Eosinophils and Neutrophils Eliminate Migrating Strongyloides ratti Larvae at the Site of Infection in the Context of Extracellular DNA Trap Formation.

Parasitic nematodes such as hookworms actively penetrate the skin of their hosts, encountering skin-resident innate immune cells that represent the host´s first line of defense. Here we use Strongyloides ratti as a model for an intestinal helminth parasite with tissue migrating stages. We show that interception and killing of migrating larvae in mice during a 1st infection occurred predominantly in skin and muscle tissue before larvae migrated via lung and head tissue to the intestine. Inhibition of larval migration was even more efficient in immune mice during a 2nd infection where larvae barely left the site of entry i.e. the foot. Using cell-deficient mice we show that interception in the tissue was predominantly mediated by neutrophils and eosinophils while basophils and mast cells were dispensable in vivo. Likewise, neutrophils and eosinophils inhibited S. ratti L3 motility in vitro in the context of ETosis. Thereby eosinophils were strictly dependent on the presence of anti-S. ratti antibodies while neutrophils inhibited L3 motility as such. Also, MPO and MMP-9 were released by neutrophils in response to L3 alone, but immune plasma further stimulated MPO release in an antibody-dependent manner. In summary, our findings highlight the central role of the skin as first line of defense against helminth parasites in both, innate and adaptive immunity.

Venestatin from parasitic helminths interferes with receptor for advanced glycation end products (RAGE)-mediated immune responses to promote larval migration.

Parasitic helminths can reside in humans owing to their ability to disrupt host protective immunity. Receptor for advanced glycation end products (RAGE), which is highly expressed in host skin, mediates inflammatory responses by regulating the expression of pro-inflammatory cytokines and endothelial adhesion molecules. In this study, we evaluated the effects of venestatin, an EF-hand Ca2+-binding protein secreted by the parasitic helminth Strongyloides venezuelensis, on RAGE activity and immune responses. Our results demonstrated that venestatin bound to RAGE and downregulated the host immune response. Recombinant venestatin predominantly bound to the RAGE C1 domain in a Ca2+-dependent manner. Recombinant venestatin effectively alleviated RAGE-mediated inflammation, including footpad edema in mice, and pneumonia induced by an exogenous RAGE ligand. Infection experiments using S. venezuelensis larvae and venestatin silencing via RNA interference revealed that endogenous venestatin promoted larval migration from the skin to the lungs in a RAGE-dependent manner. Moreover, endogenous venestatin suppressed macrophage and neutrophil accumulation around larvae. Although the invasion of larvae upregulated the abundance of RAGE ligands in host skin tissues, mRNA expression levels of tumor necrosis factor-α, cyclooxygenase-2, endothelial adhesion molecules vascular cell adhesion protein-1, intracellular adhesion molecule-1, and E-selectin were suppressed by endogenous venestatin. Taken together, our results indicate that venestatin suppressed RAGE-mediated immune responses in host skin induced by helminthic infection, thereby promoting larval migration. The anti-inflammatory mechanism of venestatin may be targeted for the development of anthelminthics and immunosuppressive agents for the treatment of RAGE-mediated inflammatory diseases.

Strongyloides venezuelensis-infection alters the profile of cytokines and liver inflammation in mice co-infected with Schistosoma mansoni.

Human co-infection by helminth species is frequent, but their consequences are mostly unknown. Here, we investigate the impact of Strongyloides venezuelensis co-infection on the immune response, schistosome burden, and the associated pathology of schistosomiasis in mice. Co-infection did not alter the schistosome parasite burden, but reduced the IL-4/IL-10 ratio during acute schistosomiasis, indicating induction of modulatory mechanisms. Simultaneous infection with S. venezuelensis and S. mansoni increased the liver concentration of IFN-γ and altered the Th2/Th1 balance, leading to great infiltration of neutrophils and macrophages, which resulted in larger liver inflammation and increased serum transaminase activity in comparison with mono-infected mice. Mice infected with S. venezuelensis at two and four weeks after S. mansoni infection showed significant increase of Th1/Th2/Th17/Treg cytokines and strong cellular infiltration in the liver in comparison with mono-infected mice. However, only in mice co-infected after two weeks of schistosomiasis, the liver immune response leads to more intense Th2 polarization, increased liver inflammation, and transaminase serum activity. S. venezuelensis co-infection during chronic schistosomiasis did not significantly alter liver inflammation. Therefore, S. venezuelensis co-infection affects the host immune responses and morbidity of schistosomiasis, but the effects largely depend on the stage of the S. mansoni infection.

Microbial Translocation Associated with an Acute-Phase Response and Elevations in MMP-1, HO-1, and Proinflammatory Cytokines in Strongyloides stercoralis Infection.

Microbial translocation, characterized by elevated levels of lipopolysaccharide (LPS) and related markers, is a common occurrence in HIV and some parasitic infections. This is usually associated with extensive inflammation and immune activation. To examine the occurrence of microbial translocation and the associated inflammatory response in asymptomatic Strongyloides stercoralis infection, we measured the plasma levels of LPS and other microbial translocation markers, acute-phase proteins, inflammatory markers, and proinflammatory cytokines in individuals with (infected [INF]) or without (uninfected [UN]) S. stercoralis infections. Finally, we also measured the levels of all of these markers in INF individuals following treatment of S. stercoralis infection. We show that INF individuals exhibit significantly higher plasma levels of microbial translocation markers (LPS, soluble CD14 [sCD14], intestinal fatty acid-binding protein [iFABP], and endotoxin core IgG antibody [EndoCAb]), acute-phase proteins (α-2 macroglobulin [α-2M], C-reactive protein [CRP], haptoglobin, and serum amyloid protein A [SAA]), inflammatory markers (matrix metalloproteinase 1 [MMP-1] and heme oxygenase 1 [HO-1]), and proinflammatory cytokines (interleukin-6 [IL-6], IL-8, monocyte chemoattractant protein 1 [MCP-1], and IL-1ß) than do UN individuals. INF individuals exhibit significantly decreased levels of tissue inhibitor of metalloproteinases 4 (TIMP-4). Following treatment of S. stercoralis infection, the elevated levels of microbial translocation markers, acute-phase proteins, and inflammatory markers were all diminished. Our data thus show that S. stercoralis infection is characterized by microbial translocation and accompanying increases in levels of acute-phase proteins and markers of inflammation and provide data to suggest that microbial translocation is a feature of asymptomatic S. stercoralis infection and is associated with an inflammatory response.

Severe strongyloidiasis: a systematic review of case reports.

BACKGROUND: Strongyloidiasis is commonly a clinically unapparent, chronic infection, but immuno suppressed subjects can develop fatal disease. We carried out a review of literature on hyperinfection syndrome (HS) and disseminated strongyloidiasis (DS), in order to describe the most challenging aspects of severe strongyloidiasis. METHODS: We conducted a structured search using PubMed to collect case reports and short case series on HS/DS published from 1991 to 2011. We restricted search to papers in English, Spanish, Italian and French. Case reports were classified as HS/DS according to given definitions. RESULTS: Records screened were 821, and 311 were excluded through titles and abstract evaluation. Of 510 full-text articles assessed for eligibility, 213 were included in qualitative analysis. As some of them were short case series, eventually the number of cases analyzed was 244.Steroids represented the main trigger predisposing to HS and DS (67% cases): they were mostly administered to treat underlying conditions (e.g. lymphomas, rheumatic diseases). However, sometimes steroids were empirically prescribed to treat signs and symptoms caused by unsuspected/unrecognized strongyloidiasis. Diagnosis was obtained by microscopy examination in 100% cases, while serology was done in a few cases (6.5%). Only in 3/29 cases of solid organ/bone marrow transplantation there is mention of pre-transplant serological screening. Therapeutic regimens were different in terms of drugs selection and combination, administration route and duration. Similar fatality rate was observed between patients with DS (68.5%) and HS (60%). CONCLUSIONS: Proper screening (which must include serology) is mandatory in high - risk patients, for instance candidates to immunosuppressive medications, currently or previously living in endemic countries. In some cases, presumptive treatment might be justified. Ivermectin is the gold standard for treatment, although the optimal dosage is not clearly defined in case of HS/DS.

Syndrome of inappropriate secretion of antidiuretic hormone associated with strongyloidiasis.

We report a case of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) with accompanying severe strongyloidiasis in a 52-year-old male. On admission, he showed drowsiness and emaciation with severe hyponatremia. We gave sodium (saline or salts) in an i.v. drip infusion and orally without improvement. A urinalysis and plasma osmotic pressure test indicated SIADH, therefore, treatment was changed to restrict his sodium intake. The hyponatremia gradually improved initially, but the appetite loss, nausea, and hyponatremia continued. Endoscopy revealed white patches on the stomach wall and histopathological examination revealed infestation of the mucosal epithelium with numerous Strongyloides stercoralis larvae. Ivermectin treatment was then initiated and the abdominal symptoms and hyponatremia gradually resolved. We carefully investigated the underlying cause of the SIADH, such as disease of the central nervous system, lung cancer, and other malignancies, but no abnormality or clear cause could be found. We concluded that the patient developed SIADH secondary to severe S. stercoralis infection.

Reduced efficacy of treatment of strongyloidiasis in HTLV-I carriers related to enhanced expression of IFN-gamma and TGF-beta1.

Strongyloidiasis, a human intestinal infection caused by Strongyloides stercoralis (S. stercoralis), is difficult to cure with drugs. In particular, a decrease of the efficacy of treatment has been reported in patients dually infected with S. stercoralis and human T-cell leukaemia virus type I (HTLV-I), both of which are endemic in Okinawa, Japan. However, the factors influencing this resistance remain unclear. In the present study, patients infected with S. stercoralis, with or without HTLV-I infection, were treated with albendazole, followed up for one year and separated into two groups, cured and non-cured. The cure rate of S. stercoralis was lower in HTLV-I carriers (P < 0.05). Serum levels of S. stercoralis-specific IgA, IgE, IgG, IgG1 and IgG4 antibodies were estimated, and a decrease of IgE (P < 0.05) and an increase of IgG4 (P < 0.05) were observed in the non-cured group, especially in HTLV-I carriers. RT-PCR of cytokines using peripheral blood mononuclear cells revealed that S. stercoralis patients with HTLV-I showed a high frequency of expression of IFN-gamma and TGF-beta1, whereas those without HTLV-I showed no expression of these cytokines. IFN-gamma- and TGF-beta1-positive HTLV-I carriers showed a decrease of IgE (P < 0.05), an increase of IgG4 (P < 0.01) and a lower cure rate (P < 0.01) compared with those who were negative for both cytokines. These results suggest that persistent infection with HTLV-I affected S. stercoralis-specific immunity and reduced therapeutic efficacy.

Expression of CD23, CD32, Mac-1 and other adhesion molecules in eosinophils in strongyloidiasis and HTLV-I-positive patients.

The relationship between human T-lymphotropic virus I (HTLV-I) infection and strongyloidiasis has recently become an important problem. This study compared the expression of CD23, CD32, Mac-1 and other adhesion molecules in eosinophils of patients with strongyloidiasis positive for anti-(HTLV-I) antibodies and in those negative for the antibodies. The expression of CD23, Mac-1 and intercellular adhesion molecule-1 (ICAM-1) on eosinophils of patients with strongyloidiasis was augmented in comparison with normal subjects and HTLV-I carriers. There were no significant differences, however, in the expression of CD23, CD32, Mac-1 and adhesion molecules (ICAM-1, leukocyte function-associated antigen-1 alpha (LFA-1 alpha), LFA-1 beta, very late antigen-4) on eosinophils of patients with strongyloidiasis positive for anti-HTLV-I antibodies in comparison with those negative for these antibodies.

Goblet cell mucins of four genera of the subfamily Cricetinae with reference to the protective activity against Strongyloides venezuelensis.

Goblet and mast cell responses in the jejunum of four genera, Mesocricetus auratus (Syrian hamster), Phodopus campbelli, Cricetulus griseus (Chinese hamster), and Tscherskia triton, belonging to the subfamily Cricetinae, were examined after infection with Strongyloides venezuelensis. Parasite eggs became detectable in faeces of all four genera on Day 7. Faecal egg count peaked around Day 8 in C. griseus and T. triton and around Day 14 in M. auratus and P. campbelli. In M. auratus and P. campbelli, faecal egg production persisted over 40 days, whereas that in C. griseus and T. triton rapidly terminated within 14 days. In all four genera examined, goblet cell hyperplasia and mastocytosis were observed at the time of expulsion of S. venezuelensis. However, in the comparative study of all four genera, neither the degree of goblet or mast cell hyperplasia nor the phenotype of mast cells correlated to the rapidity of the expulsion of S. venezuelensis. On the other hand, the rapidity of expulsion closely correlated with the degree of sulphation of goblet cell mucins because two genera, C. griseus and T. triton, having highly sulphated goblet cell mucins showed faster expulsion of S. venezuelensis than the other two genera, P. campbelli and M. auratus, having less sulphated mucins. These results suggest that physicochemical nature of mucins is critical for the expulsion of S. venezuelensis from the subfamily Cricetinae.

In vivo initiation of unstimulated in vitro interleukin-1 release by alveolar macrophages.

Alveolar macrophages (AM) can be stimulated in vitro with material such as lipopolysaccharide, and this activation releases cytokines, collectively called interleukin-1, that can stimulate local cells such as fibroblasts, systemic cells such as lymphocytes, and/or distant parenchymal cells such as hepatocytes. During murine infection with the nematode Nippostrongylus brasiliensis, AM are activated as the parasite larvae migrate through the lung. We examined AM for unstimulated release of lymphocyte-activating factor (LAF) and hepatocyte-stimulating factor (HSF) as evidence of in vivo activation. Two days after infection, marked unstimulated release of LAF was demonstrated along with a smaller increase in unstimulated release of HSF activity. Release of both activities could be further augmented by in vitro stimulation with lipopolysaccharide. Eight days after infection unstimulated HSF activity was even higher than on Day 2, whereas unstimulated LAF release returned to normal. These findings suggest that a natural infective process causes activation of the resident AM population, resulting in release of potent immune and inflammatory-modulating cytokines in situ and that AM play a crucial role in the initiation of host defense and repair responses to infection.

Synthesis of alpha 1-protease inhibitor by resident and activated mouse alveolar macrophages.

Alpha 1-protease inhibitor (alpha 1Pi), an acute-phase reactant, is the major inhibitor of neutral proteases causing lung tissue injury, such as elastase. While examining the acute-phase reaction to the nematode parasite Nippostrongylus brasiliensis, we noticed that the alveolar macrophage was closely associated with alpha 1Pi when the larvae were present in the lung. Histologic examination revealed marked edema and hemorrhage with numerous alveolar macrophages that stain intensely for intracellular alpha 1Pi. Isolation of these cells by bronchoalveolar lavage showed the macrophage to be activated. Cultured alveolar macrophages from normal and infected animals synthesized and secreted alpha 1Pi, as revealed by [35S]-methionine incorporation, but the amounts were insignificant compared with that synthesized by hepatocytes. There was, however, no apparent difference in alpha 1Pi synthetic activity between normal and activated macrophages. The presence of demonstrable intracellular alpha 1Pi in the parasite-activated alveolar macrophage likely represents endocytosis as host protease- and/or parasite protease-antiprotease complexes. Although alpha 1Pi is synthesized primarily by hepatocytes, synthesis by alveolar macrophages may provide immediate local protection in the microenvironment of the lung during an acute inflammatory response.

Disseminated Strongyloides stercoralis infection. Association with ectopic ACTH syndrome and depressed cell-mediated immunity.

A patient with disseminated Strongyloides stercoralis was evaluated to elucidate host factors that may have led to the development of this infection. The patient was found to have oat cell carcinoma with hypercortisolism produced by tumor adrenocorticotropic hormone. His serum contained a potent inhibitor of lymphocyte blastogenesis. This patient's high level of endogenous cortisol may have impaired lymphocyte function and thereby facilitated infection with S stercoralis.