Anat Cell Biol.  2022 Mar;55(1):79-91. 10.5115/acb.21.170.

Does oral ciprofloxacin affect the structure of thoracic aorta in adult and senile male albino rats? A clue to fluoroquinolones-induced risk of aortic dissection

• Al-Neklawy AF
• El-Nefiawy NE
• Rady HY

• KMID: 2527672
• DOI: http://doi.org/10.5115/acb.21.170

Abstract

In this study, the effect of oral ciprofloxacin on the structure of the thoracic aorta in rats was investigated. Twenty four male albino rats were divided into 4 groups (6 rats/group): group I (adult control), group II (adult rats treated with ciprof loxacin), group III (senile control), and group IV (senile rats treated with ciprof loxacin). Rats in groups II and IV received ciprofloxacin via oral gavage in a daily dose of 3.5 mg/kg/d for 14 days, while control rats received equivalent amount of distilled water used to dissolve the drug. After 2 weeks, all rats were sacrificed, thoracic aortae were dissected, and half of the specimens were processed for paraffin sections and examined by light microscopy. The other half of the specimens were prepared for scanning electron microscopy. Sections from rats treated with ciprofloxacin showed evident damaging effect on aortic wall particularly in (group IV). Aortic intima showed, focal desquamation of the lining epithelium. Tunica media exhibited loss of the normal concentric arrangement and degeneration of the smooth muscle cells. Immune staining for alpha smooth muscle actin showed muscle damage. Interestingly, some sections in (group IV) showed out-pouch (aneurysm like) of the aortic wall. There was dense collagen fibers deposition. Scanning electron microscopic observations of (group IV) revealed uneven intima, adherent blood cells and fibrin filaments to damaged intima, and out-pouch formation. It was concluded that oral ciprofloxacin caused deleterious structural changes in the thoracic aortic wall of rats explaining clinical observations of fluoroquinolones induced risk of aortic dissection and aneurysm.

Keyword

Fluoroquinolones; Ciprofloxacin; Aortic aneurysm; Smooth muscle actin; Scanning electron microscopy

Figure

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  Fig. 1 Photomicrographs of sections in the thoracic aortae of adult rats (H&E). (A) Group I (adult control; ×400): the tunica intima shows simple squamous endothelial cells having flattened nuclei bulging into the lumen (arrows). The tunica media shows smooth muscle cells (SMCs) having single oval nuclei (arrowheads). Notice the packed, wavy connective tissue (CT) in the tunica adventitia. (B) Group II (adult rats treated with ciprofloxacin; ×400): tunica intima reveals uneven surface with many folds. Tunica media shows many vacuoles of lost tissue (asterisks), many nuclei of SMCs are darkly stained (pyknotic; arrows). The adventitia shows loosely packed CT with multiple tissue loss (hashtags). (C) Group I (adult control; ×1,000): the simple squamous cells of the tunica intima appear having flattened nuclei bulging into the lumen (arrows). The tunica media shows the oval nuclei (arrowheads) of SMCs that have regular concentric arrangement alternating with elastic laminae. (D) Group II (adult rats treated with ciprofloxacin; ×1,000): the inner part of the tunica media shows the classical concentric arrangement of the SMCs (arrowheads). The outer part of the tunica media exhibits attenuation of the SMCs (circles) with multiple areas of tissue loss (asterisks ) and folding of the elastic laminae (arrows).

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  Fig. 2 Photomicrographs of sections in the thoracic aortae of adult rats. (A) Group I (adult control; Orcein, ×400): the laminae of elastic fibers are thick, parallel, and organized (arrows). (B) Group II (adult rats treated with ciprofloxacin; Orcein, ×400): the laminae of elastic fibers are corrugated (arrows) and fragmented (arrowheads). Also note the widening between the elastic laminae with partial loss of their regular arrangement. (C) Group I (adult control; Masson’s Trichrome, ×400): wavy collagen fibers (arrows) are seen with the smooth muscle cells (SMCs) distributed in between. Notice the packed connective tissue (CT) in tunica adventitia. (D) Group II (adult rats treated with ciprofloxacin; Masson’s Trichrome, ×400): note the aberrant increase in the collagen fibers deposition (arrows) that is encroaching on the SMCs in the tunica media. The SMCs are few, interrupted and show very faint acidophilic stain. Tunica adventitia shows very dense deposition of CT.

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  Fig. 3 Photomicrographs of sections in the thoracic aortae of adult rats (immune staining with anti-alpha smooth muscle actin antibody, ×400). (A) Group I (adult control): notice homogenous packed layers of strong positive alpha actin filaments of smooth muscle fibers (arrows) in tunica media located between elastic laminae. (B) Group II (adult rats treated with ciprofloxacin): weak positive immune reaction for alpha smooth muscle actin is observed (asterisks).

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  Fig. 4 Scanning electron microscope (SEM) photographs of sections in the thoracic aortae of adult rats. (A) Group I (adult control; ×250; scale bar, 100 μm): the vessel wall is formed of well adherent three layers; intima (I), media (M), and adventitia (Ad). The media is the thickest layer. Endothelial surface (En) appears smooth and homogenous. (B) Group I (adult control; ×450; scale bar, 50 μm): luminal En appears smooth and continuous showing nuclei (arrows) of the lining endothelium protruding into the vessel lumen with distinct boundaries between adjacent cells. The cells are aligned parallel to the long axis of the vessel. (C) Group II (adult rats treated with ciprofloxacin; ×900; scale bar, 20 μm): rough En with numerous irregular folds between the endothelial cells are seen.

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  Fig. 5 Photomicrographs of sections in the thoracic aortae of senile rats (H&E). (A) Group III (senile control; ×400): a photomicrograph showing tunica intima with areas of desquamation (arrows). Notice the area of intimal thickening with vertically aligned nuclei of smooth muscle cells (SMCs; circle). The tunica media reveals lack of concentric arrangement of SMCs with spindle shaped nuclei (triangles). Binucleated proliferating SMCs can be seen (pentagons). Notice also the sparse, loose connective tissue (CT) in the tunica adventitia. (B) Group IV (senile rats treated with ciprofloxacin; ×400): notice the outpouching of the aortic wall made of an invagination of the inner layers of aortic wall outwards (asterisk). The pouch is connected to aortic lumen by a narrow area of intimal tear. The tunica media is severely damaged with numerous pyknotic nuclei and vacuolated SMCs. The tunica media thins out at the outpouching. Ad, adventitia; L, lumen of the vessel. (C) Group III (senile control; ×1,000): tunica intima reveals un-even endothelial lining with some detached lining cells (arrows). Discontinuous internal elastic lamina is seen (hashtag). An area of intimal thickening with vertically aligned nuclei of SMCs can also be seen (circle). The tunica media shows random arrangement of SMCs nuclei, pale staining degenerating myocytes, and frequent patches of muscle tissue loss (asterisks). Proliferating binucleated SMCs are seen (pentagons). (D) Group IV (senile rats treated with ciprofloxacin; ×1,000): notice the tunica media with severe damage of SMCs with pyknotic nuclei (arrows). Notice the disarrangement of smooth muscle fibers and spacing due to tissue loss (asterisks).

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  Fig. 6 Photomicrographs of sections in the thoracic aortae of senile rats. (A) Group III (senile control; Orcein, ×400): the elastic fibers appear widely spaced (up down arrows), fragmented (arrows) and corrugated (pentagons). Branching of elastic laminae (triangle) can also be visualized. (B) Group IV (senile rats treated with ciprofloxacin; Orcein, ×400): notice the marked disruption of the regular arrangement of the elastic laminae. Some of them appear severely corrugated or fragmented (arrows). (C) Group III (senile control; Masson’s Trichrome, ×400): many of collagen fibers (arrows) are seen with sparse acidophilic smooth muscle cells in tunica media. Vacuoles (asterisks) could be seen occupying interlamellar spaces. Notice the widely separated connective tissue (CT) in tunica adventitia. (D) Group IV (senile rats treated with ciprofloxacin; Masson’s Trichrome, ×400): notice the aberrant increase in the collagen fibers’ deposition (arrows) encroaching on the muscle layer in tunica media. Vacuoles (asterisks) could be also seen occupying interlamellar spaces. Notice the aberrant decrease in the vessel wall thickness.

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  Fig. 7 Photomicrographs of sections in the thoracic aortae of senile rats (immune staining with anti-alpha smooth muscle actin antibody, ×400). (A) Group III (senile control): moderate to weak immune reactivity (asterisks) is seen in many patches through the tunica media. (B) Group IV (senile rats treated with ciprofloxacin): almost negative immune reactivity of smooth muscle fibers is seen through the whole extent of the tunica media with only sporadic patches of moderate immune reactivity appearing as brown color (asterisks).

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  Fig. 8 Scanning electron microscope (SEM) photographs of sections in the thoracic aortae of senile control rats (group III; scale bar: 20 μm). (A) Notice the rough endothelial lining (En) (×650). The media (M) is the thickest layer with outer adventitial layer (Ad). The three layers are tightly opposed to each other. (B) Luminal endothelial surface appears rough with irregular folds between endothelial cells (arrows) (×900). Notice the thinning of endothelium (asterisks) in some areas.

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  Fig. 9 Scanning electron microscope (SEM) photographs of sections in the thoracic aortae of senile rats treated with ciprofloxacin (group IV). (A) Notice outpouching (asterisk) of the vessel wall extending towards the tunica adventitia (×200; scale bar, 100 μm). The intima reveals many cracks (arrows). L, vessel lumen. (B) Notice the rough endothelial lining (En) with the presence of many fissures or cracks (asterisks) (×1,700; scale bar, 10 μm). Some areas show adherent blood cells (arrows). (C) Notice the accumulation of fibrin (arrows) (×650; scale bar, 20 μm).

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  Fig. 10 Mean total thickness of the wall of thoracic aorta (×400).

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  Fig. 11 Mean area percentage of alpha smooth muscle actin staining per microscopic field (×400).

Reference

References

1. Etminan M, Sodhi M, Ganjizadeh-Zavareh S, Carleton B, Kezouh A, Brophy JM. 2019; Oral fluoroquinolones and risk of mitral and aortic regurgitation. J Am Coll Cardiol. 74:1444–50. DOI: 10.1016/j.jacc.2019.07.035. PMID: 31514945.

2. Michalak K, Sobolewska-Włodarczyk A, Włodarczyk M, Sobolewska J, Woźniak P, Sobolewski B. 2017; Treatment of the fluoroquinolone-associated disability: the pathobiochemical implications. Oxid Med Cell Longev. 2017:8023935. DOI: 10.1155/2017/8023935. PMID: 29147464. PMCID: PMC5632915.

3. Singh S, Nautiyal A. 2017; Aortic dissection and aortic aneurysms associated with fluoroquinolones: a systematic review and meta-analysis. Am J Med. 130:1449–57.e9. DOI: 10.1016/j.amjmed.2017.06.029. PMID: 28739200.

4. Jackson MA, Schutze GE. Committee on Infectious Diseases. 2016; The use of systemic and topical fluoroquinolones. Pediatrics. 138:e20162706. DOI: 10.1542/peds.2016-2706. PMID: 27940800.

5. Stephenson AL, Wu W, Cortes D, Rochon PA. 2013; Tendon injury and fluoroquinolone use: a systematic review. Drug Saf. 36:709–21. DOI: 10.1007/s40264-013-0089-8. PMID: 23888427.

6. Raguideau F, Lemaitre M, Dray-Spira R, Zureik M. 2016; Association between oral fluoroquinolone use and retinal detachment. JAMA Ophthalmol. 134:415–21. DOI: 10.1001/jamaophthalmol.2015.6205. PMID: 26967005.

7. Lee CC, Lee MT, Chen YS, Lee SH, Chen YS, Chen SC, Chang SC. 2015; Risk of aortic dissection and aortic aneurysm in patients taking oral fluoroquinolone. JAMA Intern Med. 175:1839–47. DOI: 10.1001/jamainternmed.2015.5389. PMID: 26436523.

8. Daneman N, Lu H, Redelmeier DA. 2015; Fluoroquinolones and collagen associated severe adverse events: a longitudinal cohort study. BMJ Open. 5:e010077. DOI: 10.1136/bmjopen-2015-010077. PMID: 26582407. PMCID: PMC4654346.

9. Pasternak B, Inghammar M, Svanström H. 2018; Fluoroquinolone use and risk of aortic aneurysm and dissection: nationwide cohort study. BMJ. 360:k678. DOI: 10.1136/bmj.k678. PMID: 29519881. PMCID: PMC5842359.

10. Clouse WD, Hallett JW Jr, Schaff HV, Spittell PC, Rowland CM, Ilstrup DM, Melton LJ 3rd. 2004; Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture. Mayo Clin Proc. 79:176–80. DOI: 10.4065/79.2.176. PMID: 14959911.

11. Kent KC. 2014; Clinical practice. Abdominal aortic aneurysms. N Engl J Med. 371:2101–8. DOI: 10.1056/NEJMcp1401430. PMID: 25427112.

12. Goldfinger JZ, Halperin JL, Marin ML, Stewart AS, Eagle KA, Fuster V. 2014; Thoracic aortic aneurysm and dissection. J Am Coll Cardiol. 64:1725–39. DOI: 10.1016/j.jacc.2014.08.025. PMID: 25323262.

13. Corps AN, Harrall RL, Curry VA, Fenwick SA, Hazleman BL, Riley GP. 2002; Ciprofloxacin enhances the stimulation of matrix metalloproteinase 3 expression by interleukin-1beta in human tendon-derived cells. A potential mechanism of fluoroquinolone-induced tendinopathy. Arthritis Rheum. 46:3034–40. DOI: 10.1002/art.10617. PMID: 12428247.

14. Tsai WC, Hsu CC, Chen CP, Chang HN, Wong AM, Lin MS, Pang JH. 2011; Ciprofloxacin up-regulates tendon cells to express matrix metalloproteinase-2 with degradation of type I collagen. J Orthop Res. 29:67–73. DOI: 10.1002/jor.21196. PMID: 20602464.

15. Chang HN, Pang JH, Chen CP, Ko PC, Lin MS, Tsai WC, Yang YM. 2012; The effect of aging on migration, proliferation, and collagen expression of tenocytes in response to ciprofloxacin. J Orthop Res. 30:764–8. DOI: 10.1002/jor.21576. PMID: 22021103.

16. Paget GE, Barnes JM. Laurenc DR, Bacharach AL, editors. 1964. Chapter 6- toxicity tests. Evaluation of Drug Activities. Academic Press;New York: p. 135–66. DOI: 10.1016/B978-1-4832-2845-7.50012-8.

17. LeMaire SA, Zhang L, Luo W, Ren P, Azares AR, Wang Y, Zhang C, Coselli JS, Shen YH. 2018; Effect of ciprofloxacin on susceptibility to aortic dissection and rupture in mice. JAMA Surg. 153:e181804. DOI: 10.1001/jamasurg.2018.1804. PMID: 30046809. PMCID: PMC6233654.

18. Bancroft JD, Gamble M. 2008. Theory and practice of histological techniques. 6th ed. Churchill Livingstone/Elsevier;Philadelphia: p. 440.

19. Graham L, Orenstein JM. 2007; Processing tissue and cells for transmission electron microscopy in diagnostic pathology and research. Nat Protoc. 2:2439–50. DOI: 10.1038/nprot.2007.304. PMID: 17947985. PMCID: PMC7086545.

20. Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. 2018; Oral fluoroquinolone and the risk of aortic dissection. J Am Coll Cardiol. 72:1369–78. DOI: 10.1016/j.jacc.2018.06.067. PMID: 30213330.

21. Wang SW, Huang YB, Huang JW, Chiu CC, Lai WT, Chen CY. 2015; Epidemiology, clinical features, and prescribing patterns of aortic aneurysm in Asian population from 2005 to 2011. Medicine (Baltimore). 94:e1716. DOI: 10.1097/MD.0000000000001716. PMID: 26469911. PMCID: PMC4616784.

22. Howard DP, Banerjee A, Fairhead JF, Handa A, Silver LE, Rothwell PM. 2015; Population-based study of incidence of acute abdominal aortic aneurysms with projected impact of screening strategy. J Am Heart Assoc. 4:e001926. DOI: 10.1161/JAHA.115.001926. PMID: 26289347. PMCID: PMC4599457.

23. Abu-Dief EE, Abdelrahim EA, Abdelrahim KM. 2016; Histological modifications aging aorta in male albino rat. J Cytol Histol. 7:408. DOI: 10.4172/2157-7099.1000408.

24. Zarkovic K, Larroque-Cardoso P, Pucelle M, Salvayre R, Waeg G, Nègre-Salvayre A, Zarkovic N. 2015; Elastin aging and lipid oxidation products in human aorta. Redox Biol. 4:109–17. DOI: 10.1016/j.redox.2014.12.008. PMID: 25553420. PMCID: PMC4309857.

25. Komutrattananont P, Palee P, Prasitwattanaseree S, Mahakkanukrauh P. 2020; The estimation of age from elastic fibers in the tunica media of the aortic wall in a thai population: a preliminary study using aorta image analysis. Anat Cell Biol. 53:284–91. DOI: 10.5115/acb.20.094. PMID: 32727957. PMCID: PMC7527121.

26. Fritze O, Romero B, Schleicher M, Jacob MP, Oh DY, Starcher B, Schenke-Layland K, Bujan J, Stock UA. 2012; Age-related changes in the elastic tissue of the human aorta. J Vasc Res. 49:77–86. DOI: 10.1159/000331278. PMID: 22105095.

27. Greenberg SR. 1986; The association of medial collagenous tissue with atheroma formation in the aging human aorta as revealed by a special technique. Histol Histopathol. 1:323–6.

28. Nakashima Y. 2010; Pathogenesis of aortic dissection: elastic fiber abnormalities and aortic medial weakness. Ann Vasc Dis. 3:28–36. DOI: 10.3400/avd.ctiia09001. PMID: 23555385. PMCID: PMC3595817.

29. Wilson SK, Hutchins GM. 1982; Aortic dissecting aneurysms: causative factors in 204 subjects. Arch Pathol Lab Med. 106:175–80.

30. Larson EW, Edwards WD. 1984; Risk factors for aortic dissection: a necropsy study of 161 cases. Am J Cardiol. 53:849–55. DOI: 10.1016/0002-9149(84)90418-1.

31. Carino D, Zafar MA, Singh M, Ziganshin BA, Elefteriades JA. 2019; Fluoroquinolones and aortic diseases: is there a connection. Aorta (Stamford). 7:35–41. DOI: 10.1055/s-0039-1693468. PMID: 31529426. PMCID: PMC6748841.

32. Ishii T, Asuwa N. 2000; Collagen and elastin degradation by matrix metalloproteinases and tissue inhibitors of matrix metalloproteinase in aortic dissection. Hum Pathol. 31:640–6. DOI: 10.1053/hupa.2000.7642. PMID: 10872655.

33. Macura KJ, Corl FM, Fishman EK, Bluemke DA. 2003; Pathogenesis in acute aortic syndromes: aortic dissection, intramural hematoma, and penetrating atherosclerotic aortic ulcer. AJR Am J Roentgenol. 181:309–16. DOI: 10.2214/ajr.181.2.1810309. PMID: 12876003.

34. Vilacosta I, San Román JA. 2001; Acute aortic syndrome. Heart. 85:365–8. DOI: 10.1136/heart.85.4.365. PMID: 11250953. PMCID: PMC1729697.

35. Sandison ME, Dempster J, McCarron JG. 2016; The transition of smooth muscle cells from a contractile to a migratory, phagocytic phenotype: direct demonstration of phenotypic modulation. J Physiol. 594:6189–209. DOI: 10.1113/JP272729. PMID: 27393389. PMCID: PMC5088226.

36. Atkinson J. 1998; Aging of arterial extracellular matrix elastin: etiology and consequences. Pathol Biol (Paris). 46:555–9. French.

37. James S, Schuijers J, Daffy J, Cook J, Samiric T. 2021; Ciprofloxacin reduces tenocyte viability and proteoglycan synthesis in short-term explant cultures of equine tendon. PeerJ. 9:e12003. DOI: 10.7717/peerj.12003. PMID: 34540363. PMCID: PMC8411937.