Summary of recent abstracts. V. Leishmaniasis; visceral leishmaniasis.
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Humans↗
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Progress in vaccine research and possible effector mechanisms in visceral leishmaniasis.
Visceral leishmaniasis represents a serious public health concern in endemic regions and is rapidly emerging as an opportunistic infection in HIV patients. The disease is difficult to diagnose and prevent, and available treatment is associated with toxicity and drug resistance. Even though significant headway has been made in the development of vaccines against cutaneous leishmaniasis, visceral leishmaniasis has received limited attention. The fact that a large proportion of the people living in endemic areas have self-resolving subclinical infection and individuals once recovered are immune to reinfection provides a rationale for designing immunoprophylactic strategies against visceral leishmaniasis. The primary aim of this paper is to review advances in vaccination strategies against visceral leishmaniasis, suggesting possible effector mechanism leading to resistance. It also covers the role of immunostimulators and gives an account of the adjuvants used against visceral leishmaniasis. Vaccine strategies in different established experimental models have also been dealt with which can provide potential leads for their application in humans. In light of the available observations made during the course of studies performed on experimental models of visceral leishmaniasis there is increasing evidence that a successful approach towards a vaccine involves the requirement of Th1 subset of CD4+ cells along with Th2, CD8+, and B cells. In this review we present the possible mechanism of interaction of these cells and their effector molecules in providing resistance against visceral leishmaniasis for the future design of effective vaccine against this disease.
Adjuvants, Immunologic↗
Combined liposomal immuno- and chemotherapy of visceral leishmaniasis.
Visceral leishmaniasis is a tropical disease caused by Leishmania donovani, an obligate intracellular parasite. Host cells of these parasites are macrophages. The conventional therapy of visceral leishmaniasis uses pentavalent antimony (Pentostam). To minimize the undesired side effects of antimony and to possibly reduce the therapeutical dose of antimony it was combined with interferon gamma (IFN gamma) and encapsulated both in multilamellar vesicles for treatment of murine visceral leishmaniasis. Using liposomes composed of one synthetic phospholipid and applying the freeze-thawing technique an encapsulation rate of about 30-70% of the offered antimony concentration was obtained. In the case of IFN gamma an entrapment of 20-30% was reached. Thus these liposomes were used to perform experiments in order to achieve pharmacological data about organ distribution of the encapsulated vs. free drug. For this purpose defined amounts of antimony were injected i.v. in B 10D2/n mice. At several time-points mice were sacrificed and lung, spleen, liver, kidneys and blood samples were assessed for antimony concentration. The results presented evidence that liposomal drugs were enriched in spleen and liver, organs mainly affected by visceral leishmaniasis. It has been shown previously that liposomes are phagocytozed by macrophages, the host cells of the parasites. Therefore treatment of L. donovani infected mice with liposomal antimony and IFN-gamma resulted in a nearly complete parasite reduction, while treatment with the free drug slightly reduced the parasite burden only in the liver. The aim of these studies was to minimize the undesired side effects of antimony and to possibly reduce the necessary dosage by 1 encapsulating it into multilamellar vesicles and 2, by combining the liposomal antimony with liposomal encapsulated IFN gamma, which is known to be a potent macrophage activating agent.
Animals↗
Progress in the treatment of a neglected infectious disease: visceral leishmaniasis.
Visceral leishmaniasis (kala-azar) is a disseminated intracellular protozoal infection. Most cases (90%) occur in the rural regions of five countries: India, Sudan, Nepal, Bangladesh and Brazil. As with other infectious diseases embedded in high-level poverty, developing and/or delivering new treatments for visceral leishmaniasis had been painfully slow or nonexistent. However, despite persistent unresolved obstacles (e.g., drug affordability), renewed interest in visceral leishmaniasis and numerous successful treatment trials have combined to turn a therapeutic corner in the past 5 years, yielding new alternatives to conventional pentavalent antimony. Advances include the use of low-cost generic pentavalent antimony, rediscovery of amphotericin B, short-course regimens via lipid formulations of amphotericin B, retesting injectible paromyomycin and, of clear-cut importance, identifying miltefosine (Impavido, Zentaris) as the first effective oral therapy for this neglected disease.
Amphotericin B↗
Antiactin and antitubulin antibodies in canine visceral leishmaniasis.
Visceral leishmaniasis, a chronic and often fatal disease, is caused by the protozoan parasite Leishmania donovani. Both specific and nonspecific antibodies are produced in the course of the disease, and autoantibodies may be involved in pathogenesis. Tubulin and actin have been found to be associated with L. donovani. To learn whether antiactin and antitubulin antibodies are present in visceral leishmaniasis, we tested sera from 263 infected dogs by enzyme-linked immunosorbent assay for antibodies to the antigens L. donovani, actin, and tubulin. All samples reacted positively with L. donovani, and a high percentage reacted positively with all three antigens. Sera from 202 uninfected dogs were also tested, none reacted with L. donovani antigen, although positive reactions were observed for 8 of the samples with actin or tubulin. It was found that the antibody-antigen reaction occurred at the Fab portion of the immunoglobulin molecule. Competitive enzyme immunoassays showed that the reaction was inhibited if the positive serum was first incubated with L. donovani antigen, actin, or tubulin and then tested by enzyme-linked immunosorbent assay. These results suggest that antiactin and antitubulin antibodies are present in the sera of dogs infected with visceral leishmaniasis.
Actins↗
Restoration of IFN-gamma production and lymphocyte proliferation in visceral leishmaniasis.
Visceral leishmaniasis is associated with a marked depression of T cell responses, which has been characterized by the absence of IL-2 and IFN-gamma production by lymphocytes on in vitro stimulation with Leishmania Ag. The aim of this study was to evaluate both the mechanism of these immunologic abnormalities and the restoration of in vitro T cell responses to Leishmania Ags. A total of 15 untreated visceral leishmaniasis patients were evaluated. Although IFN-gamma and IL-4 levels in the supernatants of lymphocyte cultures were very low or absent, mRNA for these cytokines and for IL-10 were observed in PBMCs. Addition of IFN-gamma plus IL-2 enhanced lymphocyte proliferation by 158%. Restoration of T cell proliferative responses and IFN-gamma production was also observed by the addition of a neutralizing mAb alpha-IL-10. Neutralizing mAb alpha-IL-4 did not restore T cell responses but alpha-IL-10 and alpha-IL-4 mAbs had a synergistic effect on lymphocyte proliferation. The IFN-gamma levels in supernatants of lymphocyte cultures stimulated with Leishmania chagasi Ag or L. chagasi Ag plus alpha-IL-4, alpha-IL-10, or alpha-IL-4 plus alpha-IL-10 mAbs were 26 +/- 30 pg/ml, 41 +/- 18 pg/ml, 146 +/- 73 pg/ml, and 174 +/- 106 pg/ml, respectively. These data indicate that Th2 cell activation occurs in visceral leishmaniasis and that in vitro production of IFN-gamma and lymphocyte proliferation can be restored by blocking the inhibitory effect of the Th2 cytokines on mononuclear cells.
Animals↗
Recent strategies for the chemotherapy of visceral leishmaniasis.
Visceral leishmaniasis is a widespread and deadly disease. First-line drugs are antimonials, but amphotericin B and its lipid formulations B is used for treating visceral leishmaniasis that is unresponsive to antimony. New therapeutic approaches are being actively developed, including the following: use of drug carriers targeted specifically to the parasite location, thus reduce adverse effects of drug; use of immunomodulating drugs; evaluation of natural products; pharmacokinetic studies; and drug combinations. Recent clinical trials with paromomycin and miltefosine were successful and these drugs appear to be promising for the future therapy of visceral leishmaniasis. Furthermore, identification and therapeutic evaluation of specific targets in the Leishmania organism could lead to new compounds, such as antileishmanial drugs and reversal agents of drug resistance.
Journal Article↗
Visceral leishmaniasis.
Visceral leishmaniasis presents a serious problem in endemic regions that is difficult to treat or prevent. Several epidemiologic problems make the disease particularly troublesome to manage. These include the facts that classic visceral leishmaniasis is fatal if untreated and there is not reliable access to medical care in many endemic regions. When available, treatment has associated toxicity and requires the use of intravenous medications with careful monitoring for toxicity, which are complex to administer in underdeveloped nations. There is an increasing incidence of the disease in HIV-infected individuals in southern Europe, in part because of the fact that eradication of the organism from infected persons using currently available drugs appears to be difficult if not impossible. Furthermore, chronic cutaneous forms of the disease allow humans and animals to maintain the organism long-term in a bodily site that is easily accessible to the sandfly vector. More effective and less toxic treatment modalities as well as a protective vaccine are badly needed to manage this disease.
Animals↗
Cryoglobulinemic purpura in visceral leishmaniasis.
Visceral leishmaniasis may present with cytopenias along with the formation of many autoantibodies and, rarely, with the presence of mixed cryoglobulinemia, type II, resembling an autoimmune disease. The syndrome of mixed cryoglobulinemia is characterized by the triad of purpura, arthralgias, and asthenia, in conjunction with cryoglobulins in the serum. In this article mixed cryoglobulinemia, type II, was diagnosed in a negative for hepatitis B or C patient suffering from visceral leishmaniasis. Antimicrobial therapy against leishmania eliminated the cryoglobulin titer, as well as the clinical manifestations of cryoglobulinemia. The role of the immune system and the type of immune response for the formation of cryoglobulins are discussed.
Aged, 80 and over↗
[Importance of drug carriers in the treatment of visceral leishmaniasis].
Visceral leishmaniasis is caused by hemoflagellate protozoa which are obligatory parasites of the mononuclear phagocyte system. Leishmaniasis causes high morbidity and mortality worldwide. The treatment of choice remains pentavalent antimonials, but high toxicity and failures have been reported. An alternative to conventional treatment is delivery anti-leishmania agents using colloidal carrier systems. Carriers improve drug activity against intracellular disease involving the mononuclear phagocyte system. The principle of drug delivery by carrier systems has been applied successfully for anticancer drugs. Recently complete remission of polyresistant visceral leishmaniasis was obtained by injection of liposomal amphotericin B. At present, no colloidal drug carrier for antimony derivatives is available, but pentamidine can be linked experimentally to methacrylate polymer nano-particles. Drug-loaded nanoparticles have been shown to be effective against amastigote leishmania both in vitro and in vivo. Another colloidal system of major interest for drug delivery, the liposome has already been loaded with amphotericin B and used for human therapy. The concept of particulate drug carriers opens the way for new chemotherapeutic approaches in the field of parasitology.
Amphotericin B↗
Adjunct effect of immunostimulating hexapeptide analogous to human beta-casein fragment (54-59) to sodium stibogluconate against experimental visceral leishmaniasis.
Visceral leishmaniasis (VL) is a major public health problem in many tropical countries of the world. The available chemotherapeutics require parenteral administration and have other limitations like cost, toxicity, variable efficacy or restricted supplies. There is no effective treatment for immunosuppressed patients with leishmaniasis- HIV co-infection. Hence, new therapies, that are effective when treatment with the currently available drugs fails, must be developed. One of the major strategies for effective and safe treatment of leishmaniasis and other infectious diseases, in the last decade, involves the use of immunomodulators as adjunct to chemotherapy. In this context, we studied the immunomodulatory activity of a hexapeptide Val-Glu-Pro-Ile-Gly-Tyr (CDRI compound 89-215) corresponding to (54-59) fragment of human beta-casein in mice and its efficacy in adjunct chemotherapy with SSG using L. donovani/hamster model. The hexapeptide was found to enhance both humoral and CMI responses. In animal model the hexapeptide per se showed no antileishmanial activity. However, when given alongwith suiboptimal dose of SSG, it enhanced the efficacy of SSG from 24% to 80%. The activity was very close to the efficacy (85%) recorded for curative dose of SSG. Adjunct chemotherapy with immunomodulator in visceral leishmaniasis appears to be a fruitful preposition.
Adjuvants, Immunologic↗
Anti-leishmania antibodies in cerebrospinal fluid from dogs with visceral leishmaniasis.
Visceral leishmaniasis in Brazil is caused by Leishmania (Leishmania) chagasi and the dog is its most important reservoir. The clinical features in dogs include loss of weight, lymphadenopathy, renal failure, skin lesions, fever, hypergammaglobulinemia, hepatosplenomegaly, anemia, and, rarely, neurological symptoms. Most infected animals develop active disease, characterized by high anti-leishmania antibody titers and depressed lymphoproliferative ability. Antibody production is not primarily important for protection but might be involved in the pathogenesis of tissue lesions. An ELISA test was used to determine if there is an association between neurological symptoms and the presence of anti-L. chagasi antibodies in cerebrospinal fluid (CSF). Thirty serum and CSF samples from symptomatic mixed breed dogs (three with neurological symptoms) from a region of high incidence of visceral leishmaniasis in Brazil were examined for antibody using total parasite antigen and anti-dog IgG peroxidase conjugate. A high level of L. chagasi antibodies was observed in sera (mean absorbance SD, 1.939 0.405; negative control, N = 20, 0.154 0.074) and CSF (1.571 0.532; negative control, N = 10, 0.0195 0.040) from all animals studied. This observation suggests that L. chagasi can cause breakdown of filtration barriers and the transfer of antibodies and antigens from the blood to the CSF compartment. No correlation was observed between antibody titer in CSF and neurological symptoms.
Animals↗
Gamma delta T cells and the immune response in visceral leishmaniasis.
Visceral leishmaniasis (VL) caused by Leishmania donovani, a protozoan parasite, is a disease of high morbidity associated with hepatosplenomegaly, hypergammaglobulinemia, fever and death. One of the immunological hallmarks of VL is a remarkable increase in serum immunoglobulin levels as a result of polyclonal B cell activation. This study demonstrated that T lymphocytes expressing the T cell receptors (TcR) gamma delta in association with CD3 molecules are increased in circulation of patients with VL. A large proportions of TcR gamma delta-bearing T cells had CD4+ CD8- phenotype, and expressed CD25, CD38, CD71 and HLA-DR activation antigens. Furthermore, we demonstrated wide functional differences in TcR gamma delta and TcR alpha beta T cells in their proliferative response, secretion of interleukin-2 (IL-2), B cell growth factor (BCGF) and B cell differentiation factor (BCDF). It was of interest that the TcR gamma delta T cells from patients with VL could be expanded by in vitro culture with human recombinant IL-2. Although these TcR gamma delta T cells secreted diminished levels of IL-2, they produced highly augmented levels of both BCGF and BCDF, suggesting that secretion of these lymphokines in these T cell subsets is regulated independently. The relative increases in the CD4+ CDw29+ TcR gamma delta T cell subsets and their secretion of highly elevated levels of BCGF and BCDF largely accounted for the humoral immune system abnormality and hypergammaglobulinemia found in this disease. These observations may help to explain that TcR gamma delta T cells might be functional in vivo and are involved in immunological mechanisms of pathogenesis in VL.
Antigens, CD↗
IL-10 and IL-12 are the main regulatory cytokines in visceral leishmaniasis.
Visceral leishmaniasis (VL) is characterized by the absence of cytokines such as IFN-gamma and IL-12. Cure of VL is associated with a restoration of the ability to make these cytokines. The aim of the present study was to evaluate the role of IL-12 in the recovery of the ability to produce IFN-gamma and to test whether or not IL-4 IL-10 and/or TGF-beta could suppress IFN-gamma production by PBMC from treated VL patients. High stimulation index (SI) of proliferation was observed in PBMC from subjects stimulated with Leishmania chagasi antigen (181+/-83). Neutralizing IL-12 inhibited lymphoproliferation [stimulation index (SI) of 210+/-114 to 1+/-0.6 (P<0.01)] and/or the production of IFN-gamma [2792+/-402 pg/ml to 407+/-449 pg/ml (P<0.01)]. Recombinant IL-10 abrogated the lymphoproliferation (SI=2+/-3) while recombinant IL-4 or TGF-beta had no effect on this response (147+/-22 and 194+/-12 respectively). IFN-gamma was high when PBMCs were stimulated with L. chagasi (873+/-400 pg/ml) and this was abrogated by the addition of IL-10 (5+/-2 pg/ml). In contrast neither IL-4 or TGF-beta suppressed IFN-gamma production (837+/-244 pg/ml and 759+/-523 pg/ml). These results indicate that IL-12 plays an important role in the ability of treated VL patients to make IFN-gamma and that IL-10 but not IL-4 or TGF-beta inhibits this response.
Antibodies↗
Acute phase protein concentrations predict parasite clearance rate during therapy for visceral leishmaniasis.
Visceral leishmaniasis (VL) remains a major health problem in Kenya and other parts of Africa, Central America and Asia. Currently, splenic aspirate smear and culture are the standard methods of monitoring therapy and relapse. Acute phase reactant markers, C-reactive protein (CRP), serum amyloid A protein (SAA) and alpha 1-acid glycoprotein (AGP) were evaluated as less invasive techniques for monitoring therapy in 59 patients with VL before, during and after therapy. CRP, SAA and AGP were elevated in VL patients at admission and the concentrations decreased with effective therapy to reach normal levels by the end of therapy (SAA and AGP) or by 3 months follow-up (CRP). Two groups of patients were selected on the basis of rate of parasite clearance. The acute phase protein concentrations were significantly raised in those slower to clear parasites. Analysis of sensitivity and specificity of acute phase proteins as predictors of parasite clearance suggested that they might represent useful non-invasive markers for monitoring disease activity, response to therapy and relapse in VL.
Acute-Phase Proteins↗
Efficacy of picroliv in combination with miltefosine, an orally effective antileishmanial drug against experimental visceral leishmaniasis.
Visceral leishmaniasis (VL) or kala-azar continues to persist as one of the major public health problems in many tropical countries. However, no effective treatment for radical cure of the disease is yet available. Miltefosine, an alkyl phospholipid compound, is the first orally effective drug, which has shown 98% cure rate of VL patients during phase III clinical trial in India. Since this drug requires long course of treatment and has long half-life, there are fairly good chances of emergence of resistance. Furthermore, this drug has produced severe side-effects in some of the cases. We therefore examined the possibility of minimizing these effects by applying miltefosine in lower doses in combination with picrloviv, an immunomodulator against Leishmania donovani in hamsters (Mesocricetus auratus). The picroliv per se showed no antileishmanaial potential. However, when given with suboptimal dose of miltefosine, it enhanced efficacy of the latter from 45 to 86% on day 7 post treatment and from 32 to 64% on day 28 post treatment. Interestingly, the efficacy of this combination was as good as the curative dose of miltefosine alone. Thus, this combination appears to offer a fruitful strategy for treatment of VL.
Adjuvants, Immunologic↗
Leishmania donovani: effect of therapy on expression of CD2 antigen and secretion of macrophage migration inhibition factor by T-cells in patients with visceral leishmaniasis.
Visceral leishmaniasis (VL) commonly known as Kala-azar in India is one of the several clinically important infections, where Th1 sub-population of CD4+ T-cells, despite a pre-requisite, fails to express macrophage migration inhibition factor (MIF) and interferon-gamma which both activate the macrophage and coordinate the immune response to intra-cellular Leishmania sp. Expression of CD2 receptors before and after antileishmanial therapy on CD4+ T-cells of VL patients and their corresponding effect on MIF were examined. Before treatment the number of T-cells expressing CD2 was low which incorporated insignificant MIF response. The immunological reconstitution was, however, observed after treatment as manifested through upregulation of CD2+ T-cells with pronounced MIF generation response. The study, therefore, identifies a possible role of CD2 antigen in immunity to VL.
Animals↗
Leishmania infantum-induced primary and challenge infections in rhesus monkeys (Macaca mulatta): a primate model for visceral leishmaniasis.
Visceral leishmaniasis (VL) was experimentally induced in rhesus macaques (Macaca mulatta) by intravenously inoculating 2 x 10(7)amastigotes/kg of body weight of Leishmania infantum. The macaques developed a systemic disease showing characteristic features of human VL such as fever, diarrhoea, body weight loss, anaemia, hypergammaglobulinaemia and transient lymphocytosis, as well as lymph node, liver and/or spleen enlargement. Nine weeks after infection, one primate showed pronounced weight loss, became moribund and was euthanized. The necropsy findings included granulomas composed of parasite-containing macrophages, lymphocytes and plasma cells in the liver, spleen and lymph nodes. The remaining macaques had a sustained course of infection but developed a mild-to-moderate illness that subsequently showed evidence of self-cure. Of note, pathological findings included a typical cell-mediated immunity-induced granulomatous reaction that had an effect on the control of parasite replication. All infected monkeys responded with increased production of anti-Leishmania-specific IgG antibodies. Despite the fact that clinical resistance to L. infantum was not consistently associated with a parasite-specific cell-mediated immune response, drug-cured macaques from the primary infection acquired immunity to homologous re-infection. These findings point to the feasibility of using the L. infantum macaque model for pre-clinical evaluation of novel chemotherapeutics or vaccine candidates for human VL.
Animals↗