Intestinal function and injury in acquired immunodeficiency syndrome-related cryptosporidiosis

BACKGROUND/AIMS

The pathogenesis of the diarrhea in acquired immunodeficiency syndrome (AIDS)-related cryptosporidiosis is not known. The hypothesis of this study was that the intestinal dysfunction and injury are related to the number of organisms infecting the intestinal mucosa. The aim of this study was to study the influence of intensity of infection on intestinal function and injury in AIDS-related cryptosporidiosis.

METHODS

In 16 patients with AIDS with intestinal Cryptosporidium infection, the intensity of infection was quantified by counting the total number of fecal oocysts excreted in 24 hours and by determining the percent of duodenal epithelium covered by organisms. Intestinal function was assessed by vitamin B12 absorption and serum D-xylose test. Intestinal injury was assessed by morphology of duodenal mucosa, differential urinary excretion of lactulose and mannitol, and fecal alpha 1-antitrypsin clearance. Measurements were repeated after treatment with paromomycin.

RESULTS

Vitamin B12 and D-xylose absorption negatively correlated with intensity of infection. Villus atrophy occurred only in patients with oocyst excretion of > 10(8) oocyst/24 hours. Lactulose/mannitol urinary excretion ratio showed a positive correlation with intensity of infection. Intestinal function and injury improved in patients whose oocyst counts were reduced by treatment with paromomycin.

CONCLUSIONS

Cryptosporidium infection in patients with AIDS causes malabsorption and intestinal injury in proportion to the number of organisms infecting the intestine.

The infectivity of Cryptosporidium parvum in healthy volunteers

BACKGROUND

Small numbers of Cryptosporidium parvum oocysts can contaminate even treated drinking water, and ingestion of oocysts can cause diarrheal disease in normal as well as immunocompromised hosts. Since the number of organisms necessary to cause infection in humans is unknown, we performed a study to determine the infective dose of the parasite in healthy adults.

METHODS

After providing informed consent, 29 healthy volunteers without evidence of previous C. parvum infection, as determined by the absence of anti-cryptosporidium-specific antibodies, were given a single dose of 30 to 1 million C. parvum oocysts obtained from a calf. They were then monitored for oocyst excretion and clinical illness for eight weeks. Household contacts were monitored for secondary spread.

RESULTS

Of the 16 subjects who received an intended dose of 300 or more oocysts, 14 (88 percent) became infected. After a dose of 30 oocysts, one of five subjects (20 percent) became infected, whereas at a dose of 1000 or more oocysts, seven of seven became infected. The median infective dose, calculated by linear regression, was 132 oocysts. Of the 18 subjects who excreted oocysts after the challenge dose, 11 had enteric symptoms and 7 (39 percent) had clinical cryptosporidiosis, consisting of diarrhea plus at least one other enteric symptom. All recovered, and there were no secondary cases of diarrhea among household contacts.

CONCLUSIONS

In healthy adults with no serologic evidence of past infection with C. parvum, a low dose of C. parvum oocysts is sufficient to cause infection.

Arginine aminopeptidase, an integral membrane protein of the Cryptosporidium parvum sporozoite

Cryptosporidium parvum oocysts were studied for the expression of aminopeptidase by using amino acids bound to the synthetic fluorescent substrate 7-amino-4-trifluoromethyl coumarin. After 1 h of incubation, intact oocysts showed no activity; however, homogenization and solubilization with Triton X-114 followed by phase separation yielded a 22-fold increase in aminopeptidase activity in the detergent fraction. With arginyl-6-amino-2-styrylquinoline as a substrate, aminopeptidase activity was observed in permeabilized oocysts and freshly excysted sporozoites but not on intact oocysts or empty oocyst membranes after excystation. These results suggest that C. parvum expresses an arginine aminopeptidase that is an integral protein of the sporozoite membrane.

Paromomycin for cryptosporidiosis in AIDS: a prospective, double-blind trial

To test the effects of paromomycin, 10 patients with AIDS and cryptosporidiosis were randomized to paromomycin or placebo in a double-blind trial. After 14 days, patients were switched to the other treatment for 14 additional days. Measures included the number and character of each stool and weekly 24-h stool specimens for weight and oocyst excretion. During the paromomycin treatment phase, oocyst excretion decreased from 314 x 10(6) to 109 x 10(6)24 h (P < .02). Oocyst excretion increased for the 4 patients initially on placebo compared to a median decrease of 128 x 10(6)/24 h for the 6 initially treated with drug (P < .02). Stool frequency also decreased more in those treated with drug (3.6 fewer vs. 1.25 fewer/24 h, P < .05). Trends favored drug over placebo for stool weight, stool character, and Karnofsky score. Paromomycin treatment resulted in improvement in both clinical and parasitologic parameters in cryptosporidiosis in AIDS.

Duodenal morphology and intensity of infection in AIDS-related intestinal cryptosporidiosis

BACKGROUND

The pathogenesis of intestinal cryptosporidiosis is not known. Previous studies have shown that the intensity of infection varies between patients. The hypothesis of this study is that intestinal injury is related to the intensity of infection.

METHODS

The histological abnormalities associated with Cryptosporidium infection were evaluated in duodenal biopsy specimens from 18 patients with acquired immunodeficiency syndrome-associated cryptosporidiosis. The intensity of Cryptosporidium infection was assessed histologically in all patients as the percentage of mucosa covered by organisms and by quantitation of oocyst excretion in the stools of 14 patients.

RESULTS

Duodenal biopsy specimens from 13 patients (72%) showed normal villous architecture. In these patients, the inflammatory component of the lamina propria was either normal or moderately increased. This increase consisted mostly of lymphocytes and plasma cells. Five of 18 patients (28%) had flattening of the mucosa associated with a prominent neutrophilic infiltrate. The intensity of infection in patients with villous flattening as measured from biopsy specimens and stool was significantly higher than in those without flattening (92% vs. 12% mucosa occupied with organisms; 738 x 10(3) vs. 199 x 10(3) oocyst/mL stool) (P < 0.004 in both cases).

CONCLUSIONS

Most patients with intestinal Cryptosporidium infection had normal duodenal villous architecture. Severe duodenal morphological abnormalities, including flattening of the villi, were associated with high-intensity infections.

Purification and partial characterization of cysteine proteinase from Spirometra mansoni plerocercoids

Spirometra mansoni plerocercoids were dissected from the tissues of naturally infected snakes (Natrix trigrialateralia). Fresh plerocercoids were incubated in medium, and excretory-secretory products (E-S) were collected. In addition, soluble proteins from lyophilized plerocercoids (10 mg/ml) were extracted in 0.1 M sodium acetate. Proteinase activity was assayed with a synthetic fluorescent substrate, carbobenzoxy-phenylalanyl-arginyl-7-amino-4-trifluoromethylcoumarin. Proteinase was isolated from plerocercoid extract or E-S by diethylaminoethyl trisacryl M ion-exchange chromatography and thiolpropyl-Sepharose affinity chromatography. These separations resulted in a 12.2- (extract) and 15.6-fold (E-S) purification of proteinase. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the purified materials revealed a 28-kDa band, consistent with the apparent native molecular weight (gel filtration chromatography) of approximately 35 kDa. Proteinases purified from whole extracts and E-S were compared for various biochemical characteristics; inhibitor profiles indicated that activities from both sources are cysteine proteinases, they exhibited identical pH curves with optima at pH 5.5 and a 50% activity range at pH 4.7-8.0, they cleaved collagen chains to 3 identical products, and they showed only minor activity toward hemoglobin. Further, the proteinase purified from plerocercoids was utilized in immunoblots with sera from sparganosis patients. Antibody (IgG) from the infected patients, but not uninfected controls, recognized the cysteine proteinase, suggesting that this antigen may be useful in the serodiagnosis of Spirometra mansoni infection.

Intensity of infection in AIDS-associated cryptosporidiosis

A fluorescent monoclonal anti-Cryptosporidium antibody was used to count the oocysts in stools of 12 AIDS patients with chronic cryptosporidiosis. Oocyst excretion was present throughout the day in all 12 patients. Stool-to-stool variation in oocyst concentration was within one order of magnitude. Small variations were also found in daily mean oocyst concentration and total daily oocyst excretion in 3 patients who had multiple 24-h stool collections. However, there was a large patient-to-patient variation in mean oocyst concentration (from < 5.0 x 10(3) to 9.2 x 10(5) oocysts/mL) and 24-h total oocyst excretion (from < 6.0 x 10(6) to 1.2 x 10(9) oocysts/day). There was a significant correlation between oocyst excretion and numbers of Cryptosporidium organisms seen on small bowel biopsy. Oocyst excretion was reduced in 4 patients treated with paromomycin, but diarrhea improved only in the 2 patients with high initial oocyst excretion.

Proteinase activity in miracidia, transformation excretory-secretory products, and primary sporocysts of Schistosoma mansoni

Proteinase activity was detected in the culture medium of transforming miracidia and in detergent extracts of Schistosoma mansoni miracidia and primary sporocysts using a fluorescent substrate, carbobenzoxy-phenylalanyl-arginyl-7-amino-4- trifluoromethylcoumarin. Medium collected after the first 24 hr of miracidial cultivation (transformation medium; TM) contained most (80%) of the activity released during 5 days of in vitro culture. Based on proteinase activity contained in Triton X-100 extracts of whole larvae, miriacidia and primary sporocysts exhibited a similar amount of total activity per organism, whereas specific activity was about 2-fold greater in miracidia. Approximately 10% of total miracidial activity was released during the first 24 hr of transformation. This early release of proteinase is consistent with possible involvement of these enzymes in miracidial snail penetration. Proteinase activities from larval extracts and culture media were identical when characterized for thiol-dependence, inhibitor profile, and pH optimum and indicate that the proteinase(s) belongs to the cysteine class of acidic endopeptidases. Further studies with TM revealed a substrate preference for a hydrophobic amino acid in the P2 position. High performance liquid chromatography gel filtration showed 2 peaks of activity at 19,000 and 36,000 Da, whereas specific inhibitor labeling yielded heterogeneous banding in the molecular weight range of 33,000-44,000 Da. Lastly, sporocyst extracts incubated with snail plasma (cell-free hemolymph) revealed degradation of high molecular weight hemolymph proteins, including hemoglobin. The finding of significant cysteine proteinase activity in miracidia and primary sporocysts and the continued low level of secretion by sporocysts suggest a functional role of these proteinases in the establishment and/or maintenance of infections within the snail host.

Antibody response to Schistosoma mansoni adult worm cysteine proteinases in infected individuals

Antigens of the Schistosoma mansoni digestive tract are recognized early in the infective process. Two immunogenic components of the excretory/secretory products are proteolytic enzymes that degrade host hemoglobin in the lumen of the parasite gut. These enzymes, CP1 and CP2, belong to the class of cysteine proteinases. In this study, a preparation containing both proteinases has been used to detect proteinase antibodies in the sera of individuals living in Burundi. Of 133 individuals tested, 92% were excreting schistosome eggs. All patients with documented infections had positive anti-proteinase IgG titers (mean = 1:614), while 82% had positive IgM titers (mean = 1:267). Six weeks following praziquantel treatment, patients were assessed for egg excretion and antibody titer. Anti-proteinase IgG titers were significantly lower (mean = 1:259) than pre-treatment titers. Patients who were infected with S. japonicum or S. haematobium typically showed a cross-reactive IgG response. Patients from non-endemic regions yielded negative titers, and those with non-trematode parasites were negative (79%) or weakly positive. S. mansoni cysteine proteinases may be used for the detection of schistosome infections.

Coenuriasis in a spectacled langur (Presbytis obscura): praziquantel treatment and the antibody response to cyst antigens

A diagnosis of coenuriasis was made in a spectacled langur raised in captivity. Multiple cysts removed from the subcutaneous tissues and later from the abdominal cavity were identified as coenuri, typical of the genus Taenia. Post-surgical treatment of the remaining cysts with praziquantel was assessed with whole body computerized tomography (CT). CT at 6 weeks post-treatment revealed a reduction in size and increased calcification of abdominal cysts as compared to pretreatment CT. Cyst fluid antigens in ELISA assays showed a high titer (1:5, 120) IgG response in the langur serum, while no IgM response could be detected. No decrease in IgG titer was seen 6 weeks after treatment. Immunoblot analyses identified several parasite-specific antigens with apparent molecular weights of greater than 92.5 (3 bands), 88, 41, 37, and 34 kDa.

Cloned Schistosoma mansoni proteinase (hemoglobinase) as a putative serodiagnostic reagent

Expressed cDNA encoding a proteolytic enzyme from Schistosoma mansoni has been cloned recently. Circulating antibodies reacting with the recombinant protein have been detected in the blood of mice and humans infected with S. mansoni, S. japonicum, or S. haematobium. S. mansoni and S. haematobium infection can be distinguished by antibody titer.

Schistosoma mansoni: expression and role of cysteine proteinases in developing schistosomula

The adult stage of Schistosoma mansoni utilizes host hemoglobin as a nutrient source. A proteolytic enzyme (SMw32) that has "hemoglobinase" activity is secreted into the parasite gut where it appears to be rapidly activated by glutathione released from host red blood cells. In the present study the expression of this proteinase, in developing schistosomula, has been correlated with digestive tract development and a dramatic rise in enzyme activity as early as Days 8-10 of culture. No evidence of the SMw32 proteinase was found in eggs, cercariae, or in newly transformed larvae. Further, the proteinase expressed at Days 8-10 is indistinguishable from the adult worm enzyme. In the larvae, indirect immunofluorescence with an anti-SMw32 monoclonal antibody showed that the proteinase is found throughout the developing cecum. The importance of cysteine proteinases to parasite development was also studied using a specific enzyme inhibitor, Ep-459. In cultures containing Ep-459 most (75%) of the schistosomula failed to survive the 18-day study period. Moreover, those that did survive showed a decrease in their growth (body length). These data suggest that the SMw32 proteinase is a developmentally regulated enzyme and that cysteine proteinase activity is essential in providing nutrients for the growth and survival of this parasite in its mammalian host. Thus, this proteinase may be an important target for chemotherapeutic intervention.

The hypersensitivity response to the adult worm proteinase, SMw32, in Schistosoma mansoni infected mice

A cysteine proteinase (SMw32) from the digestive tract of an adult Schistosoma mansoni worm has previously been purified and characterized. During the course of infection with this parasite, a strong immune response to the enzyme occurs. We now have confirmed the presence of anti-proteinase IgE and IgG in S. mansoni infected mice and have investigated the in vivo cellular response to proteinase in infected and uninfected mice. Immediate and delayed type hypersensitivities were detected in uninfected mice sensitized by multiple injections of proteinase. In S. mansoni infected mice, immediate hypersensitivity reactions were seen at 6 and 8 weeks following infection, coincident with the increase in anti-proteinase IgE antibody. Histological sections of the injection site confirmed the presence of degranulating mast cells. In contrast, delayed type hypersensitivity could not be detected at any time during the course of the infection. In the murine model of acute infection, immediate hypersensitivity to the SMw32 proteinase was predictive of infection.

Antibody response to a purified parasite proteinase (SMw32) in Schistosoma mansoni infected mice

Indirect immunofluorescence of Schistosoma mansoni adult worm sections has revealed that the early immunoglobulin response is directed toward the parasite digestive tract. One of the components of the worm gut is a cysteine proteinase which degrades host hemoglobin ingested by the parasite. In this report the purified proteinase (SMw32) was used in ELISA and immunoblot analyses to study the specific antibody response during the course of an acute infection. We have found high titer IgG antibody in S. mansoni infected, but not uninfected, mice. The anti-proteinase response involves IgM, IgG1, IgG2a, and IgE isotypes. Total IgM and IgG levels increased by week 3 post-infection and remained elevated throughout the study (7 weeks). Increased titers (IgM, IgG) of specific anti-proteinase were also apparent by week 3 post-infection, long before fecal eggs were detectable. Mean anti-proteinase IgG stabilized at high titer by week 5 post-infection, while IgM titers decreased to near background levels. Anti-proteinase IgE was first detectable at week 4 and reached peak titers by weeks 6 and 7. The strong antibody response to the purified SMw32 proteinase is consistent with the early reactivity of S. mansoni infected mice and humans to a 31 kDa component of the worm gut described by others.

Schistosoma mansoni: anti-SMw32 proteinase response in vaccinated and challenged baboons

Antibodies to a cysteinyl proteinase of the trematode Schistosoma mansoni have been detected in serum from infected mice and humans. We have evaluated antiproteinase responses in infected baboons and in baboons vaccinated with irradiated, cryopreserved schistosomules prior to challenge. Prechallenge sera and normal, uninfected control sera were nonreactive by ELISA and immunoblots. Serum antibodies were first detectable by ELISA at two months post-challenge in both challenged (C) and vaccinated-challenged (V-C) baboons (serum dilution 1:200). By four months post-challenge, ELISA absorbance values for subgroup C baboons were significantly higher than for V-C counterparts. The immunoblot technique provided a more sensitive means of detecting antibody early in the infection. One month post-challenge, 7 of 12 C and V-C sera (diluted 1:100) contained measurable anti-proteinase antibody. By month two, 12 of 12 were immunoblot-positive. Baboons vaccinated but not challenged (subgroup V) remained negative. The presence of the anti-proteinase antibody appears to be a sensitive and early marker for infection by S. mansoni.

Purification of cysteine proteinases from adult Schistosoma mansoni

Proteolytic activity against hemoglobin and low molecular weight synthetic substrates has been previously found in homogenates and excretion/secretion products of adult Schistosoma mansoni worms. This activity is stimulated in the presence of thiol compounds and is maximally active at acidic pH. To characterize further this proteolytic activity, lyophilized adult worms were extracted, and proteinases were isolated and purified. From extracts prepared in 0.2 M citrate buffer, pH 4.9, two proteinase species were purified to homogeneity by centrifugation, gel filtration, dialysis, and chromatofocusing chromatography. The proteinases, designated SMw32 and SMw28, have apparent molecular weights (SDS-PAGE) of 31,700 +/- 1400 and 27,800 +/- 1700, respectively. Both are thiol-dependent, acidic endopeptidases that cleave hemoglobin and a synthetic substrate, CBZ-arg-arg-AFC. A statistical comparison of amino acid compositions reveals that the proteinases are highly related.

Glutathione activation of a cysteine proteinase from Schistosoma mansoni

A cysteine proteinase isolated from Schistosoma mansoni adults requires reduction by thiols for activation. The proteinase is located in the parasite digestive tract where it degrades hemoglobin released from host red blood cells. Reduced glutathione (GSH) has been shown to be effective in activation. Total glutathione concentration and the GSH/oxidized glutathione (GSSG) ratio were measured in whole blood lysate (3.2 mM, 284), serum (24 microM, 9.8) and material collected from the parasite digestive tract (4.2 mM, 137). The ratio of GSH/GSSG at which the enzyme displays half-maximal activity (Kox) is 1.0. Proteinase activation as a function of glutathione concentration and time was determined. The first-order reaction yielded a half-time of activation of 13 min at 5 mM. The second-order rate constant was 12.7 M-1 X min-1. The function of the proteinase and its possible regulation by glutathione activation are discussed.

Schistosoma mansoni: proteinase activity of "hemoglobinase" from the digestive tract of adult worms

A method of collecting samples from the Schistosoma mansoni digestive tract was used to study proteinase activity. Activity against hemoglobin and a low molecular weight synthetic substrate, carbobenzoxy-arginyl-arginyl-7-amino-4-trifluoromethylcoumarin, was demonstrated in the soluble fraction of material regurgitated by S. mansoni adults and was dependent on the addition of a thiol compound, cysteine, to the assays. Using sodium dodecyl sulfate-polyacrylamide gel electrophoresis and gel filtration chromatography (AcA54), two proteins with estimated mol wt of 32,500 and 28,500 were found in the regurgitant and were associated with proteinase activity against both hemoglobin and the synthetic substrate. Homogenates of intact worms showed greater specific activity (synthetic substrate) in the females. Further, in bisected worms proteinase activity paralleled protein content, suggesting that, once secreted into the lumen, proteinase activity was distributed throughout the worm digestive tract.

Properties of the acid thiol proteinase from Schistosoma mansoni adults

Seven beta-naphthylamine-linked peptides were tested as substrates for a previously described thiol proteinase of adult Schistosoma mansoni. The enzyme was not active on carbobenoxy-arginyl-arginyl-4-methoxy-2-naphthylamide and carbobenzoxy-alanyl-arginyl-arginyl-4-methoxy-2-naphthylamide. Enzyme activity was maximal at acidic pH (4.9-5.5) with similar optima for both macromolecular and peptide substrates. Activity of partially purified enzyme preparations against carbobenzoxy-arginyl-arginyl-4-methoxy-2-naphthylamide was stimulated more than 10-fold by thiols. The properties of this proteinase differ from those of proteolytic enzymes from the cercariae ad eggs of S. mansoni.

Pili of Neisseria meningitidis: effect of media on maintenance of piliation, characteristics of Pili, and colonial morphology

In contrast to information in the literature which indicates that meningococci rapidly lose pili upon cultivation in vitro, we found that piliation of meningococci could be maintained in vitro for 15 or more passages. Pili were present on all eight isolates tested, whether from asymptomatic carriers or from subjects with meningococcal disease. Complete loss of piliation occurred in the same two strains on two of the three media tested. On one medium (Thayer-Martin medium with supplement B), there was partial or complete loss of pili by all strains. The optimal medium for maintaining pili was chocolate agar with 1% IsoVitaleX; 95% or more of the microorganisms of six of the eight strains tested were piliated after 15 passages in vitro, and more than 60% of the microorganisms of the other two strains were piliated. Meningococci passed on this medium generally maintained their initial density of piliation (3 to 34 pili per diplococcus). The ability to predictably cultivate piliated meningococci in vitro and to select piliated and nonpiliated clones of the same strain should allow investigation of the biochemical and immunological properties of meningococcal pili as well as their possible role in the pathogenicity of Neisseria meningitidis.