Genetic Manipulation of Non-Falciparum Human Malaria Parasites.

The development of genetic manipulation of Plasmodium falciparum in the 1980s was key to study malaria biology. Genetically modified parasites have been used to study several aspects of the disease, such as red blood cell invasion, drug resistance mechanisms, gametocyte development and mosquito transmission. However, biological and genetic differences between P. falciparum and the other human malaria parasites make P. falciparum a poor model to study different species. The lack of robust systems of long-term in vitro culture of P. vivax and the other human malaria parasites lagged the genetic manipulation of these species. Here we review the efforts to generate genetically modified non-falciparum human malaria parasites, in vivo and in vitro. Using in vivo models - infection of non-human primates such as rhesus macaques and saimiri monkeys - researchers were able to generate transgenic lines of P. knowlesi, P. cynomolgi, and P. vivax. The development of long-term in vitro culture of P. knowlesi in the 2000's, using rhesus and human red blood cells, created a platform to genetically manipulate non-falciparum malaria parasites. Recently, the use of CRISPR/Cas9 technology to genome edit P. knowlesi provides another tool to non-falciparum malaria research, extending the possibilities and allowing researchers to study different aspects of the biology of these parasites and understand the differences between these species and P. falciparum.

Malaria en humanos por infección natural con Plasmodium knowlesi / Natural Plasmodium knowlesi malaria infections in humans

El primer caso informado de transmisión natural de Plasmodium knowlesi en humanos se publicó en 1965. En el sureste de Asia la presentación atípica de casos de malaria, tanto por cambios en la distribución de las especies diagnosticadas de Plasmodium, como por su morfología, motivó diversos estudios que han confirmado la infección en humanos por este plasmodio que infecta naturalmente distintas especies de simios, que son endémicos de las selvas de esta región. Los estudios recientes sugieren que la malaria por P. knowlesi no es una enfermedad emergente en humanos sino que no estaba siendo diagnosticada, debido a la similitud morfológica de este plasmodio con P. malariae y P. falciparum, lo cual dificulta su reconocimiento mediante examen microscópico. Actualmente, se puede confirmar el diagnóstico mediante reacción en cadena de la polimerasa que permite identificar cebadores específicos de P. knowlesi. La malaria por P. knowlesi ha ocasionado desenlaces fatales en humanos, lo que plantea diversos retos como la búsqueda de métodos operativos de diagnóstico para las zonas endémicas, el estudio de los vectores involucrados y la eficacia terapéutica de los medicamentos para su tratamiento. En las regiones selváticas de Suramérica se hace imperativa la vigilancia de parásitos y vectores de la malaria en simios, que potencialmente puedan ocasionar esta zoonosis.

The first reported case of natural transmission of Plasmodium knowlesi to humans was published in 1965. In Southeast Asia, the atypical presentation of malaria cases, the changes in the distribution of the Plasmodium species diagnosed and their atypical morphology prompted several studies that confirmed natural infections in humans by this protozoon which naturally infects different species of apes which are endemic in the forests of this region. Recent studies suggest that P. knowlesi malaria is not an emerging disease in humans but was rather being misdiagnosed due to its morphological similarity with P. malariae and P. falciparum, hampering its correct diagnosis by microscopic examination. Currently, the diagnosis can be confirmed by polymerase chain reaction using P. knowlesi specific primers. Malaria by P. knowlesi has lead to fatal outcomes in humans and poses several challenges such as the development of useful diagnostic tools for endemic areas, the study of the vectors involved and the therapeutic efficacy of the drugs for its treatment. In the jungle regions of South America it is imperative to monitor the parasites of simian malaria and the vectors that have the potential to transmit this zoonosis.

The emerging of the fifth malaria parasite (Plasmodium knowlesi): a public health concern?

After examining the most recent scientific evidences, which assessed the role of some malaria plasmodia that have monkeys as natural reservoirs, the authors focus their attention on Plasmodium knowlesi. The infective foci attributable to this last Plasmodium species have been identified during the last decade in Malaysia, in particular in the states of Sarawak and Sabah (Malaysian Borneo), and in the Pahang region (peninsular Malaysia). The significant relevance of molecular biology assays (polymerase chain reaction, or PCR, performed with specific primers for P. knowlesi), is underlined, since the traditional microscopic examination does not offer distinguishing features, especially when the differential diagnosis with Plasmodium malariae is of concern. Furthermore, Plasmodium knowlesi disease may be responsible of fatal cases, since its clinical presentation and course is more severe compared with those caused by P. malariae, paralleling a more elevated parasitemia. The most effective mosquito vector is represented by Anopheles latens; this mosquito is a parasite of both humans and monkeys. Among primates, the natural hosts are Macaca fascicularis, M. nemestina, M. inus, and Saimiri scirea. When remarking the possible severe evolution of P. knowlesi malaria, we underline the importance of an early recognition and a timely management, especially in patients who have their first onset in Western Hospitals, after journeys in Southeast Asian countries, and eventually participated in trekking excursions in the tropical forest. When malaria-like signs and symptoms are present, a timely diagnosis and treatment become crucial. In the light of its emerging epidemiological features, P. knowlesi may be added to the reknown human malaria parasites, whith includes P. vivax, P. ovale, P. malariae, and P. falciparum, as the fifth potential ethiologic agent of human malaria. Over the next few years, it will be mandatory to support an adequate surveillance and epidemiological network. In parallel with epidemiological and health care policy studies, also an accurate appraisal of the clinical features of P. knowlesi-affected patients will be strongly needed, since some preliminary experiences seem to show an increased disease severity, associated with increased parasitemia, in parallel with the progressive increase of inter-human infectious passages of this emerging Plasmodium.