Sequestration and microvascular congestion are associated with coma in human cerebral malaria

The pathogenesis of coma in severe Plasmodium falciparum malaria remains poorly understood. Obstruction of the brain microvasculature because of sequestration of parasitized red blood cells (pRBCs) represents one mechanism that could contribute to coma in cerebral malaria. Quantitative postmortem microscopy of brain sections from Vietnamese adults dying of malaria confirmed that sequestration in the cerebral microvasculature was significantly higher in patients with cerebral malaria (CM; n = 21) than in patients with non-CM (n = 23). Sequestration of pRBCs and CM was also significantly associated with increased microvascular congestion by infected and uninfected erythrocytes. Clinicopathological correlation showed that sequestration and congestion were significantly associated with deeper levels of premortem coma and shorter time to death. Microvascular congestion and sequestration were highly correlated as microscopic findings but were independent predictors of a clinical diagnosis of CM. Increased microvascular congestion accompanies coma in CM, associated with parasite sequestration in the cerebral microvasculature.     

Apoptosis: a potential triggering mechanism of neurological manifestation in Plasmodium falciparum malaria

Plasmodium falciparum infection can lead to a life threatening disease and the pathogenetic mechanisms of severe manifestations are not fully understood. Here, we investigated the capacity of P. falciparum-parasitized red blood cells (PRBC) from 45 children with clinical malaria to induce endothelial cell (EC) apoptosis. In all subjects, PRBC that cytoadhered to ECs could be found albeit to a variable degree. By contrast, PRBC that induce EC apoptosis were found only in nine (20%) subjects. Interestingly, children with neurological manifestations were significantly more likely to harbour apoptogenic strains. There was no quantitative relationship between the capacity of these isolates to cytoadhere and apoptosis induction. We hypothesize that P. falciparum-encoded molecules could be responsible for apoptosis induction and therefore suggest new insights in the pathogenesis of P. falciparum malaria. Further investigations are currently in progress to determine whether these results can be confirmed and to identify putative parasite apoptogenic factors.     

Genetic susceptibility to systemic lupus erythematosus protects against cerebral malaria in mice

Plasmodium falciparum has exerted tremendous selective pressure on genes that improve survival in severe malarial infections. Systemic lupus erythematosus (SLE) is an autoimmune disease that is six to eight times more prevalent in women of African descent than in women of European descent. Here we provide evidence that a genetic susceptibility to SLE protects against cerebral malaria. Mice that are prone to SLE because of a deficiency in FcγRIIB or overexpression of Toll-like receptor 7 are protected from death caused by cerebral malaria. Protection appears to be by immune mechanisms that allow SLE-prone mice better to control their overall inflammatory responses to parasite infections. These findings suggest that the high prevalence of SLE in women of African descent living outside of Africa may result from the inheritance of genes that are beneficial in the immune control of cerebral malaria but that, in the absence of malaria, contribute to autoimmune disease.     

Antigen presentation and dendritic cell biology in malaria

Dendritic cells (DCs) are important both in amplifying the innate immune response and in initiating adaptive immunity and shaping the type of T helper (Th) response. Although the role of DCs in immune responses to many intracellular pathogens has been delineated and research is underway to identify the mechanisms involved, relatively little is known concerning the role of DCs in immunity to malaria. In this review, we provide an overview and summary of previous and current studies aimed to investigate the role of DCs as antigen presenting cells (APCs). In addition, the role of DCs in inducing innate and adaptive immunity to blood-stage malaria is discussed and, where information is available, the mechanisms involved are presented. Data from studies in humans infected with Plasmodium falciparum, the major human parasite responsible for the high morbidity and mortality associated with malaria throughout many regions of the developing world, as well as data from experimental mouse models are presented. Overall, the data from these studies are conflicting. The possible reasons for these differences, including the use of different parasite species and parasite strains in the mouse studies, are discussed. Nevertheless, together the data have important implications for development of an effective malaria vaccine since the selection of appropriate Plasmodium antigens and/or adjuvants, targeting innate immune responses involving DCs, may provide optimal protection against malaria. It is hoped that this review promotes more investigation among malariologists and immunologists alike on DCs and malaria.     

Apoptotic Plasmodium-infected hepatocytes provide antigens to liver dendritic cells

Malaria starts with infection of the host liver by Plasmodium sporozoites. Inoculation with radiation-attenuated Plasmodium sporozoites induces complete protection against malaria. Protection is mediated by dendritic cells (DCs) and CD8(+) T cells, but the source of parasite antigens mediating this response remains unclear. Here, we show that hepatocytes infected with irradiated Plasmodium sporozoites undergo apoptosis shortly after infection. Infection with irradiated sporozoites induces the recruitment of DCs to the liver, where they phagocytose apoptotic infected hepatocytes containing parasite antigens. We propose that apoptotic Plasmodium-infected hepatocytes provide a source of parasite antigens for the initiation of the protective immune response.     

Effects of hydroxyurea on malaria, parasite growth and adhesion in experimental models

We recently raised concern over using hydroxyurea (HU) in the treatment of sickle cell disease in areas endemic for malaria, becauseit up-regulates the endothelial surface expression of ICAM-1, a major receptor for Plasmodium falciparum-infected erythrocytes in the brain. Using human in vitro models of cerebral malaria, we evaluated the interaction of HU with parasites and demonstrated that HU pretreatment increased the number of infected red blood cells adhering to the endothelium, but did not increase endothelial apoptosis. Moreover, using an experimental cerebral malaria model, HU pretreatment was found to prevent significantly mice from developing neurological syndrome by inhibiting parasite growth, opening potential therapeutic avenues.     

Binding of Plasmodium falciparum-infected erythrocytes to the membrane-bound form of Fractalkine/CX3CL1

Plasmodium falciparum-infected erythrocytes (pRBCs) adhere to the endothelium via receptors expressed on the surface of vascular endothelial cells (EC) and sequester in the microvasculature of several organs and block the blood circulation. The sequestration, which involves receptors, may be related to the severity of malaria. Here, we report that pRBCs bind to the membrane-bound form of Fractalkine/CX3CL1 (FKN), which is expressed on the surface of vascular EC in various organs. pRBCs adhered to FKN on the surface of FKN cDNA-transfected Chinese hamster ovary cells (CHO-FKN cells). Both the recombinant human FKN-chemokine domain (FKN-CD) and anti-FKN-CD antibody efficiently blocked adherence of pRBCs to CHO-FKN cells. Similar to binding between FKN and FKN receptor on blood mononuclear cells, two amino acid residues, Lys-7 and Arg-47 within FKN-CD, were critical for FKN-pRBC binding. Immunohistological analysis revealed the expression of FKN on EC at the site of sequestration in the brain of a patient with cerebral malaria. These results suggest that the membrane-bound form of FKN acts as a receptor for pRBCs, and this may contribute to furthering our present understanding of cytoadherence in the pathology of falciparum malaria.     

Identification of a Plasmodium falciparum intercellular adhesion molecule-1 binding domain: a parasite adhesion trait implicated in cerebral malaria

Binding of infected erythrocytes to brain venules is a central pathogenic event in the lethal malaria disease complication, cerebral malaria. The only parasite adhesion trait linked to cerebral sequestration is binding to intercellular adhesion molecule-1 (ICAM-1). In this report, we show that Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) binds ICAM-1. We have cloned and expressed PfEMP1 recombinant proteins from the A4tres parasite. Using heterologous expression in mammalian cells, the minimal ICAM-1 binding domain was a complex domain consisting of the second Duffy binding-like (DBL) domain and the C2 domain. Constructs that contained either domain alone did not bind ICAM-1. Based on phylogenetic criteria, there are five distinct PfEMP1 DBL types designated alpha, beta, gamma, delta, and epsilon. The DBL domain from the A4tres that binds ICAM-1 is DBLbeta type. A PfEMP1 cloned from a distinct ICAM-1 binding variant, the A4 parasite, contains a DBLbeta domain and a C2 domain in tandem arrangement similar to the A4tres PfEMP1. Anti-PfEMP1 antisera implicate the DBLbeta domain from A4var PfEMP1 in ICAM-1 adhesion. The identification of a P. falciparum ICAM-1 binding domain may clarify mechanisms responsible for the pathogenesis of cerebral malaria and lead to interventions or vaccines that reduce malarial disease.     

The distribution and intensity of parasite sequestration in comatose Malawian children

BACKGROUND: The sequestration of Plasmodium falciparum-infected erythrocytes in capillary beds is a characteristic feature of severe malaria and is believed to be central to disease pathogenesis. Sequestration occurs in all P. falciparum infections, including those in asymptomatic individuals. Therefore, sequestration cannot be the sole determinant of severe disease; the intensity or distribution of infected erythrocytes may also contribute. Discerning the relationship between sequestration and well-defined clinical syndromes may enhance understanding of disease mechanisms. METHODS: We measured the concentration of parasite-derived lactate dehydrogenase (pLDH) in tissue samples obtained at autopsy from patients with clinically defined cerebral malaria. On the basis of the autopsy findings, patients were divided into 2 groups: those with an identifiable, nonmalarial cause of death and those without, who were presumed to have died of cerebral malaria. The concentration of pLDH, as determined by enzyme-linked immunosorbent assay, was used to estimate parasite load in different organs. RESULTS: When pLDH could be detected, the parasite load was higher in patients with presumed cerebral malaria than in parasitemic patients with assumed cerebral malaria with a nonmalaria cause of death identified at autopsy (P<.05 for brain, intestine, and skin). CONCLUSIONS: These findings suggest that sequestration in patients with fatal cerebral malaria occurs in multiple organs and does not reflect a predilection in the parasite for the cerebral vasculature.     

Opsonin-independent phagocytosis: an effector mechanism against acute blood-stage Plasmodium chabaudi AS infection

Opsonin-independent macrophage phagocytosis was investigated as a possible mechanism of controlling early blood-stage Plasmodium chabaudi AS infection. Early during infection, peritoneal macrophages from resistant C57BL/6 (B6) mice exhibited increased phagocytosis of parasitized red blood cells (pRBCs) and free merozoites, which was absent in mice with deficient interferon (IFN)-gamma production during infection, including susceptible A/J, interleukin (IL)-12 p40, and IFN-gamma gene knockout mice. IFN-gamma treatment of macrophages collected from B6 and A/J mice early during infection enhanced phagocytosis of pRBCs, but IL-10 treatment inhibited this function. In vitro and in vivo studies in which type I and II class A scavenger receptor-deficient mice and inhibitors of scavenger and mannose receptors were used revealed that scavenger receptors other than class A type I and II and mannose receptors may play a role in malaria parasite uptake. These results indicate that opsonin-independent phagocytosis contributes to the IFN-gamma-dependent control of acute blood-stage malaria infection.     

蚊媒感染疟原虫后应答性表达增高基因的富集和筛选

目的　分离和识别蚊媒疟原虫感染相关基因并探讨其机制。方法　以斯氏按蚊 约氏疟原虫为实验模型 ,分别将刺叮约氏疟原虫感染鼠血和正常鼠血后 2 4h的饱血斯氏按蚊作为T组和D组 ,经抑制性差减杂交和选择性PCR扩增 ,建立一个T组表达特异增高基因的差减cDNA库。将此差减库分别与T组和D组的cDNAs混合探针作斑点杂交 ,筛选出差异表达基因 ,测定其序列并做基因库BLAST搜索。结果　T组相对于D组的差异表达基因得到有效富集 ,5 8个重组克隆中有 2 4个表达增高 ,阳性率为 4 1.4 %。所代表的 2 3个基因搜索结果显示 ,12个与功能已知的基因同源 ,4个与功能未知的基因同源 ,7个为新发现的基因 ;其中 9个与LPS诱导的冈比亚按蚊免疫反应性细胞系EST同源 ,占 39.1% (9/ 2 3)。结论　建立了蚊媒感染疟原虫早期 (2 4h)直接导致的全基因组应答性表达增高cDNA库 ,筛选结果显示蚊虫对疟原虫感染的反应涉及多种生化途径及机制 ,尤其与天然免疫系统和能量代谢关系密切     

CHARACTERISATION OF THE HOST RESPONSE TO PLASMODIUM FALCIPARUM INFECTION. I. CEREBRAL MALARIA

Abstract Cerebral malaria is a major form of complicated malaria consequent upon cerebral damage associated with endothelial cell necrosis. We have used assays of Plasmodium falciparum growth inhibition in vitro to study serum inhibitory factors in patients with cerebral malaria. Serum from children with cerebral malaria inhibited parasite growth in a non-synchronised 72-hour assay to a greater extent than did sera from immune adults or asymptomatic children (p < 0.001). The high level of non-specific inhibition of parasite growth was particularly evident when sera were tested against three P. falciparum isolates, and contrasted with the inhibitory effect of sera from non-malaria febrile controls. In this study, serum from patients with cerebral malaria was more inhibitory than serum from the other groups (p < 0.001) and its between-isolate variation, when tested against a panel of P. falciparum isolates in growth assays, was significantly less than that of the other groups tested (p < 0.005). These results are consistent with the hypothesis of toxin-induced endothelial cell damage, with the sequence of pathogenic events involving host-derived serum factors capable of damaging P. falciparum.     

An animal model of autoimmune emphysema

Although cigarette smoking is implicated in the pathogenesis of emphysema, the precise mechanisms of chronic progressive alveolar septal destruction are not well understood. We show, in a novel animal model, that immunocompetent, but not athymic, nude rats injected intraperitoneally with xenogeneic endothelial cells (ECs) produce antibodies against ECs and develop emphysema. Immunization with ECs also leads to alveolar septal cell apoptosis and activation of matrix metalloproteases MMP-9 and MMP-2. Anti-EC antibodies cause EC apoptosis in vitro and emphysema in passively immunized mice. Moreover, immunization also causes accumulation of CD4+ T cells in the lung. Adoptive transfer of pathogenic, spleen-derived CD4+ cells into naive immunocompetent animal also results in emphysema. This study shows for the first time that humoral- and CD4+ cell-dependent mechanisms are sufficient to trigger the development of emphysema, suggesting that alveolar septal cell destruction might result from immune mechanisms.     

Comparison of different diagnostic techniques in Plasmodium falciparum cerebral malaria

BACKGROUND & OBJECTIVES: Plasmodium falciparum cerebral malaria remains a major health problem in India. The efficacy of treatment of cerebral malaria lies in its early diagnosis through rapid diagnostic methods. ParaSights-F test detects HRP-2 antigen secreted by parasitised red blood cells and quantitative buffy coat assay (QBC) is examination of buffy coat for the presence of malarial parasite stained with acridine orange. This study was performed to evaluate the effectiveness of ParaSight-F test and QBC assay as diagnostic methods in the patients of cerebral malaria. METHODS: Fifty clinically diagnosed patients of cerebral malaria were included in the study. ParaSight-F test, QBC and conventional blood smear examination was done. Patients who were in coma and there were no obvious features of bacterial or viral etiology were investigated for cerebral malaria by these diagnostic methods. RESULTS: ParaSight-F test, QBC and peripheral blood smears were examined. Patients were followed-up for signs of clinical recovery. ParaSight-F test was positive in 47 patients, QBC in 46 while blood smear examination was positive in 28 cases. INTERPRETATION & CONCLUSION: Sensitivity and specificity of ParaSight-F test were found to be 96.6 and 94% while QBC showed 97.8 and 100% respectively. ParaSight-F test and QBC were found to be novel methods for diagnosis of cerebral malaria especially in the cases where diagnosis can not be made by conventional blood smear examination due to low parasitaemia. These rapid diagnostic methods help in early therapeutic intervention.     

Plasmodium falciparum rhoptry protein RSP2 triggers destruction of the erythroid lineage

The destruction of erythrocytes and defects in erythropoiesis are among the most frequently observed causes of morbidity in severe Plasmodium falciparum malaria. The molecular mechanisms involved remain unclear, despite extensive investigation. We show here, for the first time, that tagging with the parasite rhoptry protein ring surface protein 2 (RSP2) is not restricted to the surfaces of normal erythrocytes, as previously reported, but that it extends to erythroid precursor cells in the bone marrow of anemic malaria patients. Monoclonal mouse antibodies and human sera from patients with severe anemia, reacting with RSP2-tagged erythrocytes, induced cell destruction by phagocytosis and complement activation in vitro. Our observations reveal a new parasite mechanism implicated in the destruction of normal erythrocytes and probably dyserythropoiesis in malaria patients. These data suggest that the tagging of host cells with RSP2 may trigger anemia in falciparum malaria.     

Heparan sulfate on endothelial cells mediates the binding of Plasmodium falciparum-infected erythrocytes via the DBL1alpha domain of PfEMP1

Plasmodium falciparum may cause severe forms of malaria when excessive sequestration of infected and uninfected erythrocytes occurs in vital organs. The capacity of wild-type isolates of P falciparum-infected erythrocytes (parasitized red blood cells [pRBCs]) to bind glycosaminoglycans (GAGs) such as heparin has been identified as a marker for severe disease. Here we report that pRBCs of the parasite FCR3S1.2 and wild-type clinical isolates from Uganda adhere to heparan sulfate (HS) on endothelial cells. Binding to human umbilical vein endothelial cells (HUVECs) and to human lung endothelial cells (HLECs) was found to be inhibited by HS/heparin or enzymes that remove HS from cell surfaces. (35)S-labeled HS extracted from HUVECs bound directly to the pRBCs' membrane. Using recombinant proteins corresponding to the different domains of P falciparum erythrocyte membrane protein 1 (PfEMP1), we identified Duffy-binding-like domain-1alpha (DBL1alpha) as the ligand for HS. DBL1alpha bound in an HS-dependent way to endothelial cells and blocked the adherence of pRBCs in a dose-dependent manner. (35)S-labeled HS bound to DBL1alpha-columns and eluted as a distinct peak at 0.4 mM NaCl. (35)S-labeled chondroitin sulfate (CS) of HUVECs did not bind to PfEMP1 or to the pRBCs' membrane. Adhesion of pRBCs of FCR3S1.2 to platelet endothelial cell adhesion molecule-1 (PECAM-1)/CD31, mediated by the cysteine-rich interdomain region 1alpha (CIDR1alpha), was found be operative with, but independent of, the binding to HS. HS and the previously identified HS-like GAG on uninfected erythrocytes may act as coreceptors in endothelial and erythrocyte binding of rosetting parasites, causing excessive sequestration of both pRBCs and RBCs.     

Polymorphisms of the HLA-B and HLA-DRB1 genes in Thai malaria patients

The high degree of polymorphism of human leukocyte antigen (HLA) genes has been suggested to result from natural selection against susceptibility to a variety of infectious pathogens, including malaria. HLA molecules are considered to play a crucial role in the defense of the host against malarial infection, and different HLA class I and class II alleles have been reported to be associated with reduced susceptibility to malaria or the severity of malaria in different populations. To test for associations between HLA alleles and the severity of malaria in a Thai population, polymorphisms of HLA-B and HLA-DRB1 genes were investigated in 472 adult patients in northwest Thailand with Plasmodium falciparum malaria. In this study, malaria patients were classified into three groups: mild malaria, non-cerebral severe malaria, and cerebral malaria. Our results revealed that the allele frequencies of HLA-B46, -B56, and -DRB1*1001 were statistically different between non-cerebral severe malaria and cerebral malaria (P = 0.005), between mild malaria and cerebral malaria (P = 0.032), and between mild malaria and non-cerebral malaria (P = 0.007). However, our results may be showing false positives due to multiple testing. Thus, further study with a larger sample size must be conducted to obtain conclusive evidence of the association of these HLA-B and DRB1 alleles with the severity of malaria in Thailand.     

Association of splenomegaly with cerebral malaria and decreased concentrations of reactive nitrogen intermediates in Thailand.

The role of the spleen during Plasmodium falciparum malaria in humans is unclear. In Thailand, malaria transmission is low and splenomegaly is rarer than in high transmission areas. We compared the prevalence of splenomegaly between 52 cerebral malaria patients and 191 patients without complications despite a high parasite biomass. We also measured concentrations of reactive nitrogen intermediates (RNIs) in a fraction of these cases recruited in 1998 (24 cerebral malaria and 56 controls). Splenomegaly was significantly associated with cerebral malaria (adjusted odds ratio = 2.07 [95% confidence interval = 1-4.2]; P = 0.048). There was a linear trend for this association (P = 0.0003). After adjusting for potential confounders, concentrations of RNIs were significantly lower in the presence of splenomegaly (P = 0.01). These results suggest that in humans, as in animal models, the spleen may be involved in the pathogenesis of cerebral malaria. The relationship between RNI concentrations and the spleen suggest that nitric oxide may have a regulating role in the complex physiology of the spleen during malaria.     

Platelets reorient Plasmodium falciparum-infected erythrocyte cytoadhesion to activated endothelial cells

Severe malaria is characterized by the sequestration of Plasmodium falciparum-infected erythrocytes (IEs). Because platelets can affect tumor necrosis factor (TNF)-activated endothelial cells (ECs), we investigated their role in the sequestration of IEs, using IEs that were selected because they can adhere to endothelial CD36 (IE(CD36)), a P. falciparum receptor that is expressed on platelets. The results of coincubation studies indicated that platelets can induce IE(CD36) binding to CD36-deficient brain microvascular ECs. This induced cytoadhesion resisted physiological shear stress, was increased by EC stimulation with TNF, and was abolished by anti-CD36 monoclonal antibody. Immunofluorescence and scanning electron microscopy results showed that platelets serve as a bridge between IEs and the surface of ECs and may therefore provide receptors for adhesion to microvascular beds that otherwise lack adhesion receptors. This novel mechanism of cytoadhesion may reorient the sequestration of different parasite phenotypes and play an important role in the pathogenesis of severe malaria.