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Sharma I, Kataria P, Das J. Cerebral malaria pathogenesis: Dissecting the role of CD4 + and CD8 + T-cells as major effectors in disease pathology. Int Rev Immunol 2024:1-18. [PMID: 38618863 DOI: 10.1080/08830185.2024.2336539] [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: 09/25/2023] [Accepted: 03/24/2024] [Indexed: 04/16/2024]
Abstract
Cerebral malaria (CM) is a severe complication of Plasmodium falciparum (P. falciparum) infection, with complex pathogenesis involving multiple factors, including the host's immunological response. T lymphocytes, specifically CD4+ T helper cells and CD8+ cytotoxic T cells, are crucial in controlling parasite growth and activating cells for parasite clearance via cytokine secretion. Contrary to this, reports also suggest the pathogenic nature of T lymphocytes as they are often involved in disease progression and severity. CD8+ cytotoxic T cells migrate to the host's brain vasculature, disrupting the blood-brain barrier and causing neurological manifestations. CD4+ T helper cells on the other hand play a variety of functions as they differentiate into different subtypes which may function as pro-inflammatory or anti-inflammatory. The excessive pro-inflammatory response in CM can lead to multi-organ failure, necessitating a check mechanism to maintain immune homeostasis. This is achieved by regulatory T cells and their characteristic cytokines, which counterbalance the pro-inflammatory immune response. Maintaining a critical balance between pro and anti-inflammatory responses is crucial for determining disease outcomes in CM. A slight change in this balance may contribute to a disease severity owing to an extreme inflammatory response or unrestricted parasite growth, a potential target for designing immunotherapeutic treatment approaches. The review briefly discusses the pathogenesis of CM and various mechanisms responsible for the disruption of the blood-brain barrier. It also highlights the role of different T cell subsets during infection and emphasizes the importance of balance between pro and anti-inflammatory T cells that ultimately decides the outcome of the disease.
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Affiliation(s)
- Indu Sharma
- Academy of Scientific and Innovative Research (AcSIR), Noida, India
- Division of Immunology, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Poonam Kataria
- Academy of Scientific and Innovative Research (AcSIR), Noida, India
- Division of Immunology, National Institute of Malaria Research, Dwarka, New Delhi, India
| | - Jyoti Das
- Academy of Scientific and Innovative Research (AcSIR), Noida, India
- Division of Immunology, National Institute of Malaria Research, Dwarka, New Delhi, India
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2
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Toxoplasma gondii Dissemination in the Brain Is Facilitated by Infiltrating Peripheral Immune Cells. mBio 2022; 13:e0283822. [PMID: 36445695 PMCID: PMC9765297 DOI: 10.1128/mbio.02838-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Despite recent advances in our understanding of pathogenic access to the central nervous system (CNS), the mechanisms by which intracellular pathogens disseminate within the dense cellular network of neural tissue remain poorly understood. To address this issue, longitudinal analysis of Toxoplasma gondii dissemination in the brain was conducted using 2-photon imaging through a cranial window in living mice that transgenically express enhanced green fluorescent protein (eGFP)-claudin-5. Extracellular T. gondii parasites were observed migrating slowly (1.37 ± 1.28 μm/min) and with low displacement within the brain. In contrast, a population of highly motile infected cells transported vacuoles of T. gondii significantly faster (6.30 ± 3.09 μm/min) and with a higher displacement than free parasites. Detailed analysis of microglial dynamics using CX3CR1-GFP mice revealed that T. gondii-infected microglia remained stationary, and infection did not increase the extension/retraction of microglial processes. The role of infiltrating immune cells in shuttling T. gondii was examined by labeling of peripheral hematopoietic cells with anti-CD45 antibody. Infected CD45+ cells were found crawling along the CNS vessel walls and trafficked T. gondii within the brain parenchyma at significantly higher speeds (3.35 ± 1.70 μm/min) than extracellular tachyzoites. Collectively, these findings highlight a dual role for immune cells in neuroprotection and in facilitating parasite dissemination within the brain. IMPORTANCE T. gondii is a foodborne parasite that infects the brain and can cause fatal encephalitis in immunocompromised individuals. However, there is a limited understanding of how the parasites disseminate through the brain and evade immune clearance. We utilized intravital imaging to visualize extracellular T. gondii tachyzoites and infected cells migrating within the infected mouse brain during acute infection. The infection of motile immune cells infiltrating the brain from the periphery significantly increased the dissemination of T. gondii in the brain compared to that of free parasites migrating using their own motility: the speed and displacement of these infected cells would enable them to cover nearly 1 cm of distance per day! Among the infiltrating cells, T. gondii predominantly infected monocytes and CD8+ T cells, indicating that the parasite can hijack immune cells that are critical for controlling the infection in order to enhance their dissemination within the brain.
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French T, Steffen J, Glas A, Osbelt L, Strowig T, Schott BH, Schüler T, Dunay IR. Persisting Microbiota and Neuronal Imbalance Following T. gondii Infection Reliant on the Infection Route. Front Immunol 2022; 13:920658. [PMID: 35898505 PMCID: PMC9311312 DOI: 10.3389/fimmu.2022.920658] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/25/2022] [Indexed: 12/18/2022] Open
Abstract
Toxoplasma gondii is a highly successful parasite capable of infecting all warm-blooded animals. The natural way of infection in intermediate hosts is the oral ingestion of parasite-contaminated water or food. In murine experimental models, oral infection (p.o.) of mice with T. gondii is applied to investigate mucosal and peripheral immune cell dynamics, whereas intraperitoneal infection (i.p.) is frequently used to study peripheral inflammation as well as immune cell – neuronal interaction in the central nervous system (CNS). However, the two infection routes have not yet been systematically compared along the course of infection. Here, C57BL/6 mice were infected p.o. or i.p. with a low dose of T. gondii cysts, and the acute and chronic stages of infection were compared. A more severe course of infection was detected following i.p. challenge, characterized by an increased weight loss and marked expression of proinflammatory cytokines particularly in the CNS during the chronic stage. The elevated proinflammatory cytokine expression in the ileum was more prominent after p.o. challenge that continued following the acute phase in both i.p. or p.o. infected mice. This resulted in sustained microbial dysbiosis, especially after p.o. challenge, highlighted by increased abundance of pathobionts from the phyla proteobacteria and a reduction of beneficial commensal species. Further, we revealed that in the CNS of i.p. infected mice CD4 and CD8 T cells displayed higher IFNγ production in the chronic stage. This corresponded with an increased expression of C1q and CD68 in the CNS and reduced expression of genes involved in neuronal signal transmission. Neuroinflammation-associated synaptic alterations, especially PSD-95, VGLUT, and EAAT2 expression, were more pronounced in the cortex upon i.p. infection highlighting the profound interplay between peripheral inflammation and CNS homeostasis.
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Affiliation(s)
- Timothy French
- Institute of Inflammation and Neurodegeneration, Health Campus Immunology, Infectiology and Inflammation (GC-I), Otto-von-Guericke University, Magdeburg, Germany
| | - Johannes Steffen
- Institute of Inflammation and Neurodegeneration, Health Campus Immunology, Infectiology and Inflammation (GC-I), Otto-von-Guericke University, Magdeburg, Germany
| | - Albert Glas
- Institute of Inflammation and Neurodegeneration, Health Campus Immunology, Infectiology and Inflammation (GC-I), Otto-von-Guericke University, Magdeburg, Germany
| | - Lisa Osbelt
- Department of Microbial Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Till Strowig
- Department of Microbial Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Björn H. Schott
- Institute of Inflammation and Neurodegeneration, Health Campus Immunology, Infectiology and Inflammation (GC-I), Otto-von-Guericke University, Magdeburg, Germany
- Center for Behavioral Brain Sciences, Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany
- Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Thomas Schüler
- Institute of Molecular and Clinical Immunology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Ildiko Rita Dunay
- Institute of Inflammation and Neurodegeneration, Health Campus Immunology, Infectiology and Inflammation (GC-I), Otto-von-Guericke University, Magdeburg, Germany
- Center for Behavioral Brain Sciences, Magdeburg, Germany
- *Correspondence: Ildiko Rita Dunay,
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4
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Aaron PA, Gelli A. Harnessing the Activity of the Fungal Metalloprotease, Mpr1, To Promote Crossing of Nanocarriers through the Blood-Brain Barrier. ACS Infect Dis 2020; 6:138-149. [PMID: 31820926 DOI: 10.1021/acsinfecdis.9b00348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Cryptococcus neoformans (Cn) is the leading cause of fungal meningitis primarily in immunosuppressed patients. Cn invades the central nervous system by overcoming the highly restricted blood-brain barrier (BBB). We previously determined that a secreted fungal metalloprotease, Mpr1, that also confers crossing ability to yeast upon CnMPR1 expression in Saccharomyces cerevisiae is central to this process. This led us to question whether Mpr1 could be engineered to function as part of a nanocarrier delivery vehicle. Here, a eukaryotic expression system produced proteolytically active Mpr1 recombinant protein that was successfully conjugated to functionalized quantum dot (QD) nanoparticles and readily internalized by brain microvascular endothelial cells. An in vitro BBB model showed QD-Mpr1 crossed the BBB significantly better than mock QD, and QD-Mpr1 did not damage BBB integrity. Internalization of QD-Mpr1 occurred by membrane invaginations and endocytic pits typical of receptor-mediated endocytosis involving clathrin-coated entry points. This study substantiates the notion that fungal mechanisms of BBB entry may be harnessed for new drug delivery platform technologies.
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Affiliation(s)
- Phylicia A. Aaron
- Department of Pharmacology, School of Medicine, University of California, 3503 Genome and Biomedical Sciences Facility, 451 Health Sciences Drive, Davis, California 95616, United States
| | - Angie Gelli
- Department of Pharmacology, School of Medicine, University of California, 3503 Genome and Biomedical Sciences Facility, 451 Health Sciences Drive, Davis, California 95616, United States
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5
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Drewry LL, Jones NG, Wang Q, Onken MD, Miller MJ, Sibley LD. The secreted kinase ROP17 promotes Toxoplasma gondii dissemination by hijacking monocyte tissue migration. Nat Microbiol 2019; 4:1951-1963. [PMID: 31332383 PMCID: PMC6814536 DOI: 10.1038/s41564-019-0504-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 06/05/2019] [Indexed: 01/02/2023]
Abstract
The protozoan parasite Toxoplasma gondii is thought to exploit monocyte trafficking to facilitate dissemination across endothelial barriers such as the blood-brain barrier. Here we analyzed the migration of parasitized monocytes in model endothelial and interstitial environments. We report that infection enhanced monocyte locomotion on the surface of endothelial cells, but profoundly inhibited monocyte transmigration across endothelial barriers. In contrast, infection robustly increased monocyte and macrophage migration through collagen-rich tissues in a Rho/ROCK-dependent manner consistent with integrin-independent interstitial migration. We further demonstrated that the secreted T. gondii protein kinase ROP17 was required for enhanced tissue migration. In vivo, ROP17-deficient parasites failed to upregulate monocyte tissue migration and exhibited an early dissemination delay, leading to prolonged mouse survival. Our findings indicate that the parasite-induced changes in monocyte motility likely facilitate the transport of T. gondii through tissues and promote systemic dissemination, rather than shuttle parasites across the blood-brain barrier via extravasation.
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Affiliation(s)
- Lisa L Drewry
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nathaniel G Jones
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA.,York Biomedical Research Institute, Department of Biology, University of York, York, UK
| | - Quiling Wang
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael D Onken
- Department of Biochemistry and Molecular Biophysics, Washington University School of Medicine, St. Louis, MO, USA
| | - Mark J Miller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - L David Sibley
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO, USA.
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Drewry LL, Sibley LD. The hitchhiker's guide to parasite dissemination. Cell Microbiol 2019; 21:e13070. [PMID: 31219666 DOI: 10.1111/cmi.13070] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/21/2019] [Accepted: 06/13/2019] [Indexed: 12/29/2022]
Abstract
Toxoplasma gondii (T. gondii) is a parasitic protist that can infect nearly all nucleated cell types and tissues of warm-blooded vertebrate hosts. T. gondii utilises a unique form of gliding motility to cross cellular barriers, enter tissues, and penetrate host cells, thus enhancing spread within an infected host. However, T. gondii also disseminates by hijacking the migratory abilities of infected leukocytes. Traditionally, this process has been viewed as a route to cross biological barriers such as the blood-brain barrier. Here, we review recent findings that challenge this view by showing that infection of monocytes downregulates the program of transendothelial migration. Instead, infection by T. gondii enhances Rho-dependent interstitial migration of monocytes and macrophages, which enhances dissemination within tissues. Collectively, the available evidence indicates that T. gondii parasites use multiple means to disseminate within the host, including enhanced motility in tissues and translocation across biological barriers.
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Affiliation(s)
- Lisa L Drewry
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
| | - L David Sibley
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri
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7
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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8
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In Vitro and In Vivo Evaluation of APX001A/APX001 and Other Gwt1 Inhibitors against Cryptococcus. Antimicrob Agents Chemother 2018; 62:AAC.00523-18. [PMID: 29891599 PMCID: PMC6105804 DOI: 10.1128/aac.00523-18] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/04/2018] [Indexed: 01/21/2023] Open
Abstract
Cryptococcal meningitis (CM), caused primarily by Cryptococcus neoformans, is uniformly fatal if not treated. Treatment options are limited, especially in resource-poor geographical regions, and mortality rates remain high despite current therapies. Here we evaluated the in vitro and in vivo activity of several compounds, including APX001A and its prodrug, APX001, currently in clinical development for the treatment of invasive fungal infections. These compounds target the conserved Gwt1 enzyme that is required for the localization of glycosylphosphatidylinositol (GPI)-anchored cell wall mannoproteins in fungi. The Gwt1 inhibitors had low MIC values, ranging from 0.004 μg/ml to 0.5 μg/ml, against both C. neoformans and C. gattii APX001A and APX2020 demonstrated in vitro synergy with fluconazole (fractional inhibitory concentration index, 0.37 for both). In a CM model, APX001 and fluconazole each alone reduced the fungal burden in brain tissue (0.78 and 1.04 log10 CFU/g, respectively), whereas the combination resulted in a reduction of 3.52 log10 CFU/g brain tissue. Efficacy, as measured by a reduction in the brain and lung tissue fungal burden, was also observed for another Gwt1 inhibitor prodrug, APX2096, where dose-dependent reductions in the fungal burden ranged from 5.91 to 1.79 log10 CFU/g lung tissue and from 7.00 and 0.92 log10 CFU/g brain tissue, representing the nearly complete or complete sterilization of lung and brain tissue at the higher doses. These data support the further clinical evaluation of this new class of antifungal agents for the treatment of CM.
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Alvarado-Esquivel C, Sánchez-Anguiano LF, Hernández-Tinoco J, Ramos-Nevarez A, Estrada-Martínez S, Cerrillo-Soto SM, Medina-Heredia GE, Guido-Arreola CA, Soto-Quintero AA, Beristain-Garcia I. Association between Toxoplasma gondii infection and history of blood transfusion: a case-control seroprevalence study. J Int Med Res 2018; 46:1626-1633. [PMID: 29490516 PMCID: PMC6091851 DOI: 10.1177/0300060518757928] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objectives This study was performed to determine the association between seropositivity to Toxoplasma gondii and a history of blood transfusion. Methods Patients who had undergone blood transfusion (n = 410) and age- and sex-matched controls who had not undergone blood transfusion (n = 1230) were examined for anti-T. gondii IgG and IgM antibodies using enzyme-linked immunoassays. Results Anti-T. gondii IgG antibodies were detected in 57 (13.9%) patients and in 129 (10.5%) controls with a borderline difference [odds ratio (OR) = 1.37, 95% confidence interval (CI) = 0.98–1.92]. High anti-T. gondii IgG antibody levels (>150 IU/mL) were found in 27 (47.4%) of the 57 anti-T. gondii IgG-positive patients and in 37 (28.7%) of the 129 anti-T. gondii IgG positive controls with a significant difference (OR = 2.23, 95% CI = 1.17–4.26). Anti-T. gondii IgM antibodies were found in 13 (22.8%) of the 57 seropositive patients and in 37 (28.7%) of the 129 seropositive controls, but the difference was not significant (OR = 0.73, 95% CI = 0.35–1.52). Seroprevalence was significantly higher in patients aged >50 years than in controls of the same age and in female patients than in female controls. Conclusions These findings indicate that a history of blood transfusion is a risk factor for T. gondii infection.
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Affiliation(s)
- Cosme Alvarado-Esquivel
- 1 Biomedical Research Laboratory, Faculty of Medicine and Nutrition, Juárez University of Durango State, Avenida Universidad, Durango, Mexico
| | - Luis Francisco Sánchez-Anguiano
- 2 Institute for Scientific Research "Dr. Roberto Rivera-Damm," Juárez University of Durango State, Avenida Universidad, Durango, Mexico
| | - Jesús Hernández-Tinoco
- 2 Institute for Scientific Research "Dr. Roberto Rivera-Damm," Juárez University of Durango State, Avenida Universidad, Durango, Mexico
| | - Agar Ramos-Nevarez
- 3 Clínica de Medicina Familiar, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Predio Canoas, Durango, Mexico
| | - Sergio Estrada-Martínez
- 2 Institute for Scientific Research "Dr. Roberto Rivera-Damm," Juárez University of Durango State, Avenida Universidad, Durango, Mexico
| | - Sandra Margarita Cerrillo-Soto
- 3 Clínica de Medicina Familiar, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Predio Canoas, Durango, Mexico
| | | | - Carlos Alberto Guido-Arreola
- 3 Clínica de Medicina Familiar, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Predio Canoas, Durango, Mexico
| | | | - Isabel Beristain-Garcia
- 4 Facultad de Enfermería y Obstetricia, Juárez University of Durango State, Cuauhtémoc, Norte, Durango, Mexico
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10
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In Vitro and In Vivo Evaluation of the Antifungal Activity of APX001A/APX001 against Candida auris. Antimicrob Agents Chemother 2018; 62:AAC.02319-17. [PMID: 29311065 PMCID: PMC5826120 DOI: 10.1128/aac.02319-17] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/07/2017] [Indexed: 01/02/2023] Open
Abstract
Candida auris is an emerging multidrug-resistant yeast that has been responsible for invasive infections associated with high morbidity and mortality. C. auris strains often demonstrate high fluconazole and amphotericin B MIC values, and some strains are resistant to all three major antifungal classes. We evaluated the susceptibility of 16 C. auris clinical strains, isolated from a wide geographical area, to 10 antifungal agents, including APX001A, a novel agent that inhibits the fungal protein Gwt1 (glycosylphosphatidylinositol-anchored wall transfer protein 1). APX001A demonstrated significantly lower MIC50 and MIC90 values (0.004 and 0.031 μg/ml, respectively) than all other agents tested. The efficacy of the prodrug APX001 was evaluated in an immunocompromised murine model of disseminated C. auris infection. Significant efficacy (80 to 100% survival) was observed in all three APX001 treatment groups versus 50% survival for the anidulafungin treatment group. In addition, APX001 showed a significant log reduction in CFU counts in kidney, lung, and brain tissue (1.03 to 1.83) versus the vehicle control. Anidulafungin also showed a significant log reduction in CFU in the kidneys and lungs (1.5 and 1.62, respectively) but did not impact brain CFU. These data support further clinical evaluation of this new antifungal agent.
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11
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Aaron PA, Jamklang M, Uhrig JP, Gelli A. The blood-brain barrier internalises Cryptococcus neoformans via the EphA2-tyrosine kinase receptor. Cell Microbiol 2018; 20. [PMID: 29197141 DOI: 10.1111/cmi.12811] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 02/06/2023]
Abstract
Cryptococcus neoformans is an opportunistic fungal pathogen that causes life-threatening meningitis most commonly in populations with impaired immunity. Here, we resolved the transcriptome of the human brain endothelium challenged with C. neoformans to establish whether C. neoformans invades the CNS by co-opting particular signalling pathways as a means to promote its own entry. Among the 5 major pathways targeted by C. neoformans, the EPH-EphrinA1 (EphA2) tyrosine kinase receptor-signalling pathway was examined further. Silencing the EphA2 receptor transcript in a human brain endothelial cell line or blocking EphA2 activity with an antibody or chemical inhibitor prevented transmigration of C. neoformans in an in vitro model of the blood-brain barrier (BBB). In contrast, treating brain endothelial cells with an EphA2 chemical agonist or an EphA2 ligand promoted greater migration of fungal cells across the BBB. C. neoformans activated the EPH-tyrosine kinase pathway through a CD44-dependent phosphorylation of EphA2, promoting clustering and internalisation of EphA2 receptors. Moreover, HEK293T cells expressing EphA2 revealed an association between EphA2 and C. neoformans that boosted internalisation of C. neoformans. Collectively, the results suggest that C. neoformans promotes EphA2 activity via CD44, and this in turn creates a permeable barrier that facilitates the migration of C. neoformans across the BBB.
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Affiliation(s)
- Phylicia A Aaron
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, Davis, California, USA
| | - Mantana Jamklang
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, Davis, California, USA
| | - John P Uhrig
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, Davis, California, USA
| | - Angie Gelli
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, Davis, California, USA
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Mycophenolic acid induces differentiation of Toxoplasma gondii RH strain tachyzoites into bradyzoites and formation of cyst-like structure in vitro. Parasitol Res 2018; 117:547-563. [DOI: 10.1007/s00436-017-5738-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
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13
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Alvarado-Esquivel C, Rico-Almochantaf YDR, Hernández-Tinoco J, Quiñones-Canales G, Sánchez-Anguiano LF, Torres-González J, Schott B, Liesenfeld O, Dunay IR. Toxoplasma Gondii Exposure and Neurological Disorders: An Age- and Gender-Matched Case-Control Pilot Study. Eur J Microbiol Immunol (Bp) 2017; 7:303-309. [PMID: 29403659 PMCID: PMC5793700 DOI: 10.1556/1886.2017.00033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/09/2017] [Indexed: 01/03/2023] Open
Abstract
Little is known about the association of Toxoplasma gondii infection and neurological disorders. We performed a case-control study with 344 patients with neurological diseases and 344 neurologically healthy age- and gender-matched subjects. Sera of participants were analyzed for anti-T. gondii IgG and IgM antibodies using commercially available immunoassays. Anti-T. gondii IgG antibodies were detected in 25 (7.3%) cases and in 35 (10.2%) controls (odds ratio [OR] = 0.69; 95% confidence interval [CI]: 0.40-1.18; P = 0.17). Anti-T. gondii IgM antibodies were found in 5 (14.3%) of the 25 IgG seropositive cases and in 13 (37.1°%) of the 35 IgG seropositive controls (P = 0.15). Anti-T. gondii IgG antibodies were found in 8 (3.8%) of 213 female cases and in 23 (10.8%) of 213 female controls (OR = 0.32; 95% CI: 0.14-0.73; P = 0.005); and in 17 (13.0%) of 131 male cases and in 12 (9.2%) of 131 male controls (P = 0.32). No direct association between IgG seropositivity and specific neurological disorders was detected. We found no support for a role of latent T. gondii infection in the risk for neurological disorders in this setting. With respect to specific neurological disorders, further studies using larger patient cohorts will be required.
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Affiliation(s)
- Cosme Alvarado-Esquivel
- Biomedical Research Laboratory, Faculty of Medicine and Nutrition, Juárez University of Durango State, Avenida Universidad S/N, 34000 Durango, Mexico
| | - Yazmin del Rosario Rico-Almochantaf
- Biomedical Research Laboratory, Faculty of Medicine and Nutrition, Juárez University of Durango State, Avenida Universidad S/N, 34000 Durango, Mexico
| | - Jesús Hernández-Tinoco
- Institute for Scientific Research “Dr. Roberto Rivera-Damm,” Juárez University of Durango State, Avenida Universidad S/N, 34000 Durango, Mexico
| | - Gerardo Quiñones-Canales
- Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado, Predio Canoas S/N, 34000 Durango, Mexico
| | - Luis Francisco Sánchez-Anguiano
- Institute for Scientific Research “Dr. Roberto Rivera-Damm,” Juárez University of Durango State, Avenida Universidad S/N, 34000 Durango, Mexico
| | - Jorge Torres-González
- Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado, Predio Canoas S/N, 34000 Durango, Mexico
| | - Björn Schott
- Leibniz Institute for Neurobiology, Brenneckestr. 6, 39118 Magdeburg, Germany
- Department of Psychiatry and Psychotherapy, Campus Mitte, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Oliver Liesenfeld
- Institute for Microbiology and Hygiene, Campus Benjamin Franklin, Charité Medical School, Hindenburgdamm 27, D-12203 Berlin, Germany
| | - Ildiko Rita Dunay
- Institute of Inflammation and Neurodegeneration, Otto von Guericke University Magdeburg, Magdeburg D-39120, Leipziger Str. 44, Germany
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Understanding host-parasite relationship: the immune central nervous system microenvironment and its effect on brain infections. Parasitology 2017; 145:988-999. [PMID: 29231805 DOI: 10.1017/s0031182017002189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The central nervous system (CNS) has been recognized as an immunologically specialized microenvironment, where immune surveillance takes a distinctive character, and where delicate neuronal networks are sustained by anti-inflammatory factors that maintain local homeostasis. However, when a foreign agent such as a parasite establishes in the CNS, a set of immune defences is mounted and several immune molecules are released to promote an array of responses, which ultimately would control the infection and associated damage. Instead, a host-parasite relationship is established, in the context of which a close biochemical coevolution and communication at all organization levels between two complex organisms have developed. The ability of the parasite to establish in its host is associated with several evasion mechanisms to the immune response and its capacity for exploiting host-derived molecules. In this context, the CNS is deeply involved in modulating immune functions, either protective or pathogenic, and possibly in parasitic activity as well, via interactions with evolutionarily conserved molecules such as growth factors, neuropeptides and hormones. This review presents available evidence on some examples of CNS parasitic infections inducing different morbi-mortality grades in low- or middle-income countries, to illustrate how the CNS microenvironment affect pathogen establishment, growth, survival and reproduction in immunocompetent hosts. A better understanding of the influence of the CNS microenvironment on neuroinfections may provide relevant insights into the mechanisms underlying these pathologies.
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Na Pombejra S, Salemi M, Phinney BS, Gelli A. The Metalloprotease, Mpr1, Engages AnnexinA2 to Promote the Transcytosis of Fungal Cells across the Blood-Brain Barrier. Front Cell Infect Microbiol 2017; 7:296. [PMID: 28713781 PMCID: PMC5492700 DOI: 10.3389/fcimb.2017.00296] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/16/2017] [Indexed: 12/19/2022] Open
Abstract
Eukaryotic pathogens display multiple mechanisms for breaching the blood-brain barrier (BBB) and invading the central nervous system (CNS). Of the fungal spp., that cause disease in mammals, only some cross brain microvascular endothelial cells which constitute the BBB, and invade the brain. Cryptococcus neoformans, the leading cause of fungal meningoencephalitis, crosses the BBB directly by transcytosis or by co-opting monocytes. We previously determined that Mpr1, a secreted fungal metalloprotease, facilitates association of fungal cells to brain microvascular endothelial cells and we confirmed that the sole expression of CnMPR1 endowed S. cerevisiae with an ability to cross the BBB. Here, the gain of function conferred onto S. cerevisiae by CnMPR1 (i.e., Sc<CnMPR1> strain) was used to identify targets of Mpr1 that might reside on the surface of the BBB. Following biotin-labeling of BBB surface proteins, Sc<CnMPR1>-associated proteins were identified by LC-MS/MS. Of the 62 proteins identified several were cytoskeleton-endocytosis-associated including AnnexinA2 (AnxA2). Using an in vitro model of the human BBB where AnxA2 activity was blocked, we found that the lack of AnxA2 activity prevented the movement of S. cerevisiae across the BBB (i.e., transcytosis of Sc<CnMPR1> strain) but unexpectedly, TEM analysis revealed that AnxA2 was not required for the association or the internalization of Sc<CnMPR1>. Additionally, the co-localization of AnxA2 and Sc<CnMPR1> suggest that successful crossing of the BBB is dependent on an AxnA2-Mpr1-mediated interaction. Collectively the data suggest that AnxA2 plays a central role in fungal transcytosis in human brain microvascular endothelial cells. The movement and exocytosis of Sc<CnMPR1> is dependent on membrane trafficking events that involve AnxA2 but these events appear to be independent from the actions of AnxA2 at the host cell surface. We propose that Mpr1 activity promotes cytoskeleton remodeling in brain microvascular endothelial cells and thereby engages AnxA2 in order to facilitate fungal transcytosis of the BBB.
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Affiliation(s)
- Sarisa Na Pombejra
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, DavisDavis, CA, United States
| | - Michelle Salemi
- Proteomics Core Facility, Genome and Biomedical Sciences Facility, University of California, DavisDavis, CA, United States
| | - Brett S Phinney
- Proteomics Core Facility, Genome and Biomedical Sciences Facility, University of California, DavisDavis, CA, United States
| | - Angie Gelli
- Department of Pharmacology, School of Medicine, Genome and Biomedical Sciences Facility, University of California, DavisDavis, CA, United States
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Solving the challenge of the blood-brain barrier to treat infections caused by Trypanosoma evansi: evaluation of nerolidol-loaded nanospheres in mice. Parasitology 2017. [PMID: 28641606 DOI: 10.1017/s003118201700110x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Despite significant advances in therapies against Trypanosoma evansi, its effective elimination from the central nervous system (CNS) remains a difficult task. The incapacity of trypanocidal drugs to cross the blood-brain barrier (BBB) after systemic administrations makes the brain the main refuge area for T. evansi. Nanotechnology is showing great potential to improve drug efficacy, such as nerolidol-loaded nanospheres (N-NS). Thus, the aim of this study was to investigate whether the treatment with N-NS was able to cross the BBB and to eliminate T. evansi from the CNS. High-performance liquid chromatography revealed that N-NS can cross the BBB of T. evansi-infected mice, while free nerolidol (F-N) neither the trypanocidal drug diminazene aceturate (D.A.) were not detected in the brain tissue. Polymerase chain reaction revealed that 100% of the animals treated with N-NS were negatives for T. evansi in the brain tissue, while all infected animals treated with F-N or D.A. were positives. Thus, we concluded that nanotechnology improves the therapeutic efficacy of nerolidol, and enables the transport of its active principle through the BBB. In summary, N-NS treatment can eliminate the parasite from the CNS, and possesses potential to treat infected animals.
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17
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Klein RS, Garber C, Howard N. Infectious immunity in the central nervous system and brain function. Nat Immunol 2017; 18:132-141. [PMID: 28092376 DOI: 10.1038/ni.3656] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 12/02/2016] [Indexed: 11/09/2022]
Abstract
Inflammation is emerging as a critical mechanism underlying neurological disorders of various etiologies, yet its role in altering brain function as a consequence of neuroinfectious disease remains unclear. Although acute alterations in mental status due to inflammation are a hallmark of central nervous system (CNS) infections with neurotropic pathogens, post-infectious neurologic dysfunction has traditionally been attributed to irreversible damage caused by the pathogens themselves. More recently, studies indicate that pathogen eradication within the CNS may require immune responses that interfere with neural cell function and communication without affecting their survival. In this Review we explore inflammatory processes underlying neurological impairments caused by CNS infection and discuss their potential links to established mechanisms of psychiatric and neurodegenerative diseases.
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Affiliation(s)
- Robyn S Klein
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Neuroscience, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charise Garber
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nicole Howard
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Laperchia C, Palomba M, Seke Etet PF, Rodgers J, Bradley B, Montague P, Grassi-Zucconi G, Kennedy PGE, Bentivoglio M. Trypanosoma brucei Invasion and T-Cell Infiltration of the Brain Parenchyma in Experimental Sleeping Sickness: Timing and Correlation with Functional Changes. PLoS Negl Trop Dis 2016; 10:e0005242. [PMID: 28002454 PMCID: PMC5217973 DOI: 10.1371/journal.pntd.0005242] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/06/2017] [Accepted: 12/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The timing of Trypanosoma brucei entry into the brain parenchyma to initiate the second, meningoencephalitic stage of human African trypanosomiasis or sleeping sickness is currently debated and even parasite invasion of the neuropil has been recently questioned. Furthermore, the relationship between neurological features and disease stage are unclear, despite the important diagnostic and therapeutic implications. METHODOLOGY Using a rat model of chronic Trypanosoma brucei brucei infection we determined the timing of parasite and T-cell neuropil infiltration and its correlation with functional changes. Parasite DNA was detected using trypanosome-specific PCR. Body weight and sleep structure alterations represented by sleep-onset rapid eye movement (SOREM) periods, reported in human and experimental African trypanosomiasis, were monitored. The presence of parasites, as well as CD4+ and CD8+ T-cells in the neuropil was assessed over time in the brain of the same animals by immunocytochemistry and quantitative analyses. PRINCIPAL FINDINGS Trypanosome DNA was present in the brain at day 6 post-infection and increased more than 15-fold by day 21. Parasites and T-cells were observed in the parenchyma from day 9 onwards. Parasites traversing blood vessel walls were observed in the hypothalamus and other brain regions. Body weight gain was reduced from day 7 onwards. SOREM episodes started in most cases early after infection, with an increase in number and duration after parasite neuroinvasion. CONCLUSION These findings demonstrate invasion of the neuropil over time, after an initial interval, by parasites and lymphocytes crossing the blood-brain barrier, and show that neurological features can precede this event. The data thus challenge the current clinical and cerebrospinal fluid criteria of disease staging.
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Affiliation(s)
- Claudia Laperchia
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria Palomba
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paul F. Seke Etet
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Jean Rodgers
- Institute of Biodiversity Animal Health and Comparative Medicine, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Barbara Bradley
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Paul Montague
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Gigliola Grassi-Zucconi
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Peter G. E. Kennedy
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Marina Bentivoglio
- Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- National Institute of Neuroscience (INN), Verona Unit, Verona, Italy
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Diagnostic Challenges of Cryptococcus neoformans in an Immunocompetent Individual Masquerading as Chronic Hydrocephalus. Case Rep Neurol Med 2016; 2016:7381943. [PMID: 27525140 PMCID: PMC4971305 DOI: 10.1155/2016/7381943] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/24/2016] [Indexed: 12/03/2022] Open
Abstract
Cryptococcus neoformans can cause disseminated meningoencephalitis and evade immunosurveillance with expression of a major virulence factor, the polysaccharide capsule. Direct diagnostic assays often rely on the presence of the cryptococcal glucuronoxylomannan capsular antigen (CrAg) or visualization of the capsule. Strain specific phenotypic traits and environmental conditions influence differences in expression that can thereby compromise detection and timely diagnosis. Immunocompetent hosts may manifest clinical signs and symptoms indolently, often expanding the differential and delaying appropriate treatment and diagnosis. We describe a 63-year-old man who presented with a progressive four-year history of ambulatory dysfunction, headache, and communicating hydrocephalus. Serial lumbar punctures (LPs) revealed elevated protein (153–300 mg/dL), hypoglycorrhachia (19–47 mg/dL), lymphocytic pleocytosis (89–95% lymphocyte, WBC 67–303 mg/dL, and RBC 34–108 mg/dL), and normal opening pressure (13–16 cm H2O). Two different cerebrospinal fluid (CSF) CrAg assays were negative. A large volume CSF fungal culture grew unencapsulated C. neoformans. He was initiated on induction therapy with amphotericin B plus flucytosine and consolidation/maintenance therapy with flucytosine, but he died following discharge due to complications. Elevated levels of CSF Th1 cytokines and decreased IL6 may have affected the virulence and detection of the pathogen.
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Seroprevalence and Associated Risk Factors for Toxoplasma gondii Infection in Healthy Blood Donors: A Cross-Sectional Study in Sonora, Mexico. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9597276. [PMID: 27446960 PMCID: PMC4944021 DOI: 10.1155/2016/9597276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 06/15/2016] [Indexed: 12/20/2022]
Abstract
Toxoplasma gondii (T. gondii) can be transmitted by blood transfusion. We determined the prevalence of T. gondii infection in healthy blood donors in Hermosillo city, Mexico, and the association of infection with T. gondii with the sociodemographic, clinical, and behavioral characteristics of blood donors. Four hundred and eight blood donors who attended two public blood banks in Hermosillo city were examined for anti-T. gondii IgG and IgM antibodies by using enzyme-linked immunoassays. Of the 408 blood donors (mean age 31.77 ± 9.52; range 18–60 years old) studied, 55 (13.5%) were positive for anti-T. gondii IgG antibodies, and 12 (21.8%) of them were also positive for anti-T. gondii IgM antibodies. Multivariate analysis showed that seropositivity to T. gondii was associated with age (OR = 1.74; 95% CI: 1.03–2.94; P = 0.03) and tobacco use (OR = 2.09; 95% CI: 1.02–4.29; P = 0.04). Seropositivity to T. gondii was correlated with the number of pregnancies, deliveries, and cesarean sections. The seroprevalence of T. gondii infection in blood donors in Sonora is the highest reported in blood donors in northern Mexico so far. This is the first report of an association of T. gondii exposure and tobacco use. Further research to confirm this association is needed.
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Carreño A, Gacitúa M, Fuentes JA, Páez-Hernández D, Araneda C, Chávez I, Soto-Arriaza M, Manríquez JM, Polanco R, Mora GC, Otero C, Swords WB, Arratia-Pérez R. Theoretical and experimental characterization of a novel pyridine benzimidazole: suitability for fluorescence staining in cells and antimicrobial properties. NEW J CHEM 2016. [DOI: 10.1039/c5nj02772a] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Imidazopyridine showed fluorescence properties suitable for imaging with both prokaryotic and eukaryotic cells.
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22
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Krüger T, Engstler M. Flagellar motility in eukaryotic human parasites. Semin Cell Dev Biol 2015; 46:113-27. [DOI: 10.1016/j.semcdb.2015.10.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/26/2015] [Accepted: 10/26/2015] [Indexed: 12/31/2022]
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