- Email: [email protected]
Ovarian vein thrombosis (OVT) following invasive group A Streptococcus (iGAS) puerperal sepsis associated with expression of streptococcal pyrogenic exotoxin genes speC, speG and speJ
Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
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References Heavy ion radiotherapy for recurrent metastatic lung tumor during pregnancy Dear Editors We report the case of a pregnant woman with metastatic lung tumor who was treated using heavy ion radiotherapy. The patient had been diagnosed with synovial sarcoma of the left upper arm at 24 years old in 2003. Primary tumor resection, 17 courses of chemotherapy, and 5 partial resections of metastatic lung tumor were performed. In July 2009, she was referred to Osaka City University Hospital. At 15 weeks of gestation, contrast-enhanced computed tomography (CT) revealed new tumors at the left diaphragm, left chest wall, and parathoracic area (Fig. 1a). At the National Institute of Radiological Science, heavy ion radiotherapy was prescribed to tumors in the left diaphragm, left chest wall, and parathoracic region from 22 weeks to 26 weeks of gestation (16 fractions; total dose to the tumor, 57.6 GyE). Total dose to the lower abdomen for the full course of treatment was 34.5 mSV. At a gestational age of 27 weeks, contrast-enhanced CT of the chest showed a significant reduction in size of the irradiated tumors and the enhancement disappeared (Fig. 1b). However, a new metastatic tumor in the posterior mediastinum measuring 3 cm in diameter was recognized on the same CT. Given the rapid growth and multiple metastatic tumors, we performed cesarean section at 30 weeks of gestation. A girl weighing 1420 g was delivered. The mother died 2 years and 9 months after delivery. At 2 and a half years of age, the girl showed normal cognitive and physical development without any complications, but was subsequently lost to follow-up. The efficacy of carbon-ion radiotherapy for patients with unresectable malignant tumors has been reported previously [1–4]. In 2010, Mu¨nter et al. reported the case of a pregnant woman with primary skull-base cancer treated using carbon-ion therapy [5]. They measured total dose to the pelvic region during treatment as 82 mSv and a healthy boy was delivered. No descriptions were provided regarding the gestational ages at which treatment was performed. The child showed age-appropriate development at 1 year old. In addition to the high degree of uncertainty in terms of predicting late effects, clinical dilemmas include deciding when to start and stop heavy ion radiotherapy and when to deliver the fetus in consideration of the maternal condition. In our case, we expected that regional effects on the largest pulmonary metastatic tumor might postpone the general deterioration of the mother, and in the meantime, the fetus might achieve further maturation.
[1] Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N, ESMO Guidelines Working Group. Cancer, fertility and pregnancy, ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Acta Oncol 2010;21(May Suppl 5): v266–v273. [2] Imai R, Kamada T, Tsuji H, Tsujii H, Tsuburai Y, Tatezaki S, Working Group for Bone, Soft Tissue Sarcomas. Cervical spine osteosarcoma treated with carbonion radiotherapy. Lancet Oncol 2006;7(Dec 12):1034–5. [3] Matsunobu A, Imai R, Kamada T, et al., Working Group for Bone, Soft Tissue Sarcomas. Impact of carbon ion radiotherapy for unresectable osteosarcoma of the trunk. Cancer 2012;118(Sep 18):4555–63. [4] Iwata S, Yonemoto T, Ishii T, Kumagai K, Imai R, Hagiwara Y, Kamada T, Tatezaki S. Efficacy of carbon-ion radiotherapy and high-dose chemotherapy for patients with unresectable Ewing’s sarcoma family of tumors. Int J Clin Oncol 2013;18(Dec 6):1114–8. [5] Mu¨nter MW, Wengenroth M, Fehrenbacher G, Schardt D, Nikoghosyan A, Durante M, Debus J. Heavy ion radiotherapy during pregnancy. Fertil Steril 2010;94(Nov 6):2329.e5–9.e.
D. Tachibana* M. Koyama M. Saito M. Hoshi Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka, Japan R. Imai T. Kamada National Institute of Radiological Science, Japan *Corresponding author E-mail address: [email protected] (D. Tachibana).
Received 31 October 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.11.016
Ovarian vein thrombosis (OVT) following invasive group A Streptococcus (iGAS) puerperal sepsis associated with expression of streptococcal pyrogenic exotoxin genes speC, speG and speJ Dear Editor, We report a 33-year old breastfeeding woman with sudden onset of high fever and right-sided lower abdominal pain five days after giving birth to a healthy baby. Her medical history revealed gestation diabetes during her first pregnancy, three previous early
Fig. 1. Contrast-enhanced CT of the chest showing enlarged tumor on the left diaphragm. The enhanced area inside the tumor at 15 weeks of gestation (a) shows a dramatic reduction in enhancement at 27 weeks of gestation, after carbon-ion radiotherapy (b).
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Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
Fig. 1. Contrast-enhanced MRI of thorax and abdomen (A, B) with dorsal pleural effusions, enlarged ovary on the right side, thrombotic material in right ovarian vein (arrows) and edema in the surrounding tissue. (A) Axial T2w FS sequence demonstrating edema in the surrounding tissue (arrow); (B) Axial contrast enhanced T1w FS sequence showing dark thrombotic material in the right ovarian vein (arrow) and bright signal in the non-affected left vein (dotted arrow); circles: enlargement of A/B). Streptococcus pyogenes detection (C–E): b-hemolytic streptococci from patient’s vaginal swab growing on Columbia blood agar (b-hemolysis shown using back light as cutout image in (C)); microscopical detection of gram-positive streptococci from patient’s vaginal swab (D) and in peripheral blood cultures during septic episodes following gram-stain, indicating iGAS (E). (Zeiss Axio Vision microscope, 1000 magnification). Superantigen-gene PCR with detected streptococcal superantigen-genes for pyrogenic exotoxin speG, speC und speJ (arrows, boxes). [Abbreviations: G = speG (spe = streptococcal pyrogenic exotoxin), A = speA; PK = positive control, NK = negative control, C = speC; SSA = streptococcal superantigen, I = speI; H = speH; L = speL; M = speM; Z = smeZ (sme = streptococcal mitogenic exotoxin); J = speJ] (F).
pregnancy terminations and some depressive episodes in an otherwise healthy woman. This was her second spontaneous vaginal delivery without any complications. No antibiotic or gynecological intervention was needed because of the uncomplicated peripartum period. On clinical examination, the patient had right-sided lower abdominal pain with palpable painful inguinal lymph nodes, reddened throat, tachycardia and fever. Blood analysis showed highly elevated CRP levels (260 mg/l) and white blood cell count (20 Gpt/l). A vaginal swab and blood cultures were
taken and patient was started on empiric antibiotic treatment using ampicillin/sulbactam and metronidazol. Contrast-enhanced axial T2w FS and axial contrast enhanced T1w FS sequence magnetic resonance imaging (MRI) of the thorax and the abdomen showed slight dorsal pleural effusions, an enlarged right ovary, thrombotic material in the right ovarian vein and edema in the surrounding tissue (Fig. 1). Other organs were without pathological findings. b-Hemolytic streptococci were isolated from vaginal swab and grown under aerobic conditions on Columbia blood agar
Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
(Fig. 1). Further biochemical and serological analysis identified these b-hemolytic streptococci as group A streptococci (GAS) i.e. Streptococcus pyogenes. Microscopy (Axio Vision microscope, Zeiss, Jena, Germany) analysis showed gram-positive streptococci (S. pyogenes) both in vaginal swab (Fig. 1) and in blood cultures taken from patient during septic episodes (Fig. 1). Antimicrobial susceptibility testing (AST) showed no resistance except to aminoglycosides. To assess the virulence of the strain superantigen gene PCR was carried out and detected superantigen genes speC, speG und speJ (Fig. 1). After confirmation of a right-sided ovarian venous thrombosis and postnatal Streptococcus pyogenes sepsis, initial antibiotic treatment was continued according to sensibility in AST. Antithrombotic (low molecular weight heparine) and supportive treatment (rehydration, antipyretics) was added. This treatment lead to an immediate clinical improvement with much reduced abdominal pain and decline of fever. All infection parameters decreased within three days (CRP 17.7 mg/l, WBC 11.5 Gpt/l). A control vaginal swab and repeated blood cultures were tested negative and patient was dismissed from hospital in good clinical health. Ovarian vein thrombosis (OVT) is a rare entity during postpartum period associated with significant maternal morbidity due to delayed diagnosis [1]. The vast majority of published reviews and case reports focus on diagnostic imaging but not on the infectious agent [2,3]. Group A beta-hemolytic streptococcus (GAS; S. pyogenes) is one of the leading infectious agents of maternal mortality worldwide [4–6]. In comparison to developing countries, postpartum GAS sepsis is a rare event nowadays in the western world, though incidence seems to be on the rise again [7,8]. Although localized GAS infection is manageable with simple antibiotic treatment regimens, invasive GAS (iGAS) might be more difficult to treat [9–11]. The M-protein, a protein which is located on the surface of the streptococcal cell wall, plays an important role as GAS virulence factor [12], and different Mprotein gene (emm) sequences have been described [13]. Three novel streptococcal pyrogenic exotoxins (SPEs) superantigen genes (spe-g, spe-h and spe-j) were identified from GAS [14]. SPEs are discussed as important virulence factors of iGAS due to their ability to induce inflammatory signals, such as interleukins or tumor necrosis factor [15]. Some SPEs seem to have been shared within different streptococcal species [16]. The SPE superantigen gene PCR was established as a useful technique and is considered to be more important than emm typing [17]. In a recent study, relationships between emm types and superantigen genes were established. It was found that emm28 type was consistent with speC, speG and speJ detection, and that speG was found to be most prevalent in all GAS isolates analyzed [18]. The emm distributions seem to differ between invasive and non-invasive GAS [19]. In the postpartum period, the combination of lateral, prevalently right-sided, lower abdominal pain, high fever and highly elevated CRP is suspicious for puerperal sepsis-induced OVT caused by an iGAS strain. OVT diagnosis can be made with confidence using ultrasound or magnetic resonance imaging. In order to assess the virulence of this iGAS strain, we performed SPE gene analysis, as superantigen gene analysis was found to be a more reliable tool in a previous univariate analysis tool than emm typing [17]. Our results are in concordance to previous findings where the superantigen genes speC and speG were equally found in non-invasive and iGAS, whereas the speJ gene was significantly more frequently detected in iGAS than in non-invasive GAS [17,18]. We therefore argue that the detection of speC and speG, and especially speJ, in a patient suffering from puerperal sepsis and OVT might be indicative for a hypervirulent iGAS strain against which an immediate start of AST-adapted antibiotic, antithrombotic and supportive treatment is urgently needed. The analysis of
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streptococcal superantigen patterns in a future clinical study might give a deeper knowledge about the severity of streptococcal infections in obstetrics. Acknowledgement Preliminary data of this work were demonstrated as poster presentation at the 113th General Annual Meeting of the American Society of Microbiology (ASM) in Denver, CO, USA, on 20 May 2013.
References [1] Kominiarek A, Hibbard JU. Postpartum ovarian vein thrombosis: an update. Obstet Gynecol Surv 2006;61(May (5)):337–42. [2] Kamaya A, Ro K, Benedetti NJ, Chang PL, Desser TS. Imaging and diagnosis of postpartum complications: sonography and other imaging modalities. Ultrasound Q 2009;(September (3)):151–62. [3] Sharma P, Abdi S. Ovarian vein thrombosis. Clin Radiol 2012;67(September (9)):893–8. [4] Paul SP, Jerwood S. Group A streptococcal septicemia, meningitis and cerebral abscess: case report and literature review. Turk J Pediatr 2012;54(March–April (2)):180–3. [5] Ben Zakour NL, Venturini C, Beatson SA, Walker MJ. Analysis of a Streptococcus pyogenes puerperal sepsis cluster by use of whole-genome sequencing. J Clin Microbiol 2012;50(July (7)):2224–8. http://dx.doi.org/10.1128/JCM.00675-12. Epub 2012 Apr 18. [6] Soares EM, Mason KL, Rogers LM, Serezani CH, Faccioli LH, Aronoff DM. Leukotriene B4 enhances innate immune defense against the puerperal sepsis agent Streptococcus pyogenes. J Immunol 2013 [Epub ahead of print]. [7] Mason KL, Aronoff DM. Postpartum group a Streptococcus sepsis and maternal immunology. Am J Reprod Immunol 2012;67(February (2)):91–100. http:// dx.doi.org/10.1111/j.1600-0897.2011.01083.x. Epub 2011 October 24. Review. [8] Martin J, Murchan S, O’Flanagan D, Fitzpatrick F. Invasive Group A streptococcal disease in Ireland, 2004 to 2010. Euro Surveill 2011;16(October (41)). doi:pii:19988. [9] Arthur C, Linam LE, Linam WM. Group A beta-hemolytic streptococcal colitis with secondary bacteremia. Pediatr Infect Dis J 2012;31(October (10)):1093–5. http://dx.doi.org/10.1097/INF.0b013e31826318c6. [10] Tajiri T, Tate G, Masunaga A, et al. Autopsy cases of fulminant bacterial infection in adults: clinical onset depends on the virulence of bacteria and patient immune status. J Infect Chemother 2012;18(October (5)):637–45. http://dx.doi.org/10.1007/s10156-012-0384-9. Epub 2012 February 22. [11] Sriskandan S. Severe peripartum sepsis. J R Coll Physicians Edinb 2011;41(December (4)):339–46. doi:10.4997/JRCPE.2011.411. Review. [12] Ogunniyi AD, Mahdi LK, Trappetti C, et al. Identification of genes that contribute to the pathogenesis of invasive pneumococcal disease by in vivo transcriptomic analysis. Infect Immun 2012;80(September (9)):3268–78. http:// dx.doi.org/10.1128/IAI.00295-12. Epub 2012 July 9. [13] Alouf JE, Mu¨ller-Alouf H. Staphylococcal and streptococcal superantigens: molecular, biological and clinical aspects. Int J Med Microbiol 2003;292(February (7–8)):429–40. [14] Thomas Proft S, Moffatt L, Berkahn CJ, Fraser JD. Identification and characterization of novel superantigens from Streptococcus pyogenes. J Exp Med 1999;189(January (1)):89–101. [15] Byrne JLB, Aagaard-Tillery KM, Johnson JL, Wright LJ, Silver RM. Group A streptococcal puerperal sepsis: initial characterization of virulence factors in association with clinical parameters. J Reprod Immunol 2009;82:74–83. [16] Sachse S, Seidel P, Gerlach D, et al. Superantigen-like gene(s) in human pathogenic Streptococcus dysgalactiae, subsp. equisimilis: genomic localisation of the gene encoding streptococcal pyrogenic exotoxin G (speGdys). FEMS Immunol Med Microbiol 2002;34:159–67. [17] Lintges M, van der Linden M, Ralf-Dieter H, et al. Superantigen genes are more important than the emm type for the invasiveness of group A streptococcus infection. J Infect Dis 2010;202(1):20–8. [18] Commons R, Rogers S, Gooding T, et al. Superantigen genes in group A streptococcal isolates and their relationship with emm types. J Med Microbiol 2008;57:1238–46. [19] Va¨ha¨kuopus S, Vuento R, Siljander T, Syrja¨nen J, Vuopio J. Distribution of emm types in invasive and non-invasive group A and G streptococci. Eur J Clin Microbiol Infect Dis 2012;31:1251–6.
Matthias Karrasch* Ju¨rgen Ro¨del Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany Norman Mu¨hler Department of Obstetrics,
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Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
University Hospital of Friedrich-Schiller-University Jena, Germany Birgit Edel Svea Sachse Karl-Hermann Schmidt Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany Uwe Schneider Dietmar Schlembach Department of Obstetrics, University Hospital of Friedrich-Schiller-University Jena, Germany Hans-Joachim Mentzel Institute of Diagnostic and Interventional Radiology, University Hospital of Friedrich-Schiller-University Jena, Germany Wolfgang Pfister Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany
c-KIT-U-R2 50 -CAAACACAAACTTCACCAAATAATCAC-30 . The PCR conditions were as follows: 45 cycles of 95 8C for 5 s, 58 8C for 15 s, and 72 8C for 45 s. The resulting PCR products were resolved using 2% agarose gel electrophoresis with SYBR SafeTM DNA Gel Stain (Invitrogen, Ltd., UK). Additionally, the levels of methylation and un-methylation of DNA in samples were determined by using specific methyl- and un-methyl- primer sets with SYBR green dye in a real-time PCR machine. The number of PCR cycles (Ct) of methyland un-methyl- DNA in each sample was normalized with Actin gene DNA. We demonstrated that the DNA methylation ratio in the c-KIT (+) tumor area (26T) was higher than that in its adjacent nontumor cervical epithelium (26N); similarly, the DNA methylation ratio in the c-KIT (+) tumor area (26T) was also higher than that in another randomly selected c-KIT () tumor area (12T) and its nontumor cervical epithelium (12N) from another case. In other words, the DNA methylation ratio of 26T was relatively higher than that of all the 26N, 12T and 12N. (Fig. 1A–C) Tight association of DNA methylation and silencing of gene expression has been already established. Hypomethylation is the mechanism for ectopic oncogene activation while hypermethylation is the mechanism for tumor
Ekkehard Schleußner Department of Obstetrics, University Hospital of Friedrich-Schiller-University Jena, Germany *Corresponding author at: Institute of Medical Microbiology, University Hospital of Friedrich-Schiller University Jena, Erlanger Allee 101, D-07743 Jena, Germany. Tel.: +49 3641 9393611; fax: +49 3641 9393502 E-mail address: [email protected] (M. Karrasch).
Received 17 February 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.11.019
Unusual c-KIT (+) squamous cell carcinoma of the uterine cervix showing paradoxical hypermethylation of the c-KIT proto-oncogene Dear Editors, We found one unusual case in 54 squamous cell carcinomas (SCC) of the uterine cervix where there was neither c-KIT(CD117) gene amplification nor c-KIT/PDGFRA activating mutation, but cKIT/PDGFRA protein overexpression was detected, previously [1,2]. However, the molecular mechanisms still remain unknown. The aim of this report was to investigate the methylationassociated regulation of the c-KIT gene expression in this extraordinary case. The methylation status (DNA methylation to un-methylation ratio) of the c-KIT promoter in both tumor area (T) and adjacent non-tumor cervical epithelium (N) from such c-KIT (+) individual (#26) and both (T and N) from another randomly selected c-KIT () individual (#12) was quantified by using a real-time methylation specific PCR (RT-MSPCR) method. The remaining 52 samples with c-KIT () were not taken into account for additional testing in this preliminary brief report. For investigating the relationship between DNA methylation status and the cKIT gene expression, we designed two sets of methylation-specific (MS) PCR primers located between the first exon and first intron regions. The primers were: c-KIT-M-F2 50 -CGTGGATTAGAGTTCGGATTTTATC-30 and c-KIT-M-R2 50 -ACAAACTTCGCCGAATAATCG30 ; c-KIT-U-F2 50 -GAA TGTGGATTAGAGTTTGGATTTTATT-30 and
Fig. 1. Methylation status of the c-KIT promoter region in one uncommon case of cKIT (+) SCC (case Number 26; #26) and another randomly selected case of c-KIT () SCC (case Number 12; #12) of the uterine cervix is shown. (A) ‘‘26T’’ indicates the tumor tissue with a band of methylated DNA and another weak band of unmethylated DNA; ‘‘26N’’ indicates a control pair of the adjacent normal cervical epithelium in non-tumor tissue that showed a strong band of un-methylated DNA but not methylated DNA. ‘‘12T’’ indicates tumor tissue with no band of methylated DNA and another weak band of un-methylated DNA; ‘‘12N’’ indicates a control pair of the adjacent normal cervical epithelium in non-tumor tissue that showed a weak band of un-methylated DNA but not methylated DNA. M indicates methylated DNA; U indicates un-methylated DNA. Actin served as an internal control in duplex PCR. An A549 lung cancer cell line served as a PCR control. N indicates non-tumor tissue with normal cervical epithelium; T indicates tumor tissue of a SCC of uterine cervix. The number before ‘‘T’’ or ‘‘N’’ indicates the patient number. (B) indicates that the DNA methylation status of the c-KIT gene promoter region is significantly higher in the tumor tissue of patient #26 (26T) compared with non-tumor tissue (no product). In 12T, the tumor and non-tumor tissues had no product. (C) Unmethylation status of the c-KIT gene promoter region was significantly higher the in non-tumor tissue compared with the tumor tissue when analyzed by quantitative PCR. The tumor tissue of Patient #12 served as the c-KIT () tumor control. An A549 lung cancer cell line served as the PCR control.
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References Heavy ion radiotherapy for recurrent metastatic lung tumor during pregnancy Dear Editors We report the case of a pregnant woman with metastatic lung tumor who was treated using heavy ion radiotherapy. The patient had been diagnosed with synovial sarcoma of the left upper arm at 24 years old in 2003. Primary tumor resection, 17 courses of chemotherapy, and 5 partial resections of metastatic lung tumor were performed. In July 2009, she was referred to Osaka City University Hospital. At 15 weeks of gestation, contrast-enhanced computed tomography (CT) revealed new tumors at the left diaphragm, left chest wall, and parathoracic area (Fig. 1a). At the National Institute of Radiological Science, heavy ion radiotherapy was prescribed to tumors in the left diaphragm, left chest wall, and parathoracic region from 22 weeks to 26 weeks of gestation (16 fractions; total dose to the tumor, 57.6 GyE). Total dose to the lower abdomen for the full course of treatment was 34.5 mSV. At a gestational age of 27 weeks, contrast-enhanced CT of the chest showed a significant reduction in size of the irradiated tumors and the enhancement disappeared (Fig. 1b). However, a new metastatic tumor in the posterior mediastinum measuring 3 cm in diameter was recognized on the same CT. Given the rapid growth and multiple metastatic tumors, we performed cesarean section at 30 weeks of gestation. A girl weighing 1420 g was delivered. The mother died 2 years and 9 months after delivery. At 2 and a half years of age, the girl showed normal cognitive and physical development without any complications, but was subsequently lost to follow-up. The efficacy of carbon-ion radiotherapy for patients with unresectable malignant tumors has been reported previously [1–4]. In 2010, Mu¨nter et al. reported the case of a pregnant woman with primary skull-base cancer treated using carbon-ion therapy [5]. They measured total dose to the pelvic region during treatment as 82 mSv and a healthy boy was delivered. No descriptions were provided regarding the gestational ages at which treatment was performed. The child showed age-appropriate development at 1 year old. In addition to the high degree of uncertainty in terms of predicting late effects, clinical dilemmas include deciding when to start and stop heavy ion radiotherapy and when to deliver the fetus in consideration of the maternal condition. In our case, we expected that regional effects on the largest pulmonary metastatic tumor might postpone the general deterioration of the mother, and in the meantime, the fetus might achieve further maturation.
[1] Pentheroudakis G, Orecchia R, Hoekstra HJ, Pavlidis N, ESMO Guidelines Working Group. Cancer, fertility and pregnancy, ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Acta Oncol 2010;21(May Suppl 5): v266–v273. [2] Imai R, Kamada T, Tsuji H, Tsujii H, Tsuburai Y, Tatezaki S, Working Group for Bone, Soft Tissue Sarcomas. Cervical spine osteosarcoma treated with carbonion radiotherapy. Lancet Oncol 2006;7(Dec 12):1034–5. [3] Matsunobu A, Imai R, Kamada T, et al., Working Group for Bone, Soft Tissue Sarcomas. Impact of carbon ion radiotherapy for unresectable osteosarcoma of the trunk. Cancer 2012;118(Sep 18):4555–63. [4] Iwata S, Yonemoto T, Ishii T, Kumagai K, Imai R, Hagiwara Y, Kamada T, Tatezaki S. Efficacy of carbon-ion radiotherapy and high-dose chemotherapy for patients with unresectable Ewing’s sarcoma family of tumors. Int J Clin Oncol 2013;18(Dec 6):1114–8. [5] Mu¨nter MW, Wengenroth M, Fehrenbacher G, Schardt D, Nikoghosyan A, Durante M, Debus J. Heavy ion radiotherapy during pregnancy. Fertil Steril 2010;94(Nov 6):2329.e5–9.e.
D. Tachibana* M. Koyama M. Saito M. Hoshi Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi Abenoku, Osaka, Japan R. Imai T. Kamada National Institute of Radiological Science, Japan *Corresponding author E-mail address: [email protected] (D. Tachibana).
Received 31 October 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.11.016
Ovarian vein thrombosis (OVT) following invasive group A Streptococcus (iGAS) puerperal sepsis associated with expression of streptococcal pyrogenic exotoxin genes speC, speG and speJ Dear Editor, We report a 33-year old breastfeeding woman with sudden onset of high fever and right-sided lower abdominal pain five days after giving birth to a healthy baby. Her medical history revealed gestation diabetes during her first pregnancy, three previous early
Fig. 1. Contrast-enhanced CT of the chest showing enlarged tumor on the left diaphragm. The enhanced area inside the tumor at 15 weeks of gestation (a) shows a dramatic reduction in enhancement at 27 weeks of gestation, after carbon-ion radiotherapy (b).
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Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
Fig. 1. Contrast-enhanced MRI of thorax and abdomen (A, B) with dorsal pleural effusions, enlarged ovary on the right side, thrombotic material in right ovarian vein (arrows) and edema in the surrounding tissue. (A) Axial T2w FS sequence demonstrating edema in the surrounding tissue (arrow); (B) Axial contrast enhanced T1w FS sequence showing dark thrombotic material in the right ovarian vein (arrow) and bright signal in the non-affected left vein (dotted arrow); circles: enlargement of A/B). Streptococcus pyogenes detection (C–E): b-hemolytic streptococci from patient’s vaginal swab growing on Columbia blood agar (b-hemolysis shown using back light as cutout image in (C)); microscopical detection of gram-positive streptococci from patient’s vaginal swab (D) and in peripheral blood cultures during septic episodes following gram-stain, indicating iGAS (E). (Zeiss Axio Vision microscope, 1000 magnification). Superantigen-gene PCR with detected streptococcal superantigen-genes for pyrogenic exotoxin speG, speC und speJ (arrows, boxes). [Abbreviations: G = speG (spe = streptococcal pyrogenic exotoxin), A = speA; PK = positive control, NK = negative control, C = speC; SSA = streptococcal superantigen, I = speI; H = speH; L = speL; M = speM; Z = smeZ (sme = streptococcal mitogenic exotoxin); J = speJ] (F).
pregnancy terminations and some depressive episodes in an otherwise healthy woman. This was her second spontaneous vaginal delivery without any complications. No antibiotic or gynecological intervention was needed because of the uncomplicated peripartum period. On clinical examination, the patient had right-sided lower abdominal pain with palpable painful inguinal lymph nodes, reddened throat, tachycardia and fever. Blood analysis showed highly elevated CRP levels (260 mg/l) and white blood cell count (20 Gpt/l). A vaginal swab and blood cultures were
taken and patient was started on empiric antibiotic treatment using ampicillin/sulbactam and metronidazol. Contrast-enhanced axial T2w FS and axial contrast enhanced T1w FS sequence magnetic resonance imaging (MRI) of the thorax and the abdomen showed slight dorsal pleural effusions, an enlarged right ovary, thrombotic material in the right ovarian vein and edema in the surrounding tissue (Fig. 1). Other organs were without pathological findings. b-Hemolytic streptococci were isolated from vaginal swab and grown under aerobic conditions on Columbia blood agar
Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
(Fig. 1). Further biochemical and serological analysis identified these b-hemolytic streptococci as group A streptococci (GAS) i.e. Streptococcus pyogenes. Microscopy (Axio Vision microscope, Zeiss, Jena, Germany) analysis showed gram-positive streptococci (S. pyogenes) both in vaginal swab (Fig. 1) and in blood cultures taken from patient during septic episodes (Fig. 1). Antimicrobial susceptibility testing (AST) showed no resistance except to aminoglycosides. To assess the virulence of the strain superantigen gene PCR was carried out and detected superantigen genes speC, speG und speJ (Fig. 1). After confirmation of a right-sided ovarian venous thrombosis and postnatal Streptococcus pyogenes sepsis, initial antibiotic treatment was continued according to sensibility in AST. Antithrombotic (low molecular weight heparine) and supportive treatment (rehydration, antipyretics) was added. This treatment lead to an immediate clinical improvement with much reduced abdominal pain and decline of fever. All infection parameters decreased within three days (CRP 17.7 mg/l, WBC 11.5 Gpt/l). A control vaginal swab and repeated blood cultures were tested negative and patient was dismissed from hospital in good clinical health. Ovarian vein thrombosis (OVT) is a rare entity during postpartum period associated with significant maternal morbidity due to delayed diagnosis [1]. The vast majority of published reviews and case reports focus on diagnostic imaging but not on the infectious agent [2,3]. Group A beta-hemolytic streptococcus (GAS; S. pyogenes) is one of the leading infectious agents of maternal mortality worldwide [4–6]. In comparison to developing countries, postpartum GAS sepsis is a rare event nowadays in the western world, though incidence seems to be on the rise again [7,8]. Although localized GAS infection is manageable with simple antibiotic treatment regimens, invasive GAS (iGAS) might be more difficult to treat [9–11]. The M-protein, a protein which is located on the surface of the streptococcal cell wall, plays an important role as GAS virulence factor [12], and different Mprotein gene (emm) sequences have been described [13]. Three novel streptococcal pyrogenic exotoxins (SPEs) superantigen genes (spe-g, spe-h and spe-j) were identified from GAS [14]. SPEs are discussed as important virulence factors of iGAS due to their ability to induce inflammatory signals, such as interleukins or tumor necrosis factor [15]. Some SPEs seem to have been shared within different streptococcal species [16]. The SPE superantigen gene PCR was established as a useful technique and is considered to be more important than emm typing [17]. In a recent study, relationships between emm types and superantigen genes were established. It was found that emm28 type was consistent with speC, speG and speJ detection, and that speG was found to be most prevalent in all GAS isolates analyzed [18]. The emm distributions seem to differ between invasive and non-invasive GAS [19]. In the postpartum period, the combination of lateral, prevalently right-sided, lower abdominal pain, high fever and highly elevated CRP is suspicious for puerperal sepsis-induced OVT caused by an iGAS strain. OVT diagnosis can be made with confidence using ultrasound or magnetic resonance imaging. In order to assess the virulence of this iGAS strain, we performed SPE gene analysis, as superantigen gene analysis was found to be a more reliable tool in a previous univariate analysis tool than emm typing [17]. Our results are in concordance to previous findings where the superantigen genes speC and speG were equally found in non-invasive and iGAS, whereas the speJ gene was significantly more frequently detected in iGAS than in non-invasive GAS [17,18]. We therefore argue that the detection of speC and speG, and especially speJ, in a patient suffering from puerperal sepsis and OVT might be indicative for a hypervirulent iGAS strain against which an immediate start of AST-adapted antibiotic, antithrombotic and supportive treatment is urgently needed. The analysis of
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streptococcal superantigen patterns in a future clinical study might give a deeper knowledge about the severity of streptococcal infections in obstetrics. Acknowledgement Preliminary data of this work were demonstrated as poster presentation at the 113th General Annual Meeting of the American Society of Microbiology (ASM) in Denver, CO, USA, on 20 May 2013.
References [1] Kominiarek A, Hibbard JU. Postpartum ovarian vein thrombosis: an update. Obstet Gynecol Surv 2006;61(May (5)):337–42. [2] Kamaya A, Ro K, Benedetti NJ, Chang PL, Desser TS. Imaging and diagnosis of postpartum complications: sonography and other imaging modalities. Ultrasound Q 2009;(September (3)):151–62. [3] Sharma P, Abdi S. Ovarian vein thrombosis. Clin Radiol 2012;67(September (9)):893–8. [4] Paul SP, Jerwood S. Group A streptococcal septicemia, meningitis and cerebral abscess: case report and literature review. Turk J Pediatr 2012;54(March–April (2)):180–3. [5] Ben Zakour NL, Venturini C, Beatson SA, Walker MJ. Analysis of a Streptococcus pyogenes puerperal sepsis cluster by use of whole-genome sequencing. J Clin Microbiol 2012;50(July (7)):2224–8. http://dx.doi.org/10.1128/JCM.00675-12. Epub 2012 Apr 18. [6] Soares EM, Mason KL, Rogers LM, Serezani CH, Faccioli LH, Aronoff DM. Leukotriene B4 enhances innate immune defense against the puerperal sepsis agent Streptococcus pyogenes. J Immunol 2013 [Epub ahead of print]. [7] Mason KL, Aronoff DM. Postpartum group a Streptococcus sepsis and maternal immunology. Am J Reprod Immunol 2012;67(February (2)):91–100. http:// dx.doi.org/10.1111/j.1600-0897.2011.01083.x. Epub 2011 October 24. Review. [8] Martin J, Murchan S, O’Flanagan D, Fitzpatrick F. Invasive Group A streptococcal disease in Ireland, 2004 to 2010. Euro Surveill 2011;16(October (41)). doi:pii:19988. [9] Arthur C, Linam LE, Linam WM. Group A beta-hemolytic streptococcal colitis with secondary bacteremia. Pediatr Infect Dis J 2012;31(October (10)):1093–5. http://dx.doi.org/10.1097/INF.0b013e31826318c6. [10] Tajiri T, Tate G, Masunaga A, et al. Autopsy cases of fulminant bacterial infection in adults: clinical onset depends on the virulence of bacteria and patient immune status. J Infect Chemother 2012;18(October (5)):637–45. http://dx.doi.org/10.1007/s10156-012-0384-9. Epub 2012 February 22. [11] Sriskandan S. Severe peripartum sepsis. J R Coll Physicians Edinb 2011;41(December (4)):339–46. doi:10.4997/JRCPE.2011.411. Review. [12] Ogunniyi AD, Mahdi LK, Trappetti C, et al. Identification of genes that contribute to the pathogenesis of invasive pneumococcal disease by in vivo transcriptomic analysis. Infect Immun 2012;80(September (9)):3268–78. http:// dx.doi.org/10.1128/IAI.00295-12. Epub 2012 July 9. [13] Alouf JE, Mu¨ller-Alouf H. Staphylococcal and streptococcal superantigens: molecular, biological and clinical aspects. Int J Med Microbiol 2003;292(February (7–8)):429–40. [14] Thomas Proft S, Moffatt L, Berkahn CJ, Fraser JD. Identification and characterization of novel superantigens from Streptococcus pyogenes. J Exp Med 1999;189(January (1)):89–101. [15] Byrne JLB, Aagaard-Tillery KM, Johnson JL, Wright LJ, Silver RM. Group A streptococcal puerperal sepsis: initial characterization of virulence factors in association with clinical parameters. J Reprod Immunol 2009;82:74–83. [16] Sachse S, Seidel P, Gerlach D, et al. Superantigen-like gene(s) in human pathogenic Streptococcus dysgalactiae, subsp. equisimilis: genomic localisation of the gene encoding streptococcal pyrogenic exotoxin G (speGdys). FEMS Immunol Med Microbiol 2002;34:159–67. [17] Lintges M, van der Linden M, Ralf-Dieter H, et al. Superantigen genes are more important than the emm type for the invasiveness of group A streptococcus infection. J Infect Dis 2010;202(1):20–8. [18] Commons R, Rogers S, Gooding T, et al. Superantigen genes in group A streptococcal isolates and their relationship with emm types. J Med Microbiol 2008;57:1238–46. [19] Va¨ha¨kuopus S, Vuento R, Siljander T, Syrja¨nen J, Vuopio J. Distribution of emm types in invasive and non-invasive group A and G streptococci. Eur J Clin Microbiol Infect Dis 2012;31:1251–6.
Matthias Karrasch* Ju¨rgen Ro¨del Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany Norman Mu¨hler Department of Obstetrics,
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Letter to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 184 (2015) 125–131
University Hospital of Friedrich-Schiller-University Jena, Germany Birgit Edel Svea Sachse Karl-Hermann Schmidt Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany Uwe Schneider Dietmar Schlembach Department of Obstetrics, University Hospital of Friedrich-Schiller-University Jena, Germany Hans-Joachim Mentzel Institute of Diagnostic and Interventional Radiology, University Hospital of Friedrich-Schiller-University Jena, Germany Wolfgang Pfister Institute of Medical Microbiology, University Hospital of Friedrich-Schiller-University Jena, Germany
c-KIT-U-R2 50 -CAAACACAAACTTCACCAAATAATCAC-30 . The PCR conditions were as follows: 45 cycles of 95 8C for 5 s, 58 8C for 15 s, and 72 8C for 45 s. The resulting PCR products were resolved using 2% agarose gel electrophoresis with SYBR SafeTM DNA Gel Stain (Invitrogen, Ltd., UK). Additionally, the levels of methylation and un-methylation of DNA in samples were determined by using specific methyl- and un-methyl- primer sets with SYBR green dye in a real-time PCR machine. The number of PCR cycles (Ct) of methyland un-methyl- DNA in each sample was normalized with Actin gene DNA. We demonstrated that the DNA methylation ratio in the c-KIT (+) tumor area (26T) was higher than that in its adjacent nontumor cervical epithelium (26N); similarly, the DNA methylation ratio in the c-KIT (+) tumor area (26T) was also higher than that in another randomly selected c-KIT () tumor area (12T) and its nontumor cervical epithelium (12N) from another case. In other words, the DNA methylation ratio of 26T was relatively higher than that of all the 26N, 12T and 12N. (Fig. 1A–C) Tight association of DNA methylation and silencing of gene expression has been already established. Hypomethylation is the mechanism for ectopic oncogene activation while hypermethylation is the mechanism for tumor
Ekkehard Schleußner Department of Obstetrics, University Hospital of Friedrich-Schiller-University Jena, Germany *Corresponding author at: Institute of Medical Microbiology, University Hospital of Friedrich-Schiller University Jena, Erlanger Allee 101, D-07743 Jena, Germany. Tel.: +49 3641 9393611; fax: +49 3641 9393502 E-mail address: [email protected] (M. Karrasch).
Received 17 February 2014 http://dx.doi.org/10.1016/j.ejogrb.2014.11.019
Unusual c-KIT (+) squamous cell carcinoma of the uterine cervix showing paradoxical hypermethylation of the c-KIT proto-oncogene Dear Editors, We found one unusual case in 54 squamous cell carcinomas (SCC) of the uterine cervix where there was neither c-KIT(CD117) gene amplification nor c-KIT/PDGFRA activating mutation, but cKIT/PDGFRA protein overexpression was detected, previously [1,2]. However, the molecular mechanisms still remain unknown. The aim of this report was to investigate the methylationassociated regulation of the c-KIT gene expression in this extraordinary case. The methylation status (DNA methylation to un-methylation ratio) of the c-KIT promoter in both tumor area (T) and adjacent non-tumor cervical epithelium (N) from such c-KIT (+) individual (#26) and both (T and N) from another randomly selected c-KIT () individual (#12) was quantified by using a real-time methylation specific PCR (RT-MSPCR) method. The remaining 52 samples with c-KIT () were not taken into account for additional testing in this preliminary brief report. For investigating the relationship between DNA methylation status and the cKIT gene expression, we designed two sets of methylation-specific (MS) PCR primers located between the first exon and first intron regions. The primers were: c-KIT-M-F2 50 -CGTGGATTAGAGTTCGGATTTTATC-30 and c-KIT-M-R2 50 -ACAAACTTCGCCGAATAATCG30 ; c-KIT-U-F2 50 -GAA TGTGGATTAGAGTTTGGATTTTATT-30 and
Fig. 1. Methylation status of the c-KIT promoter region in one uncommon case of cKIT (+) SCC (case Number 26; #26) and another randomly selected case of c-KIT () SCC (case Number 12; #12) of the uterine cervix is shown. (A) ‘‘26T’’ indicates the tumor tissue with a band of methylated DNA and another weak band of unmethylated DNA; ‘‘26N’’ indicates a control pair of the adjacent normal cervical epithelium in non-tumor tissue that showed a strong band of un-methylated DNA but not methylated DNA. ‘‘12T’’ indicates tumor tissue with no band of methylated DNA and another weak band of un-methylated DNA; ‘‘12N’’ indicates a control pair of the adjacent normal cervical epithelium in non-tumor tissue that showed a weak band of un-methylated DNA but not methylated DNA. M indicates methylated DNA; U indicates un-methylated DNA. Actin served as an internal control in duplex PCR. An A549 lung cancer cell line served as a PCR control. N indicates non-tumor tissue with normal cervical epithelium; T indicates tumor tissue of a SCC of uterine cervix. The number before ‘‘T’’ or ‘‘N’’ indicates the patient number. (B) indicates that the DNA methylation status of the c-KIT gene promoter region is significantly higher in the tumor tissue of patient #26 (26T) compared with non-tumor tissue (no product). In 12T, the tumor and non-tumor tissues had no product. (C) Unmethylation status of the c-KIT gene promoter region was significantly higher the in non-tumor tissue compared with the tumor tissue when analyzed by quantitative PCR. The tumor tissue of Patient #12 served as the c-KIT () tumor control. An A549 lung cancer cell line served as the PCR control.