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Bensalel J, Gallego-Delgado J. Exploring adjunctive therapies for cerebral malaria. Front Cell Infect Microbiol 2024; 14:1347486. [PMID: 38410724 PMCID: PMC10895034 DOI: 10.3389/fcimb.2024.1347486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024] Open
Abstract
Cerebral malaria (CM) is one of the most severe complications of malaria infection characterized by coma and neurological effects. Despite standardized treatment of malaria infection with artemisinin-based combination therapies (ACT), the mortality rate is still high, and it primarily affects pediatric patients. ACT reduces parasitemia but fails to adequately target the pathogenic mechanisms underlying CM, including blood-brain-barrier (BBB) disruption, endothelial activation/dysfunction, and hyperinflammation. The need for adjunctive therapies to specifically treat this form of severe malaria is critical as hundreds of thousands of people continue to die each year from this disease. Here we present a summary of some potential promising therapeutic targets and treatments for CM, as well as some that have been tested and deemed ineffective or, in some cases, even deleterious. Further exploration into these therapeutic agents is warranted to assess the effectiveness of these potential treatments for CM patients.
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Affiliation(s)
- Johanna Bensalel
- Ph.D. Program in Biology, The Graduate Center, The City University of New York, New York, NY, United States
- Department of Biological Sciences, Lehman College, City University of New York, New York, NY, United States
| | - Julio Gallego-Delgado
- Ph.D. Program in Biology, The Graduate Center, The City University of New York, New York, NY, United States
- Department of Biological Sciences, Lehman College, City University of New York, New York, NY, United States
- Ph.D. Program in Biochemistry, The Graduate Center, The City University of New York, New York, NY, United States
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2
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Hadjilaou A, Brandi J, Riehn M, Friese MA, Jacobs T. Pathogenetic mechanisms and treatment targets in cerebral malaria. Nat Rev Neurol 2023; 19:688-709. [PMID: 37857843 DOI: 10.1038/s41582-023-00881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
Malaria, the most prevalent mosquito-borne infectious disease worldwide, has accompanied humanity for millennia and remains an important public health issue despite advances in its prevention and treatment. Most infections are asymptomatic, but a small percentage of individuals with a heavy parasite burden develop severe malaria, a group of clinical syndromes attributable to organ dysfunction. Cerebral malaria is an infrequent but life-threatening complication of severe malaria that presents as an acute cerebrovascular encephalopathy characterized by unarousable coma. Despite effective antiparasite drug treatment, 20% of patients with cerebral malaria die from this disease, and many survivors of cerebral malaria have neurocognitive impairment. Thus, an important unmet clinical need is to rapidly identify people with malaria who are at risk of developing cerebral malaria and to develop preventive, adjunctive and neuroprotective treatments for cerebral malaria. This Review describes important advances in the understanding of cerebral malaria over the past two decades and discusses how these mechanistic insights could be translated into new therapies.
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Affiliation(s)
- Alexandros Hadjilaou
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany.
- Institut für Neuroimmunologie und Multiple Sklerose, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Johannes Brandi
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
| | - Mathias Riehn
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
| | - Manuel A Friese
- Institut für Neuroimmunologie und Multiple Sklerose, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Jacobs
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
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3
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Akide Ndunge OB, Kilian N, Salman MM. Cerebral Malaria and Neuronal Implications of Plasmodium Falciparum Infection: From Mechanisms to Advanced Models. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2202944. [PMID: 36300890 PMCID: PMC9798991 DOI: 10.1002/advs.202202944] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Indexed: 06/01/2023]
Abstract
Reorganization of host red blood cells by the malaria parasite Plasmodium falciparum enables their sequestration via attachment to the microvasculature. This artificially increases the dwelling time of the infected red blood cells within inner organs such as the brain, which can lead to cerebral malaria. Cerebral malaria is the deadliest complication patients infected with P. falciparum can experience and still remains a major public health concern despite effective antimalarial therapies. Here, the current understanding of the effect of P. falciparum cytoadherence and their secreted proteins on structural features of the human blood-brain barrier and their involvement in the pathogenesis of cerebral malaria are highlighted. Advanced 2D and 3D in vitro models are further assessed to study this devastating interaction between parasite and host. A better understanding of the molecular mechanisms leading to neuronal and cognitive deficits in cerebral malaria will be pivotal in devising new strategies to treat and prevent blood-brain barrier dysfunction and subsequent neurological damage in patients with cerebral malaria.
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Affiliation(s)
- Oscar Bate Akide Ndunge
- Department of Internal MedicineSection of Infectious DiseasesYale University School of Medicine300 Cedar StreetNew HavenCT06510USA
| | - Nicole Kilian
- Centre for Infectious Diseases, ParasitologyHeidelberg University HospitalIm Neuenheimer Feld 32469120HeidelbergGermany
| | - Mootaz M. Salman
- Department of PhysiologyAnatomy and GeneticsUniversity of OxfordOxfordOX1 3QUUK
- Kavli Institute for NanoScience DiscoveryUniversity of OxfordOxfordUK
- Oxford Parkinson's Disease CentreUniversity of OxfordOxfordUK
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4
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Memvanga PB, Nkanga CI. Liposomes for malaria management: the evolution from 1980 to 2020. Malar J 2021; 20:327. [PMID: 34315484 PMCID: PMC8313885 DOI: 10.1186/s12936-021-03858-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022] Open
Abstract
Malaria is one of the most prevalent parasitic diseases and the foremost cause of morbidity in the tropical regions of the world. Strategies for the efficient management of this parasitic infection include adequate treatment with anti-malarial therapeutics and vaccination. However, the emergence and spread of resistant strains of malaria parasites to the majority of presently used anti-malarial medications, on the other hand, complicates malaria treatment. Other shortcomings of anti-malarial drugs include poor aqueous solubility, low permeability, poor bioavailability, and non-specific targeting of intracellular parasites, resulting in high dose requirements and toxic side effects. To address these limitations, liposome-based nanotechnology has been extensively explored as a new solution in malaria management. Liposome technology improves anti-malarial drug encapsulation, bioavailability, target delivery, and controlled release, resulting in increased effectiveness, reduced resistance progression, and fewer adverse effects. Furthermore, liposomes are exploited as immunological adjuvants and antigen carriers to boost the preventive effectiveness of malaria vaccine candidates. The present review discusses the findings from studies conducted over the last 40 years (1980-2020) using in vitro and in vivo settings to assess the prophylactic and curative anti-malarial potential of liposomes containing anti-malarial agents or antigens. This paper and the discussion herein provide a useful resource for further complementary investigations and may pave the way for the research and development of several available and affordable anti-malarial-based liposomes and liposomal malaria vaccines by allowing a thorough evaluation of liposomes developed to date for the management of malaria.
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Affiliation(s)
- Patrick B Memvanga
- Faculty of Pharmaceutical Sciences, Laboratory of Pharmaceutics and Phytopharmaceutical Drug Development, University of Kinshasa, B.P. 212, Kinshasa XI, Democratic Republic of the Congo.
| | - Christian I Nkanga
- Faculty of Pharmaceutical Sciences, Laboratory of Pharmaceutics and Phytopharmaceutical Drug Development, University of Kinshasa, B.P. 212, Kinshasa XI, Democratic Republic of the Congo
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5
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Barbosa-Silva MC, Lima MN, Battaglini D, Robba C, Pelosi P, Rocco PRM, Maron-Gutierrez T. Infectious disease-associated encephalopathies. Crit Care 2021; 25:236. [PMID: 34229735 PMCID: PMC8259088 DOI: 10.1186/s13054-021-03659-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Infectious diseases may affect brain function and cause encephalopathy even when the pathogen does not directly infect the central nervous system, known as infectious disease-associated encephalopathy. The systemic inflammatory process may result in neuroinflammation, with glial cell activation and increased levels of cytokines, reduced neurotrophic factors, blood-brain barrier dysfunction, neurotransmitter metabolism imbalances, and neurotoxicity, and behavioral and cognitive impairments often occur in the late course. Even though infectious disease-associated encephalopathies may cause devastating neurologic and cognitive deficits, the concept of infectious disease-associated encephalopathies is still under-investigated; knowledge of the underlying mechanisms, which may be distinct from those of encephalopathies of non-infectious cause, is still limited. In this review, we focus on the pathophysiology of encephalopathies associated with peripheral (sepsis, malaria, influenza, and COVID-19), emerging therapeutic strategies, and the role of neuroinflammation.
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Affiliation(s)
- Maria C Barbosa-Silva
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Maiara N Lima
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- National Institute of Science and Technology for Regenerative Medicine, Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil
| | - Tatiana Maron-Gutierrez
- Laboratory of Immunopharmacology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation, Fiocruz, Av. Brasil, 4365, Pavilhão 108, sala 45, Manguinhos, Rio de Janeiro, RJ, 21040-360, Brazil.
- Rio de Janeiro Network on Neuroinflammation, Carlos Chagas Filho Foundation for Supporting Research in the State of Rio de Janeiro (FAPERJ), Rio de Janeiro, Brazil.
- National Institute of Science and Technology on Neuroimmunomodulation, Rio de Janeiro, Rio de Janeiro, Brazil.
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Moreira DR, Uberti ACMG, Gomes ARQ, Ferreira MES, da Silva Barbosa A, Varela ELP, Dolabela MF, Percário S. Dexamethasone increased the survival rate in Plasmodium berghei-infected mice. Sci Rep 2021; 11:2623. [PMID: 33514836 PMCID: PMC7846581 DOI: 10.1038/s41598-021-82032-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/11/2021] [Indexed: 01/30/2023] Open
Abstract
The present study aimed to evaluate the effects of dexamethasone on the redox status, parasitemia evolution, and survival rate of Plasmodium berghei-infected mice. Two-hundred and twenty-five mice were infected with Plasmodium berghei and subjected to stimulation or inhibition of NO synthesis. The stimulation of NO synthesis was performed through the administration of L-arginine, while its inhibition was made by the administration of dexamethasone. Inducible NO synthase (iNOS) inhibition by dexamethasone promoted an increase in the survival rate of P. berghei-infected mice, and the data suggested the participation of oxidative stress in the brain as a result of plasmodial infection, as well as the inhibition of brain NO synthesis, which promoted the survival rate of almost 90% of the animals until the 15th day of infection, with possible direct interference of ischemia and reperfusion syndrome, as seen by increased levels of uric acid. Inhibition of brain iNOS by dexamethasone caused a decrease in parasitemia and increased the survival rate of infected animals, suggesting that NO synthesis may stimulate a series of compensatory redox effects that, if overstimulated, may be responsible for the onset of severe forms of malaria.
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Affiliation(s)
- Danilo Reymão Moreira
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Ana Carolina Musa Gonçalves Uberti
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Antonio Rafael Quadros Gomes
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Michelli Erica Souza Ferreira
- grid.411204.20000 0001 2165 7632Laboratory of Pathophysiology and Therapeutic Research, Centro de Ciências Sociais Saúde e Tecnologia – CCSST, Federal University of Maranhão, Campus Avançado - Bom Jesus, Prédio de Medicina, Av. da Universidade, S/N, Imperatriz, MA 65915-240 Brazil
| | - Aline da Silva Barbosa
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Everton Luiz Pompeu Varela
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Maria Fani Dolabela
- grid.271300.70000 0001 2171 5249Institute of Health Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
| | - Sandro Percário
- grid.271300.70000 0001 2171 5249Oxidative Stress Research Laboratory, Institute of Biological Sciences, Federal University of Pará, Av. Augusto Corrêa, 01, Belém, PA 66075-110 Brazil
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7
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Gondim BLC, da Silva Catarino J, de Sousa MAD, de Oliveira Silva M, Lemes MR, de Carvalho-Costa TM, de Lima Nascimento TR, Machado JR, Rodrigues V, Oliveira CJF, Cançado Castellano LR, da Silva MV. Nanoparticle-Mediated Drug Delivery: Blood-Brain Barrier as the Main Obstacle to Treating Infectious Diseases in CNS. Curr Pharm Des 2020; 25:3983-3996. [PMID: 31612822 DOI: 10.2174/1381612825666191014171354] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Parasitic infections affecting the central nervous system (CNS) present high morbidity and mortality rates and affect millions of people worldwide. The most important parasites affecting the CNS are protozoans (Plasmodium sp., Toxoplasma gondii, Trypanosoma brucei), cestodes (Taenia solium) and free-living amoebae (Acantamoeba spp., Balamuthia mandrillaris and Naegleria fowleri). Current therapeutic regimens include the use of traditional chemicals or natural compounds that have very limited access to the CNS, despite their elevated toxicity to the host. Improvements are needed in drug administration and formulations to treat these infections and to allow the drug to cross the blood-brain barrier (BBB). METHODS This work aims to elucidate the recent advancements in the use of nanoparticles as nanoscaled drug delivery systems (NDDS) for treating and controlling the parasitic infections that affect the CNS, addressing not only the nature and composition of the polymer chosen, but also the mechanisms by which these nanoparticles may cross the BBB and reach the infected tissue. RESULTS There is a strong evidence in the literature demonstrating the potential usefulness of polymeric nanoparticles as functional carriers of drugs to the CNS. Some of them demonstrated the mechanisms by which drugloaded nanoparticles access the CNS and control the infection by using in vivo models, while others only describe the pharmacological ability of these particles to be utilized in in vitro environments. CONCLUSION The scarcity of the studies trying to elucidate the compatibility as well as the exact mechanisms by which NDDS might be entering the CNS infected by parasites reveals new possibilities for further exploratory projects. There is an urgent need for new investments and motivations for applying nanotechnology to control parasitic infectious diseases worldwide.
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Affiliation(s)
- Brenna Louise Cavalcanti Gondim
- Human Immunology Research and Education Group-GEPIH, Technical School of Health, Federal University of Paraiba, Joao Pessoa, Paraiba, Brazil.,Post-Graduation Program in Dentistry, Department of Dentistry, State University of Paraíba, Campina Grande, Paraíba, Brazil
| | - Jonatas da Silva Catarino
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | | | - Mariana de Oliveira Silva
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Marcela Rezende Lemes
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | | | - Tatiana Rita de Lima Nascimento
- Human Immunology Research and Education Group-GEPIH, Technical School of Health, Federal University of Paraiba, Joao Pessoa, Paraiba, Brazil
| | - Juliana Reis Machado
- Department of Pathology, Genetics and Evolution, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Virmondes Rodrigues
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Carlo José Freire Oliveira
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Lúcio Roberto Cançado Castellano
- Human Immunology Research and Education Group-GEPIH, Technical School of Health, Federal University of Paraiba, Joao Pessoa, Paraiba, Brazil
| | - Marcos Vinicius da Silva
- Department of Microbiology, Immunology and Parasitology, Federal University of Triangulo Mineiro, Uberaba, Minas Gerais, Brazil
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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9
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Abstract
Over 90% of the world's severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
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10
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Boggild A, Brophy J, Charlebois P, Crockett M, Geduld J, Ghesquiere W, McDonald P, Plourde P, Teitelbaum P, Tepper M, Schofield S, McCarthy A. Summary of recommendations for the diagnosis and treatment of malaria by the Committee to Advise on Tropical Medicine and Travel (CATMAT). CANADA COMMUNICABLE DISEASE REPORT = RELEVE DES MALADIES TRANSMISSIBLES AU CANADA 2014; 40:133-143. [PMID: 29769894 PMCID: PMC5864436 DOI: 10.14745/ccdr.v40i07a02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND On behalf of the Public Health Agency of Canada, the Committee to Advise on Tropical Medicine and Travel (CATMAT) developed the Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers for Canadian health care providers who are preparing patients for travel to malaria-endemic areas and treating travellers who have returned ill. These recommendations aim to achieve appropriate diagnosis and management of malaria, a disease that is still uncommon in Canada. OBJECTIVE To provide recommendations on the appropriate diagnosis and treatment of malaria. METHODS CATMAT reviewed all major sources of information on malaria diagnosis and treatment, as well as recent research and national and international epidemiological data, to tailor guidelines to the Canadian context. The evidence-based medicine recommendations were developed with associated rating scales for the strength and quality of the evidence. RECOMMENDATIONS Malarial management depends on rapid identification of the disease, as well as identification of the malaria species and level of parasitemia. Microscopic identification of blood samples is both rapid and accurate but can be done only by trained laboratory technicians. Rapid diagnostic tests are widely available, are simple to use and do not require specialized laboratory equipment or training; however, they do not provide the level of parasitemia and do require verification. Polymerase chain reaction (PCR), although still limited in availability, is emerging as the gold standard for high sensitivity and specificity in identifying the species.
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Affiliation(s)
- A Boggild
- University Health Network, Toronto General Hospital (Toronto, ON)
| | - J Brophy
- Division of Infectious Diseases, Children’s Hospital of Eastern Ontario (Ottawa, ON)
| | - P Charlebois
- Internal Medicine, Canadian Forces Health Services Centre (Atlantic) (Halifax, NS)
| | - M Crockett
- Paediatrics and Child Health, University of Manitoba (Winnipeg, MB)
| | - J Geduld
- Infectious Disease Prevention and Control Branch, Public Health Agency of Canada (Ottawa, ON)
| | - W Ghesquiere
- Infectious Diseases and Internal Medicine, University of British Columbia (Victoria, BC)
| | - P McDonald
- Therapeutic Products Directorate, Health Canada (Ottawa, ON)
| | - P Plourde
- Faculty of Medicine, University of Manitoba (Winnipeg, MB)
| | | | - M Tepper
- Communicable Disease Control Program, Directorate of Force Health Protection (Ottawa, ON)
| | - S Schofield
- Pest Management Entomology, Directorate of Forces Health Protection (Ottawa, ON)
| | - A McCarthy
- Tropical Medicine and International Health Clinic, Division of Infectious Disease, Ottawa Hospital General Campus (Ottawa, ON)
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11
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Waknine-Grinberg JH, Even-Chen S, Avichzer J, Turjeman K, Bentura-Marciano A, Haynes RK, Weiss L, Allon N, Ovadia H, Golenser J, Barenholz Y. Glucocorticosteroids in nano-sterically stabilized liposomes are efficacious for elimination of the acute symptoms of experimental cerebral malaria. PLoS One 2013; 8:e72722. [PMID: 23991146 PMCID: PMC3753236 DOI: 10.1371/journal.pone.0072722] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 07/12/2013] [Indexed: 01/07/2023] Open
Abstract
Cerebral malaria is the most severe complication of Plasmodium falciparum infection, and a leading cause of death in children under the age of five in malaria-endemic areas. We report high therapeutic efficacy of a novel formulation of liposome-encapsulated water-soluble glucocorticoid prodrugs, and in particular β-methasone hemisuccinate (BMS), for treatment of experimental cerebral malaria (ECM), using the murine P. berghei ANKA model. BMS is a novel derivative of the potent steroid β-methasone, and was specially synthesized to enable remote loading into nano-sterically stabilized liposomes (nSSL), to form nSSL-BMS. The novel nano-drug, composed of nSSL remote loaded with BMS, dramatically improves drug efficacy and abolishes the high toxicity seen upon administration of free BMS. nSSL-BMS reduces ECM rates in a dose-dependent manner and creates a survival time-window, enabling administration of an antiplasmodial drug, such as artemisone. Administration of artemisone after treatment with the nSSL-BMS results in complete cure. Treatment with BMS leads to lower levels of cerebral inflammation, demonstrated by changes in cytokines, chemokines, and cell markers, as well as diminished hemorrhage and edema, correlating with reduced clinical score. Administration of the liposomal formulation results in accumulation of BMS in the brains of sick mice but not of healthy mice. This steroidal nano-drug effectively eliminates the adverse effects of the cerebral syndrome even when the treatment is started at late stages of disease, in which disruption of the blood-brain barrier has occurred and mice show clear signs of neurological impairment. Overall, sequential treatment with nSSL-BMS and artemisone may be an efficacious and well-tolerated therapy for prevention of CM, elimination of parasites, and prevention of long-term cognitive damage.
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Affiliation(s)
- Judith H. Waknine-Grinberg
- Laboratory of Membrane and Liposome Research, Department of Biochemistry, Institute for Medical Research – Israel-Canada (IMRIC), The Hebrew University - Hadassah Medical School, Jerusalem, Israel
- Department of Microbiology and Molecular Genetics, The Kuvin Center for the Study of Infectious and Tropical Diseases, The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Simcha Even-Chen
- Laboratory of Membrane and Liposome Research, Department of Biochemistry, Institute for Medical Research – Israel-Canada (IMRIC), The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Jasmine Avichzer
- Agnes Ginges Center for Human Neurogenetics, Department of Neurology, Hadassah University Hospital, Jerusalem, Israel
| | - Keren Turjeman
- Laboratory of Membrane and Liposome Research, Department of Biochemistry, Institute for Medical Research – Israel-Canada (IMRIC), The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Annael Bentura-Marciano
- Department of Microbiology and Molecular Genetics, The Kuvin Center for the Study of Infectious and Tropical Diseases, The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Richard K. Haynes
- Department of Chemistry, Institute of Molecular Technology for Drug Discovery and Synthesis, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong
| | - Lola Weiss
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Hospital, Jerusalem, Israel
| | - Nahum Allon
- Laboratory of Membrane and Liposome Research, Department of Biochemistry, Institute for Medical Research – Israel-Canada (IMRIC), The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Haim Ovadia
- Agnes Ginges Center for Human Neurogenetics, Department of Neurology, Hadassah University Hospital, Jerusalem, Israel
| | - Jacob Golenser
- Department of Microbiology and Molecular Genetics, The Kuvin Center for the Study of Infectious and Tropical Diseases, The Hebrew University - Hadassah Medical School, Jerusalem, Israel
| | - Yechezkel Barenholz
- Laboratory of Membrane and Liposome Research, Department of Biochemistry, Institute for Medical Research – Israel-Canada (IMRIC), The Hebrew University - Hadassah Medical School, Jerusalem, Israel
- * E-mail: (YB), (JG)
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12
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Martins YC, Daniel-Ribeiro CT. A new hypothesis on the manifestation of cerebral malaria: the secret is in the liver. Med Hypotheses 2013; 81:777-83. [PMID: 23978689 DOI: 10.1016/j.mehy.2013.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023]
Abstract
Despite the abundance of information on cerebral malaria (CM), the pathogenesis of this disease is not completely understood. At present, two nonexclusive dominant hypotheses exist to explain how the neurological syndrome manifests: the sequestration (or mechanical) hypothesis and the inflammatory hypothesis. The sequestration hypothesis states that sequestration of Plasmodium falciparum-parasitized red blood cells (pRBCs) to brain capillary endothelia causes obstruction of capillary blood flow followed by brain tissue anoxia and coma. The inflammatory hypothesis postulates that P. falciparum infection releases toxic molecules in the circulation, inducing an imbalanced systemic inflammatory response that leads to coagulopathy, brain endothelial cell dysfunction, accumulation of leukocytes in the brain microcirculation, blood brain barrier (BBB) leakage, cerebral vasoconstriction, edema, and coma. However, both hypotheses, even when considered together, are not sufficient to fully explain the pathogenesis of CM. Here, we propose that the development of acute liver failure (ALF) together with BBB breakdown are the necessary and sufficient conditions for the genesis of CM. ALF is characterized by coagulopathy and hepatic encephalopathy (HE) in a patient without pre-existing liver disease. Signs of hepatic dysfunction have been shown to occur in 2.5-40% of CM patients. In addition, recent studies with murine models demonstrated that mice presenting experimental cerebral malaria (ECM) had hepatic damage and brain metabolic changes characteristic of HE. However, the occurrence of CM in patients with mild or without apparent hepatocellular liver damage and the presence of liver damage in non-CM murine models indicate that the development of ALF during malaria infection is not the single factor responsible for neuropathology. To solve this problem, we also propose that BBB breakdown contributes to the pathogenesis of CM and synergizes with hepatic failure to cause neurological signs and symptoms. BBB dysfunction would thus occur in CM by a mechanism similar to the one occurring in sepsis and is in agreement with the inflammatory hypothesis. Nevertheless, differently from in the inflammatory hypothesis, BBB leakage would facilitate the penetration of ammonia and other toxins into the brain parenchyma, but would not be sufficient to cause CM when occurring alone. We believe our hypothesis better explains the pathogenesis of CM, does not have problems to deal with the exception data not explained by the previous hypotheses, and reveals new targets for adjunctive therapy.
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Affiliation(s)
- Yuri Chaves Martins
- Laboratório de Pesquisas em Malária, Instituto Oswaldo Cruz and Centro de Pesquisa Diagnóstico e Treinamento em Malária, Fiocruz, Rio de Janeiro, RJ, Brazil; Department of Pathology, Albert Einstein College of Medicine, The Bronx, NY, USA.
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13
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Lipoxin A₄ and 15-epi-lipoxin A₄ protect against experimental cerebral malaria by inhibiting IL-12/IFN-γ in the brain. PLoS One 2013; 8:e61882. [PMID: 23613965 PMCID: PMC3628580 DOI: 10.1371/journal.pone.0061882] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 03/17/2013] [Indexed: 12/12/2022] Open
Abstract
Cerebral malaria is caused by infection with Plasmodium falciparum and can lead to severe neurological manifestations and predominantly affects sub-Saharan African children. The pathogenesis of this disease involves unbalanced over-production of pro-inflammatory cytokines. It is clear that signaling though IL-12 receptor is a critical step for development of cerebral malaria, IL-12 genetic deficiency failed to show the same effect, suggesting that there is redundancy among the soluble mediators which leads to immunopathology and death. Consequently, counter-regulatory mediators might protect the host during cerebral malaria. We have previously showed that endogenously produced lipoxins, which are anti-inflammatory mediators generated by 5-lipoxygenase (5-LO)-dependent metabolism of arachidonic acid, limit host damage in a model of mouse toxoplasmosis. We postulated here that lipoxins might also play a counter-regulatory role during cerebral malaria. To test this hypothesis, we infected 5-LO-deficient hosts with P. berghei ANKA strain, which induces a mouse model of cerebral malaria (ECM). Our results show accelerated mortality concomitant with exuberant IL-12 and IFN-γ production in the absence of 5-lipoxygenase. Moreover, in vivo administration of lipoxin to 5-LO-deficient hosts prevented early mortality and reduced the accumulation of CD8+IFN-γ+ cells in the brain. Surprisingly, WT animals treated with lipoxin either at the time of infection or 3 days post-inoculum also showed prolonged survival and diminished brain inflammation, indicating that although protective, endogenous lipoxin production is not sufficient to optimally protect the host from brain damage in cerebral malaria. These observations establish 5-LO/LXA4 as a host protective pathway and suggest a new therapeutic approach against human cerebral malaria (HCM). (255 words).
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14
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Okoromah CAN, Afolabi BB, Wall ECB. Mannitol and other osmotic diuretics as adjuncts for treating cerebral malaria. Cochrane Database Syst Rev 2011; 2011:CD004615. [PMID: 21491391 PMCID: PMC4018680 DOI: 10.1002/14651858.cd004615.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cerebral oedema occurs with cerebral malaria, and some clinicians think osmotic diuretics, such as mannitol or urea, may improve outcomes. OBJECTIVES To compare mannitol or urea to placebo or no diuretic for treating children or adults with cerebral malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (Issue 4, 2010), CENTRAL (The Cochrane Library Issue 12, 2010), MEDLINE (1966 to November 2010), EMBASE (1974 to November 2010), LILACS (1982 to November 2010), and the reference lists of articles. We contacted relevant organizations and researchers. SELECTION CRITERIA Randomized or quasi-randomized controlled trials comparing mannitol or urea to placebo or no treatment in children and adults with cerebral malaria. Primary outcomes were death, life-threatenining sequelae and major neurological sequelae at six months. DATA COLLECTION AND ANALYSIS Two authors applied the inclusion criteria, assessed risk of bias, and extracted data independently. MAIN RESULTS One trial met the inclusion criteria, comparing mannitol 20% to saline placebo in 156 Ugandan children. Allocation was concealed. No difference in mortality, time to regain consciousness, or neurological sequelae were detected. AUTHORS' CONCLUSIONS There are insufficient data to know what the effects of osmotic diuretics are in children with cerebral malaria. Larger, multicentre trials are needed.
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Affiliation(s)
- Christy AN Okoromah
- College of Medicine, University of LagosDepartment of Paediatrics and Child HealthIdi‐ArabaSurulereLagosLagosNigeriaPMB 12003
| | - Bosede B Afolabi
- University of LagosDepartment of Obstetrics and GynaecologyCollege of MedicinePMB 12003, Idi‐ArabaLagosNigeria
| | - Emma CB Wall
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
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15
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Finney CAM, Lu Z, Hawkes M, Yeh WC, Liles WC, Kain KC. Divergent roles of IRAK4-mediated innate immune responses in two experimental models of severe malaria. Am J Trop Med Hyg 2010; 83:69-74. [PMID: 20595480 DOI: 10.4269/ajtmh.2010.09-0753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Severe malaria represents a clinical spectrum of disease. We propose that innate immune inflammatory responses to malaria play key roles in the pathogenesis and clinical outcomes of distinct severe malaria syndromes. To investigate this hypothesis, mice deficient in IRAK4, central to Toll-like receptor (TLR)-mediated signaling, were studied in two experimental models of malaria: Plasmodium berghei (PbA) and Plasmodium chabaudi (PccAS). Irak4(-/-)mice had decreased pro-inflammatory cytokine production during infection in both models. However, animals were relatively protected from PbA-associated symptoms compared with wild-type mice, whereas Irak4(-/-) animals were more susceptible to PccAS-associated disease. These results show that IRAK4-mediated innate immune inflammatory responses play critical roles in divergent clinical outcomes in murine malaria models. As such, integrated approaches, using more than one model, are required to fully understand the parasite/host interactions that characterize severe malaria, and more importantly, to fully assess the effect of adjunctive therapies targeting innate immune responses to malaria.
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Affiliation(s)
- Constance A M Finney
- McLaughlin-Rotman Centre for Global Health, McLaughlin Centre for Molecular Medicine, UHN and University of Toronto, Ontario, Canada
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16
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Lackner P, Part A, Burger C, Dietmann A, Broessner G, Helbok R, Reindl M, Schmutzhard E, Beer R. Glatiramer acetate reduces the risk for experimental cerebral malaria: a pilot study. Malar J 2009; 8:36. [PMID: 19250545 PMCID: PMC2651188 DOI: 10.1186/1475-2875-8-36] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Accepted: 02/27/2009] [Indexed: 11/10/2022] Open
Abstract
Background Cerebral malaria (CM) is associated with high mortality and morbidity caused by a high rate of transient or persistent neurological sequelae. Studies on immunomodulatory and neuroprotective drugs as ancillary treatment in murine CM indicate promising potential. The current study was conducted to evaluate the efficacy of glatiramer acetate (GA), an immunomodulatory drug approved for the treatment of relapsing remitting multiple sclerosis, in preventing the death of C57Bl/6J mice infected with Plasmodium berghei ANKA. Methods and Results GA treatment led to a statistically significant lower risk for developing CM (57.7% versus 84.6%) in treated animals. The drug had no effect on the course of parasitaemia. The mechanism of action seems to be an immunomodulatory effect since lower IFN-gamma levels were observed in treated animals in the early course of the disease (day 4 post-infection) which also led to a lower number of brain sequestered leukocytes in treated animals. No direct neuro-protective effect such as an inhibition of apoptosis or reduction of micro-bleedings in the brain was found. Conclusion These findings support the important role of the host immune response in the pathophysiology of murine CM and might lead to the development of new adjunctive treatment strategies.
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Affiliation(s)
- Peter Lackner
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria.
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17
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van der Heyde HC, Nolan J, Combes V, Gramaglia I, Grau GE. A unified hypothesis for the genesis of cerebral malaria: sequestration, inflammation and hemostasis leading to microcirculatory dysfunction. Trends Parasitol 2006; 22:503-8. [PMID: 16979941 DOI: 10.1016/j.pt.2006.09.002] [Citation(s) in RCA: 304] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 08/10/2006] [Accepted: 09/01/2006] [Indexed: 11/25/2022]
Abstract
A unifying hypothesis for the genesis of cerebral malaria proposes that parasite antigens (released by replication in blood, surface molecules on parasitized erythrocytes, or merozoites) activate platelets that, in turn, contribute to the activation of the inflammatory response and increased levels of endothelial cell adhesion molecules (eCAMs). Increased levels of eCAMs result in further parasitized-erythrocyte sequestration and marked local inflammation that might disrupt the brain microvasculature, which cannot be repaired by the hemostasis system because of its procoagulant state. Disruption of the brain microvasculature can result in vascular leak and/or hemorrhaging into the brain; similar processes can occur in other vascular beds, including the lung. The blockage of functional capillaries by parasitized and/or unparasitized erythrocytes with decreased deformability or rosettes is also a key interaction between hemostasis and mechanical obstruction leading to pathogenesis. The events resulting in the development of cerebral malaria complications are multi-factorial, encompassing a dynamic interaction between three processes, thereby explaining the complexity of this deadly syndrome.
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Abstract
Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence
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Kuhn SM, McCarthy AE. Paediatric malaria: What do paediatricians need to know? Paediatr Child Health 2006; 11:349-54. [PMID: 19030303 PMCID: PMC2528622 DOI: 10.1093/pch/11.6.349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Although malaria is principally a disease of the tropical and subtropical regions of the world, it is an important disease to be familiar with for both local and global reasons. It remains to be one of the most important infectious diseases of the world, particularly in sub-Saharan Africa, killing more than one million people - mostly children - every year. In Canada, at least 350 to 1100 imported cases are reported annually, 25% of which are in the paediatric age group, as a result of both travel and migration. Because malaria is a potentially severe and sometimes fatal disease that is unfamiliar to many paediatricians in Canada, it is important that clinicians become familiar with its clinical presentation; understand when it should be suspected; and have an approach to prompt diagnosis, appropriate treatment and effective prevention methods.
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Affiliation(s)
- Susan M Kuhn
- Alberta Children’s Hospital and University of Calgary, Calgary, Alberta
| | - Anne E McCarthy
- Ottawa Hospital General Campus, University of Ottawa, Ottawa, Ontario
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