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Journal of Clinical Microbiology, May 1999, p. 1447-1453, Vol. 37, No. 5
0095-1137/99/$04.00+0
Molecular Cloning and Characterization of the Ehrlichia
chaffeensis Variable-Length PCR Target: an Antigen-Expressing Gene
That Exhibits Interstrain Variation
John W.
Sumner,*
James E.
Childs, and
Christopher D.
Paddock
Viral and Rickettsial Zoonoses Branch,
Division of Viral and Rickettsial Diseases, National Center for
Infectious Diseases, Centers for Disease Control and Prevention,
Atlanta, Georgia 30333
Received 27 October 1998/Returned for modification 17 December
1998/Accepted 5 February 1999
 |
ABSTRACT |
A clone expressing an immunoreactive protein with an apparent
molecular mass of 44 kDa was selected from an Ehrlichia
chaffeensis Arkansas genomic library by probing with
anti-E. chaffeensis hyperimmune mouse ascitic fluid.
Nucleotide sequencing revealed an open reading frame (ORF) capable of
encoding a 198-amino-acid polypeptide. The ORF contained four
imperfect, direct, tandem 90-bp repeats. The nucleotide and deduced
amino acid sequences did not show close homologies to entries in the
molecular databases. PCR with primers whose sequences matched the
sequences flanking the ORF was performed with DNA samples extracted
from cell cultures infected with nine different isolates of E. chaffeensis, blood samples from seven patients with
monocytic ehrlichiosis, and Amblyomma americanum ticks collected in four different states. The resulting amplicons varied in length, containing three to six repeat units. This
gene, designated the variable-length PCR target, is useful for PCR
detection of E. chaffeensis and differentiation of isolates.
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INTRODUCTION |
Human ehrlichiosis was first
described in the United States in 1987 (17), and the first
isolation of an Ehrlichia species from a North American
patient was reported in 1991 (8). The organism was
designated a new species, Ehrlichia chaffeensis, because the
16S rRNA gene sequence of the isolate was significantly different from
that of previously described Ehrlichia species (2). Infection with E. chaffeensis results in a
moderate to severe febrile illness observed most frequently in the
southeastern and south-central regions of the United States (11,
13, 28). Over 70% of patients describe a history of tick bite or
exposure 1 to 2 weeks preceding the illness. Several studies have
implicated the lone star tick, Amblyomma americanum, as the
primary vector of E. chaffeensis (4, 12, 16).
Approximately 750 cases of E. chaffeensis infection have
been confirmed serologically by the Centers for Disease Control and
Prevention (CDC) to date (5).
The emergence or recognition of human diseases caused by
tick-transmitted ehrlichiae has stimulated interest in the molecular biology of these obligate intracellular bacteria. The cloning and
characterization of several antigen-expressing genes belonging to
E. chaffeensis have recently been described, including the groESL heat shock operon (24, 25) and the 120-kDa
immunodominant surface protein gene (29, 30). Ohashi et al.
(18) and Reddy et al. (22) have described a
multigene family of E. chaffeensis that demonstrates
homology to major surface antigen genes (MAP 1) of a closely related
bacterium, Cowdria ruminantium (21, 27).
Initially, E. chaffeensis was isolated and propagated in
cell culture with difficulty, but more recently, multiple isolations of
this pathogen from human patients from several geographic areas have
been described. The original isolate was designated the Arkansas strain
(2, 8). The 91HE17 and Sapulpa isolates were described in
1995 (10) and 1997 (6), respectively. Since 1996, six additional isolates of E. chaffeensis have been obtained
at CDC from blood samples from patients with ehrlichiosis
(reference 19 and data herein). The availability of multiple
isolates now provides ample material for the study of the molecular and
immunologic diversity among different strains of E. chaffeensis. In this report, we describe the cloning and
sequencing of an E. chaffeensis gene containing
repetitive sequence motifs. We have referred to this gene as the
variable-length PCR target (VLPT) and have described sequence
differences among PCR products amplified from the Arkansas, Jax, and
St. Vincent isolates of E. chaffeensis (19). In
this report, we describe the detection of VLPT by PCR in a variety of
samples from different sources, sequence variation among the amplicons,
and recombinant expression of the VLPT protein in Escherichia coli.
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MATERIALS AND METHODS |
Isolation and cultivation of E. chaffeensis.
The
Arkansas, 91HE17, Sapulpa, Jax, and St. Vincent isolates of E. chaffeensis were obtained from clinical samples as described previously (6, 8, 10, 19). The Liberty, Osceola, Wakulla, and West Paces isolates were recovered from EDTA-anticoagulated whole
blood collected from patients with clinical disease by a previously
described method (19). Briefly, patient blood samples (1 to
5 ml) were diluted with 2 volumes of sterile Hanks' balanced salt
solution and layered onto Histopaque 1083 (Sigma Diagnostics, St.
Louis, Mo.). The prepared samples were centrifuged at 400 × g for 10 min. The leukocyte pellets were resuspended in culture medium (minimal essential medium containing Earle's salts and 16 mM
sodium bicarbonate [GIBCO BRL, Grand Island, N.Y.], 8.8% heat-inactivated fetal bovine serum [Hyclone Laboratories, Logan, Utah], 1.8 mM L-glutamine [GIBCO BRL], 0.1 mM minimal
essential medium with nonessential amino acids [GIBCO BRL], and 8.8 mM HEPES buffer [GIBCO BRL]). Semiconfluent monolayers of DH82 cells
in a 25-cm2 polystyrene cell culture flask were inoculated
with the cell suspensions. Cultures were incubated at 37°C in a 5.0%
CO2 atmosphere. Isolates of E. chaffeensis were
maintained in continuous culture in DH82 cells as described previously
(8, 19).
Construction of genomic expression library.
Cell-free
preparations of E. chaffeensis Arkansas were obtained from
infected DH82 cell cultures as described previously (24). DNA was extracted by proteinase K digestion and phenol-chloroform extraction and was fragmented for library construction by using EcoRI star activity (1). DNA fragments from 2 to
10 kb in size were isolated by agarose gel electrophoresis and were
cloned into Stratagene's Lambda Zap II vector by the procedures
recommended by the manufacturer (Stratagene, La Jolla, Calif.).
Immunoscreening of expression library.
Clones were screened
by using anti-E. chaffeensis hyperimmune mouse ascitic
fluid (HMAF; kindly provided by Tom Ksiazek, Special Pathogens Branch,
CDC). Preparation of HMAF has been described previously
(14). Recombinant clones expressing reactive proteins were
selected by immunoscreening phage plaques on lawns of E. coli XL-1 Blue. Nitrocellulose filters soaked in 10 mM
isopropyl-
-D-thiogalactopyranoside and placed over lawns
during plaque formation were reacted with a 1:200 dilution of HMAF for
1 h in Tris-buffered saline containing Tween 20 (TBST). The
filters were washed three times in TBST and reacted for 1 h with
anti-mouse immunoglobulin G (heavy and light chains) peroxidase
conjugate (Kirkegaard & Perry Laboratories, Gaithersburg, Md.) diluted
1:5,000 in TBST. The filters were then washed three times with TBST and
reacted with tetramethylbenzidine membrane substrate (Kirkegaard & Perry). Immunoreactive plaques were subjected to three rounds of plaque
purification. Phagemids from reactive plaques were rescued and excised
by the Stratagene protocol, producing pBluescript plasmids containing inserts.
Immunoblotting.
E. coli containing excised recombinant
phagemid or transformed with plasmid subclones was grown overnight at
37°C in 5 ml of Luria broth containing ampicillin (100 µg/ml).
Fresh cultures containing 1 mM
isopropyl-
-D-thiogalactopyranoside were subsequently inoculated with 50 µl of the overnight culture. Several 200-µl samples were removed when the optical density of the culture reached 0.3 to 0.4 (600-nm wavelength), and the bacterial cells were pelleted by centrifugation at 10,000 × g for 3 min. The
bacteria were resuspended in sample buffer (Novex, San Diego, Calif.)
containing 5% 2-mercaptoethanol and 1% sodium dodecyl sulfate (SDS),
heated at 100°C for 5 min, and centrifuged at 10,000 × g for 3 min. Ten-microliter samples of each supernatant were
loaded into individual wells of 4 to 20% gradient Tris-glycine-SDS
gels (Novex) for SDS-polyacrylamide gel electrophoresis at 100 V for 90 min. The proteins were transferred to nitrocellulose membranes (Novex)
for 2 h at 90 V with a Mini-Transblot Cell (Bio-Rad, Hercules,
Calif.). The filters were reacted with the HMAF as described above for immunoscreening.
Subcloning.
The restriction endonucleases, calf intestinal
alkaline phosphatase, and T4 DNA ligase used for mapping and the
construction of subclones were obtained from Boehringer Mannheim,
Indianapolis, Ind., or New England Biolabs, Beverly, Mass. Some
subclones were made by cloning PCR products directly into the T/A
cloning vector pGEM-T (Promega Corp., Madison, Wis.) according to the
manufacturer's recommendations.
Nucleotide sequencing.
Plasmids were purified with Wizard
Minipreps (Promega Corp., Madison, Wis.), and Wizard PCR preps (Promega
Corp.) were used for purification of PCR products. PCR products were
sequenced directly, with the exception of one product obtained from an
individual tick (tick 97-36; see Table 1) that was cloned into plasmid
pGEM-T prior to sequencing (Promega Corp.). If gel purification was
necessary prior to sequencing, 40 µl of the individual PCR mixture
was electrophoresed in gels containing 1.2% low-melting-point agarose
(Boehringer Mannheim) and the appropriate band was excised. Purified
preparations were sequenced with the Prism Ready Reaction DyeDeoxy
Cycle Sequencing kit (Applied Biosystems, Foster City, Calif.) and a
Perkin-Elmer 9600 thermocycler. Thermocycler parameters for sequencing
were 96°C for 1 min, 50°C for 15 s, and 60°C for 4 min for
25 cycles. Unincorporated fluorescence-labeled deoxynucleoside
triphosphates were removed with Centri-Sep columns according to the
manufacturer's recommendations (Princeton Separations, Inc., Adelphia,
N.J.). Samples were loaded onto 5% polyacrylamide gels for
electrophoresis and detection on Applied Biosystem model 370A or 377 automated sequencers. Both strands were sequenced, initially by primer
walking and later with established primer sets.
Samples selected for analysis of the VLPT gene.
Three
categories of specimens were evaluated by PCR for detection of the VLPT
gene (see Table 1): (i) EDTA-anticoagulated whole-blood samples from
patients with E. chaffeensis infection confirmed by PCR with
primers HE1 and HE3 (3) for detection of the 16S rRNA gene;
(ii) nine isolates of E. chaffeensis, in DH82 cells,
obtained from human patients (Arkansas, 91HE17, and Sapulpa [kindly
provided by D. H. Walker], Jax, St. Vincent, Osceola, Wakulla,
Liberty, and West Paces); and (iii) individual and pooled A. americanum ticks collected from geographic regions where E. chaffeensis is endemic.
Extraction of E. chaffeensis DNA from patient blood,
isolates, and ticks.
DNA was extracted from 200 µl of patient
whole blood by using the QIAmp Blood Kit (Qiagen Inc., Santa Clarita,
Calif.) according to the manufacturer's recommendations. Similarly,
DNA was extracted from 20 µl of supernatant from E. chaffeensis-infected DH82 cell cultures. Individual ticks were
minced in a cryotube with a sterile scalpel blade, and DNA was
extracted with QIAmp tissue kits (Qiagen, Inc.). Extraction of DNA from
pooled A. americanum ticks (see Table 2) was conducted at
CDC's Ft. Collins facility as part of a previous study, and the
extraction procedure has been described previously (4, 15).
PCR amplification.
PCRs were performed with GeneAmp kits
(Roche Molecular Systems, Inc., Branchburg, N.J.) according to the
manufacturer's recommendations and Perkin-Elmer thermal cyclers. Ten
microliters from each DNA extraction was added to 90 µl of the master
mixture for each 100-µl PCR mixture. The final reagent concentrations
were 0.5 µM each primer, 2.5 U of AmpliTaq DNA polymerase per
reaction mixture, 10 mM Tris-HCl (pH 8.3), 50 mM KCl, 1.5 mM
MgCl2, and each deoxynucleoside triphosphate at a
concentration of 200 µM. The following thermocycler parameters were
used: 3 cycles of 94°C (1 min), 52°C (2 min), and 70°C (90 s),
followed by 37 cycles of 88°C (1 min), 55°C (2 min), and 70°C (90 s), followed by an extension period (68°C, 5 min). VLPT primers FB5A
(5'-GTGACATCTTAGTTTAATAGAAC) and FB3A (5'-AAGACTGAAACGTTATAGAG) were used in primary PCRs. Nested
PCR with primers FB5 (5'-AAATAGGGTATAAATATGTCAC) and FB3
(5'-GCCTAATTCAGATAAACTAAC) was performed with extracts from
individual ticks. One microliter of the primary PCR product was used as
a template in the nested reactions. The cycling parameters for the
nested PCRs were the same as those used for the primary reactions.
Samples were also tested by a PCR assay with primers HE1 and HE3
targeted to the 16S rRNA gene (rDNA) of E. chaffeensis as
described by Anderson et al. (3). In addition, extracts from
individual isolates in cell culture were tested by PCR with primers WF1
and WR2 for amplification of the 120-kDa antigen gene as described by
Yu et al. (29). PCR products were detected by
electrophoresis of 10-µl samples in 1.4% Tris-acetate agarose gels
containing ethidium bromide.
Computer analysis of sequence data.
Nucleotide sequences
were edited and assembled with the TED and XBAP programs of the STADEN
sequence analysis package (23). Nucleotide sequence homology
searches were made through the National Center for Biotechnology
Information BLAST network service. Sequence homology comparisons were
made with the GAP program of the GCG package (Genetics Computer Group,
Madison, Wis.). Multiple-sequence alignments were made with the PILEUP
and PRETTY programs of the GCG package.
Nucleotide sequence accession numbers.
The nucleotide
sequence accession numbers for the complete VLPT sequences of the
following E. chaffeensis isolates are as indicated: 91HE17,
AF121237; Arkansas, AF121232; Jax, AF121234; Liberty, AF121236;
Osceola, AF121233; Sapulpa, AF121230; St. Vincent, AF121231; Wakulla,
AF121238; and West Paces, AF121235.
 |
RESULTS |
Sequence analysis of E. chaffeensis Arkansas
clone.
pBluescript clones derived from 10 immunoreactive
plaques were analyzed by SDS-polyacrylamide gel electrophoresis and
immunoblotting with HMAF. Three of 10 clones expressed an
immunoreactive protein that comigrated with an E. chaffeensis Arkansas protein with an apparent molecular mass of
approximately 44 kDa. Restriction endonuclease digestion with
EcoRI showed that each of the three clones contained an
insert of approximately 7 kb, and nucleotide sequencing with M13
universal and reverse primers showed identical sequences for the
inserts of each clone near the plasmid junction. One clone was selected
for further analysis. After restriction mapping, subclones were made
and screened for protein expression. A subclone containing a 2.6-kb
fragment of the original insert expressed a 44-kDa protein. The
complete insert was sequenced by primer walking. The longest open
reading frame (ORF) encoded a 198-amino-acid polypeptide, approximately
one-half the size predicted for a 44-kDa protein. A sequence compatible
with a ribosome-binding site was found 11 bp upstream of the
putative ATG start codon (Fig. 1). Multiple stop codons were found downstream of the first stop codon, and
homologous sequences were not found elsewhere in the insert. Sequence homology searches with the nucleotide and deduced amino acid
sequences did not show significant similarities to entries in the
genetic databases.

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FIG. 1.
Nucleotide and deduced amino acid sequences of the
E. chaffeensis Arkansas VLPT. The following features are
indicated in boldface type: putative ribosome-binding site (RBS),
translation initiation codon, and termination codon (asterisk). An
aspartic acid codon (GAT) and the sequence 5'-GTTTTATAT,
which are absent from sequences amplified from some strains of
E. chaffeensis, and four individual nucleotide positions
where substitutions (A or G) occur among different strains are also
indicated in boldface type. PCR primers are underlined and labeled, and
directions are indicated. The nucleotide sequence was numbered by
designating the A of the putative translation initiation codon number
1.
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VLPT PCR.
Multiple sample types were evaluated by using the
primers derived from the sequenced clone. Analysis of sequences from
nine isolates, seven clinical whole-blood specimens, seven A. americanum tick pools, and one individual tick are listed in Table
1. Amplicons of four different sizes were
produced, with each differing in apparent size by a factor of 90 bp
(Fig. 2). Nucleotide sequencing revealed
that the size differences resulted from variations in the number of
repeat units. The corresponding patient blood samples from which six of
the isolates (Jax, Liberty, Osceola, St. Vincent, Wakulla, and West
Paces) were obtained were tested individually. For each blood sample,
the VLPT sequence was identical to the VLPT sequence of the
corresponding isolate (data not shown). The seven blood samples listed
in Table 1 were collected from ehrlichiosis patients for whom isolates
were not obtained.

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FIG. 2.
Agarose gel electrophoresis of PCR products amplified
from different cell culture isolates of E. chaffeensis and
control samples with VLPT primers FB5A and FB3A. Lanes: A, water; B,
extraction blank; C, uninfected DH82 cells; D, St. Vincent; E,
Arkansas; F, Jax; G, Osceola; H, 91HE17; I, Wakulla. The outside lanes
contain X174/HaeIII molecular mass markers.
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In addition to demonstrating concordance between repeat unit number for
isolates and the corresponding whole blood samples,
we investigated
whether the number of repeat units in the VLPT
remained stable with
passage in cell culture. DNA samples were
extracted from the St.
Vincent, Jax, Osceola, and Wakulla isolates
after the eighth cell
culture passage. The sizes of the amplicons
obtained from patient blood
samples were identical to those obtained
from the corresponding isolate
after the eighth cell culture passage,
indicating that the number of
repeat units remained stable through
multiple passages in cell
culture.
PCR specificity.
DNA samples extracted from the blood of a
healthy patient and uninfected DH82 cells were included as negative
controls and did not produce amplicons. DNA samples extracted from
related bacteria were tested in PCRs with VLPT primers (FB5A-FB3A and FB5-FB3) to assess primer specificity. Samples included DNA extracted from cultures individually infected with the human granulocytic ehrlichiosis agent (strain USG3), Ehrlichia canis Florida,
Ehrlichia muris AS145, and Ehrlichia risticii
HRC-IL and from purified Anaplasma marginale Virginia,
Bartonella henselae Houston 1, and Rickettsia rickettsii R. DNA extracted from E. coli XL-1 Blue,
which was used for construction of the genomic library, was also
tested. None of the DNA samples produced bands of significant intensity and size compatible with those of the VLPT amplicons obtained from
E. chaffeensis. DNA extracted from whole blood from a dog naturally infected with Ehrlichia ewingii produced an
amplicon of approximately 1,600 bp in a primary PCR with primers FB5A
and FB3A. This amplicon was sequenced and did not contain an ORF with sequence homology to VLPT. DNA samples extracted from several strains
of C. ruminantium were tested with VLPT primers FB5 and FB3,
and amplicons of different sizes were obtained from different strains;
however, none of the products hybridized with a labeled E. chaffeensis VLPT probe (20a).
Detection of E. chaffeensis in ticks.
To determine
whether VLPT PCR would be useful for detection of E. chaffeensis in ticks and to determine whether a variable number of
repeat units would also be present in samples of nonhuman origin, 10 pools of A. americanum ticks were tested with primers FB5A
and FB3A. Seven of the pools were selected on the basis of previous
positive results for the E. chaffeensis 16S rDNA
(4) and three pools that produced negative results were
selected as controls (Table 2). The VLPT
PCR results (Table 2) showed an exact correlation with the 16S rDNA PCR
results. Three VLPT amplicon sizes were obtained, and these
corresponded to three, four, or five repeat units (Table 1). Two bands
were visible in the PCR product from pool 95: a bright band comigrating
with a three-repeat unit marker and a faint band comigrating with a
four-repeat unit marker (data not shown). We were not able to recover
sufficient DNA from the faint band for sequencing, but these results
may indicate that more than one variant was detected in the pool.
Nested VLPT PCR was performed with DNA extracted from 42 individual
adult
A. americanum ticks collected in Baker County, Fla.
Negative controls, a water extraction blank, and a colony-raised
adult
female
A. americanum tick did not produce products. As a
positive control, an adult female
A. americanum tick
infected
with
E. chaffeensis Arkansas by capillary feeding
(
20) produced
a four-repeat-unit amplicon, as expected. Six
of 42 tick extracts
produced amplicons of the VLPT four-repeat-unit
size. One of the
six amplicons was sequenced and was confirmed to be
VLPT (Table
1). Primary PCR with VLPT primer pair FB5A-FB3A and 16S
rDNA
primer pair HE1-HE3 did not produce visible products from
individual
ticks.
Sequence variation among VLPT amplicons.
The amplicons were
sequenced to confirm their identities and to characterize the sequence
variations. Variations occurred at several levels, including the number
and sequences of repeat units, the occurrence of a codon deletion
(aspartic acid residue) immediately preceding the first repeat unit,
the occurrence of a 9-bp deletion in the region downstream of the
coding sequence, and single substitutions in certain nucleotide
positions (Table 1 and Fig. 1).
Amplicons from different samples contained three to six repeat units,
representing the four different sizes. To facilitate
characterization
of sequence differences, the deduced amino acid
sequences of the repeat
units from all amplicons were aligned,
and type numbers were assigned
for conserved sequences. There
were five conserved types that differed
at 4 to 18 amino acid
positions. Two additional types (types 6 and 7)
were each found
in only one amplicon. The nucleotide sequences of
individual repeat
unit types were very conserved, with little variation
in the third
positions of codons. The deduced amino acid sequence of
E. chaffeensis Wakulla, the only example of a six-repeat
unit VLPT in our series,
is shown in Fig.
3, and the repeat units are numbered to
illustrate
the five conserved types. A total of six different repeat
profiles
(number and order of repeat unit types) were represented among
the VLPT sequences amplified from isolates and patient whole blood
(Table
1). Repeat types are listed in the downstream-to-upstream
orientation. Type 1 represents the partial repeat always found
the
farthest downstream (Fig.
3). Among the amplicon sequences
containing
three or four repeats, the types and linear order of
repeat units were
conserved (e.g., 1, 2, 4 and 1, 2, 3, 4). Amplicons
containing more
than four repeat units usually contained a duplication
of the type 3 unit or the addition of a type 5 unit. Among the
amplicon sequences
containing five repeats, we found three variations
in the types and
order of repeat units (Table
1).

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FIG. 3.
Deduced amino acid sequence of the VLPT gene of E. chaffeensis Wakulla with the six repeat units aligned and numbered
according to sequence type. Repeat units with conserved sequences were
categorized and numbered to facilitate description of genetic
variation. Repeat unit types and the order in which they occur vary
among some strains.
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In seven of the amplicons (representing one isolate, four patient blood
samples, and two tick pools), three nucleotides representing
an
aspartic acid codon were absent. When present, this aspartic
acid
residue was the 17th residue from the amino terminus and
immediately
preceded the beginning of the first repeat
unit.
A gap consisting of a nine-nucleotide deletion (5'-GTTTTATAT)
occurred in the same position in seven amplicons (representing
one isolate, four patient samples, and two tick pools). The G
in this
sequence is located 45 nucleotides downstream of the putative
stop
codon, and the sequence is marked in boldface type in Fig.
1. A
repetitive motif (GTTTT) that may facilitate recombination
was found in
this region. The nine-base gap and the aspartic acid
deletions were
found more often in the amplicons with a larger
number of repeats, and
these deletions were always associated
with each other in amplicons
derived from the isolates and patient
blood samples but not the tick
pools.
Adenosine or guanosine substitutions were found primarily at four
distinct positions (positions

69, 6, 27, and 487) among
the different
VLPT amplicons (Table
1). Nucleotide substitutions
at positions 27 and
487 resulted in amino acid substitutions from
methionine to isoleucine
and serine to glycine, respectively.
Position 6 corresponds to the
second nucleotide from the 3' end
of primer FB5. We are currently
evaluating the use of a primer
slightly upstream of FB5, because
sequence variation in the primer
site could adversely affect PCR
sensitivity.
In summary, among the three-repeat-unit varieties, the Sapulpa, St.
Vincent, and West Paces isolates had identical sequences,
but the
sequence of the amplicon from tick pool 95 differed at
position 487 and
had the 9-base gap. Among the four-repeat-unit
varieties, amplicons
from the Arkansas, Jax, and Osceola isolates,
patient 5, patient 6, and
tick pool 97 had identical VLPT sequences,
although the Osceola isolate
had a three-repeat-unit version of
the 120-kDa antigen gene and the
others had the four-repeat-unit
version. The sequences of the remaining
four-repeat-unit versions,
those from tick pools 20, 85, and 130 and
the Liberty isolate,
are different from those listed above and from
each other. Among
the five-repeat-unit varieties, amplicons from the
91HE17 isolate,
patient 2, and tick pool 25 had identical VLPT
sequences. Amplicons
from patients 1, 3, and 7 had identical sequences,
and the sequences
from patient 4 and tick pool 9 were unique. The
Wakulla isolate
contained six repeat
units.
Expression of VLPT protein from cloned amplicons.
Amplicons
from the St. Vincent, Jax, and 91HE17 isolates (representing the
three-, four-, and five-repeat-unit versions, respectively) were cloned
into an expression vector, and E. coli lysates were examined
for expression of the VLPT protein. The VLPT genes of the Arkansas and
Jax isolates were equal in size (four repeat units) and expressed
comigrating proteins. The proteins expressed by the St. Vincent and
91HE17 clones were proportional to the sizes of the ORFs (Fig.
4). Expression of the VLPT was cytotoxic to E. coli, resulting in colonies approximately a quarter
the size of those produced by the same strain of E. coli not
transformed with a recombinant plasmid containing the VLPT insert.

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FIG. 4.
Western immunoblot reacted with anti-E.
chaffeensis HMAF showing the proteins expressed by three different
size variations of the VLPT gene. The lanes contained lysates from
purified E. chaffeensis Arkansas (lane Ec) E. coli transformed with a VLPT clone selected from the E. chaffeensis Arkansas genomic library (lane Ac), and E. coli transformed with plasmids containing PCR amplicons from the
following strains: St. Vincent (lane 3R), Jax (lane 4R), and 91HE17
(lane 5R) (R indicates the number of 90-bp repeat units found in the
VLPT gene of each strain).
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Amplification of 120-kDa antigen gene.
PCR amplification of
the E. chaffeensis 120-kDa antigen gene was performed to
additionally characterize each isolate, because variation among strains
was described previously (30). Two size variants were found
(Table 1), and these corresponded to the three- and four-repeat-unit
versions described previously (6, 30) in the Sapulpa and
Arkansas strains of E. chaffeensis, respectively. The
Osceola, St. Vincent, and West Paces isolates produced amplicons of the
same size as that produced by the Sapulpa strain, and the Jax, Wakulla,
Liberty, and 91HE17 isolates produced amplicons of the same size as
that produced by the Arkansas strain. These amplicons were partially
sequenced with a single primer to confirm their identities. The
corresponding patient blood samples were not tested. DNA samples from
the tick pools were previously tested by PCR with the 120-kDa antigen
gene primers (30), and one of the two size variations (e.g.,
three or four repeat units) was found in each pool (Table 1).
 |
DISCUSSION |
In this report we present the results of the cloning,
sequencing, and expression of a previously uncharacterized
E. chaffeensis gene and describe a wide range of sequence
variation among PCR amplicons derived from different isolates, patient
samples, and ticks. The VLPT gene appears to be a sensitive and
specific marker for E. chaffeensis. This gene has multiple
diagnostic applications and represents a potentially important tool for
the study of the molecular epidemiology of E. chaffeensis.
The VLPT gene conveniently differentiates strains of E. chaffeensis. Some of the established DNA fingerprinting techniques
for the detection of genetic diversity among strains of bacteria, such
as arbitrary primed PCR (randomly amplified polymorphic DNA [RAPD]
PCR [RAPD-PCR]), have the advantage of targeting the entire genome
and require little knowledge of the nucleotide sequence
(26). However, RAPD-PCR is difficult to apply to obligate
intracellular bacteria, primarily because of problems associated with
contamination of preparations with host-cell DNA. Consequently,
conserved genes or regions of known sequence must be targeted.
Two of the first Ehrlichia genes sequenced, the 16S rRNA
gene (1) and the groESL operon (24),
appear to be completely conserved among several isolates of E. chaffeensis (19). Analysis of tRNA interrepeat length
polymorphisms has been used to detect and differentiate
Ehrlichia species (9), but the utility of this
method for the detection of differences among strains of the same
species has not been determined. Two E. chaffeensis genes for which isolate-dependent sequence polymorphisms have been
demonstrated are the 120-kDa antigen gene (29) and the VLPT
described in this report. PCR amplification and nucleotide sequencing
of the VLPT repeat region are convenient and more informative than PCR amplification and nucleotide sequencing of the 120-kDa antigen gene
because of the smaller size of the VLPT repeat region and the greater
variability in the number of repeat units. Finer resolution can be
obtained by combining data obtained from assays with these genes.
Interestingly, among the samples for which the number of repeats have
been determined for both genes, there appears to be some correlation
between gene sizes. In our study, the three-repeat-unit version of the
120-kDa antigen was always associated with fewer (e.g., three or four)
repeat units in the VLPT. We have not detected any significant sequence
homology between these two genes. The recently described p28 antigen
gene family of E. chaffeensis may also prove to be useful
for the study of strain variation (18), since variation was
detected in a related gene family, map-1 of C. ruminantium (21).
On a practical level, VLPT PCR is useful when conducting experiments
involving different strains of E. chaffeensis. We have found
it to be convenient to use DNA extracted from the Wakulla isolate as a
positive PCR control. To date, the six-repeat version found in the
Wakulla isolate appears to be relatively rare, and its use allows us to
discern false-positive PCR results that might result from contamination
of test samples with amplicons derived from a positive control. This is
particularly important when nested PCR is used. Isolates and patient
samples are easily identified by the VLPT size differences determined
by gel electrophoresis of PCR amplicons. However, if sequencing is
available, other variations at the nucleotide level may be discerned,
allowing even finer separation. These variations include the presence
or absence of the aspartic acid codon preceding the repeat region, the
presence or absence of a 9-bp gap beyond the coding sequence, and
individual nucleotide substitutions that occur at defined positions.
Isolates, patient blood samples, and tick samples (24 total samples)
could be segregated into 12 different groups by using information
derived from individual VLPT sequences.
On an epidemiologic level, it would be interesting to find a
correlation between the geographic origin of samples and variations in
gene sequences. A previous report on the geographic distribution of
variants of the 120-kDa antigen gene failed to demonstrate convincing
geographic clustering of three- and four-repeat-unit variants among DNA
samples from tick pools. All tick pools showed a single PCR band,
suggesting that a single-repeat variant was present in each pool
(30). We were not able to identify obvious patterns among
VLPT sequences from similar geographic locations, but relatively few
samples have been tested. The ticks included in each individual pool
were collected in the same county, and we were interested to see
whether we would find more than one version of the VLPT in a single
pool. A single tick pool produced two amplicons that comigrated with
the VLPT markers, suggesting the presence of two versions in the same
pool; however, the second (less intense) band could not be recovered in
sufficient quantity to verify its identity by sequencing. We are
currently developing labeled probes for confirmation of amplicon
identity by hybridization methods. Amplicons were separated by gel
electrophoresis, but different sequence types with the same number of
repeats would not have separated. Although the electropherograms did
not reveal ambiguities, sequence data from the tick pools should
probably be interpreted with more caution than sequence data derived
from isolates and patient blood samples. The VLPT PCR appears to be as
sensitive as 16S rDNA PCR for the detection of E. chaffeensis and produces less background, particularly with ticks.
Current data do not allow us to determine the frequency with which VLPT
sequences change or whether changes occur randomly or may be associated
with the function of the protein. The wide geographic distribution of
different sequence types may indicate frequent change. However,
in a limited number of passages, isolate-specific sequence
patterns remained stable in cell culture, suggesting that this gene
could be used as a reliable marker to distinguish among isolates of
E. chaffeensis.
The VLPT ORFs of the St. Vincent, Jax, and 91HE17 isolates code for
polypeptides of 168, 198, and 228 amino acids, respectively. The
corresponding calculated molecular masses (without posttranslational modification) are 19, 22, and 25 kDa. The apparent molecular masses of
the VLPT proteins (Fig. 4) derived by electrophoretic mobility were
approximately twice those calculated from the length of the ORF. The
cause of this discrepancy remains to be determined. The E. chaffeensis 120-kDa antigen also migrates as though it has a
molecular mass much higher than that predicted from the length of the
ORF (29).
In our laboratory, characterization of the VLPT gene was concurrent
with efforts to obtain new isolates of E. chaffeensis. The
latter efforts produced six new isolates, and we naturally concentrated
our efforts on using the VLPT gene as a tool for the differentiation of
these isolates. Fundamental immunologic investigations on the role of
this gene, the cellular location of the gene product, and its potential
use as a diagnostic reagent remain.
 |
ACKNOWLEDGMENTS |
We thank Davis Janowski (Florida Department of Health) for
guidance and assistance in collecting ticks; Scott Folks (Tallahassee Community Hospital), Lisa Rotz (CDC), and G. Merrill Shore (St. Vincent's Medical Center, Jacksonville, Fla.) for identifying the
human monocytic ehrlichiosis patients from whom isolates were obtained;
Pablo Manzowitz (National University of Tucuman, Argentina) for
construction of VLPT subclones; Tom Ksiazek (CDC) for providing anti-E. chaffeensis hyperimmune mouse ascitic fluid David
Walker (UTMB) for providing the Sapulpa and 91HE17 isolates; Burt
Anderson (University of South Florida) for providing DNA extracted from B. henselae and R. rickettsii; Steven Stockham
(University of Missouri-Columbia) for providing canine blood infected
with E. ewingii; Robin Gager and Michael Levy (North
Carolina State University) for providing E. canis; Will Goff
(Animal Disease Research Unit, Agricultural Research Service, U.S.
Department of Agriculture, Pullman, Wash.) for providing A. marginale DNA; Cynthia Holland (Antech Diagnostic Laboratories,
Irvine, Calif.) for providing E. risticii; Yasuko Rikihisa
(Ohio State University) for providing E. muris; Michael
Zyzak (U.S. Naval Medical Research Detachment, Lima, Peru) for
providing the A. americanum tick infected with E. chaffeensis by capillary feeding; and the staff of CDC's
Biotechnology Core Laboratory for providing oligonucleotide primers.
 |
FOOTNOTES |
*
Corresponding author. Mailing address: Viral and
Rickettsial Zoonoses Branch, Centers for Disease Control and
Prevention, 1600 Clifton Rd., Mailstop G-13, Atlanta, GA 30333. Phone:
(404) 639-1075. Fax: (404) 639-4436. E-mail: jws3{at}cdc.gov.
 |
REFERENCES |
| 1.
|
Anderson, B., and G. McDonald.
1993.
Construction of DNA libraries of A-T rich organisms using EcoRI star activity.
Anal. Biochem.
211:325-327[Medline].
|
| 2.
|
Anderson, B. E.,
J. E. Dawson,
D. C. Jones, and K. H. Wilson.
1991.
Ehrlichia chaffeensis, a new species associated with human ehrlichiosis.
J. Clin. Microbiol.
29:2838-2842[Abstract/Free Full Text].
|
| 3.
|
Anderson, B. E.,
J. W. Sumner,
J. E. Dawson,
T. Tzianabos,
C. R. Greene,
J. G. Olson,
D. B. Fishbein,
M. Olsen-Rasmussen,
B. P. Holloway,
E. H. George, and A. F. Azad.
1992.
Detection of the etiologic agent of human ehrlichiosis by polymerase chain reaction.
J. Clin. Microbiol.
30:775-780[Abstract/Free Full Text].
|
| 4.
|
Anderson, B. E.,
K. G. Sims,
J. G. Olson,
J. E. Childs,
J. F. Piesman,
C. M. Happ,
G. O. Maupin, and B. J. Johnson.
1993.
Amblyomma americanum: a potential vector of human ehrlichiosis.
Am. J. Trop. Med. Hyg.
49:239-244.
|
| 5.
| Centers for Disease Control and Prevention. 1998. Unpublished data.
|
| 6.
|
Chen, S. M.,
X. J. Yu,
V. L. Popov,
E. L. Westerman,
F. G. Hamilton, and D. H. Walker.
1997.
Genetic and antigenic diversity of Ehrlichia chaffeensis: comparative analysis of a novel human strain from Oklahoma and previously isolated strains.
J. Infect. Dis.
175:856-863[Medline].
|
| 7.
|
Dame, J. B.,
S. M. Mahan, and C. A. Yowell.
1992.
Phylogenetic relationship of Cowdria ruminantium, agent of heartwater, to Anaplasma marginale and other members of the order Rickettsiales determined on the basis of 16S rRNA gene sequence.
Int. J. Syst. Bacteriol.
42:270-274[Abstract/Free Full Text].
|
| 8.
|
Dawson, J. E.,
B. E. Anderson,
D. B. Fishbein,
J. L. Sanchez,
C. S. Goldsmith,
K. H. Wilson, and C. W. Duntley.
1991.
Isolation and characterization of an Ehrlichia sp. from a patient with human ehrlichiosis.
J. Clin. Microbiol.
29:2741-2745[Abstract/Free Full Text].
|
| 9.
|
Dawson, J. E.,
C. K. Warner,
S. A. Ewing,
S. R. Telford,
R. E. Corstvet,
R. Brennan, and J. G. Olson.
1997.
Fingerprinting of Ehrlichia species by repetitive element polymerase chain reaction.
Am. J. Trop. Med. Hyg.
57:109-114.
|
| 10.
|
Dumler, J. S.,
S. M. Chen,
K. Asanovich,
E. Trigiani,
V. L. Popov, and D. H. Walker.
1995.
Isolation and characterization of a new strain of Ehrlichia chaffeensis from a patient with nearly fatal monocytic ehrlichiosis.
J. Clin. Microbiol.
33:1704-1711[Abstract].
|
| 11.
|
Eng, T. R.,
J. R. Harkess,
D. B. Fishbein,
J. E. Dawson,
C. N. Greene,
M. A. Redus, and F. T. Satalowich.
1988.
Epidemiologic, clinical and laboratory findings of human ehrlichiosis in the United States.
JAMA
264:2251-2258.
|
| 12.
|
Ewing, S. A.,
J. E. Dawson,
A. A. Kocan,
R. W. Barker,
C. K. Warner,
R. J. Panciera,
J. C. Fox,
K. M. Kocan, and E. F. Blouin.
1995.
Experimental transmission of Ehrlichia chaffeensis (Rickettsiales: Ehrlichieae) among white-tailed deer by Amblyomma americanum (Acari: Ixodidae).
J. Med. Entomol.
32:368-374[Medline].
|
| 13.
|
Fishbein, D. B.,
A. Kemp,
J. E. Dawson,
N. R. Greene,
M. A. Redus, and D. H. Fields.
1989.
Human ehrlichiosis: prospective active surveillance in febrile hospitalized patients.
J. Infect. Dis.
160:803-809[Medline].
|
| 14.
|
Gamble, W. C.,
W. A. Chappell, and E. H. George.
1978.
Comparison of viral antibody titers of acid-precipitated and non-precipitated mouse ascitic fluid.
Health Lab. Sci.
15:91-94[Medline].
|
| 15.
|
Johnson, B.,
C. Happ,
L. Mayer, and J. Piesman.
1992.
Detection of Borrelia burgdorferi in ticks by species-specific amplification of the flagellin gene.
Am. J. Trop. Med. Hyg.
47:730-741.
|
| 16.
|
Lockhart, J. M.,
W. R. Davidson,
D. E. Stallknecht, and J. E. Dawson.
1996.
Site-specific geographic association between Amblyomma americanum (Acari:Ixodidae) infestations and Ehrlichia chaffeensis-reactive (Rickettsiales:Ehrlichieae) antibodies in white-tailed deer.
J. Med. Entomol.
33:153-158[Medline].
|
| 17.
|
Maeda, K.,
N. Markowitz,
R. C. Hawley,
M. Ristic,
D. Cox, and J. E. McDade.
1987.
Human infection with Ehrlichia canis, a leukocytic rickettsia.
N. Engl. J. Med.
316:853-856[Medline].
|
| 18.
|
Ohashi, N.,
N. Zhi,
Y. Zhang, and Y. Rikihisa.
1998.
Immunodominant major outer membrane proteins of Ehrlichia chaffeensis are encoded by a polymorphic gene family.
Infect. Immun.
66:132-139[Abstract/Free Full Text].
|
| 19.
|
Paddock, C. D.,
J. W. Sumner,
G. M. Shore,
D. C. Bartley,
R. C. Elie,
J. G. McQuade,
C. R. Martin,
C. S. Goldsmith, and J. E. Childs.
1997.
Isolation and characterization of Ehrlichia chaffeensis strains from patients with fatal ehrlichiosis.
J. Clin. Microbiol.
35:2496-2502[Abstract].
|
| 20.
| Rechav, Y., M. Zyzak, L. J. Fielden, and J. E. Childs. Comparison of methods for introducing and producing
artificial infection of ixodid ticks with Ehrlichia
chaffeensis. J. Med. Entomol., in press.
|
| 20a.
| Reddy, G.R. Personal communication.
|
| 21.
|
Reddy, G. R.,
C. R. Sulsona,
R. H. Harrison,
S. M. Mahan,
M. J. Burridge, and A. F. Barbet.
1996.
Sequence heterogeneity of the major antigenic protein 1 genes from Cowdria ruminantium isolates from different geographical areas.
Clin. Diagn. Lab. Immunol.
3:417-422[Abstract].
|
| 22.
|
Reddy, G. R.,
C. R. Sulsona,
A. F. Barbet,
M. M. Suman,
M. J. Burridge, and A. R. Alleman.
1998.
Molecular characterization of a 28 kDa surface antigen gene family of the tribe Ehrlichieae.
Biochem. Biophys. Res. Commun.
247:636-643[Medline].
|
| 23.
|
Staden, R.
1994.
The STADEN package.
Methods Mol. Biol.
25:9-170[Medline].
|
| 24.
|
Sumner, J. W.,
K. G. Sims,
D. C. Jones, and B. E. Anderson.
1993.
Ehrlichia chaffeensis expresses an immunoreactive protein homologous to the Escherichia coli GroEL protein.
Infect. Immun.
61:3536-3539[Abstract/Free Full Text].
|
| 25.
|
Sumner, J. W.,
W. L. Nicholson, and R. F. Massung.
1997.
PCR amplification and comparison of nucleotide sequences from the groESL heat shock operon of Ehrlichia species.
J. Clin. Microbiol.
35:2087-2092[Abstract].
|
| 26.
|
Vaneechoutte, M., and J. Van Eldere.
1997.
The possibilities and limitations of nucleic acid amplification technology in diagnostic microbiology.
J. Med. Microbiol.
46:188-194[Abstract/Free Full Text].
|
| 27.
|
van Vliet, A. H. M.,
F. Jongejan,
M. van Kleef, and B. A. M. van der Zeijst.
1994.
Molecular cloning, sequence analysis, and expression of the gene encoding the immunodominant 32-kilodalton protein of Cowdria ruminantium.
Infect. Immun.
62:1451-1456[Abstract/Free Full Text].
|
| 28.
|
Walker, D. H., and J. S. Dumler.
1996.
Emergence of the ehrlichioses as human health problems.
Emerg. Infect. Dis.
2:18-29[Medline].
|
| 29.
|
Yu, X. J.,
P. Crocquet-Valdes, and D. H. Walker.
1997.
Cloning and sequencing of a gene for the 120-kDa immunodominant protein of Ehrlichia chaffeensis.
Gene
184:149-154[Medline].
|
| 30.
|
Yu, X.,
J. F. Piesman,
J. G. Olson, and D. H. Walker.
1997.
Geographic distribution of different genetic types of Ehrlichia chaffeensis.
Am. J. Trop. Med. Hyg.
56:679-680.
|
Journal of Clinical Microbiology, May 1999, p. 1447-1453, Vol. 37, No. 5
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