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Introduction: Chronic nonbacterial osteomyelitis (CNO) is an inflammatory disorder of unknown etiology. In children and adolescents CNO predominantly affects the metaphyses of the long bones, but lesions can occur at any site of the skeleton. Prospectively followed cohorts using a standardized protocol in diagnosis and treatment have rarely been reported. Methods: Thirty-seven children diagnosed with CNO were treated with naproxen continuously for the first 6 months. If assessment at that time revealed progressive disease or no further improvement, sulfasalazine and short-term corticosteroids were added. The aims of our short-term follow-up study were to describe treatment response in detail and to identify potential risk factors for an unfavorable outcome. Results: Naproxen treatment was highly effective in general, inducing a symptom-free status in 43% of our patients after 6 months. However, four nonsteroidal anti-inflammatory drug (NSAID) partial-responders were additionally treated with sulfasalazine and short-term corticosteroids. The total number of clinical detectable lesions was significantly reduced. Mean disease activity estimated by the patient/physician and the physical aspect of health-related quality of life including functional ability (global assessment/childhood health assessment questionnaire and childhood health assessment questionnaire) and pain improved significantly. Forty-one percent of our patients showed radiological relapses, but 67% of them were clinically silent. Conclusions: Most children show a favorable clinical course in the first year of anti-inflammatory treatment with NSAIDs. Relapses and new radiological lesions can occur at any time and at any site in the skeleton but may not be clinically symptomatic. Whole-body magnetic resonance imaging proved to be very sensitive for initial and follow-up diagnostics.
Disruption of the blood-brain barrier (BBB) is a hallmark event in the pathophysiology of bacterial meningitis. Several inflammatory mediators, such as tumor necrosis factor alpha (TNF-a), nitric oxide and matrix metalloproteinases (MMPs), contribute to this disruption. Here we show that infection of human brain microvascular endothelial cells (HBMEC) with Neisseria meningitidis induced an increase of permeability at prolonged time of infection. This was paralleled by an increase in MMP-8 activity in supernatants collected from infected cells. A detailed analysis revealed that MMP-8 was involved in the proteolytic cleavage of the tight junction protein occludin, resulting in its disappearance from the cell periphery and cleavage to a lower-sized 50-kDa protein in infected HBMEC. Abrogation of MMP-8 activity by specific inhibitors as well as transfection with MMP-8 siRNA abolished production of the cleavage fragment and occludin remained attached to the cell periphery. In addition, MMP-8 affected cell adherence to the underlying matrix. A similar temporal relationship was observed for MMP activity and cell detachment. Injury of the HBMEC monolayer suggested the requirement of direct cell contact because no detachment was observed when bacteria were placed above a transwell membrane or when bacterial supernatant was directly added to cells. Inhibition of MMP-8 partially prevented detachment of infected HBMEC and restored BBB permeability. Together, we established that MMP-8 activity plays a crucial role in disassembly of cell junction components and cell adhesion during meningococcal infection.
Neisseria meningitidis is a facultatively pathogenic human commensal and strictly adapted to its niche within the human host, the nasopharynx. Not much is known about the regulatory processes required for adaptation to this environment. Therefore the role of the transcriptional regulator NMB1843, one of the two predicted regulators of the MarR family in the meningococcal genome, was investigated. As this gene displayed a high sequence homology to FarR, the Fatty acid resistance Regulator in N. gonorrhoeae, we designated the meningococcal protein FarR (NmFarR). Homology modeling of this protein revealed a dimeric structure with the characteristic winged helix-turn-helix DNA binding motif of the MarR family. NmFarR is highly conserved among meningococcal strains and expression of farR during exponential growth is controlled post-transcriptionally, being highest in the late exponential phase. By means of electrophoretic mobility shift assays (EMSAs) the direct and specific binding of FarR to the farAB promoter region was shown, comparable to its homologue in gonococci. As FarR is involved in fatty acid resistance in N. gonorrhoeae, susceptibility assays with the medium chain lauric acid (C12:0), the long chain saturated palmitic acid (C16:0) and the long chain unsaturated linoleic acid (C18:2) were performed, testing a wide variety of strains of both species. In contrast to the unusually susceptible gonococci, a high intrinsic fatty acid resistance was detected in almost all meningococcal isolates. The molecular basis for this intrinsic resistance in N. meningitidis was elucidated, showing that both a functional FarAB efflux pump system as well as an intact lipopolysaccharide (LPS) are responsible for palmitic acid resistance. However, even despite circumvention of the intrinsic resistance, FarR could not be connected with fatty acid resistance in meningococci. Instead, FarR was shown to directly and specifically repress expression of the Neisseria adhesin A (nadA), a promising vaccine candidate absent in N. gonorrhoeae. Microarray analyses verified these results and disclosed no further similarly regulated genes, rendering the FarR regulon the smallest regulon in meningococci reported until now. The exact FarR binding site within the nadA promoter region was identified as a 16 bp palindromic repeat and its influence on nadA transcription was proved by reporter gene fusion assays. This repression was also shown to be relevant for infection as farR deficient mutant strains displayed an increased attachment to epithelial cells. Furthermore, farR transcription was attested to be repressed upon contact with active complement components within human serum. Concluding, it is shown that FarR adopted a role in meningococcal host niche adaptation, holding the balance between immune evasion by repressing the highly antigenic nadA and host cell attachment via this same adhesin.