Parasite virulence factors during falciparum malaria: rosetting, cytoadherence, and modulation of cytoadherence by cytokines

To determine virulence factors of isolates of Plasmodium falciparum and the potential role of cytokines in cerebral malaria, 46 Malagasy patients presenting with cerebral (n = 10), severe (n = 10), and uncomplicated (n = 26) malaria were enrolled in a study. The capacity of 21 of 46 P. falciparum isolates to form rosettes in vitro and to adhere to human umbilical vein endothelial cells (HUVECs) that express intercellular adhesion molecule-1 receptors and to C32 amelanotic melanoma cells that express mainly CD36 receptors was investigated together with the effects of tumor necrosis factor alpha (TNF-alpha), granulocyte macrophage-colony-stimulating factor (GM-CSF), interleukin-3 (IL-3), and IL-6 alone and in two-by-two combinations on the cytoadherence of infected erythrocytes to HUVECs. Plasma levels of these cytokines were also measured in the patients at admission. The percentage of rosette formation was higher for the isolates from patients with cerebral (n = 6; 19.5%) and severe (n = 6; 30.5%) malaria than for those from patients with uncomplicated malaria (n = 9; 5%) (P < 0.002). The cytoadherence properties of the isolates did not differ among the three groups whatever the target cell used, but adherence to melanoma cells was systematically higher than that to HUVECs. Adhesion to HUVECs was increased more after TNF-alpha stimulation than after GM-CSF, IL-3, or IL-6 stimulation (P < 0.01). Only the combination of TNF-alpha and IL-3 enhanced cytoadherence more than TNF-alpha used alone (P < 0.02). No difference in the modulation of cytoadherence by cytokines was found in relation to the severity of the disease. TNF-alpha and IL-6 levels in peripheral blood were higher in the patients with cerebral and severe malaria than in the patients with uncomplicated malaria (P < 0.005). Most of the patients' sera contained little or no IL-3 or GM-CSF. Our results challenge the role of intercellular adhesion molecule-1 as the principal receptor mediating the cytoadherence of P. falciparum-infected erythrocytes and contrast with data obtained in the murine model.

Chloroquine-induced inhibition of the production of TNF, but not of IL-6, is affected by disruption of iron metabolism

There is now considerable evidence that cerebral malaria may be related to the over-production of tumour necrosis factor (TNF). Nevertheless, our knowledge is very poor concerning the biological events which lead up to this TNF over-production. Furthermore, interleukin-6 (IL-6) is produced in large amounts during malaria infection and seems to have inhibitory action on TNF production. Anti-malarial drugs were investigated for their ability to interfere with TNF and IL-6 secretion by human non-immune macrophages stimulated by lipopolysaccharides (LPS) or Plasmodium falciparum culture supernatant. Macrophages were pretreated with chloroquine, quinine, proguanil, mefloquine or halofantrine before stimulation. TNF and IL-6 production were suppressed in a dose-dependent manner when macrophages were treated with chloroquine, but not with other anti-malarial drugs. Considering that chloroquine probably acts via lysosomotropic mechanisms, and that iron metabolism may interfere with the non-specific immune response, we focused our attention on these biochemical events in order to investigate the mechanisms by which chloroquine inhibits cytokine production. Our results demonstrated that chloroquine-induced inhibition of TNF and IL-6 production is not mediated through a lysosomotropic mechanism, and that chloroquine probably acts on TNF secretion by disrupting iron homeostasis. Inhibition of IL-6 production seems not to be mediated through these pathways. These observations suggest that chloroquine may help to prevent cerebral malaria whatever the drug sensitivity of the parasite strain, and may provide new tools for an anti-disease therapy regardless of the emergence of parasite multi-drug resistance.

Ring-infected erythrocyte surface antigen (Pf/155RESA) induces tumour necrosis factor-alpha production

Cerebral malaria is probably related to an overstimulation of the immune system and the cytokine network. We have previously demonstrated that tumour necrosis factor (TNF) secretion by human macrophages can be induced by soluble and heat-stable malarial antigens. Indirect evidence from epidemiological and in vitro studies suggests that Pf155/RESA can be considered as a candidate for triggering TNF secretion. Thus we conducted experiments to investigate the relationship between Pf155/RESA and TNF production. The SGE1 strain of Plasmodium falciparum was compared with the P. falciparum FCR3 strain, which does not express Pf155/RESA protein, for ability to induce TNF secretion by normal human macrophages in vitro. Synthetic peptides from the Pf155/RESA antigen ((EENV)4, (EENVEHDA)4, (DDEHVEEPTVA)3), were used in some experiments. TNF levels were measured by an immunoradiometric assay. We observed that the RESA-defective strain induces lower levels of TNF after schizont rupture than the SGE1 strain. Moreover, substantial TNF secretion was detected when macrophages were incubated with all three peptides, maximum levels being obtained with the (EENV)4 peptide. Although previous reports have described TNF-inducing activity of phospholipid from P. falciparum, these findings strengthen the evidence for Pf155/RESA antigens also being involved in TNF production during malaria.

Neopterin levels in plasma during a longitudinal study in an area endemic for malaria

Neopterin levels in plasma were measured during a longitudinal study of 75 patients living in an area endemic for malaria. The maximum levels were observed in August/September, the period of peak transmission of the disease. During the dry season, levels remain elevated. No relationship was found between the level of neopterin and the individual's immune status against malaria. Tumor necrosis factor (TNF), activated T lymphocytes subpopulations, soluble interleukin 2 receptors, and anti-circumsporozoite protein antibodies were not correlated with neopterin levels during the period of peak transmission. In contrast, neopterin levels were correlated with anti-Plasmodium falciparum antibodies detected by immunofluorescence. It was concluded that, in a population of chronic parasite carriers subjected to repeated infestations, neopterin was a good indicator of slowly acquired immunity in stable transmission area, but it poorly reflected acute immune responses.

Pharmacokinetic and pharmacodynamic study of amodiaquine and its two metabolites after a single oral dose in human volunteers

The pharmacokinetics of amodiaquine (AQ, Flavoquine, CAS 6398-98-7) and its metabolites, mono (AQml) and bis-desethyl amodiaquine (AQm2) were investigated in 8 healthy volunteers after an oral dose of 306.2 mg of AQ. Metabolic clearance was the main AQ elimination pathway. AQ disappeared rapidly, from the plasma and blood, whereas AQml appeared rapidly in keeping with a hepatic first-pass effect. By contrast, AQ was little excreted in urine and AQm2 formation from AQm1 was low. Blood AQm1 concentrations were higher than plasma levels, with an AQm1/AQ concentration ratio of 5 to 10. This result was related to strong uptake of AQm1 by white blood cells, as shown by an in vitro study. On the basis of plasma concentrations, there was no preferential uptake by red blood cells, the pharmacological target cells; effective AQ concentrations should thus be analyzed in plasma rather than in whole blood. The inhibitory activity of patients' sera on Plasmodium falciparum growth in vitro appears to be directly related to the AQm1 concentration.

Possible role of specific immunoglobulin M antibodies to Plasmodium falciparum antigens in immunoprotection of humans living in a hyperendemic area, Burkina Faso

Two seroepidemiological studies were performed in an area of Burkina Faso hyperendemic for malaria to estimate the protective role of immunoglobulin M (IgM) antibodies. Six cross-sectional surveys were carried out on children (ages, < 16 years) in the village of Karankasso. The evolution of antibodies to crude extracts of Plasmodium falciparum (IgG or IgM antisomatic and IgG antiexoantigens) were tested by IFI or enzyme-linked immunosorbent assay and were followed up according to the fluctuations of the parasite densities. Specific IgG antibodies had the same evolution as parasite densities. By contrast, specific IgM antibodies increased when IgG and parasite densities began to decrease (despite a high inoculation rate). A longitudinal survey of 77 children and adults was conducted in another village (Dafinso). In that study, clinical follow-up of the selected individuals allowed us to define three groups in the population. Children in group 1 were considered nonimmune (children with one or more malaria attacks). Group 2 was composed of semiimmune children who did not present with any malarial attack during the survey but who had high levels of parasitemia during the transmission period. Group 3 was composed of immunoprotected adults. Specific IgM and IgG antibodies to crude extracts or a recombinant antigen (glutamate-rich protein) of P. falciparum were tested. Specific IgM antibodies were lower in group 1 (nonimmune) than in groups 2 (semiimmune) and 3 (immunoprotected). Furthermore, there was a negative correlation between parasite densities and the levels of specific IgM antibodies. We discuss the possible role of IgM antibodies in the acquisition of immunity to malaria.

An improved assay for the detection of Toxoplasma gondii antibodies in human serum by flow cytometry

The diagnosis of toxoplasmosis relies primarily on the demonstration of specific antibodies to Toxoplasma gondii. We describe a flow cytometry method for the determination of antibodies to whole fixed tachyzoites by indirect immunofluorescence. Fixed tachyzoites in suspension have characteristic light scattering properties. The amount of IgM, IgG, and IgA antibodies from patients' sera bound to the tachyzoites can be estimated from the mean fluorescence intensities observed using class-specific conjugates for different Ig heavy chains. Appropriate serum dilutions for the estimation of specific IgG titres and for the discrimination between sera positive and negative for IgA and IgM antibodies were established using 40 random sera from pregnant women. The method proved to be quantitative and highly sensitive as compared with currently used assays. Coefficients of variation between series ranged from 6.4% to 12.2% and could be controlled by the inclusion of positive and negative standard sera in the test series. The method might represent a major improvement in cost effectiveness as compared with routine immunofluorescence assay by fluorescent microscopy when the volume of testing is sufficient. It can be fully automated, and its large scale application is currently under investigation.

Relationships between circulating S-antigens, naturally acquired antibodies to Plasmodium falciparum exoantigens and malaria attack in a mesoendemic area

A survey involving 77 individuals living in two savannah villages near Bobo Dioulasso (Burkina Faso, West Africa), was performed in June 1987 (before), August-September (during) and January 1988 after the seasonal transmission. The clinical longitudinal study during the seasonal period permitted us to define three different groups in terms of both age and occurrence of malaria attack (MA; greater than or equal to 5000 parasites/mm3 of blood and axillary fever greater than or equal to 37.8 degrees C). The presence of circulating stable antigen (S-Ag) and the antibody responses against exoantigens (E-Ag) of Plasmodium falciparum were also evaluated at three observations periods: beginning, during and after the transmission season. The adult group (III) had the highest rates of IgG Ab to E-Ag although, IgM prevalence to E-Ag was maximal in the group II (individuals with no malaria attack and age less than or equal to 15 years old). Group I (persons with less than or equal to 15 years old and who contracted at least one MA) did not have any S-Ag at the first observation period and showed the lowest rate of antibodies to E-Ag. The probability of occurrence of an MA calculated from these parameters at the beginning of the transmission period were correct in 78.9% of the cases in children (Groups I & II) and in 71.8% of adults during the subsequent transmission period. Therefore these values could be used for evaluating the probability of occurrence of a clinical MA during the transmission period in a mesoendemic area. S-Ag and antibodies to E-Ag could participate positively in the mechanisms involved in the development of the immune status.

Rapid in vivo detection of chloroquine resistance by the Quantitative Buffy Coat Malaria Diagnosis System

The use of the Giemsa-stained thick blood smear for the diagnosis of malaria has not been supplanted since the discovery of the parasite by A. Laveran in 1880. Recently, a new direct diagnosis technique, the Quantitative Buffy Coat (QBC)* Malaria Diagnosis System, has been developed. We compared this technique with the thick blood smear diagnosis in a study of the efficacy of chloroquine therapy in Zaire. A total of 815 subjects were screened; 71 participated in the trial. They were given chloroquine at a dose of 25 mg/kg of body weight over three days and were examined for parasitemia two and seven days after treatment. Chloroquine resistance was detected in 38% of the subjects by thick blood smear and in 45% by the QBC test. Of greater interest was the time required for each diagnosis: an average of 17 min was required to examine microscopic fields with 1,000 leukocytes by thick blood smear analysis compared with less than one min by the QBC system. In addition, we did not observe diminished attention from fatigue by microscopists using the QBC system despite the large number of tests conducted. We conclude that the QBC system is an important tool for studies of drug resistance.

Monocyte tissue factor expression induced by Plasmodium falciparum-infected erythrocytes

Monocytes are active elements of the host response against Plasmodium falciparum. They are able to express tissue factor and trigger the extrinsic pathway of blood coagulation the activation of which remained unclear in malaria. Our aim was to assess the tissue factor expression of purified blood monocytes stimulated by cultured Plasmodium falciparum-infected erythrocytes. Malaria parasite induced an early generation of tissue factor with a peak between 8 and 12 h of stimulation. Maximum expression was observed for parasitemia ranging from 1 to 2%. Plasmodium falciparum culture supernatants had the same effect showing the existence of a soluble factor able to induce the tissue factor expression. These data, demonstrating an activation of the tissue factor pathway by the malaria parasite, emphasize thrombin generation. Therefore, thrombin could participate in malaria pathology either in the microcirculatory blockade via platelet and fibrinogen activation or as a mitotic.

Levels of cytokines in plasma during Plasmodium falciparum malaria attacks

The variation of levels of tumor necrosis factor, granulocyte-macrophage colony-stimulating factor, gamma interferon, neopterin, and interleukin-2 receptors in plasma were monitored in 16 patients presenting with an acute Plasmodium falciparum malaria attack. Relations among cytokine levels and between cytokine levels and hematological and parasitological data were assessed.

Relationships between clinical protection and antibodies to Plasmodium falciparum RESA (ring-infected erythrocyte surface antigen) peptides

A longitudinal study involving 76 individuals living in Dafinso and Vallée du Kou (near Bobo-Dioulasso, Burkina Faso, West Africa) was performed in June 1987 (beginning of the transmission period), August-September 1987 (during) and January 1988 (after). The serological antibody (Ab) responses against synthetic peptides representing repeat amino acid sequences of the P. falciparum Ring-Infected Erythrocyte Surface Antigen (RESA): (EENV)5, (EENVEHDA)4, (DDEHVEEPTVA)2 were evaluated by ELISA. The clinical longitudinal study during the transmission period allowed us to define three different groups in terms of age and occurrence of clinical malarial attack (greater than 5000 parasites mm-3 of blood and axillary fever greater than 37.7 degrees C). Levels (A620) of Ab to (EENVEHDA)4 and (DDEHVEEPTVA)2 were correlated with age. The adult group (III) had the highest prevalences of Ab to RESA peptides. No significant difference was found between groups of children with or without malaria attack. Nevertheless, at the beginning of the transmission period, children who had at least one malaria attack during the study presented the lowest level of antibodies to RESA peptides.

Development of natural immunity in Plasmodium falciparum malaria: study of antibody response by Western immunoblotting

A longitudinal study was carried out in Burkina Faso to investigate the natural development of the immune response to Plasmodium falciparum malaria. Three bleedings were carried out before, during, and after the seasonal peak of transmission. Detailed antigen mapping and antibody prevalence of the 248 collected serum samples were established by immunoblotting on the basis of several epidemiological and biological parameters. An improved Western immunoblotting system was used to analyze up to 67 serum samples on each nitrocellulose sheet. This system allowed us to perform the entire study with strictly comparable conditions. Two different blood-stage antigens (exoantigens and somatic antigens) were used to analyze the distribution of different classes and subclasses of immunoglobulins according to the age of the individuals, the presence or absence of a malarial attack, the transmission period, the origin of parasite isolates, and the response to intraerythrocytic stages. Although this analysis emphasizes strong individual variations, reactions with two major antigens of 115 and 103 kDa were especially noted. These antigens induced high antibody levels and prevalences but were probably not involved in protection. The prevalence of immunoglobulin G (IgG) antibodies differed by isotype. Most of antigens stimulating IgG production were also responsible for the IgM antibody response. The role played by these antibodies in the development of natural immunity against malaria is discussed.

[Malaria: chloroquine resistance]

Chloroquine remains the most commonly antimalaric drug utilized all around the world (340 t in 1988). Its efficiency is linked to its action on the digestive vacuole of plasmodium. Since 1957, the areas of resistance are spreading over of an alarming way, striking all continents. 3,000 cases of malaria are imported in France each year, and 90% of the strains tested in vitro by incorporating tritium hypoxanthine are resistant to chloroquine. The resistant parasites are able to exclude chloroquine from their cytoplasm and produce in great number two genes to synthetize a glycoprotein, probable agent of cellular exclusion of the antimalaric drug. Despite of it, to prescribe chloroquine in prophylaxis remains indispensable, because the risk of severe malaria due to some sensitive strains of Plasmodium falciparum.

Correlation between beta 2-microglobulin and soluble interleukin-2 receptor levels in plasma of individuals living in a malarial endemic region

beta 2-Microglobulin (beta 2m) levels were related to the expected immunoprotection in 81 individuals living in a malarial mesoendemic area near Bobo-Dioulasso (Burkina Faso), who were longitudinally followed. Soluble interleukin-2 receptor (sIL-2R) levels were positively correlated to those of beta 2m (r = 0.44; n = 237; P less than 0.001). This suggests that most of the beta 2m could have originated from activated T and B cell membrane turnover. In our study, both beta 2m and sIL-2R were inversely related to IgG antibodies (Ab) against somatic antigen of Plasmodium falciparum (Som-Ag). Therefore, these molecules at high levels could have a down regulating activity, directly or indirectly, on B cells producing this kind of Ab.

[Focus on Schistosoma intercalatum]

Area of frequent occurrence of Schistosoma intercalatum is limited to few countries along the Guinea Gulf although the main intervening agents, Bulinus globosus, Bulinus forskalii are dispersed all over Africa. Reservoir of Schistosoma intercalatum is only human and its cycle is difficult to keep up in test animals. Clinical manifestations are, the most often, a simultaneous inflammation of the rectum and sigmoid. Diagnosis is based on the presence of ova with terminal spine in feces or in biopsies of rectal mucosae. Serology, not specific of this species, eases finding of low infestations. Treatment is based on Praziquantel.

Longitudinal survey in an endemic region of plasma soluble interleukin-2 receptor and antibody levels in Plasmodium falciparum malaria

A survey involving 81 individuals living in Dafinso and Vallée du Kou no. 4 (near Bobo-Dioulasso), Burkina Faso, was performed in June 1987, August to September 1987, and January 1988, respectively, at the beginning of, during, and after the transmission season of malaria. The clinical longitudinal study during the transmission period allowed us to define three different groups in terms of both age and occurrence of malaria attack (5,000 Plasmodium falciparum per mm3 of blood and axillary fever of greater than 37.7 degrees C) as follows: group 1, persons less than or equal to 15 years old who had at least one malaria attack during the transmission period; group 2, individuals less than or equal to 15 years old who did not have any malaria attacks; and group 3, individuals considered to be protected (adults greater than 15 years old with no malaria attacks). Soluble interleukin-2 receptor (sIL-2R) levels were found to be significantly increased (P less than 0.001) in the first two groups (1,047 +/- 481 U/ml [mean +/- standard deviation]) as compared with the adult group (605 +/- 307 U/ml). Considering all the groups, no significant difference was observed between observation periods. Levels of sIL-2R were inversely correlated (r = -0.39, n = 237, P less than 0.01) with age (range, 4 to 67 years). Negative correlations were also noticed between the levels of sIL-2R and those of antibodies to somatic antigen of P. falciparum (immunoglobulin G [IgG] class [r = -0.33, n = 237, P less than 0.01] and IgM class [r = -0.20, n = 237, P less than 0.05]). IgG antibody levels to somatic antigen were correlated with age, but IgM antibody levels to somatic antigen were not. The possible role played by sIL-2R in effector mechanisms against malaria is discussed.

[Immunization against human malaria: present knowledge]

The authors review different aspects of immunization against malaria according to the different stages of the parasitic cycle of Plasmodium falciparum: sporozoite vaccine preventing organism infestation, merozoïte vaccine and gametocyte vaccines preventing the accomplishment of the sexual cycle. Progress of molecular biology and better knowledge of cellular immunity provide some prospects regarding parasitic vaccinology, thanks to genetic engineering. Recombinant vaccines in vitro, in vivo and synthetized are under study and provide the best prospects regarding immunization against human malaria.