of this workshop were to identify current deficiencies in knowledge and research approaches, quality of methodologies used for detection of the infection, designs of epidemiological studies and to encourage prioritization of approaches in basic, applied and clinical research in a collaborative, multidisci plinary and multicenter effort. Some of the experimental evidence put forward to the audience by the experts supported the hypothesis that recurrent or chronic persistent and reactivated Chlamydia pneumoniae infections may be risk factors in atherogenesis and the development of cardiovascular disease, in asthma bronchiale of adult onset and chronic obstructive pulmonary disease. Evidence that these infections initiate, perpetuate or accelerate these major dis eases when combined with other risk factors was vividly discussed as well as were the goals of future research. The possible involvement of Chlamydia pneumoniae in the pathogenesis of neurological diseases such as Morbus Alzheimer and Mul tiple Sclerosis met with considerable skepticism. On the basis of current knowledge the following goals for future basic and applied research have been identified: - encouragement and promotion of international multicenter, multidisciplinary collaborations of clinical and basic researchers for development and application of standardized noninvasive diagnostic tools for the detection of chronic Chla mydia pneumoniae infections, VI - analysis of the influence of host genetics, classical identified risk factors and different agent-host interactions on susceptibility to chronic, recurrent or reac tivated Chlamydia pneumoniae infections and the development of chronic dis eases, - search for surrogate diagnostic markers for chronic inflammation by Chlamydia pneumoniae infections to develop better diagnostic strategies that would iden tify subpopulations of patients at risk for cardiovascular diseases which would profit from antimicrobial therapy, - promotion of more basic research on the natural history and pathogenicity of chronic, persistent and reactivated Chlamydia pneumoniae infections, - inclusion of better standardized and expanded diagnostic strategies in design and monitoring of epidemiological cohort and case control studies, - encouragement to develop better antimicrobial agents and therapeutic strategies and regimens (e.g. combinations of antibiotics) to increase treatment efficacy in subpopulations of chronic diseased patients with chronic, reactivated or remit tent Chlamydia pneumoniae infections and use of more standardized diagnostic methodology to monitor efficacy of antimicrobial therapy in selected groups of patients. All comments and questions in response to individual presentations have been enclosed in these proceedings to give the readers interested in the field of Chla mydia pneumoniae and chronic diseases a life-like picture of the often diverse opinions of the experts. VII Introduction - R. Kurth ......................................................................................... 1 Chapter 1 Biology, Immunology and Pathology of Chlamydia Pneumoniae Infections 1.1 Pathogenic mechanisms of chronic Chlamydia infections E. Straube, J. Radel ........................................................................................... 3 1.2 Biology, immunology and persistence of Chlamydia pneumoniae: Links to chronic disease G./. Byrne and M. V. Kalayoglu ......................................................................... 8 Chronic chlamydial diseases: C. pneumoniae and atherosclerosis .................... 9 Chlamydial Hsp60 and the chronic disease process ........................................ 10 Summary ......................................................................................................... 11 1.3 Animal models for Chlamydia pneumoniae infection M. Leinonen and P. Saikku .............................................................................. 19 Monkey models for C. pneumoniae infection ................................................. 19 Mouse models for C. pneumoniae infection .................................................... 19 Rabbit model for C. pneumoniae infection ...................................................... 20 Animal models for C. pneumoniae-associated atherosclerosis ........................ 20 Conclusions ............................................................................... ~ ..................... 21 1.4 Molecular biology and serodiagnostics of Chlamydia pneumoniae - potential way to a vaccine G. Christiansen, A.S. Madsen, T. Boesen, K. Hjem¢, L. Daugaard, K. Knudsen, P. Mygind, S. Birkelund .............................................................. 25 Introduction ..................................................................................................... 25 The GGAI gene family .................................................................................... 25 Migration of GGAI proteins in SDS-PAGE .................................................... 27 Antigenicity of GGAI proteins ........................................................................ 27 Immunoblotting with human sera .................................................................... 28 Conclusion and considerations for future work ............................................... 29 Chapter 2 DiagnosiS of Chlamydia pneumoniae Infections 2.1 Direct detection of Chlamydia pneumoniae in atherosclerotic plaques M. Maass ......................................................................................................... 33 Introduction ..................................................................................................... 33 Immunohistochemistry .................................................................................... 35 PCR ................................................................................................................. 35 Cell Culture ..................................................................................................... 37 Conclusion ....................................................................................................... 37 VIII 2.2 Detection of Chlamydia pneumoniae DNA in white blood cells 1. Boman .......................................................................................................... 42 2.3 Detection of Chlamydia pneumoniae in clinical specimens byPCR-EIA C.A. lantos ...................................................................................................... 48 2.4 State of the art in the diagnosis of acute and chronic Chlamydia pneumoniae infection M.R. Hammerschlag ........................................................................................ 52 Culture of C. pneumoniae ............................................................................... 52 Detection of antibody to C. pneumoniae in serum .......................................... 53 Chapter 3 Chronic Diseases Possibly Associated with Chlamydia pneumoniae Infections 3.1 Epidemiological data on respiratory tract infection with Chlamydia pneumoniae and clinical complications 1. Boman ........................................................... 63 i .............................................. 3.2 Role of C. pneumoniae in severe asthma and COPD: Epidemiology and treatment R. Cosentini, F. Blasi ....................................................................................... 68 Asthma ............................................................................................................ 68 Chronic bronchitis ........................................................................................... 69 3.3.1 Chlamydia pneumoniae in atherosclerosis P. Saikku ......................................................................................................... 73 Introduction ..................................................................................................... 73 Epidemiological and seroepidemiological findings ......................................... 73 Histopathological studies ................................................................................. 74 Intervention trials ............................................................................................ 74 Possible pathogenetic mechanisms by which an infection could affect the development of atherosclerosis and coronary heart disease .................... 75 Conclusions ..................................................................................................... 76 3.3.2 Prevalence of Chlamydia pneumoniae in human coronary plaques with acute coronary syndrome G. Bauriedel, U. Welsch and B. Liideritz ........................................................ 84 Introduction ..................................................................................................... 84 Patients and methods ....................................................................................... 85 Results ............................................................................................................. 85 3.3.3 Chlamydiallipopolysaccharide and atherosclerosis H. Brade .......................................................................................................... 91 3.3.4 Clinical trial designs to study antibiotic intervention in atherosclerosis M. Dunne ......................................................................................................... 97 IX 3.3.5 Why antibiotics against Chlamydia pneumoniae for treatment of atherosclerotic disease could fail 1.M. Ossewaarde ........................................................................................... 103 3.3.6 Atherosclerosis: Why the search for a causative infectious agent is not warranted S. Bhakdi ........................................................................................................ 108 3.4 Chlamydia infections and arthritis 1. Sieper ......................................................................................................... 112 3.5 Chlamydia pneumoniae, APOE genotype, and Alzheimer's disease A.P. Hudson, H.e. Gerard, 1.A. Whittum-Hudson, D.M. Appelt, B.l. Balin ....................................................................................................... 121 Alzheimer's disease ....................................................................................... 12 1 APOE allele types and Alzheimer's disease .................................................. 122 Pathogenesis and epidemiology of Chlamydia pneumoniae ......................... 122 Chlamydia pneumoniae DNA in the Alzheimer's brain ................................ 123 Ultrastructural analysis of Chlamydia pneumoniae in the Alzheimer's brain ........................................................................................ 124 Culture of Chlamydia pneumoniae from Alzheimer's brain tissue ............... 126 Immunohistochemical analyses ..................................................................... 126 Chlamydia pneumoniae infection and APOE allele types ............................. 128 Future research directions .............................................................................. 128 3.6 Association of Chlamydia pneumoniae with Multiple Sclerosis: Protocol for detection of C. pneumoniae in the CSF and summary of preliminary results e. W. Stratton, S. Sriram, S. fao, A. Tharp, L. Ding, J.D. Bannan, W.M. Mitchell ................................................................................................ 137 Introduction ................................................................................................... 137 Materials and methods ................................................................................... 137 Results ........................................................................................................... 143 Discussion ..................................................................................................... 148 Chapter 4 Epidemiology and Public Health Impacts of Chlamydia pneumoniae Infections 4.1 Trends and variations of chronic diseases in populations - Can infectious agents help to solve the puzzles? H.W. Hense .................................................................................................... 153 x 4.2 The epidemiology of Chlamydia pneumoniae versus the epidemiology of potential Chlamydial diseases (Atherosclerosis, Multiple Sclerosis, M. Alzheimer) W Stille, C. Stephan, M Madeo, E. Bauer-Krylov ......................................... 163 Epidemiology of Chlamydia pneumoniae ...................................................... 163 Seroepidemiology ........................................................................................... 163 Epidemiology of Multiple Sclerosis ............................................................... 167 Epidemiology of Alzheimer's Disease ........................................................... 168 Conclusion ...................................................................................................... 168 4.3 The high male mortality of coronary heart diseases can be explained as a result of chronic infection E. Bauer-Krylov, W. Stille .............................................................................. 171 4.4 The Spandauer Gesundheitstest - Retrospective cohort study on Chlamydia pneumoniae infections and cardiovascular disease - A study concept T Ziese ............................................................................................................ 178 Introduction .................................................................................................... 178 Study goals ..................................................................................................... 178 Study outline ................................................................................................... 178 4.5 Public health impact of atherosclerosis and Chlamydia pneumoniae infections - What do we know and what to expect from future research JM Ossewaarde ............................................................................................ 184 Introduction .................................................................................................... 184 Epidemiology of cardiovascular diseases in the Netherlands ......................... 184 Epidemiology of Chlamydia pneumon iae infections ...................................... 185 Respiratory tract infections as a risk factor for cardiovascular disease .......... 186 Association of C. pneumoniae infections and cardiovascular diseases ........... 186 Public health consequences ............................................................................ 187 Conclusions .................................................................................................... 187 Chapter 5 Final Discussion: Pro and Contra the Role of Chlamydia pneumoniae in Chronic Diseases ....... 193