Human African trypanosomiasis: clinical presentation and immune response.

Human African trypanosomiasis or sleeping sickness is caused by infection with two subspecies of the tsetse-fly-vectored haemoflagellate parasite Trypanosoma brucei. Historically, epidemic sleeping sickness has caused massive loss of life, and related animal diseases have had a crucial impact on development in sub-Saharan Africa. After a period of moderately successful control during the mid-part of the 20th century, sleeping sickness incidence is currently rising, and control is hampered by a combination of factors, including civil unrest and the possible development of drug resistance by the parasites. The prevailing view is that the disease is invariably fatal without anti-trypanosomal drug treatment. However, there have also been intriguing reports of wide variations in disease severity as well as evidence of asymptomatic carriers of trypanosomes. These differences in the presentation of the disease will be discussed in the context of our knowledge of the immunology of trypanosomiasis. The impact of dysregulated inflammatory responses in both systemic and CNS pathology will be examined and the potential for host genotype variation in disease severity and control will be discussed.

Anaemia in human African trypanosomiasis caused by Trypanosoma brucei rhodesiense.

OBJECTIVE: To find out if indeed anaemia is a major sign in human trypanosomiasis caused by Trypanosoma brucei rhodensiense. DESIGN: A one year cross-sectional study of all admitted and surveyed Trypanosoma brucei rhodensiense infected patients (June 2001-June 2002) SETTING: Nkhotakota District Hospital-Central Region of Malawi. RESULTS: After survey and investigations, 28 patients (16 males and 12 females) were admitted to Nkhotakota District Hospital with a parasite positive Trypanosoma brucei rhodensiense infection. Twenty four (85.7%) of them were anaemic. Their mean haemoglobin was 8.96 +/- 3.07 g/dl compared to controls that had a mean haemoglobin concentration of 12.17 +/- 1.35 g/dl (p < 0.000001, 95% CI -4.342 to -2.0785) (n = 45). None of the trypanosomiasis infected individuals had schistosomiasis or hookworms. Two patients had malaria. One of them was an 18-year-old pregnant woman with hepatosplenomegaly, who developed ante partum haemorrhage. She was jaundiced and had haemoglobin of 10 g/dl. She died after two weeks following the diagnosis and treatment. The other was a two-year-old girl who had haemoglobin of 8.4 g/dl. She also had hepatosplenomegaly. All the other patients looked well nourished with no other signs of chronic diseases. Hepatosplenomegaly was significantly related to the severity of illness (p = 0.011) but not to anaemia. CONCLUSION: Though basic, this study has shown that anaemia is indeed a complication of human Africa trypanosomiasis caused by Trypanosoma brucei rhodesiense. There is need for further investigation to investigate the type of anaemia that is caused by this disease.

Direct detection and identification of African trypanosomes by fluorescence in situ hybridization with peptide nucleic acid probes.

We have developed a rapid and easy to perform fluorescence in situ hybridization test that allows specific identification of trypanosomes from the subgenus Trypanozoon, using peptide nucleic acid probes. Probes were designed to target subgenus-specific sequences on the multiple-copy 18S rRNA, greatly facilitating the detection of a single trypanosome.

Nitric oxide and cytokine synthesis in human African trypanosomiasis.

Plasma and cerebrospinal fluid (CSF) concentrations of nitrate and the cytokines interferon (IFN)-gamma, tumor necrosis factor (TNF)-alpha, interleukin (IL)-10, and IL-4 were measured in 91 African trypanosomiasis patients before and after treatment. Nitrate levels overall were not significantly elevated over those for control persons, but a marginal increase in plasma nitrate was detected in patients reporting illness of <40 days' duration. Plasma IFN-gamma and total TNF-alpha concentrations increased during infection, but free TNF-alpha levels were low in all patients. The most dramatic cytokine response was for IL-10, which was significantly elevated in both plasma and CSF during infection but returned to control levels after treatment. The results indicate that human African trypanosomiasis leads to the development of a strong anti-inflammatory cytokine response.

African trypanosome infections in mice that lack the interferon-gamma receptor gene: nitric oxide-dependent and -independent suppression of T-cell proliferative responses and the development of anaemia.

Infection of mice with African trypanosomes leads to a severe immunosuppression, mediated by suppressor macrophages. Using ex vivo macrophage culture and in vivo cell transfer, it has been shown that nitric oxide (NO) is a potent effector product of these cells and causes both lymphocyte unresponsiveness and dyserythropoiesis. We explored the role of NO in vivo during trypanosome infection using mice with a disrupted interferon-gamma-receptor gene, which were unable to respond with macrophage activation and NO synthesis. These mice were less effective at controlling parasitaemia than the wild types, but showed an improved splenic T-cell responsiveness and reduced anaemia during the early stages of infection. The data indicate that, in the mouse, NO is a significant mediator of immunosuppression only in early infection. Beyond day 10 of infection, NO-independent mechanisms are of primary significance and the control of parasitaemia and T-cell responsiveness are not directly related.

Nitric oxide production in vervet monkeys (Cercopithecus aethiops) infected with Trypanosoma brucei.

A retrospective study of nitrate concentration in serum and cerebrospinal fluid (CSF) from vervet monkeys (Cercopithecus aethiops) infected with Trypanosoma brucei was undertaken. Serum nitrate was significantly elevated in parasitaemic animals. CSF nitrate detection correlated with the presence of parasites in the CNS. The results provide evidence for the production of nitric oxide (NO) in response to infection in a primate model of human African trypanosomiasis and provide the basis for the use of such a model in studies of the immunopathological effects of NO in human trypanosomiasis.

Nitric oxide produced in the lungs of mice immunized with the radiation-attenuated schistosome vaccine is not the major agent causing challenge parasite elimination.

Mice vaccinated with radiation-attenuated cercariae of Schistosoma mansoni exhibit high levels of protection against a challenge with normal larvae. The immune effector mechanism, which operates against schistosomula in the lungs, requires CD4+ T cells capable of producing interferon-gamma (IFN-gamma). This cytokine can stimulate production of nitric oxide (NO), via its ability to up-regulate inducible nitric oxide synthase (iNOS). We have therefore evaluated the potential role of NO in the effector mechanism operating in vaccinated mice. Evidence for the production of NO in the lungs of such animals was obtained from assays on antigen-stimulated airway cell cultures. Enhanced levels of NO, compared with those in cultures from control mice, were detected both after vaccination and after challenge; elevated levels of iNOS mRNA were also present in whole lung after challenge. However, administration of an iNOS inhibitor to vaccinated mice after percutaneous challenge did not significantly increase the worm burden. Furthermore, when mice with a disrupted iNOS gene were vaccinated they showed a highly significant level of protection. Although NO from activated macrophages can mediate cytotoxic killing of newly transformed schistosomula in vitro, we have demonstrated that the addition of erythrocytes to these larvicidal assays abolishes its effects. We interpret this to mean that once migrating schistosomula enter the bloodstream they will be protected against the cytotoxic actions of NO. Our data thus provide little evidence to implicate NO as a major component of the pulmonary effector response to S. mansoni in vaccinated mice.

Characterization of calcineurin from Hymenolepis microstoma and H. diminuta and its interaction with cyclosporin A.

The drug cyclosporin A (CsA) exerts its immunosuppressive action by binding to the cytosolic protein, cyclophilin (CyP) and, as a complex, binding to and inhibiting the calcium/calmodulin-dependent serine threonine phosphatase, calcineurin. It is unknown whether a similar mode of action occurs during the drug's antiparasite activity. Calmodulin-binding proteins from the helminth parasites Hymenolepis microstoma and H. diminuta were purified by affinity chromatography, yielding single polypeptide bands of 60000 M(r), according to SDS-PAGE. These proteins were tested for calcineurin activity by the dephosphorylation of the RII peptide (part of the catalytic subunit of cAMP-dependent protein kinase). Both proteins were calcium- and calmodulin-dependent and were inhibited by mammalian cyclophilin complexed with cyclosporin A (IC50 values of 0.75 microgram CyP for H. microstoma and 0.90 microgram CyP for H. diminuta). However, neither of the parasite calcineurins was inhibited by H. microstoma cyclophilin/CsA. These data suggest the anthelmintic mode of action of CsA in these helminth models does not involve the inhibition of a signal transduction pathway requiring interaction with calcineurin.

Hymenolepis diminuta and H. microstoma: uptake of cyclosporin A and drug binding to parasite cyclophilins.

Cyclosporin A (CsA) acts as a powerful immunosuppressant through its binding to the cytosolic isomerase, cyclophilin (CyP), forming a complex which inhibits the phosphatase activity of calcineurin. The drug is also selectively anti-parasitic but its mode of action remains unknown. The mouse tapeworm, Hymenolepis microstoma is sensitive to CsA, but the rat tapeworm, H. diminuta is not susceptible either in rats, mice or in vitro. Using these two tapeworm models, the uptake and binding of CsA were examined in relation to parasite cyclophilins. Uptake and compartmentalization of the drug were markedly different in the two species: H. microstoma takes up more drug than does H. diminuta and sequesters more drug into intracellular compartments. Characterization of cyclophilins using both CsA binding and isomerase activity assays reveals that H. microstoma possesses two cyclophilin isoforms (M(r) 17,700 and 21,400) with isomerase activity that is inhibited by CsA. using identical assays, we have been unable to demonstrate CsA-binding proteins or CsA-sensitive isomerase activity in H. diminuta. These data suggest that the anthelmintic action of CsA relates in some way to the presence and function of parasite cyclophilins.

Suppressor macrophages in Trypanosoma brucei infection: nitric oxide is related to both suppressive activity and lifespan in vivo.

African trypanosome infections cause immunosuppression in both experimental rodent and natural hosts. One characteristic of this is an eliciting of suppressor macrophages which results in an unresponsiveness in lymphocytes. Macrophages from Trypanosoma brucei-infected mice have previously been shown to produce high levels of nitric oxide (NO). Using model systems based on in vivo macrophage transfer and drug cure, we have sought to determine the relationship between NO and suppressed lymphocyte responses. Peritoneal macrophages from T. brucei-infected mice inhibited the Concanavalin A (Con-A) response of spleen cells from syngeneic recipients 3-4 days after transfer in vivo due to the activity of suppressor macrophages. When macrophage NO synthesis was inhibited either in vitro or in vivo the suppressive effects were partially abrogated. These data provide evidence of a role for NO in mediating immunosuppression during murine T. brucei infection. Suppression in spleens of mice receiving suppressor macrophages was transient, with total recovery of spleen cell mitogen responses six days after transfer. Suppression and recovery was found to coincide with the presence or absence (respectively) of donor macrophages in recipient spleens. When T. brucei-infected mice were treated with a curative dose of a trypanocide there followed a recovery of lymphocyte responsiveness after a period of 4-5 days, and this directly correlated with a reduction of macrophage NO synthesis to control levels both in vivo and in vitro. The apparent loss of suppressor macrophage activity after 4-6 days in both drug cured animals and recipients of macrophage transfer was shown to be due to NO-mediated apoptosis of these cells.

Trypanosoma brucei is protected from the cytostatic effects of nitric oxide under in vivo conditions.

In mice infected with Trypanosoma brucei, splenic and peritoneal macrophages release substantial amounts of nitric oxide (NO). The production of NO by activated macrophages has been reported to be a nonspecific immune-effector mechanism against several parasites, and in this work we investigate the role of NO in killing T. brucei. Addition of bloodstream trypanosomes to peritoneal macrophages activated in vitro resulted in an NO-dependent inhibition of parasite growth. This effect was totally abrogated when dilutions of whole blood were included in the cultures, suggesting that bloodstream parasites such as T. brucei are not susceptible to NO-mediated killing in vivo.

Suppressive macrophages occurring in murine Trypanosoma brucei infection inhibit T-cell responses in vivo and in vitro.

Intraperitoneal injection of Trypanosoma brucei AnTat 1.1 into mice of the C3H.He, BALB/c or C57BL/6 strains resulted in impaired immune responses from day 3 onwards, as measured by the reduction in DNA synthesis in spleen cell populations stimulated with concanavalin A (Con-A) in vitro. Adherent cells from the peritoneum (PC) or from the spleen of infected mice, consisting predominantly of macrophages, caused a 60-80% reduction of the Con-A response in spleen cells from syngeneic recipients 3-4 days after transfer in vivo. Adherent PC from irradiated or athymic mice were equally suppressive. Spleen cells from infected mice reduced the proliferative response of spleen cells from uninfected mice upon co-cultivation in vitro. This dominant suppressive effect was abolished after the selective removal of macrophages from the spleen cell population by treatment with L-leucine methylester. Moreover, the macrophage-depleted spleen cells from infected mice responded normally to Con-A provided they were supplemented with splenic adherent cells from naive mice as a source of accessory cells. Both the cell transfer and co-cultivation experiments suggest that infection with African trypanosomes changes the properties of macrophages to a state which allows them actively to suppress immune responses.