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Elek's test

Elek's test, also known as the Elek plate test, is an in vitro immunoprecipitation assay developed in 1948 by Hungarian-born British microbiologist Stephen D. Elek to detect toxigenic strains of Corynebacterium diphtheriae, the causative agent of diphtheria, by identifying production of the bacterium's potent exotoxin.^[1] The test operates on the principle of gel diffusion, where a strip impregnated with diphtheria antitoxin is placed on a nutrient agar plate containing tellurite and serum; the test strain is then streaked perpendicular to the strip, allowing toxin secreted by toxigenic bacteria to diffuse and form visible precipitin lines upon reacting with the antitoxin, confirming virulence within 24–48 hours of incubation.^[2]^[3] As the gold standard for phenotypic confirmation of diphtheria toxin production, Elek's test remains essential in public health laboratories despite molecular alternatives like PCR for the tox gene, which detect genetic potential but not functional expression, ensuring accurate identification of outbreak strains and guiding antitoxin therapy decisions.^[3]^[2] Modifications, such as accelerated incubation protocols reducing time to 16–24 hours or alternative media like Columbia blood agar, have addressed limitations in speed and reagent availability while preserving the test's specificity, though challenges persist in resource-limited settings due to the need for standardized antitoxin and expertise in interpreting faint precipitin lines.^[4]^[5]

History

Development and early adoption

Stephen D. Elek, a Hungarian-born British microbiologist, developed the Elek test in 1948 as an in vitro immunoprecipitation assay to detect toxigenic strains of Corynebacterium diphtheriae, replacing ethically problematic animal inoculation methods such as guinea pig toxin neutralization challenges.^[6] The test's creation was driven by the need for a humane, reproducible alternative amid persistent diphtheria outbreaks in post-World War II Europe, where disrupted vaccination programs led to resurgences of the disease and strained laboratory resources for virulence confirmation.^[7] Elek first described the method in a 1948 British Medical Journal article, detailing its adaptation of gel diffusion principles to visualize toxin-antitoxin precipitation lines on agar plates inoculated with bacterial strains and antitoxin-impregnated filter paper strips.^[6] Initial validation involved comparing Elek test results with established in vivo assays using known toxigenic and non-toxigenic C. diphtheriae strains, demonstrating high correlation in identifying toxin production without requiring live animal sacrifices.^[1] By 1949, Elek published further refinements in the Journal of Medical Laboratory Technology, emphasizing the test's specificity for diphtheria toxin through visible precipitin band formation, which confirmed its reliability over variable animal-based endpoints.^[8] This alignment with clinical toxigenicity outcomes facilitated early adoption in diagnostic laboratories during the 1950s, as the method's simplicity—requiring basic agar media and incubation—outweighed the logistical burdens of animal testing, enabling faster strain screening amid global efforts to eradicate diphtheria.^[1] Laboratories in the UK and other regions rapidly integrated it, reducing dependency on resource-intensive vivisection while maintaining diagnostic accuracy for public health surveillance.^[9]

Standardization and global use

The Elek immunoprecipitation test, developed in 1948, was standardized as the gold standard for confirming diphtheria toxigenicity by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) during the mid-20th century, with protocols emphasizing the use of reference antitoxin and control strains to distinguish strong and weak toxin producers through distinct precipitin line formation.^[10]^[2] This standardization facilitated consistent phenotypic detection of Corynebacterium diphtheriae toxin production worldwide, replacing earlier in vivo guinea pig assays due to ethical and practical limitations, while incorporating modifications like those adopted in reference laboratories by the 1960s for enhanced reliability.^[11] During the 1990s diphtheria resurgence in Eastern Europe and former Soviet states, where over 157,000 cases occurred amid socioeconomic disruptions and vaccination lapses, the Elek test played a critical role in outbreak investigations by confirming toxigenic strains through immunoprecipitation lines, enabling targeted public health responses including mass immunization campaigns.^[7]^[12] Its application in these epidemics, particularly in Russia and Ukraine starting in 1990, supported strain characterization and surveillance, contributing to eventual incidence declines following restored vaccination efforts.^[13] Despite widespread vaccination reducing diphtheria incidence in many regions, the Elek test remains integral to global surveillance networks, providing essential phenotypic confirmation of toxin production in low-resource settings where molecular alternatives like PCR may be unavailable or insufficient for verifying active toxigenicity.^[14]^[15] WHO guidelines continue to prioritize it for outbreak-prone areas, underscoring its value in distinguishing toxigenic from non-toxigenic isolates amid sporadic resurgences.^[16]

Scientific Principle

Immunodiffusion mechanism

The Elek test utilizes double immunodiffusion in agar gel, a biophysical process in which diphtheria toxin antigen, secreted by toxigenic Corynebacterium diphtheriae, diffuses radially outward from the site of bacterial growth, while antitoxin antibodies diffuse from a parallel source, enabling their convergence within the gel matrix.^[7]^[2] This radial diffusion follows Fick's laws of diffusion, driven by concentration gradients, without external electrophoretic forces, allowing soluble molecules to migrate independently until optimal stoichiometric ratios are achieved.^[17] Precipitin line formation occurs at the zone of equivalence, where multivalent toxin molecules—each bearing multiple epitopes—and bivalent or multivalent horse-derived antitoxin antibodies undergo specific non-covalent binding, resulting in extensive cross-linking into a three-dimensional lattice of insoluble immune complexes that exceed solubility limits and visibly precipitate as opaque bands.^[7]^[18] The toxin's A-B subunit structure, with its receptor-binding B domain and enzymatic A domain, provides unique epitopes recognized by the antitoxin, ensuring immunological specificity and preventing precipitation from non-homologous bacterial antigens or non-toxigenic strains.^[19] This mechanism causally links observable precipitation to active phenotypic toxin expression, as diffusion requires extracellular secretion of functional toxin protein; strains harboring the tox gene but failing to transcribe or translate it under culture conditions produce no diffusable antigen, yielding no lines and distinguishing true toxigenicity from genotypic carriage alone.^[2]^[7] The test's reliance on precipitation kinetics thus confirms not mere genetic potential but the causal production of biologically active toxin capable of eliciting the immune response.^[19]

Procedure

Preparation and execution

The preparation of Elek's test begins with the formulation of Elek agar medium, which consists of proteose peptone, maltose, sodium chloride, and agar, supplemented with 20% diphtheria toxin-free newborn bovine or calf serum to support bacterial growth and toxin production.^[10] This medium is melted, mixed with the serum, poured into sterile Petri dishes (typically 15-18 ml per 90 mm plate), and allowed to solidify at room temperature under aseptic conditions in a biosafety cabinet to prevent contamination.^[10] Prepared plates are stored at 2-8°C for up to two weeks, with new batches verified for sterility and performance using known strains prior to use.^[10] A sterile filter paper strip (approximately 5 mm wide and 50 mm long) is impregnated with diphtheria antitoxin at a concentration of 500 IU/ml, either by soaking and drying in advance (stored at 2-8°C for up to six months) or freshly prepared to ensure potency.^[10] The strip is placed longitudinally along the center of the solidified agar plate surface using sterile forceps, ensuring it adheres lightly without deep embedding to facilitate diffusion. Antitoxin potency must be confirmed periodically through parallel testing with control strains, as degradation can lead to false-negative outcomes.^[10] Suspect Corynebacterium diphtheriae isolates, obtained from primary culture confirmation, are streaked perpendicular to the antitoxin strip using sterile inoculating loops, starting from the edge of the strip and extending across the plate to form a continuous line of growth; typically, multiple test strains can be accommodated alongside controls on the same plate. Positive controls include toxigenic reference strains such as NCTC 10648, while negative controls use non-toxigenic strains like NCTC 10356, inoculated similarly to validate reagent integrity and procedural reliability.^[10] All manipulations employ strict sterile technique to minimize airborne or cross-contamination risks. Plates are incubated aerobically at 35-37°C for 24-48 hours, with initial checks possible after 16-24 hours in optimized setups, though full development often requires the longer duration to ensure adequate toxin diffusion and interaction.^[10] Incubation occurs in a standard aerobic incubator without enhanced CO₂, and plates are protected from light and desiccation by sealing or humidified environments to maintain consistent conditions.^[10]

Result interpretation

In the Elek test, a positive result indicating toxigenicity is characterized by the formation of a discrete precipitin line of identity between the bacterial streak and the antitoxin-impregnated strip, where the diffusing diphtheria toxin from a toxigenic Corynebacterium diphtheriae strain meets the antitoxin at the zone of equivalence.^[20] This line typically emerges at an acute angle, often approximately 45°, and demonstrates confluence by merging seamlessly with the precipitin line from the positive control strain without forming a spur, confirming antigenic identity.^[18] The position and sharpness of the line reflect the relative diffusion rates and concentrations of toxin and antitoxin, with stronger toxin producers yielding more prominent bands observable after 24 hours of incubation at 37°C.^[3] A negative result occurs in the absence of any precipitin line or when a line forms but fails to meet the positive control line at a point of identity, as seen with non-toxigenic strains lacking functional toxin production.^[20] Weak or low-level toxigenicity may manifest as faint, thin, or delayed precipitin lines that require careful inspection and comparison to controls, though such subtle patterns demand verification to rule out suboptimal diffusion or media issues.^[18] Readings should ideally be performed at 24 hours to minimize artifacts, as incubation beyond 48 hours can produce nonspecific precipitation lines from non-toxin bacterial products, potentially mimicking positives in non-toxigenic strains.^[3]^[21] To distinguish true toxin-specific lines from artifacts like nonspecific precipitation, parallel controls (known toxigenic and non-toxigenic strains) are essential, with non-identity patterns or isolated lines indicating irrelevance; confirmatory toxin neutralization assays may be employed if ambiguity persists, as antitoxin blocks specific lines while sparing nonspecific ones.^[3] Quantitative assessment of line confluence and intensity provides insight into toxin yield, aiding strain classification in research contexts, though clinical toxigenicity is binary (present or absent).^[18]

Applications

Diagnostic use in diphtheria

Elek's test confirms diphtheria toxin production in Corynebacterium diphtheriae isolates recovered from patient throat or nasal swabs, enabling differentiation of toxigenic strains that cause systemic toxemia from non-toxigenic carriers.^[2] This phenotypic verification follows initial culture on selective media such as Loeffler's or tellurite agar, where presumptive identification precedes toxin assay to guide urgent clinical decisions.^[3] Verification of toxigenicity via precipitin line formation is essential before diphtheria antitoxin administration, as the antitoxin targets free circulating toxin to mitigate myocarditis and neuropathy risks, with empirical evidence from outbreaks underscoring its role in reducing mortality when toxin-positive cases are identified promptly.^[22]^[23] The test extends to Corynebacterium ulcerans, a zoonotic pathogen transmissible from companion animals like dogs and cats, where toxin detection in human respiratory isolates confirms virulence in cutaneous or pharyngeal presentations mimicking classical diphtheria.^[24]^[25] In outbreak settings, such as those involving migrants or underserved populations, Elek's test has reliably corroborated tox gene presence with functional toxin expression across hundreds of isolates.^[23]

Surveillance and research roles

Elek's test facilitates diphtheria surveillance in WHO-coordinated global networks by confirming toxigenicity in Corynebacterium diphtheriae isolates from suspected cases and environmental samples, enabling differentiation of epidemic-potential toxigenic strains from non-toxigenic ones during resurgences.^[26]^[27] This phenotypic confirmation supports real-time tracking of strain prevalence and geographic spread, as integrated into standardized laboratory protocols for vaccine-preventable disease monitoring.^[3] In the 1990s diphtheria epidemic across former Soviet Union states, including Russia where cases surged from 1,211 in 1990 to over 39,000 by 1994, the Elek test was routinely applied to identify toxigenic variants driving the outbreak, which totaled more than 150,000 cases regionally by 1998.^[7]^[28] For research, the test's immunodiffusion readout permits assessment of toxin production intensity through precipitation line strength, correlating with relative virulence across strains and informing studies on genetic variants in the tox gene that influence epidemic potential.^[29] This has validated the persistence of toxigenic strains antigenically compatible with diphtheria toxoid vaccines, underscoring vaccine efficacy against toxin-mediated disease while highlighting gaps in coverage as a causal factor in sustained transmission within under-vaccinated populations.^[30]^[22] Such analyses reveal that incomplete immunization allows toxigenic circulation, as evidenced by Elek-positive isolates in low-coverage settings, rather than vaccine failure or novel toxin variants evading immunity.^[31]

Strengths and Limitations

Key advantages

Elek's test offers phenotypic confirmation of diphtheria toxin production by directly detecting the secreted protein through immunoprecipitation lines of identity on agar plates, thereby verifying actual toxin expression rather than relying on genotypic detection of the tox gene. This phenotypic approach mitigates false positives common in PCR assays, where the tox gene may be present but silent due to regulatory mutations, promoter deletions, or other non-expression factors, ensuring that only truly toxigenic strains are identified.^[3]^[7]^[32] As a reference method, it demonstrates high specificity and inter-laboratory reproducibility when using optimized protocols, such as reduced antitoxin volumes and standardized incubation conditions, allowing reliable detection across diverse Corynebacterium diphtheriae strains, including weakly toxigenic isolates.^[3]^[10] The test's in vitro immunodiffusion format is cost-effective and animal-free, requiring minimal specialized equipment beyond basic microbiology lab resources, unlike historical guinea pig inoculation or resource-intensive molecular alternatives, while providing causal evidence of virulence by linking observable toxin activity to potential pathogenicity in clinical and outbreak contexts.^[3]^[7]

Principal drawbacks

The Elek test demands high-potency diphtheria antitoxin for reliable precipitation line formation, but such antitoxin is increasingly scarce due to limited production and distribution challenges, restricting its feasibility in routine diagnostics outside reference laboratories.^[7] ^[33] Declining expertise in test execution and interpretation exacerbates errors, as the assay is technically demanding and highly susceptible to subjective misreading of precipitin lines, particularly in under-resourced or low-volume settings.^[11] Sensitivity limitations are evident for weakly toxigenic Corynebacterium diphtheriae strains, where toxin yields may fall below detection thresholds, yielding false negatives despite PCR confirmation of the tox gene; extended incubation beyond 48 hours can mitigate this partially but often fails to identify low producers.^[34] ^[3] The standard procedure incurs a 48- to 72-hour turnaround from plating to interpretable results, delaying confirmation of functional toxigenicity in urgent cases, though this reflects the assay's reliance on observable protein diffusion rather than gene presence alone.^[35]

Comparisons with Alternatives

Molecular detection methods

Molecular detection methods, such as polymerase chain reaction (PCR) assays targeting the tox gene of Corynebacterium diphtheriae, enable rapid identification of potential toxigenicity by amplifying genetic sequences associated with toxin production. Developed and refined since the 1990s, these methods, including real-time PCR variants introduced post-2000, can detect the gene in clinical specimens or isolates within hours, facilitating preliminary screening in outbreaks.^[36]^[37] However, PCR solely identifies the presence of the tox gene and does not assess its transcriptional activation or actual toxin expression, which depends on environmental factors like iron availability and phage-mediated lysogeny.^[34]^[38] This genotypic approach risks false positives from non-toxigenic tox gene-bearing (NTTB) strains, where the tox gene is detected but no functional toxin is produced, as the gene may be defective, silenced, or uninduced.^[34]^[38] NTTB isolates, comprising a small but documented proportion of carriers, can lead to overestimation of virulence risk if PCR results are interpreted without phenotypic confirmation, potentially misdirecting public health responses.^[38] For instance, in a 2025 South African diphtheria situational analysis, NTTB strains were identified as PCR-positive for tox yet Elek-negative, underscoring discrepancies in outbreak investigations.^[39] Guidelines from the CDC and WHO emphasize Elek's test for validating PCR positives to confirm active toxin production, as genotypic detection alone insufficiently establishes causal virulence.^[2]^[10] The CDC mandates Elek immunoprecipitation for toxin verification post-isolate identification, while WHO recommends PCR as a triage tool followed by Elek on gene-positive samples to avoid reliance on unexpressed genetic markers.^[2]^[10] Such integration highlights the superiority of phenotypic assays like Elek for truth-seeking assessments of infectivity, where empirical toxin demonstration trumps genetic presumption.^[33]^[2]

Other phenotypic assays

Enzyme immunoassays (EIA) for diphtheria toxin detection involve capturing the toxin with polyclonal antitoxin antibodies and detecting it via enzyme-linked monoclonal antibodies specific to the toxin's fragment A, enabling quantitative measurement with a detection limit of 0.1 ng/ml.^[40] These assays provide results within 3 hours of colony selection, offering speed advantages over Elek's test, which requires 24-48 hours for precipitation line formation.^[9] However, EIA primarily detects toxin antigen presence without inherent confirmation of biological activity or neutralization, potentially leading to false positives from cross-reactivity with non-functional toxin variants or structurally similar proteins, though clinical correlations with Elek's test remain high in validated studies.^[40] ^[9] Vero cell cytotoxicity assays assess toxigenicity by observing cell rounding and death induced by diphtheria toxin at doses such as 4 times the minimum cytotoxic dose, providing a functional measure of toxin's ADP-ribosyltransferase activity on elongation factor 2.^[41] These assays achieve high sensitivity and specificity, reported at 100% in some standardization efforts for antitoxin potency, and serve as ethical alternatives to in vivo guinea pig tests by using established monkey kidney cell lines.^[9] ^[42] Nonetheless, they demand specialized cell culture facilities, exhibit variability due to cell passage effects and subjective microscopic interpretation, and lack the direct immunoprecipitation visualization of Elek's test, making them less standardized for routine epidemiological confirmation of toxin production.^[42] ^[2] Elek's test maintains superiority among phenotypic methods for its unambiguous demonstration of functional toxin through visible toxin-antitoxin precipitation lines on agar, directly confirming active toxigenicity without reliance on indirect cytotoxicity or antigen detection, which enhances specificity in outbreak investigations where distinguishing true diphtheria strains from carriers is critical.^[2] ^[43] Comparative studies across 55 Corynebacterium diphtheriae isolates show Elek's alignment with cytotoxicity and immunochemical results but underscore its role as the reference for phenotypic validation, particularly in resource-limited settings where visual endpoint reliability trumps the logistical demands of cell-based or immunoassay alternatives.^[44]

Recent Developments

Optimizations and challenges

Recent optimizations to the Elek test have focused on enhancing sensitivity for weakly toxigenic strains, including adaptations using Columbia blood agar as an alternative base medium to standard tellurite agar, which facilitates clearer precipitin line formation and reduces false negatives in low-toxin producers.^[45]^[46] A 2022 protocol refined the test's design, incorporating standardized antitoxin disc placement and incubation at 37°C for 24 hours, enabling reliable detection across Corynebacterium species; this approach confirmed toxin production in all 31 examined C. ulcerans isolates using either purified or non-purified equine antitoxin sourced from overnight cultures on blood or tellurite agar.^[34]^[19] Persistent challenges include the limited commercial availability of diphtheria antitoxin essential for immunoprecipitation, compounded by supply chain disruptions and regulatory hurdles for equine-derived products, particularly in low-incidence regions where stockpiling is deprioritized.^[7] Declining laboratory expertise poses another barrier, as reduced caseloads since widespread vaccination have eroded proficiency in performing and interpreting the assay, even at reference centers; a 2024 analysis noted that this expertise gap risks misdiagnosis during sporadic outbreaks involving emerging zoonotic strains like C. ulcerans.^[7] Recent studies from 2022 to 2024 have targeted C. ulcerans optimization, yet underscore the need for sustained training amid these resource constraints.^[45]^[33] Although hybrid phenotypic-molecular workflows are advocated to expedite initial screening, the Elek test remains the confirmatory gold standard for toxin detection per CDC protocols, as unvalidated rapid immunochromatographic or PCR-based alternatives may overlook non-canonical toxin variants or yield inconclusive results without phenotypic validation.^[2]^[7] This retention counters overreliance on molecular proxies alone, emphasizing the test's causal specificity in linking genotype to functional virulence.^[36]

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