M1 macrophage features in severe Plasmodium falciparum malaria patients with pulmonary oedema.

BACKGROUND: Pulmonary oedema (PE) is a serious complication of Plasmodium falciparum malaria which can lead to acute lung injury in severe cases. Lung macrophages are activated during malaria infection due to a complex host-immune response. The molecular basis for macrophage polarization is still unclear but understanding the predominant subtypes could lead to new therapeutic strategies where the diseases present with lung involvement. The present study was designed to study the polarization of lung macrophages, as M1 or M2 macrophages, in the lungs of severe P. falciparum malaria patients, with and without evidence of PE. METHODS: Lung tissue samples, taken from patients who died from severe P. falciparum malaria, were categorized into severe malaria with PE and without PE (non-PE). Expression of surface markers (CD68+, all macrophages; CD40+, M1 macrophage; and CD163+, M2 macrophage) on activated lung macrophages was used to quantify M1/M2 macrophage subtypes. RESULTS: Lung injury was demonstrated in malaria patients with PE. The expression of CD40 (M1 macrophage) was prominent in the group of severe P. falciparum malaria patients with PE (63.44 ± 1.98%), compared to non-PE group (53.22 ± 3.85%, p < 0.05), whereas there was no difference observed for CD163 (M2 macrophage) between PE and non-PE groups. CONCLUSIONS: The study demonstrates M1 polarization in lung tissues from severe P. falciparum malaria infections with PE. Understanding the nature of macrophage characterization in malaria infection may provide new insights into therapeutic approaches that could be deployed to reduce lung damage in severe P. falciparum malaria.

Lung endothelial cell antigen cross-presentation to CD8+T cells drives malaria-associated lung injury.

Malaria-associated acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) are life-threatening manifestations of severe malaria infections. The pathogenic mechanisms that lead to respiratory complications, such as vascular leakage, remain unclear. Here, we confirm that depleting CD8+T cells with anti-CD8ß antibodies in C57BL/6 mice infected with P. berghei ANKA (PbA) prevent pulmonary vascular leakage. When we transfer activated parasite-specific CD8+T cells into PbA-infected TCRß-/- mice (devoid of all T-cell populations), pulmonary vascular leakage recapitulates. Additionally, we demonstrate that PbA-infected erythrocyte accumulation leads to lung endothelial cell cross-presentation of parasite antigen to CD8+T cells in an IFNγ-dependent manner. In conclusion, pulmonary vascular damage in ALI is a consequence of IFNγ-activated lung endothelial cells capturing, processing, and cross-presenting malaria parasite antigen to specific CD8+T cells induced during infection. The mechanistic understanding of the immunopathogenesis in malaria-associated ARDS and ALI provide the basis for development of adjunct treatments.

Lethal strongyloidiasis - Diagnostic and forensic issues.

Strongyloidiasis is an infectious disease affecting approximately 30-100 million people globally. The main human pathogen is Strongyloides stercoralis which may cause a brief period of acute symptoms and signs after the initial infection, and then lapse into a chronic asymptomatic carrier state for decades due to the nematode's unique ability to autoinfect hosts. Immunosuppression from steroid therapy, T-lymphocytic viral (HTLV-1) infections, or a variety of underlying medical conditions may then result in dissemination and the highly lethal and infectious hyperinfection syndrome. Clinical suspicions for the condition are often not high in non-endemic areas, the diagnosis is difficult, and the incidence is increasing, particularly given recent mass population movements. Indications of infection at autopsy include gastrointestinal ulceration and haemorrhage, with pulmonary oedema, congestion, haemorrhage and diffuse alveolar damage.

Outbreak of toxoplasmosis in four squirrel monkeys (Saimiri sciureus) in Japan.

Toxoplasma gondii is a protozoan parasite that causes fatal disease in New World monkeys. Several reports have described outbreaks of toxoplasmosis in squirrel monkeys. Here, we report the death of four squirrel monkeys in a captive colony from acute toxoplasmosis, one of which developed toxoplasmosis about 1 year after the initial outbreak. Serum anti-T. gondii antibody was detected by a latex agglutination test in the animals, and one presented seropositive before clinical signs were observed. Macroscopically, the lungs were severely affected and three animals showed pulmonary edema. Microscopically, interstitial pneumonia was observed in all animals. In the liver and heart, multifocal mononuclear cell infiltration with necrosis was detected. Parasite loading tended to be higher in the lungs, liver and heart than in the spleen, kidney and brain. The parasite was isolated from the brain of one animal and this isolate showed type II restriction patterns in the SAG1, SAG2, SAG3, BTUB, GRA6, c22-8, c29-2 and PK1 genes of T. gondii and type I restriction patterns in the L358 and Apico genes by PCR-Restriction Fragment Length Polymorphism analysis. The clinical signs were reduced in mice infected with this isolate compared with those infected with reference type II strain PLK in a bioassay. To our knowledge, this is the first report of isolation of the parasite from squirrel monkeys in Japan and offers the opportunity for genomic and pathogenic analyses to aid our understanding of acute toxoplasmosis.

Dysregulation of pulmonary endothelial protein C receptor and thrombomodulin in severe falciparum malaria-associated ARDS relevant to hemozoin.

To investigate the role of the protein C system, endothelial protein C receptor (EPCR) and thrombomodulin (TM) in the pathogenesis of malaria-associated acute respiratory distress syndrome (ARDS) in relation to hemozoin and proinflammatory cytokines-induced type II pneumocyte injury and -aggravated pulmonary resolution. A total of 29 left-over lung specimens that were obtained from patients who died from severe falciparum malaria were examined. Histopathological, immunohistochemical and electron microscopic analyses revealed that ARDS coexisted with pulmonary edema and systemic bleeding; the severity was dependent on the level of hemozoin deposition in the lung and internal alveolar hemorrhaging. The loss of EPCR and TM was primarily identified in ARDS patients and was related to the level of hemozoin, parasitized red blood cell (PRBC) and white blood cell accumulation in the lung. Moreover, an in vitro analysis demonstrated that interleukin-13 and -31 and hemozoin induced pneumocytic cell injury and apoptosis, as assessed by EB/AO staining, electron microscopy and the up-regulation of CARD-9 mRNA (caspase recruitment domain-9 messenger-ribonucleic acid). The dysregulation of EPCR and TM in the lung, especially in those with increased levels of hemozoin, may play an important role in the pathogenesis of malaria-associated ARDS through an apoptotic pathway.

Unusual presentation of neosporosis in a neonatal puppy from a litter of bulldogs.

CASE REPORT: A 17-day-old Bulldog puppy died soon after presentation for weakness and tachypnoea. Gross lesions included diffuse pulmonary oedema and a region of myocardial pallor that resembled an infarct. Inflammation was observed histopathologically in many organs, with numerous clusters of intracellular protozoa that stained positively using Neospora caninum immunohistochemistry. Myocarditis was severe and had associated necrosis of individual myocytes, but the tissue was not infarcted. The bitch had an antibody titre of 1 : 1600 for N. caninum. All six littermates were sold and reported to be healthy at 6 months of age. CONCLUSION: Unusual aspects of this case include the occurrence of clinical disease in only 1 of 7 neonatal puppies, widespread dissemination of the organism in multiple tissues, and regional pallor associated with myocarditis that gave a false gross appearance of infarction. This report also adds Bulldogs to the list of dog breeds shown to be susceptible to clinical neosporosis.

Postmortem characterization of patients with clinical diagnosis of Plasmodium vivax malaria: to what extent does this parasite kill?

BACKGROUND: Severe disease attributable to Plasmodium vivax infection is already well described worldwide; however, autopsies in these patients are scarce. METHODS: From 1996 to 2010, 19 patient deaths with a clinical diagnosis of P. vivax infection occurred in a tertiary care center in the Brazilian Amazon. Seventeen of these 19 deaths were fully autopsied. Clinical charts, macroscopic autopsy reports, and stored paraffinized tissue blocks were retrieved. Nested polymerase chain reaction was performed in paraffinized samples of spleen and lung to confirm P. vivax monoinfection. Immunohistofluorescence was used to detect P. vivax parasitized red blood cells (RBCs). RESULTS: Of 17 autopsies, 13 revealed that death could be attributed to P. vivax infection; in the remaining 4, acute diseases other than malaria were found to be the cause of death. The primary complication in patients in which malaria contributed to death was acute respiratory distress syndrome (ARDS) and pulmonary edema associated with the accumulation of neutrophils in the interalveolar space (6 cases). Spleen rupture (3 cases) and multiorgan dysfunction syndrome (3 cases) were the second most common complications. One child evolving with coma was also characterized, but no parasite was detected in the brain tissue. In one patient who developed ARDS and presented negative peripheral parasitemia by the time of death, scattered parasitized red blood cells were seen inside pulmonary capillaries, suggesting some sequestration in the lung. CONCLUSIONS: In 13 of 17 deceased patients, P. vivax infection was the plausible cause of death. However, more studies are needed to understand pathogenesis related to severe disease.

Comparative histopathology of mice infected with the 17XL and 17XNL strains of Plasmodium yoelii.

Plasmodium yoelii 17XL was used to investigate the mechanism of Plasmodium falciparum-caused cerebral malaria, although its histological effect on other mouse organs is still unclear. Here, histological examination was performed on mice infected with P. yoelii 17XL; the effect of P. yoelii 17XL infection on anemia and body weight loss, as well as its lesions in the brain, liver, kidney, lung, and spleen, also was investigated. Plasmodium yoelii 17XL-infected red blood cells were sequestered in the microcirculation of the brain and in the kidney. Compared with the nonlethal P. yoelii 17XNL strain, infection by P. yoelii 17XL caused substantial pulmonary edema, severe anemia, and significant body weight loss. Although P. yoelii 17XNL and 17XL produced a similar focal necrosis in the mouse liver, infection of P. yoelii 17XL induced coalescing of red and white pulp. Mortality caused by P. yoelii 17XL may be due to cerebral malaria, as well as respiratory distress syndrome and severe anemia. Plasmodium yoelii 17XL-infected rodent malaria seems to be a useful model for investigating severe malaria caused by P. falciparum.

Reduced activity of the epithelial sodium channel in malaria-induced pulmonary oedema in mice.

Lung complications during malaria infection can range from coughs and impairments in gas transfer to the development of acute respiratory distress syndrome (ARDS). Infecting C57BL/6 mice with Plasmodium berghei K173 strain (PbK) resulted in pulmonary oedema, capillaries congested with leukocytes and infected red blood cells (iRBCs), and leukocyte infiltration into the lungs. This new model of malaria-associated lung pathology, without any accompanying cerebral complications, allows the investigation of mechanisms leading to the lung disease. The activity of the amiloride-sensitive epithelial sodium channel (ENaC) in alveolar epithelial cells is decreased by several respiratory tract pathogens and this is suggested to contribute to pulmonary oedema. We show that PbK, a pathogen that remains in the circulation, also decreased the activity and expression of ENaC, suggesting that infectious agents can have indirect effects on ENaC activity in lung epithelial cells. The reduced ENaC activity may contribute to the pulmonary oedema induced by PbK malaria.

Co-infection with Trypanosoma cruzi protects mice against early death by neurological or pulmonary disorders induced by Plasmodium berghei ANKA.

OBJECTIVE: The objective of this study was to investigate whether the infection of C57BL/6 mice by P. berghei ANKA, which causes severe malaria, was modulated by co-infection with Trypanosoma cruzi. METHODS: Groups of C57BL/6 mice were infected either with P. berghei ANKA, T. cruzi strain G, or with both parasites. The presence of parasites was checked by microscopic examination of blood samples. Symptoms of neurological or respiratory disorders, as well as mortality, were registered. Breakdown of the blood brain barrier was determined by injecting the dye Evans blue. Histological sections of the lung were prepared and stained with hematoxilin-eosin. RESULTS: All mice infected only with P. berghei ANKA died within 7-11 days post-infection, either with symptoms of cerebral malaria or with respiratory abnormalities. The animals co-infected with T. cruzi strain G survived longer, without any of the referred to symptoms. Protection against the early death by severe malaria was effective when mice were given T. cruzi 15 days before P. berghei inoculation. Breakdown of the blood brain barrier and extensive pulmonary oedema, caused by malaria parasites, were much less pronounced in co-infected mice. The degree of protection to severe malaria and early death, conferred by co-infection with T. cruzi, was comparable to that conferred by treatment with anti-CD8 antibodies. CONCLUSION: Co-infection with T. cruzi protects C57BL/6 against the early death by malaria infection, by partially preventing either the breakdown of the blood brain, and cerebral malaria as a consequence, or the pulmonary oedema.

Pulmonary complications of babesiosis: case report and literature review.

Reported here is a rare case of babesiosis with pulmonary complications followed by a review of the literature. Babesiosis presents clinically as a malaria-like illness with fever, chills, headache, fatigue with lymphopenia, atypical lymphocytes, mildly or transiently elevated serum transaminases, thrombocytopenia, and increased lactate dehydrogenase (LDH) levels. The diagnosis of babesiosis is based on identification of Babesia spp. on a peripheral blood smear. Babesiosis is usually mild in normal hosts, but it may be severe or even fatal in asplenic patients. Pulmonary manifestations are rare in babesiosis, but non-cardiogenic pulmonary edema (NCPE) is the most frequent manifestation. NCPE in babesiosis does not appear to be related to the degree of parasitemia or splenic function and its onset may be early or late. NCPE usually resolves rapidly with supportive treatment; it is rarely fatal. Clinicians should suspect NCPE in patients with babesiosis who acutely develop shortness of breath and have chest radiograph findings compatible with acute pulmonary edema without cardiomegaly or pleural effusions.

Treatment of East Coast fever of cattle with a combination of parvaquone and frusemide.

Pulmonary oedema is a common sign of East Coast fever (ECF, Theileria parva infection) of cattle. A trial was conducted on farms in Uganda to compare a product containing both the antitheilerial compound parvaquone and the diuretic compound frusemide with one containing only parvaquone, in the treatment of ECF. The trial involved 40 clinical cases of ECF, some of them complicated by other infections, in cattle of all ages and on several farms. Confirmed cases were treated with either parvaquone+frusemide (P+F) or parvaquone alone (P). Survival after treatment with P+F was 77% compared with 71% with P. Five of the 10 fatalities were complicated cases. The cure rate for severe but uncomplicated ECF was 89% with P+F and 40% with P. Pulmonary signs were resolved within 24-48 h after treatment with P+F and clinical recovery was noticeably more rapid than with P. The antiparasitic effect of the two treatments was similar. P+F could be particularly useful when reporting, diagnosis or laboratory confirmation of ECF is delayed, because advanced cases are more likely to be encountered under these circumstances.

Case reports: pernicious complications of benign tertian malaria.

We describe 2 patients with complications of Plasmodium vivax malaria. Both patients developed marked intravascular haemolysis and haemoglobinuria despite normal levels of glucose-6-phosphate dehydrogenase activity in blood. One required mechanical ventilation because of life-threatening hypoxia due to acute respiratory distress syndrome.

Malaria and the lung.

Pulmonary edema that results from increased pulmonary capillary permeability is the most important pulmonary manifestation of malaria. It is a common feature of severe malaria but also occurs rarely in milder disease. Mortality rate is high. The pathophysiologic basis is unclear. In the field, there is much clinical overlap between malaria and pneumonia in children. For physicians in nonmalarial areas, malaria always should be considered in the differential diagnosis of a sick patient who has traveled to a malaria-endemic area. More research is needed to better define and tailor treatments for malarial and nonmalarial ALI and ARDS.

Acute pulmonary Sarcocystis falcatula-like infection in three Victoria crowned pigeons (Goura victoria) housed indoors.

Three free-roaming Victoria crowned pigeons (Goura victoria) housed in a completely enclosed tropical exhibit were found dead without antemortem signs of illness. The birds died within 9 days of each other. Gross necropsy revealed moderate pulmonary edema in all three birds. Histopathologic examination revealed pulmonary edema and pulmonary protozoal merozoites compatible with Sarcocystis spp., Toxoplasma gondii, or Neospora spp. infection. Immunohistochemical staining for T. gondii and Neospora spp. were negative. Immunohistochemical staining identified a Sarcocystis falcatula-like parasite in all three birds. It is suspected that new exhibit soil contaminated with feces from the Virginia opossum (Didelphis virginiana) was the source of the infective sporocysts.

Why is the pathology of falciparum worse than that of vivax malaria?

Here, Ian Clark and Bill Cowden summarize new evidence suggesting that nitric oxide (NO) generated by inducible NO synthase (iNOS) provides a functional link between the previously competing approaches to malarial disease pathogenesis: ischaemic hypoxia and NO. When combined with the newly recognized roles of iNOS in renal and pulmonary function and glucose metabolism, synergy between inflammatory cytokines and hypoxia in iNOS induction provides a framework to help explain, at a molecular level, the differences in the pathology seen in falciparum and vivax malaria. Thus sequestration, through localized hypoxia, might contribute to pathology by enhancing cytokine-induced iNOS. Generalized hypoxia might have the same effect.

Relationship between airway microvascular leakage, edema, and baseline airway functions.

This study was designed to examine the relationship among microvascular leakage, edema, and baseline airway function. Microvascular leakage was induced in the airways of anesthetized, tracheostomized New Zealand White rabbits (n = 22) by using nebulized N-formyl-methionyl-leucyl-phenylalanine (10 mg) and was measured in the trachea by using the Evans blue dye technique. Airway wall thickness was assessed morphometrically in the right main bronchus after Formalin fixation at a pressure of 25 cmH2O. Areas calculated included the mucosal wall area, the adventitial wall area, the total wall area, and the percentage of total wall area consisting of blood vessels. A neutrophil count was also performed by analyzing numbers of cells in both the mucosal wall area and the adventitial wall area. Airway function was assessed before and 30 min after challenge with N-formyl-methionyl-leucyl-phenylalanine by determining airway resistance, functional residual capacity, specific airway resistance, and flow-volume and pressure-volume curves (after paralysis of the animals with suxamethonium). The concentration of Evans blue dye in tracheal tissue ranged from 31.3 to 131.2 micrograms. There was a significant correlation between this concentration and both the adventitial wall area (P < 0.01) and mucosal neutrophil numbers (P < 0.005). There was no correlation between Evans blue concentration and either blood vessel area or changes in respiratory physiology parameters before and after challenge. There was no significant difference between any respiratory physiology measurements before and after challenge. We conclude that an increase in microvascular leakage correlates with airway edema in the adventitia; however, these airway changes have no significant effect on airway elastic or resistive properties.

Canine neosporosis: a case report and literature review.

A three-year-old, intact female vizsla presented for signs of an acute-onset, progressive spinal cord disease. Postmortem examination revealed multifocal central nervous system (CNS) lesions, severe pneumonia with pulmonary edema, and congestion of the liver. Protozoal cysts were found in multiple spinal cord and brain stem sections. Immunohistochemical staining positively identified these cysts as Neospora caninum. A literature review of Neospora caninum infection in the dog with summary of the pathogenesis, clinical signs, diagnostic evaluation, treatment success, and pathology is presented to provide the clinician with an overview of this increasingly prevalent disease.