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Bruno F, Castelli G, Li B, Reale S, Carra E, Vitale F, Scibetta S, Calzolari M, Varani S, Ortalli M, Franceschini E, Gennari W, Rugna G, Späth GF. Genomic and epidemiological evidence for the emergence of a L. infantum/L. donovani hybrid with unusual epidemiology in northern Italy. mBio 2024:e0099524. [PMID: 38832792 DOI: 10.1128/mbio.00995-24] [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: 04/04/2024] [Accepted: 04/30/2024] [Indexed: 06/05/2024] Open
Abstract
Leishmania (L.) infantum is one of the main causative agents of animal and human leishmaniasis across many endemic areas in South America, Europe, North Africa, and Asia. Despite its clinical significance, little is known about the genetic diversity of L. infantum circulating in a given endemic area. Here, we investigate this important open question by applying a comparative genomics approach to seven L. infantum isolates from different hosts and Italian regions, including the northern part of the country (Emilia-Romagna, RER), Sicily, and Sardinia, as an initial attempt to explore the breadth of parasite genetic heterogeneity in Italy. Additionally, microsatellite analysis was carried out to compare the isolates from RER with other 70 L. infantum strains from the same region as well as 65 strains belonging to the L. donovani complex from other countries. We revealed important karyotypic instability and identified strain-specific changes in gene dosage, which affected important virulence factors such as amastins and surface antigen-like proteins. Single nucleotide polymorphism-based clustering analysis of these genomes together with over 80 publicly available L. infantum and L. donovani genomes placed the Italian isolates into three geographically distinct clusters within the Mediterranean basin and uncovered three isolates clustering with putative L. infantum/L. donovani hybrids isolated in Cyprus. As judged by microsatellite profiling, these hybrid isolates are representative of a sub-population of parasites circulating in northern Italy that preferentially infect humans but not dogs. Our results place Italy at the crossroads of L. infantum infection in the Mediterranean and call attention to the public health risk represented by the introduction of non-European Leishmania species.IMPORTANCEThis study closes important knowledge gaps with respect to Leishmania (L.) infantum genetic heterogeneity in a given endemic country, as exemplified here for Italy, and reveals genetic hybridization as a main cause for re-emerging human leishmaniasis in northern Italy. The observed high diversity of Leishmania parasites on the Italian peninsula suggests different geographical origins, with genomic adaptation to various ecologies affecting both pathogenicity and transmission potential. This is documented by the discovery of a putative L. infantum/L. donovani hybrid strain, which has been shown to preferentially infect humans but not dogs. Our results provide important information to health authorities, which need to consider the public health risk represented by the introduction of new Leishmania species into EU countries due to population displacement or travel from countries where exotic/allochthonous parasite species are endemic.
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Affiliation(s)
- F Bruno
- WOAH Leishmania Reference Laboratory, Istituto Zooprofilattico Sperimentale della Sicilia, Centro di Referenza Nazionale per le Leishmaniosi (C.Re.Na.L.), Palermo, Italy
| | - G Castelli
- WOAH Leishmania Reference Laboratory, Istituto Zooprofilattico Sperimentale della Sicilia, Centro di Referenza Nazionale per le Leishmaniosi (C.Re.Na.L.), Palermo, Italy
| | - B Li
- Bioinformatics and Biostatistics Hub, Institut Pasteur, Université Paris Cité, Paris, France
| | - S Reale
- WOAH Leishmania Reference Laboratory, Istituto Zooprofilattico Sperimentale della Sicilia, Centro di Referenza Nazionale per le Leishmaniosi (C.Re.Na.L.), Palermo, Italy
| | - E Carra
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Brescia, Italy
| | - F Vitale
- WOAH Leishmania Reference Laboratory, Istituto Zooprofilattico Sperimentale della Sicilia, Centro di Referenza Nazionale per le Leishmaniosi (C.Re.Na.L.), Palermo, Italy
| | - S Scibetta
- WOAH Leishmania Reference Laboratory, Istituto Zooprofilattico Sperimentale della Sicilia, Centro di Referenza Nazionale per le Leishmaniosi (C.Re.Na.L.), Palermo, Italy
| | - M Calzolari
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Brescia, Italy
| | - S Varani
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - M Ortalli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - E Franceschini
- Infectious Disease Unit, Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | - W Gennari
- Virology and Molecular Microbiology Unit, University Hospital of Modena, Modena, Italy
| | - G Rugna
- Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia Romagna "B. Ubertini", Brescia, Italy
| | - G F Späth
- Unité de Parasitologie moléculaire et Signalisation, INSERM U1201, Institut Pasteur, Université Paris Cité, Paris, France
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Madusanka RK, Karunaweera ND, Silva H, Selvapandiyan A. Antimony resistance and gene expression in Leishmania: spotlight on molecular and proteomic aspects. Parasitology 2024; 151:1-14. [PMID: 38012864 PMCID: PMC10941051 DOI: 10.1017/s0031182023001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/04/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
Leishmaniasis is a vector-borne parasitic disease caused by Leishmania parasites with a spectrum of clinical manifestations, ranging from skin lesions to severe visceral complications. Treatment of this infection has been extremely challenging with the concurrent emergence of drug resistance. The differential gene expression and the discrepancies in protein functions contribute to the appearance of 2 distinct phenotypes: resistant and sensitive, but the current diagnostic tools fail to differentiate between them. The identification of gene expression patterns and molecular mechanisms coupled with antimony (Sb) resistance can be leveraged to prompt diagnosis and select the most effective treatment methods. The present study attempts to use comparative expression of Sb resistance-associated genes in resistant and sensitive Leishmania, to disclose their relative abundance in clinical or in vitro selected isolates to gain an understanding of the molecular mechanisms of Sb response/resistance. Data suggest that the analysis of resistance gene expression would verify the Sb resistance or susceptibility only to a certain extent; however, none of the individual expression patterns of the studied genes was diagnostic as a biomarker of Sb response of Leishmania. The findings highlighted will be useful in bridging the knowledge gap and discovering innovative diagnostic tools and novel therapeutic targets.
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Affiliation(s)
- Rajamanthrilage Kasun Madusanka
- Department of Parasitology, Faculty of Medicine, University of Colombo, No. 25, Kynsey Road, Colombo 8, Sri Lanka
- Department of Molecular Medicine, School of Interdisciplinary Sciences and Technology, Jamia Hamdard, New Delhi 110062, India
| | - Nadira D. Karunaweera
- Department of Parasitology, Faculty of Medicine, University of Colombo, No. 25, Kynsey Road, Colombo 8, Sri Lanka
| | - Hermali Silva
- Department of Parasitology, Faculty of Medicine, University of Colombo, No. 25, Kynsey Road, Colombo 8, Sri Lanka
| | - Angamuthu Selvapandiyan
- Department of Molecular Medicine, School of Interdisciplinary Sciences and Technology, Jamia Hamdard, New Delhi 110062, India
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Kaushal RS, Naik N, Prajapati M, Rane S, Raulji H, Afu NF, Upadhyay TK, Saeed M. Leishmania species: A narrative review on surface proteins with structural aspects involved in host-pathogen interaction. Chem Biol Drug Des 2023; 102:332-356. [PMID: 36872849 DOI: 10.1111/cbdd.14227] [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: 01/13/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
In tropical and subtropical regions of the world, leishmaniasis is endemic and causes a range of clinical symptoms in people, from severe tegumentary forms (such as cutaneous, mucocutaneous, and diffuse leishmaniasis) to lethal visceral forms. The protozoan parasite of the genus Leishmania causes leishmaniasis, which is still a significant public health issue, according to the World Health Organization 2022. The public's worry about the neglected tropical disease is growing as new foci of the illness arise, which are exacerbated by alterations in behavior, changes in the environment, and an enlarged range of sand fly vectors. Leishmania research has advanced significantly during the past three decades in a few different avenues. Despite several studies on Leishmania, many issues, such as illness control, parasite resistance, parasite clearance, etc., remain unresolved. The key virulence variables that play a role in the pathogenicity-host-pathogen relationship of the parasite are comprehensively discussed in this paper. The important Leishmania virulence factors, such as Kinetoplastid Membrane Protein-11 (KMP-11), Leishmanolysin (GP63), Proteophosphoglycan (PPG), Lipophosphoglycan (LPG), Glycosylinositol Phospholipids (GIPL), and others, have an impact on the pathophysiology of the disease and enable the parasite to spread the infection. Leishmania infection may arise from virulence factors; they are treatable with medications or vaccinations more promptly and might greatly shorten the duration of treatment. Additionally, our research sought to present a modeled structure of a few putative virulence factors that might aid in the development of new chemotherapeutic approaches for the treatment of leishmaniasis. The predicted virulence protein's structure is utilized to design novel drugs, therapeutic targets, and immunizations for considerable advantage from a higher understanding of the host immune response.
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Affiliation(s)
- Radhey Shyam Kaushal
- Department of Biotechnology, Parul Institute of Applied Sciences and Centre of Research for Development, Parul University, Vadodara, 391760, Gujarat, India
| | - Nidhi Naik
- Department of Microbiology, Parul Institute of Applied Sciences, Parul University, Vadodara, 391760, Gujarat, India
| | - Maitri Prajapati
- Department of Microbiology, Parul Institute of Applied Sciences, Parul University, Vadodara, 391760, Gujarat, India
| | - Shruti Rane
- Department of Microbiology, Parul Institute of Applied Sciences, Parul University, Vadodara, 391760, Gujarat, India
| | - Himali Raulji
- Department of Microbiology, Parul Institute of Applied Sciences, Parul University, Vadodara, 391760, Gujarat, India
| | - Ngo Festus Afu
- Department of Biochemistry, Parul Institute of Applied Sciences, Parul University, Vadodara, 391760, Gujarat, India
| | - Tarun Kumar Upadhyay
- Department of Biotechnology, Parul Institute of Applied Sciences and Centre of Research for Development, Parul University, Vadodara, 391760, Gujarat, India
| | - Mohd Saeed
- Department of Biology, College of Sciences, University of Ha'il, P.O. Box 2440, Hail, 81411, Saudi Arabia
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Kumari D, Mahajan S, Kour P, Singh K. Virulence factors of Leishmania parasite: Their paramount importance in unraveling novel vaccine candidates and therapeutic targets. Life Sci 2022; 306:120829. [PMID: 35872004 DOI: 10.1016/j.lfs.2022.120829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/15/2022] [Accepted: 07/17/2022] [Indexed: 12/30/2022]
Abstract
Leishmaniasis is a neglected tropical disease and remains a global concern for healthcare. It is caused by an opportunistic protozoan parasite belonging to the genus Leishmania and affects millions worldwide. This disease is mainly prevalent in tropical and subtropical regions and is associated with a high risk of public morbidity and mortality if left untreated. Transmission of this deadly disease is aggravated by the bite of female sand-fly vectors (Phlebotomus and Lutzomyia). With time, significant advancement in leishmaniasis-related research has been carried out to cope with the disease burden. Still, the Leishmania parasite has also co-evolved with its host and adapted successfully within the host's lethal milieu/environment. Thus, understanding and knowledge of various leishmanial virulence factors responsible for the parasitic infection are essential for exploring drug targets and vaccine candidates. The present review elucidates the importance of virulence factors in pathogenesis and summarizes the major leishmanial virulence molecules contributing to the parasitic infection during host-pathogen interaction. Furthermore, we have also elaborated on the potential contribution of leishmanial virulence proteins in developing vaccine candidates and exploring novel therapeutics against this parasitic disease. We aim to represent a clearer picture of parasite pathogenesis within the human host that can further aid in unraveling new strategies to fight against the deadly infection of leishmaniasis.
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Affiliation(s)
- Diksha Kumari
- Infectious Diseases Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Shavi Mahajan
- Infectious Diseases Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India
| | - Parampreet Kour
- Infectious Diseases Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India
| | - Kuljit Singh
- Infectious Diseases Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India.
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Phenotypical and genotypical differences among Leishmania (Leishmania) amazonensis isolates that caused different clinical frames in humans and dogs: A systematic review. Acta Trop 2021; 221:106018. [PMID: 34157292 DOI: 10.1016/j.actatropica.2021.106018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/15/2021] [Accepted: 06/15/2021] [Indexed: 11/23/2022]
Abstract
Leishmania (Leishmania) amazonensis is an important etiological agent of American cutaneous leishmaniasis (ACL) in Brazil. The species causes a large spectrum of clinical manifestations in humans and dogs, ranging from cutaneous, cutaneous diffuse, mucocutaneous, and visceral involvement, however, the factors that drive the development of different disease forms by the same species are not yet fully known. In the present work, it was systematically reviewed the studies addressing phenotypic and genotypic characteristics of Leishmania (L.) amazonensis isolates causing cutaneous and visceral clinical frames in humans and dogs, comparing the results observed. For this, four research databases were searched for the following keywords: (Leishmania amazonensis AND visceral leishmaniasis) AND (tropism OR virulence OR visceralization OR adaptations OR mutation OR clinical presentation OR resistance OR survival OR wide spectrum). The results revealed that the complexity disease seems to involve the combination of genetic factors of the parasite (as modifications in molecules related to the virulence and metabolism) and also of the host's immune background and status. Nonetheless, the exact mechanism that leads to different clinical manifestations between strains of the same species is still uncertain and future studies must be developed to better elucidate this phenomenon.
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Bwalya AK, Irekwa RM, Mbugua A, Munyao MM, Rotich PK, Nyandwaro TT, Njoroge CW, Mwangi AW, Yego JJ, Kiyaga S, Nzou SM. Investigation of single nucleotide polymorphisms in <i>MRPA</i> and <i>AQP-1</i> genes of <i>Leishmania donovani</i> as resistance markers in visceral leishmaniasis in Kenya. AIMS MOLECULAR SCIENCE 2021. [DOI: 10.3934/molsci.2021011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Rastrojo A, García-Hernández R, Vargas P, Camacho E, Corvo L, Imamura H, Dujardin JC, Castanys S, Aguado B, Gamarro F, Requena JM. Genomic and transcriptomic alterations in Leishmania donovani lines experimentally resistant to antileishmanial drugs. INTERNATIONAL JOURNAL FOR PARASITOLOGY-DRUGS AND DRUG RESISTANCE 2018; 8:246-264. [PMID: 29689531 PMCID: PMC6039315 DOI: 10.1016/j.ijpddr.2018.04.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/10/2018] [Accepted: 04/10/2018] [Indexed: 12/20/2022]
Abstract
Leishmaniasis is a serious medical issue in many countries around the World, but it remains largely neglected in terms of research investment for developing new control and treatment measures. No vaccines exist for human use, and the chemotherapeutic agents currently used are scanty. Furthermore, for some drugs, resistance and treatment failure are increasing to alarming levels. The aim of this work was to identify genomic and trancriptomic alterations associated with experimental resistance against the common drugs used against VL: trivalent antimony (SbIII, S line), amphotericin B (AmB, A line), miltefosine (MIL, M line) and paromomycin (PMM, P line). A total of 1006 differentially expressed transcripts were identified in the S line, 379 in the A line, 146 in the M line, and 129 in the P line. Also, changes in ploidy of chromosomes and amplification/deletion of particular regions were observed in the resistant lines regarding the parental one. A series of genes were identified as possible drivers of the resistance phenotype and were validated in both promastigotes and amastigotes from Leishmania donovani, Leishmania infantum and Leishmania major species. Remarkably, a deletion of the gene LinJ.36.2510 (coding for 24-sterol methyltransferase, SMT) was found to be associated with AmB-resistance in the A line. In the P line, a dramatic overexpression of the transcripts LinJ.27.T1940 and LinJ.27.T1950 that results from a massive amplification of the collinear genes was suggested as one of the mechanisms of PMM resistance. This conclusion was reinforced after transfection experiments in which significant PMM-resistance was generated in WT parasites over-expressing either gene LinJ.27.1940 (coding for a D-lactate dehydrogenase-like protein, D-LDH) or gene LinJ.27.1950 (coding for an aminotransferase of branched-chain amino acids, BCAT). This work allowed to identify new drivers, like SMT, the deletion of which being associated with resistance to AmB, and the tandem D-LDH-BCAT, the amplification of which being related to PMM resistance.
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Affiliation(s)
- Alberto Rastrojo
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Paola Vargas
- Instituto de Parasitología y Biomedicina ''López-Neyra'' (IPBLN-CSIC), Granada, Spain
| | - Esther Camacho
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Universidad Autónoma de Madrid, Madrid, Spain
| | - Laura Corvo
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Universidad Autónoma de Madrid, Madrid, Spain
| | - Hideo Imamura
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jean-Claude Dujardin
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Santiago Castanys
- Instituto de Parasitología y Biomedicina ''López-Neyra'' (IPBLN-CSIC), Granada, Spain
| | - Begoña Aguado
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Universidad Autónoma de Madrid, Madrid, Spain
| | - Francisco Gamarro
- Instituto de Parasitología y Biomedicina ''López-Neyra'' (IPBLN-CSIC), Granada, Spain.
| | - Jose M Requena
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Universidad Autónoma de Madrid, Madrid, Spain.
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Gene deleted live attenuated Leishmania vaccine candidates against visceral leishmaniasis elicit pro-inflammatory cytokines response in human PBMCs. Sci Rep 2016; 6:33059. [PMID: 27624408 PMCID: PMC5021981 DOI: 10.1038/srep33059] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 08/08/2016] [Indexed: 02/03/2023] Open
Abstract
Currently no effective vaccine is available for human visceral leishmaniasis(VL) caused by Leishmania donovani. Previously, we showed that centrin1 and p27gene deleted live attenuated Leishmania parasites (LdCen1(-/-) and Ldp27(-/-)) are safe, immunogenic and protective in animal models. Here, to assess the correlates of protection, we evaluated immune responses induced by LdCen1(-/-) and Ldp27(-/-) in human blood samples obtained from healthy, healed VL (HVL), post kala-azar dermal leishmaniasis(PKDL) and VL subjects. Both parasites infected human macrophages, as effectively as the wild type parasites. Further, LdCen1(-/-) and Ldp27(-/-) strongly stimulated production of pro-inflammatory cytokines including, IL-12, IFN-γ, TNF-α, IL-2, IL-6 and IL-17 in the PBMCs obtained from individuals with a prior exposure to Leishmania (HVL and PKDL). There was no significant stimulation of anti-inflammatory cytokines (IL-4 and IL-10). Induction of Th1 biased immune responses was supported by a remarkable increase in IFN-γ secreting CD4(+) and CD8(+) T cells and IL-17 secreting CD4(+) cells in PBMCs from HVL cases with no increase in IL-10 secreting T cells. Hence, LdCen1(-/-) and Ldp27(-/-) are promising as live vaccine candidates against VL since they elicit strong protective immune response in human PBMCs from HVL, similar to the wild type parasite infection, mimicking a naturally acquired protection following cure.
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Geiger A, Bossard G, Sereno D, Pissarra J, Lemesre JL, Vincendeau P, Holzmuller P. Escaping Deleterious Immune Response in Their Hosts: Lessons from Trypanosomatids. Front Immunol 2016; 7:212. [PMID: 27303406 PMCID: PMC4885876 DOI: 10.3389/fimmu.2016.00212] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/17/2016] [Indexed: 12/21/2022] Open
Abstract
The Trypanosomatidae family includes the genera Trypanosoma and Leishmania, protozoan parasites displaying complex digenetic life cycles requiring a vertebrate host and an insect vector. Trypanosoma brucei gambiense, Trypanosoma cruzi, and Leishmania spp. are important human pathogens causing human African trypanosomiasis (HAT or sleeping sickness), Chagas' disease, and various clinical forms of Leishmaniasis, respectively. They are transmitted to humans by tsetse flies, triatomine bugs, or sandflies, and affect millions of people worldwide. In humans, extracellular African trypanosomes (T. brucei) evade the hosts' immune defenses, allowing their transmission to the next host, via the tsetse vector. By contrast, T. cruzi and Leishmania sp. have developed a complex intracellular lifestyle, also preventing several mechanisms to circumvent the host's immune response. This review seeks to set out the immune evasion strategies developed by the different trypanosomatids resulting from parasite-host interactions and will focus on: clinical and epidemiological importance of diseases; life cycles: parasites-hosts-vectors; innate immunity: key steps for trypanosomatids in invading hosts; deregulation of antigen-presenting cells; disruption of efficient specific immunity; and the immune responses used for parasite proliferation.
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Affiliation(s)
- Anne Geiger
- UMR INTERTRYP, IRD-CIRAD, CIRAD TA A-17/G, Montpellier, France
| | | | - Denis Sereno
- UMR INTERTRYP, IRD-CIRAD, CIRAD TA A-17/G, Montpellier, France
| | - Joana Pissarra
- UMR INTERTRYP, IRD-CIRAD, CIRAD TA A-17/G, Montpellier, France
| | | | - Philippe Vincendeau
- UMR 177, IRD-CIRAD Université de Bordeaux Laboratoire de Parasitologie, Bordeaux, France
| | - Philippe Holzmuller
- UMRCMAEE CIRAD-INRA TA-A15/G “Contrôle des maladies animales exotiques et émergentes”, Montpellier, France
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Ramesh V, Singh R, Avishek K, Verma A, Deep DK, Verma S, Salotra P. Decline in Clinical Efficacy of Oral Miltefosine in Treatment of Post Kala-azar Dermal Leishmaniasis (PKDL) in India. PLoS Negl Trop Dis 2015; 9:e0004093. [PMID: 26492039 PMCID: PMC4619646 DOI: 10.1371/journal.pntd.0004093] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 08/29/2015] [Indexed: 02/04/2023] Open
Abstract
Background Recent studies have shown significant decline in the final cure rate after miltefosine treatment in visceral leishmaniasis. This study evaluates the efficacy of miltefosine in the treatment of post kala-azar dermal leishmaniasis (PKDL) patients recruited over a period of 5 years with 18 months of follow-up. Methodology In this study 86 confirmed cases of PKDL were treated with two different dosage regimens of miltefosine (Regimen I- 50mg twice daily for 90 days and Regimen II- 50 mg thrice for 60 days) and the clinical outcome assessed monthly. Cure/relapse was ascertained by clinical and histopathological examination, and measuring parasite burden by quantitative real-time PCR. In vitro susceptibility of parasites towards miltefosine was estimated at both promastigote and amastigote stages. Results Seventy three of eighty six patients completed the treatment and achieved clinical cure. Approximately 4% (3/73) patients relapsed by the end of 12 months follow-up, while a total of 15% (11/73) relapsed by the end of 18 months. Relapse rate was significantly higher in regimen II (31%) compared to regimen I (10.5%)(P<0.005). Parasite load at the pre-treatment stage was significantly higher (P<0.005) in cases that relapsed compared to the cases that remained cured. In vitro susceptibility towards miltefosine of parasites isolated after relapse was significantly lower (>2 fold) in comparison with the pre-treatment isolates (P<0.005). Conclusion Relapse rate in PKDL following miltefosine treatment has increased substantially, indicating the need of introducing alternate drugs/ combination therapy with miltefosine. Increasing resistance to antimonials has paved the way for the oral drug miltefosine for PKDL treatment. Recent studies show a significant decline in the final cure rate of VL after miltefosine treatment in the Indian subcontinent. This is the first study to evaluate the efficacy of miltefosine treatment in a large number of PKDL cases with 18 months follow-up. PKDL cases that completed miltefosine treatment responded well and showed initial cure; however, with 18 months of follow up period, the final cure rate was only about 85%. Treatment regimen based on high dosage over short duration resulted in high relapse rate. We observed that the parasites isolated from the cases that relapsed were more tolerant to miltefosine (>2 fold) compared to the isolates from pre-treatment stage. Estimation of parasite load at pre-treatment stage indicated that the patients with higher initial parasitic burden were at a higher risk of relapse. The declining efficacy of monotherapy with miltefosine warrants the need of alternate regimens for treatment of PKDL.
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Affiliation(s)
- V. Ramesh
- Dermatology Department, Safdarjung Hospital and Vardhman Mahavir Medical College (VMMC), New Delhi, India
| | - Ruchi Singh
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Kumar Avishek
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Aditya Verma
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Deepak Kumar Deep
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Sandeep Verma
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Poonam Salotra
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
- * E-mail:
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