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Mahor H, Mukherjee A, Sarkar A, Saha B. Anti-leishmanial therapy: Caught between drugs and immune targets. Exp Parasitol 2023; 245:108441. [PMID: 36572088 DOI: 10.1016/j.exppara.2022.108441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/12/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
Leishmaniasis is an enigmatic disease that has very restricted options for chemotherapy and none for prophylaxis. As a result, deriving therapeutic principles for curing the disease has been a major objective in Leishmania research for a long time. Leishmania is a protozoan parasite that lives within macrophages by subverting or switching cell signaling to the pathways that ensure its intracellular survival. Therefore, three groups of molecules aimed at blocking or eliminating the parasite, at least, in principle, include blockers of macrophage receptor- Leishmania ligand interaction, macrophage-activating small molecules, peptides and cytokines, and signaling inhibitors or activators. Macrophages also act as an antigen-presenting cell, presenting antigen to the antigen-specific T cells to induce activation and differentiation of the effector T cell subsets that either execute or suppress anti-leishmanial functions. Three groups of therapeutic principles targeting this sphere of Leishmania-macrophage interaction include antibodies that block pro-leishmanial response of T cells, ligands that activate anti-leishmanial T cells and the antigens for therapeutic vaccines. Besides these, prophylactic vaccines have been in clinical trials but none has succeeded so far. Herein, we have attempted to encompass all these principles and compose a comprehensive review to analyze the feasibility and adoptability of different therapeutics for leishmaniasis.
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Affiliation(s)
- Hima Mahor
- National Centre for Cell Science, Ganeshkhind, Pune, 411007, India
| | - Arka Mukherjee
- Trident Academy of Creative Technology, Bhubaneswar, 751024, Odisha, India
| | - Arup Sarkar
- Trident Academy of Creative Technology, Bhubaneswar, 751024, Odisha, India
| | - Bhaskar Saha
- National Centre for Cell Science, Ganeshkhind, Pune, 411007, India; Trident Academy of Creative Technology, Bhubaneswar, 751024, Odisha, India.
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Seth A, Kar S. Host-directed antileishmanial interventions: Harvesting unripe fruits to reach fruition. Int Rev Immunol 2022; 42:217-236. [PMID: 35275772 DOI: 10.1080/08830185.2022.2047670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Leishmaniasis is an exemplary paradigm of immune evasion, fraught with the perils of limited clinical assistance, escalating costs of treatment and made worse with the lack of suitable vaccine. While drugs remain central to large-scale disease control, the growing emergence of parasite resistance necessitates the need for combination therapy involving host-directed immunological agents. Also, since prolonged disease progression is associated with strong immune suppression of the host, augmentation of host immunity via restoration of the immunoregulatory circuit involving antigen-presenting cells and T-cells, activation of macrophage function and/or CD4+ T helper 1 cell differentiation may serve as an ideal approach to resolve severe cases of leishmaniasis. As such, therapies that embody a synergistic approach that involve direct killing of the parasite in addition to elevating host immunity are likely to pave the way for widespread elimination of leishmaniasis in the future. With this review, we aim to recapitulate the various immunotherapeutic agents found to hold promise in antileishmanial treatment both in vitro and in vivo. These include parasite-specific antigens, dendritic cell-targeted therapy, recombinant inhibitors of various components intrinsic to immune cell signaling and agonists or antagonists to immune cells and cytokines. We also summarize their abilities to direct therapeutic skewing of the host cell-immune response and review their potential to combat the disease either alone, or as adjunct modalities.
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Affiliation(s)
- Anuradha Seth
- Division of Molecular Microbiology and Immunology, CSIR-Central Drug Research Institute, Lucknow, India.,Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, Uttar Pradesh, India
| | - Susanta Kar
- Division of Molecular Microbiology and Immunology, CSIR-Central Drug Research Institute, Lucknow, India
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3
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Segarra S. Nutritional Modulation of the Immune Response Mediated by Nucleotides in Canine Leishmaniosis. Microorganisms 2021; 9:2601. [PMID: 34946204 PMCID: PMC8703464 DOI: 10.3390/microorganisms9122601] [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: 11/08/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 12/24/2022] Open
Abstract
Leishmaniasis is an emerging, uncontrolled, and neglected zoonotic disease. Climate change is contributing to its ongoing global expansion. The dog is the main reservoir; hence the importance of implementing effective treatment, prevention, and control measures in this animal species to protect public health. However, although the standard treatment for canine leishmaniosis (CanL) is effective, it does not provide full parasitological clearance, and side effects and drug resistance have been described. The host's immune system plays a key role in the establishment and evolution of leishmaniasis. Dietary nucleotides modulate the immune response and, given their reported efficacy and safety in sick and clinically healthy Leishmania-infected dogs and because they represent a sustainable option with no associated side effects or resistance, they could be included within the prevention, treatment, and control strategies for leishmaniasis. This article briefly summarizes the scientific literature on CanL management, including unresolved issues, and reviews the scientific evidence on immunomodulatory effects of dietary nucleotides in different animal species. It also proposes a CanL management algorithm, including nucleotides. It is concluded that nutritional modulation of the immune response with nucleotides can contribute to better management of leishmaniasis following a One Health approach, especially in the COVID-19 era.
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Affiliation(s)
- Sergi Segarra
- R&D Bioiberica S.A.U., 08950 Esplugues de Llobregat, Spain
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4
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Cardoso JMDO, Brito RCFD, Mathias FAS, Reis LES, Vieira JFP, Ostolin TLVDP, Andrade HMD, Ramos GS, Frézard F, Aguiar-Soares RDDO, Roatt BM, Reis AB. Comparative evaluation of meglumine antimoniate encapsulated in a mixture of conventional and PEGylated liposomes and immunotherapy using an anti-canine IL-10 receptor-blocking monoclonal antibody on canine visceral leishmaniasis. Mol Immunol 2021; 141:70-78. [PMID: 34814056 DOI: 10.1016/j.molimm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/28/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
This study compared the therapeutic potential of the chemotherapy using meglumine antimoniate encapsulated in a mixture of conventional and PEGylated liposomes (Nano Sbv) and immunotherapy with anti-canine IL-10 receptor-blocking monoclonal antibody (Anti IL-10R) on canine visceral leishmaniasis (CVL). Twenty mongrel dogs naturally infected by L. infantum, displaying clinical signs of visceral leishmaniasis were randomly divided in two groups. In the first one, nine dogs received six intravenous doses of a mixture of conventional and PEGylated liposomes containing meglumine antimoniate at 6.5 mg Sb/kg/dose. In the second one, eleven dogs received two intramuscular doses of 4 mg of anti-canine IL-10 receptor-blocking monoclonal antibody. The animals were evaluated before (T0) and 30, 90, and 180 days after treatments. Our major results demonstrated that both treatments were able to maintain hematological and biochemical parameters, increase circulating T lymphocytes subpopulations, increase the IFN-γ producing T-CD4 lymphocytes, restore the lymphoproliferative capacity and improve the clinical status. However, although these improvements were observed in the initial post-treatment times, they did not maintain until the end of the experimental follow-up. We believe that the use of booster doses or the association of chemotherapy and immunotherapy (immunochemotherapy) is promising to improve the effectiveness of treating CVL for improving the clinical signs and possibly reducing the parasite burden in dogs infected with Leishmania infantum.
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Affiliation(s)
- Jamille Mirelle de Oliveira Cardoso
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Rory Cristiane Fortes de Brito
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Fernando Augusto Siqueira Mathias
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - Levi Eduardo Soares Reis
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | - João Filipe Pereira Vieira
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil
| | | | - Hélida Monteiro de Andrade
- Laboratório de Leishmanioses, Departamento de Parasitologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Guilherme Santos Ramos
- Laboratório de Biofísica de Sistemas Nanoestruturados, Departamento de Fisiologia e Biofısica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Frédéric Frézard
- Laboratório de Biofísica de Sistemas Nanoestruturados, Departamento de Fisiologia e Biofısica, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Bruno Mendes Roatt
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais, INCT-DT, Brazil
| | - Alexandre Barbosa Reis
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais, INCT-DT, Brazil.
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5
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Pradhan S, Schwartz RA, Patil A, Grabbe S, Goldust M. Treatment options for leishmaniasis. Clin Exp Dermatol 2021; 47:516-521. [PMID: 34480806 DOI: 10.1111/ced.14919] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
Leishmaniasis is broadly classified into three types: cutaneous, mucocutaneous and visceral. The visceral form is most dangerous and can result in death. Although leishmaniasis is an ancient disease, its treatment is still challenging. Several drugs, differing in their cost, toxicity, treatment duration and emergence of drug resistance, are used for different types of leishmaniasis. To overcome these limitations, the search for newer drugs and other treatments continues. In this article, we discuss conventional drugs, other treatments, including newer options such as immunotherapy and immunochemotherapy, and future prospects for leishmaniasis treatment.
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Affiliation(s)
| | - R A Schwartz
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - A Patil
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - S Grabbe
- Department of Pharmacology, DY Patil Deemed, To Be University, Navi Mumbai, Maharashtra, India.,Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - M Goldust
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
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6
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Silva JC, Lins CR, Lacerda SS, Ramos RE, Araújo HD, Melo-Junior MR, Alves LC, Brayner FA, Nunes IS, Melo FL, Carvalho BM. In vitro and in vivo effects of P-MAPA immunomodulator on schistosomiasis. Acta Trop 2021; 218:105909. [PMID: 33789153 DOI: 10.1016/j.actatropica.2021.105909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
Schistosomiasis is an infectious disease caused by helminth parasites of the genus Schistosoma; it is transmitted in over 78 countries. The main strategy for schistosomiasis control is treatment of infected people with praziquantel (PZQ). As PZQ-resistant strains have emerged, new anti-schistosomal agents have become necessary. We evaluated the in vitro and in vivo effect of P-MAPA, an aggregated polymer of protein magnesium ammonium phospholinoleate-palmitoleate anhydride with immunomodulatory properties; it is produced by Aspergillus oryzae fermentation. In vitro, P-MAPA (5, 50, and 100 µg/mL) damaged the Schistosoma mansoni tegument, causing thorn losses and tuber destruction in male worms and peeling and erosion in females after 24-h incubation. In vivo, P-MAPA (5 and 100 mg/kg, alone and combined with PZQ - 50 mg/kg) reduced the number of eggs by up to 69.20% in the liver and 88.08% in the intestine. Furthermore, granulomas were reduced up to 83.13%, and there was an increase in the number of dead eggs and a reduction of serum aspartate aminotransferase levels. These data suggest that P-MAPA activity can help improve schistosomiasis treatment and patients' quality of life.
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P-MAPA, a Fungi-Derived Immunomodulatory Compound, Induces a Proinflammatory Response in a Human Whole Blood Model. Mediators Inflamm 2020; 2020:8831389. [PMID: 33299378 PMCID: PMC7707968 DOI: 10.1155/2020/8831389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/29/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
P-MAPA is a complex compound, derived from Aspergillus oryzae cultures, that has shown immunomodulatory properties in infection and cancer animal models. Despite promising results in these models, the mechanisms of cellular activation by P-MAPA, suggested to be Toll-like receptor- (TLR-) dependent, and its effect on human immune cells, remain unclear. Using an ex vivo model of human whole blood, the effects of P-MAPA on complement system activation, production of cytokines, and the expression of complement receptors (CD11b, C5aR, and C3aR), TLR2, TLR4, and the coreceptor CD14 were analyzed in neutrophils and monocytes. P-MAPA induced complement activation in human blood, detected by increased levels of C3a, C5a, and SC5b-9 in plasma. As a consequence, CD11b expression increased and C5aR decreased upon activation, while C3aR expression remained unchanged in leukocytes. TLR2 and TLR4 expressions were not modulated by P-MAPA treatment on neutrophils, but TLR4 expression was reduced in monocytes, while CD14 expression increased in both cell types. P-MAPA also induced the production of TNF-α, IL-8, and IL-12 and oxidative burst, measured by peroxynitrite levels, in human leukocytes. Complement inhibition with compstatin showed that P-MAPA-induced complement activation drives modulation of C5aR, but not of CD11b, suggesting that P-MAPA acts through both complement-dependent and complement-independent mechanisms. Compstatin also significantly reduced the peroxynitrite generation. Altogether, our results show that P-MAPA induced proinflammatory response in human leukocytes, which is partially mediated by complement activation. Our data contribute to elucidate the complement-dependent and complement-independent mechanisms of P-MAPA, which ultimately result in immune cell activation and in its immunomodulatory properties in infection and cancer animal models.
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8
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Silva JCS, Bernardes MVADS, Melo FL, Sá MPBO, Carvalho BM. Praziquantel versus praziquantel associated with immunomodulators in mice infected with schistosoma mansoni: A systematic review and meta-analysis. Acta Trop 2020; 204:105359. [PMID: 31987779 DOI: 10.1016/j.actatropica.2020.105359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 01/16/2020] [Accepted: 01/23/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Juliana Carla Serafim Silva
- Faculty of Medical Sciences - University of Pernambuco (FCM/UPE), Rua Arnóbio Marques, 310, Santo Amaro, Recife, Pernambuco, Brazil, CEP: 50.100-130
| | | | - Fábio Lopes Melo
- Aggeu Magalhães Institute (IAM), Campus da UFPE - Av. Prof. Moraes Rego, s/n - Cidade Universitária, Recife, Pernambuco, Brazil, CEP 50.670-420
| | - Michel Pompeu Barros Oliveira Sá
- Faculty of Medical Sciences - University of Pernambuco (FCM/UPE), Rua Arnóbio Marques, 310, Santo Amaro, Recife, Pernambuco, Brazil, CEP: 50.100-130
| | - Bruno Melo Carvalho
- Faculty of Medical Sciences - University of Pernambuco (FCM/UPE), Rua Arnóbio Marques, 310, Santo Amaro, Recife, Pernambuco, Brazil, CEP: 50.100-130; Institute of Biological Sciences - University of Pernambuco (ICB/UPE), Rua Arnóbio Marques, 310, Santo Amaro, Recife, Pernambuco, Brazil. CEP: 50.100-130.
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Gonçalves AAM, Leite JC, Resende LA, Mariano RMDS, Silveira P, Melo-Júnior OADO, Ribeiro HS, de Oliveira DS, Soares DF, Santos TAP, Marques AF, Galdino AS, Martins-Filho OA, Dutra WO, da Silveira-Lemos D, Giunchetti RC. An Overview of Immunotherapeutic Approaches Against Canine Visceral Leishmaniasis: What Has Been Tested on Dogs and a New Perspective on Improving Treatment Efficacy. Front Cell Infect Microbiol 2019; 9:427. [PMID: 31921703 PMCID: PMC6930146 DOI: 10.3389/fcimb.2019.00427] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 11/29/2019] [Indexed: 12/14/2022] Open
Abstract
Visceral leishmaniasis (VL), caused by digenetic protozoa of the genus Leishmania, is the most severe form of leishmaniasis. Leishmania infantum is one of the species responsible for VL and the disease caused is considered a zoonosis whose main reservoir is the dog. Canine visceral leishmaniasis (CVL) can lead to the death of the animal if left untreated. Furthermore, the available pharmocologial treatment for CVL presents numerous disadvantages, such as relapses, toxicity, drug resistance, and the fact treated animals continue to be reservoirs when treatment fails to achieve parasitological cure. Moreover, the available VL control methods have not been adequate when it comes to controlling parasite transmission. Advances in immune response knowledge in recent years have led to a better understanding of VL pathogenesis, allowing new treatments to be developed based on immune system activation, often referred to as immunotherapy. In fact, well-defined protocols have been described, ranging from the use of immunomodulators to the use of vaccines. This treatment, which can also be associated with chemotherapy, has been shown to be effective in restoring or inducing an adequate immune response to reduce parasitic burden, leading to clinical improvement. This review focuses on immunotherapy directed at dogs infected by L. infantum, including a literature review of what has already been done in dogs. We also introduce a promising strategy to improve the efficacy of immunotherapy.
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Affiliation(s)
- Ana Alice Maia Gonçalves
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Jaqueline Costa Leite
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Lucilene Aparecida Resende
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Reysla Maria da Silveira Mariano
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Patricia Silveira
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Otoni Alves de Oliveira Melo-Júnior
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Helen Silva Ribeiro
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Diana Souza de Oliveira
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Diogo Fonseca Soares
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Thaiza Aline Pereira Santos
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Alexandre Ferreira Marques
- Laboratory of Immuno-Proteome and Parasite Biology, Department of Parasitology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Olindo Assis Martins-Filho
- Laboratory of Diagnostic and Monitoring Biomarkers, René Rachou Institute, FIOCRUZ-Minas, Belo Horizonte, Brazil
| | - Walderez Ornelas Dutra
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Denise da Silveira-Lemos
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Rodolfo Cordeiro Giunchetti
- Laboratory of Biology of Cell Interactions, Department of Morphology, Institute of Biological Sciences, Federal University of Minas Gerais, Belo Horizonte, Brazil
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10
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Need for sustainable approaches in antileishmanial drug discovery. Parasitol Res 2019; 118:2743-2752. [DOI: 10.1007/s00436-019-06443-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/23/2019] [Indexed: 12/16/2022]
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11
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Immunotherapy in clinical canine leishmaniosis: a comparative update. Res Vet Sci 2019; 125:218-226. [PMID: 31280121 DOI: 10.1016/j.rvsc.2019.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 05/22/2019] [Accepted: 06/18/2019] [Indexed: 12/13/2022]
Abstract
Leishmaniosis due to Leishmania infantum is a complex infection that can affect both humans and dogs, and present a wide range of clinical signs and clinicopathological abnormalities. The conventional treatment of this disease is challenging due to the fact that complete parasitological cure commonly does not occur. Furthermore, treatment of the disease with the conventionally used drugs has several shortcomings. These include the need for long-term treatment, side effects and the formation of drug resistance. Moreover, it is important to highlight that the host immune responses play a crucial role in the outcome of this infection. For this reason, the use of immunotherapy in clinical leishmaniosis to improve the result of treatment with the conventional anti-leishmanial drugs by enhancing the immune response is imperative. The aim of this review is to provide a comparative overview of the wide range of immunotherapeutical approaches and strategies for the treatment of L. infantum infection in animals focusing on dogs.
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Segarra S, Miró G, Montoya A, Pardo-Marín L, Teichenné J, Ferrer L, Cerón JJ. Prevention of disease progression in Leishmania infantum-infected dogs with dietary nucleotides and active hexose correlated compound. Parasit Vectors 2018; 11:103. [PMID: 29467015 PMCID: PMC5822671 DOI: 10.1186/s13071-018-2705-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 02/12/2018] [Indexed: 12/14/2022] Open
Abstract
Background The prevalence of Leishmania infantum infection in clinically healthy dogs can be several times higher than that of clinical disease in endemic areas. Although treatment is not recommended in dogs with subclinical infection, these animals should be managed to prevent disease progression and parasite transmission to human beings or to other dogs. Dietary nucleotides and active hexose correlated compound (AHCC) have been shown to modulate the immune response. A recent study in dogs with clinical leishmaniosis receiving an initial 28-day course of methylglucamine antimoniate showed that six-month administration of a dietary supplement containing nucleotides plus AHCC achieves similar efficacy to allopurinol. Since the type of immune response plays a key role in the evolution of patients with leishmaniosis, the present study was aimed at evaluating the preventive effect of this supplement in avoiding or delaying disease progression in clinically healthy Leishmania-infected dogs. Methods Forty-six dogs were included in this multicenter, randomized, double-blind, placebo-controlled trial. Dogs received once-daily oral administration of a placebo or a dietary supplement containing nucleotides plus AHCC. Disease progression was monitored throughout the study in both groups. At 0, 60, 180 and 365 days of treatment, clinical signs were evaluated using a validated clinical scoring system, and several analytes were measured from blood, urine, and bone marrow samples. Results During the study, a significantly lower (P = 0.047) proportion of dogs changed their clinical status and became sick in the supplement group (3/20; 15%), compared to the placebo group (10/22; 45.5%). ELISA-determined antibody titers were significantly reduced compared to baseline at all time points with the supplement (P < 0.01), but not with the placebo. The mean clinical score of disease severity was significantly lower in the supplement group after 180 days (P = 0.014). No significant differences were observed for the other parameters. The dietary supplement was well tolerated. Conclusions Oral administration of nucleotides plus AHCC for 365 days in clinically healthy L. infantum-infected dogs is safe, allows a significant reduction in anti-Leishmania antibodies, and leads to a lower disease progression rate, hence exerting a preventive effect.
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Affiliation(s)
- Sergi Segarra
- R&D Bioiberica S.A.U, pl. Francesc Macià 7, 08029, Barcelona, Spain.
| | - Guadalupe Miró
- Department of Animal Health, Veterinary Faculty, Universidad Complutense de Madrid, Avda. Puerta de Hierro s/n, 28040, Madrid, Spain
| | - Ana Montoya
- Department of Animal Health, Veterinary Faculty, Universidad Complutense de Madrid, Avda. Puerta de Hierro s/n, 28040, Madrid, Spain
| | - Luis Pardo-Marín
- Interlab-UMU, Campus de Excelencia "Mare Nostrum", University of Murcia, Campus Espinardo, 30071, Murcia, Spain
| | - Joan Teichenné
- Eurecat - Health and Nutrition Unit, TECNIO, CEICS, av. Universitat 1, 43204, Reus, Spain
| | - Lluís Ferrer
- Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, 200 Westboro Road, North Grafton, MA, 01536, USA
| | - José Joaquín Cerón
- Interlab-UMU, Campus de Excelencia "Mare Nostrum", University of Murcia, Campus Espinardo, 30071, Murcia, Spain
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13
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Miró G, Petersen C, Cardoso L, Bourdeau P, Baneth G, Solano-Gallego L, Pennisi MG, Ferrer L, Oliva G. Novel Areas for Prevention and Control of Canine Leishmaniosis. Trends Parasitol 2017; 33:718-730. [PMID: 28601528 DOI: 10.1016/j.pt.2017.05.005] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/03/2017] [Accepted: 05/05/2017] [Indexed: 11/19/2022]
Abstract
There have been multiple recent advances regarding tools for the control and prevention of canine leishmaniosis (CanL), including new preventative vaccines. In this review, these advances are evaluated based on control targets, including vector and parasite. Leishvet recommendations are provided for control practices based on the dog's risk of infection. New topical insecticide formulations have proven to be effective in preventing sand fly bites, and subsequently infection. Parasite control occurs through chemotherapeutic or immunologic means, which decrease or prevent transmission to other animals, including humans. Leishmaniosis control programs that include a combination of coordinated measures, either in individuals or for prevention across reservoir populations, are required.
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Affiliation(s)
- Guadalupe Miró
- Department of Animal Health, Veterinary Faculty, Universidad Complutense de Madrid, Madrid, Spain
| | - Christine Petersen
- College of Public Health, Center for Emerging Infectious Diseases, University of Iowa, Iowa City, Iowa, USA.
| | - Luís Cardoso
- Department of Veterinary Sciences, School of Agrarian and Veterinary Sciences, University of Trás-os-Montes e Alto Douro (UTAD), Vila Real, Portugal
| | - Patrick Bourdeau
- Veterinary School of Nantes ONIRIS, University of Nantes, LUNAM, Nantes 44307, France
| | - Gad Baneth
- Koret School of Veterinary Medicine, The Hebrew University of Jerusalem, P.O. Box 12, Rehovot 76100, Israel
| | - Laia Solano-Gallego
- Departament de Medicina i Cirurgia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Bellaterra 08193, Spain
| | - Maria Grazia Pennisi
- Department of Veterinary Sciences, University of Messina, Polo Universitario Annunziata, Messina 98168, Italy
| | - Lluís Ferrer
- Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, USA
| | - Gaetano Oliva
- Department of Veterinary Medicine and Food Production, University of Naples Federico II, Via Delpino 1, Naples 80137, Italy
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14
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Roatt BM, Aguiar-Soares RDDO, Reis LES, Cardoso JMDO, Mathias FAS, de Brito RCF, da Silva SM, Gontijo NDF, Ferreira SDA, Valenzuela JG, Corrêa-Oliveira R, Giunchetti RC, Reis AB. A Vaccine Therapy for Canine Visceral Leishmaniasis Promoted Significant Improvement of Clinical and Immune Status with Reduction in Parasite Burden. Front Immunol 2017; 8:217. [PMID: 28321217 PMCID: PMC5338076 DOI: 10.3389/fimmu.2017.00217] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/15/2017] [Indexed: 12/18/2022] Open
Abstract
Herein, we evaluated the treatment strategy employing a therapeutic heterologous vaccine composed of antigens of Leishmania braziliensis associated with MPL adjuvant (LBMPL vaccine) for visceral leishmaniasis (VL) in symptomatic dogs naturally infected by Leishmania infantum. Sixteen dogs received immunotherapy with MPL adjuvant (n = 6) or with a vaccine composed of antigens of L. braziliensis associated with MPL (LBMPL vaccine therapy, n = 10). Dogs were submitted to an immunotherapeutic scheme consisting of 3 series composed of 10 subcutaneous doses with 10-day interval between each series. The animals were evaluated before (T0) and 90 days after treatment (T90) for their biochemical/hematological, immunological, clinical, and parasitological variables. Our major results showed that the vaccine therapy with LBMPL was able to restore and normalize main biochemical (urea, AST, ALP, and bilirubin) and hematological (erythrocytes, hemoglobin, hematocrit, and platelets) parameters. In addition, in an ex vivo analysis using flow cytometry, dogs treated with LBMPL vaccine showed increased CD3+ T lymphocytes and their subpopulations (TCD4+ and TCD8+), reduction of CD21+ B lymphocytes, increased NK cells (CD5-CD16+) and CD14+ monocytes. Under in vitro conditions, the animals developed a strong antigen-specific lymphoproliferation mainly by TCD4+ and TCD8+ cells; increasing in both TCD4+IFN-γ+ and TCD8+IFN-γ+ as well as reduction of TCD4+IL-4+ and TCD8+IL-4+ lymphocytes with an increased production of TNF-α and reduced levels of IL-10. Concerning the clinical signs of canine visceral leishmaniasis, the animals showed an important reduction in the number and intensity of the disease signs; increase body weight as well as reduction of splenomegaly. In addition, the LBMPL immunotherapy also promoted a reduction in parasite burden assessed by real-time PCR. In the bone marrow, we observed seven times less parasites in LBMPL animals compared with MPL group. The skin tissue showed a reduction in parasite burden in LBMPL dogs 127.5 times higher than MPL. As expected, with skin parasite reduction promoted by immunotherapy, we observed a blocking transmission to sand flies in LBMPL dogs with only three positive dogs after xenodiagnosis. The results obtained in this study highlighted the strong potential for the use of this heterologous vaccine therapy as an important strategy for VL treatment.
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Affiliation(s)
- Bruno Mendes Roatt
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil
| | | | - Levi Eduardo Soares Reis
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto, Minas Gerais , Brazil
| | - Jamille Mirelle de Oliveira Cardoso
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto, Minas Gerais , Brazil
| | - Fernando Augusto Siqueira Mathias
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto, Minas Gerais , Brazil
| | - Rory Cristiane Fortes de Brito
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto, Minas Gerais , Brazil
| | - Sydnei Magno da Silva
- Laboratório de Bioensaios em Leishmania, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia , Uberlândia, Minas Gerais , Brazil
| | - Nelder De Figueiredo Gontijo
- Laboratório de Fisiologia de Insetos Hematófagos, Departamento de Parasitologia, Universidade Federal de Minas Gerais , Belo Horizonte, Minas Gerais , Brazil
| | - Sidney de Almeida Ferreira
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto, Minas Gerais , Brazil
| | - Jesus G Valenzuela
- Vector Molecular Biology Section, Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health , Rockville, MD , USA
| | - Rodrigo Corrêa-Oliveira
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil
| | - Rodolfo Cordeiro Giunchetti
- Laboratório de Biologia das Interações Celulares, Departamento de Morfologia, Universidade Federal de Minas Gerais , Belo Horizonte, Minas Gerais , Brazil
| | - Alexandre Barbosa Reis
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto, Ouro Preto, Minas Gerais, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil
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15
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Reguera RM, Morán M, Pérez-Pertejo Y, García-Estrada C, Balaña-Fouce R. Current status on prevention and treatment of canine leishmaniasis. Vet Parasitol 2016; 227:98-114. [PMID: 27523945 DOI: 10.1016/j.vetpar.2016.07.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 01/17/2023]
Abstract
Canine leishmaniasis (CanL) is a parasite-borne disease mainly induced by Leishmania infantum in the Old World and Leishmania chagasi (infantum) in the New World. CanL is a zoonosis transmitted by the bite of infected Phlebotominae flies that act as vectors. CanL is a very serious disease that usually produces death when remains untreated and can be a focus of transmission to other dogs or humans. Infected dogs and other domestic and wild animals act as reservoirs and are a real threat to uninfected/healthy dogs and humans in endemic areas where the sand flies are present. Prevention of new infections in dogs can help to stop the current increase of the disease in humans, reinforcing the concept of "One Health" approach. The management of CanL is being performed using prophylactic measures in healthy dogs - insecticides impregnated in collars or immunostimulants applied by spot-on devices - and chemotherapy in animals that suffer from the disease. Antimonials as first-line monotherapy have proven efficacy in reducing most of the clinical signs of CanL, but they need to be administered during several days, and no complete parasite clearance is achieved, favouring the presence of relapses among treated dogs. Therefore, new drugs, such as miltefosine, or combinations of this drug or antimonials with allopurinol are in the pipeline of clinical treatment of CanL. Recently, there has been an emergence of protective - prophylactic - and curative - autogenous vaccines - immunotherapy tools to face CanL, whose results are still under study. This review highlights the current use of preventive and eradicative weapons to fight against this disease, which is a scourge for dogs and a continuous threat to human beings.
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Affiliation(s)
- Rosa M Reguera
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Miguel Morán
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Yolanda Pérez-Pertejo
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Carlos García-Estrada
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain; Instituto de Biotecnología de León (INBIOTEC), Parque Científico de León, Avenida Real, n° 1, 24006 León, Spain
| | - Rafael Balaña-Fouce
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain; Instituto de Biotecnología de León (INBIOTEC), Parque Científico de León, Avenida Real, n° 1, 24006 León, Spain.
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16
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Abstract
Canine leishmaniosis (CanL) is caused by the parasite Leishmania infantum and is a systemic disease, which can present with variable clinical signs, and clinicopathological abnormalities. Clinical manifestations can range from subclinical infection to very severe systemic disease. Leishmaniosis is categorized as a neglected tropical disease and the complex immune responses associated with Leishmania species makes therapeutic treatments and vaccine development challenging for both dogs and humans. In this review, we summarize innate and adaptive immune responses associated with L. infantum infection in dogs, and we discuss the problems associated with the disease as well as potential solutions and the future direction of required research to help control the parasite.
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17
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Roatt BM, Aguiar-Soares RDDO, Coura-Vital W, Ker HG, Moreira NDD, Vitoriano-Souza J, Giunchetti RC, Carneiro CM, Reis AB. Immunotherapy and Immunochemotherapy in Visceral Leishmaniasis: Promising Treatments for this Neglected Disease. Front Immunol 2014; 5:272. [PMID: 24982655 PMCID: PMC4055865 DOI: 10.3389/fimmu.2014.00272] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 05/27/2014] [Indexed: 11/25/2022] Open
Abstract
Leishmaniasis has several clinical forms: self-healing or chronic cutaneous leishmaniasis or post-kala-azar dermal leishmaniasis; mucosal leishmaniasis; visceral leishmaniasis (VL), which is fatal if left untreated. The epidemiology and clinical features of VL vary greatly due to the interaction of multiple factors including parasite strains, vectors, host genetics, and the environment. Human immunodeficiency virus infection augments the severity of VL increasing the risk of developing active disease by 100–2320 times. An effective vaccine for humans is not yet available. Resistance to chemotherapy is a growing problem in many regions, and the costs associated with drug identification and development, make commercial production for leishmaniasis, unattractive. The toxicity of currently drugs, their long treatment course, and limited efficacy are significant concerns. For cutaneous disease, many studies have shown promising results with immunotherapy/immunochemotherapy, aimed to modulate and activate the immune response to obtain a therapeutic cure. Nowadays, the focus of many groups centers on treating canine VL by using vaccines and immunomodulators with or without chemotherapy. In human disease, the use of cytokines like interferon-γ associated with pentavalent antimonials demonstrated promising results in patients that did not respond to conventional treatment. In mice, immunomodulation based on monoclonal antibodies to remove endogenous immunosuppressive cytokines (interleukin-10) or block their receptors, antigen-pulsed syngeneic dendritic cells, or biological products like Pam3Cys (TLR ligand) has already been shown as a prospective treatment of the disease. This review addresses VL treatment, particularly immunotherapy and/or immunochemotherapy as an alternative to conventional drug treatment in experimental models, canine VL, and human disease.
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Affiliation(s)
- Bruno Mendes Roatt
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Pesquisas Clínicas, Ciências Farmacêuticas, Escola de Farmácia, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais , Belo Horizonte , Brazil
| | | | - Wendel Coura-Vital
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Pesquisas Clínicas, Ciências Farmacêuticas, Escola de Farmácia, Universidade Federal de Ouro Preto , Ouro Preto , Brazil
| | - Henrique Gama Ker
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Pesquisas Clínicas, Ciências Farmacêuticas, Escola de Farmácia, Universidade Federal de Ouro Preto , Ouro Preto , Brazil
| | - Nádia das Dores Moreira
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil
| | - Juliana Vitoriano-Souza
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil
| | - Rodolfo Cordeiro Giunchetti
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Biologia das Interações Celulares, Departamento de Morfologia, Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Cláudia Martins Carneiro
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Pesquisas Clínicas, Ciências Farmacêuticas, Escola de Farmácia, Universidade Federal de Ouro Preto , Ouro Preto , Brazil
| | - Alexandre Barbosa Reis
- Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Laboratório de Pesquisas Clínicas, Ciências Farmacêuticas, Escola de Farmácia, Universidade Federal de Ouro Preto , Ouro Preto , Brazil ; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais , Belo Horizonte , Brazil
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18
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Effects of P-MAPA immunomodulator on Toll-like receptor 2, ROS, nitric oxide, MAPKp38 and IKK in PBMC and macrophages from dogs with visceral leishmaniasis. Int Immunopharmacol 2013; 18:373-8. [PMID: 24374021 DOI: 10.1016/j.intimp.2013.12.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/09/2013] [Indexed: 11/22/2022]
Abstract
Leishmania (L.) chagasi is the etiologic agent of visceral leishmaniasis (VL) that can be transmitted to humans and dogs. VL in Brazil represents a serious public health problem; therefore, it is important to study new alternatives to treat infected dogs. In dogs, the therapeutic arsenal against canine VL is limited. The immunomodulator protein aggregate magnesium-ammonium phospholinoleate-palmitoleate anhydride (P-MAPA) improves immunocompetence when the immune system is impaired, but its dependence on Toll-like receptors (TLRs) and the mechanisms involved in immune response remain unclear. The in vitro action of P-MAPA on the expression of TLR2 and TLR4, reactive oxygen species (ROS), nitric oxide (NO) and p38 mitogen-activated protein kinase (p38 MAPK) and IKK phosphorylation was studied in mononuclear cells from peripheral blood and macrophages from healthy and Leishmania-infected dogs. The PBMC or macrophages were isolated and cultured with different concentrations of P-MAPA (20,100 and 200 μg/ml) in a humid environment at 37°C with 5% CO(2). Observation revealed that Leishmania-infected dogs showed a decrease in TLR2 in macrophages compared with healthy dogs and in induction with P-MAPA. ROS were increased in PBMCs from Leishmania spp.-infected dogs compared with healthy dogs and P-MAPA improved ROS production. NO production was increased in culture supernatant from macrophages stimulated by P-MAPA in both healthy and Leishmania spp. infected dogs. Treatment of macrophages from healthy dogs with immunomodulatory P-MAPA induced p38 MAPK and IKK phosphorylation, suggesting signal transduction by this pathway. These findings suggest that P-MAPA has potential as a therapeutic drug in the treatment of canine visceral leishmaniasis.
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