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Radwanska M, Vereecke N, Deleeuw V, Pinto J, Magez S. Salivarian Trypanosomosis: A Review of Parasites Involved, Their Global Distribution and Their Interaction With the Innate and Adaptive Mammalian Host Immune System. Front Immunol 2018; 9:2253. [PMID: 30333827 PMCID: PMC6175991 DOI: 10.3389/fimmu.2018.02253] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/11/2018] [Indexed: 01/27/2023] Open
Abstract
Salivarian trypanosomes are single cell extracellular parasites that cause infections in a wide range of hosts. Most pathogenic infections worldwide are caused by one of four major species of trypanosomes including (i) Trypanosoma brucei and the human infective subspecies T. b. gambiense and T. b. rhodesiense, (ii) Trypanosoma evansi and T. equiperdum, (iii) Trypanosoma congolense and (iv) Trypanosoma vivax. Infections with these parasites are marked by excessive immune dysfunction and immunopathology, both related to prolonged inflammatory host immune responses. Here we review the classification and global distribution of these parasites, highlight the adaptation of human infective trypanosomes that allow them to survive innate defense molecules unique to man, gorilla, and baboon serum and refer to the discovery of sexual reproduction of trypanosomes in the tsetse vector. With respect to the immunology of mammalian host-parasite interactions, the review highlights recent findings with respect to the B cell destruction capacity of trypanosomes and the role of T cells in the governance of infection control. Understanding infection-associated dysfunction and regulation of both these immune compartments is crucial to explain the continued failures of anti-trypanosome vaccine developments as well as the lack of any field-applicable vaccine based anti-trypanosomosis intervention strategy. Finally, the link between infection-associated inflammation and trypanosomosis induced anemia is covered in the context of both livestock and human infections.
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Affiliation(s)
- Magdalena Radwanska
- Laboratory for Biomedical Research, Ghent University Global Campus, Incheon, South Korea
| | - Nick Vereecke
- Laboratory for Biomedical Research, Ghent University Global Campus, Incheon, South Korea.,Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Violette Deleeuw
- Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Joar Pinto
- Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Stefan Magez
- Laboratory for Biomedical Research, Ghent University Global Campus, Incheon, South Korea.,Laboratory of Cellular and Molecular Immunology, Vrije Universiteit Brussel, Brussels, Belgium
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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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Kato CD, Matovu E, Mugasa CM, Nanteza A, Alibu VP. The role of cytokines in the pathogenesis and staging of Trypanosoma brucei rhodesiense sleeping sickness. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2016; 12:4. [PMID: 26807135 PMCID: PMC4722787 DOI: 10.1186/s13223-016-0113-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 01/06/2016] [Indexed: 12/12/2022]
Abstract
Human African trypanosomiasis due to Trypanosoma brucei rhodesiense is invariably fatal if untreated with up to 12.3 million people at a risk of developing the disease in Sub-Saharan Africa. The disease is characterized by a wide spectrum of clinical presentation coupled with differences in disease progression and severity. While the factors determining this varied response have not been clearly characterized, inflammatory cytokines have been partially implicated as key players. In this review, we consolidate available literature on the role of specific cytokines in the pathogenesis of T. b. rhodesiense sleeping sickness and further discuss their potential as stage biomarkers. Such information would guide upcoming research on the immunology of sleeping sickness and further assist in the selection and evaluation of cytokines as disease stage or diagnostic biomarkers.
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Affiliation(s)
- Charles D. Kato
- />School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O BOX 7062, Kampala, Uganda
| | - Enock Matovu
- />School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O BOX 7062, Kampala, Uganda
| | - Claire. M. Mugasa
- />School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O BOX 7062, Kampala, Uganda
| | - Ann Nanteza
- />School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O BOX 7062, Kampala, Uganda
| | - Vincent P. Alibu
- />College of Natural Sciences, Makerere University, P.O. BOX 7062, Kampala, Uganda
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Kato CD, Alibu VP, Nanteza A, Mugasa CM, Matovu E. Interleukin (IL)-6 and IL-10 Are Up Regulated in Late Stage Trypanosoma brucei rhodesiense Sleeping Sickness. PLoS Negl Trop Dis 2015; 9:e0003835. [PMID: 26090964 PMCID: PMC4474433 DOI: 10.1371/journal.pntd.0003835] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/17/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Sleeping sickness due to Trypanosoma brucei rhodesiense has a wide spectrum of clinical presentations coupled with differences in disease progression and severity across East and Southern Africa. The disease progresses from an early (hemo-lymphatic) stage to the late (meningoencephalitic) stage characterized by presence of parasites in the central nervous system. We hypothesized that disease progression and severity of the neurological response is modulated by cytokines. METHODS A total of 55 sleeping sickness cases and 41 healthy controls were recruited passively at Lwala hospital, in Northern Uganda. A panel of six cytokines (IFN-γ, IL1-β, TNF-α, IL-6, TGF-β and IL-10) were assayed from paired plasma and cerebrospinal fluid (CSF) samples. Cytokine concentrations were analyzed in relation to disease progression, clinical presentation and severity of neurological responses. RESULTS Median plasma levels (pg/ml) of IFN-γ (46.3), IL-6 (61.7), TGF-β (8755) and IL-10 (256.6) were significantly higher in cases compared to controls (p< 0.0001). When early stage and late stage CSF cytokines were compared, IL-10 and IL-6 were up regulated in late stage patients and were associated with a reduction in tremors and cranioneuropathy. IL-10 had a higher staging accuracy with a sensitivity of 85.7% (95% CI, 63.7%-97%) and a specificity of 100% (95% CI, 39.8%-100%) while for IL-6, a specificity of 100% (95% CI, 47.8%-100%) gave a sensitivity of 83.3% (95% CI, 62.2%-95.3%). CONCLUSION Our study demonstrates the role of host inflammatory cytokines in modulating the progression and severity of neurological responses in sleeping sickness. We demonstrate here an up-regulation of IL-6 and IL-10 during the late stage with a potential as adjunct stage biomarkers. Given that both cytokines could potentially be elevated by other CNS infections, our findings should be further validated in a large cohort of patients including those with other inflammatory diseases such as cerebral malaria.
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Affiliation(s)
- Charles D. Kato
- School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, Kampala, Uganda
| | - Vincent P. Alibu
- College of Natural Sciences, Makerere University, Kampala, Uganda
| | - Ann Nanteza
- School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, Kampala, Uganda
| | - Claire M. Mugasa
- School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, Kampala, Uganda
| | - Enock Matovu
- School of Bio-security, Biotechnical & Laboratory Sciences, College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, Kampala, Uganda
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Wang CC, Lin YR, Liao MH, Jan TR. Oral supplementation with areca-derived polyphenols attenuates food allergic responses in ovalbumin-sensitized mice. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 13:154. [PMID: 23816049 PMCID: PMC3717086 DOI: 10.1186/1472-6882-13-154] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/18/2013] [Indexed: 11/21/2022]
Abstract
Background Arecae semen, the dried slice of areca nuts, is a traditional Chinese medicine used to treat intestinal parasitosis, rectal tenesmus and diarrhea. Areca nuts contain a rich amount of polyphenols that have been shown to modulate the functionality of mast cells and T cells. The objective of this study is to investigate the effect of polyphenol-enriched areca nut extracts (PANE) against food allergy, a T cell-mediated immune disorder. Methods BALB/c mice were left untreated or administered with PANE (0.05% and 0.1%) via drinking water throughout the entire experiment. The mice were sensitized with ovalbumin (OVA) twice by intraperitoneal injection, and then repeatedly challenged with OVA by gavage to induce food allergic responses. Results PANE administration attenuated OVA-induced allergic responses, including the occurrence of diarrhea and the infiltration and degranulation of mast cells in the duodenum. The serum level of OVA-specific IgE and the expression of interleukin-4 in the duodenum were suppressed by PANE treatment. In addition, PANE administration induced Gr-1+, IL-10+ and Gr-1+IL-10+ cells in the duodenum. Conclusion These results demonstrate that oral intake of areca-derived polyphenols attenuates food allergic responses accompanied with a decreased Th2 immunity and an enhanced induction of functional myeloid-derived suppressor cells.
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Tiberti N, Matovu E, Hainard A, Enyaru JC, Lejon V, Robin X, Turck N, Ngoyi DM, Krishna S, Bisser S, Courtioux B, Büscher P, Kristensson K, Ndung'u JM, Sanchez JC. New biomarkers for stage determination in Trypanosoma brucei rhodesiense sleeping sickness patients. Clin Transl Med 2013; 2:1. [PMID: 23369533 PMCID: PMC3561069 DOI: 10.1186/2001-1326-2-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/25/2012] [Indexed: 12/26/2022] Open
Abstract
Accurate stage determination is crucial in the choice of treatment for patients suffering from sleeping sickness, also known as human African trypanosomiasis (HAT). Current staging methods, based on the counting of white blood cells (WBC) and the detection of parasites in the cerebrospinal fluid (CSF) have limited accuracy. We hypothesized that immune mediators reliable for staging T. b. gambiense HAT could also be used to stratify T. b. rhodesiense patients, the less common form of HAT. A population comprising 85 T. b. rhodesiense patients, 14 stage 1 (S1) and 71 stage 2 (S2) enrolled in Malawi and Uganda, was investigated. The CSF levels of IgM, MMP-9, CXCL13, CXCL10, ICAM-1, VCAM-1, neopterin and B2MG were measured and their staging performances evaluated using receiver operating characteristic (ROC) analyses. IgM, MMP-9 and CXCL13 were the most accurate markers for stage determination (partial AUC 88%, 86% and 85%, respectively). The combination in panels of three molecules comprising CXCL13-CXCL10-MMP-9 or CXCL13-CXCL10-IgM significantly increased their staging ability to partial AUC 94% (p value < 0.01). The present study highlighted new potential markers for stage determination of T. b. rhodesiense patients. Further investigations are needed to better evaluate these molecules, alone or in panels, as alternatives to WBC to make reliable choice of treatment.
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Affiliation(s)
- Natalia Tiberti
- Department of Human Protein Sciences, University of Geneva, Geneva, Switzerland.
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Etet PFS, Palomba M, Colavito V, Grassi-Zucconi G, Bentivoglio M, Bertini G. Sleep and Rhythm Changes at the Time ofTrypanosoma bruceiInvasion of the Brain Parenchyma in the Rat. Chronobiol Int 2012; 29:469-81. [DOI: 10.3109/07420528.2012.660713] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Neuroinflammation and brain infections: historical context and current perspectives. ACTA ACUST UNITED AC 2010; 66:152-73. [PMID: 20883721 DOI: 10.1016/j.brainresrev.2010.09.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 12/25/2022]
Abstract
An overview of current concepts on neuroinflammation and on the dialogue between neurons and non-neuronal cells in three important infections of the central nervous systems (rabies, cerebral malaria, and human African trypanosomiasis or sleeping sickness) is here presented. Large numbers of cases affected by these diseases are currently reported. In the context of an issue dedicated to Camillo Golgi, historical notes on seminal discoveries on these diseases are also presented. Neuroinflammation is currently closely associated with pathogenetic mechanisms of chronic neurodegenerative diseases. Neuroinflammatory signaling in brain infections is instead relatively neglected in the neuroscience community, despite the fact that the above infections provide paradigmatic examples of alterations of the intercellular crosstalk between neurons and non-neuronal cells. In rabies, strategies of immune evasion of the host lead to silencing neuroinflammatory signaling. In the intravascular pathology which characterizes cerebral malaria, leukocytes and Plasmodium do not enter the brain parenchyma. In sleeping sickness, leukocytes and African trypanosomes invade the brain parenchyma at an advanced stage of infection. Both the latter pathologies leave open many questions on the targeting of neuronal functions and on the pathogenetic role of non-neuronal cells, and in particular astrocytes and microglia, in these diseases. All three infections are hallmarked by very severe clinical pictures and relative sparing of neuronal structure. Multidisciplinary approaches and a concerted action of the neuroscience community are needed to shed light on intercellular crosstalk in these dreadful brain diseases. Such effort could also lead to new knowledge on non-neuronal mechanisms which determine neuronal death or survival.
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Immunobiology of African trypanosomes: need of alternative interventions. J Biomed Biotechnol 2010; 2010:389153. [PMID: 20182644 PMCID: PMC2826769 DOI: 10.1155/2010/389153] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 10/29/2009] [Accepted: 12/23/2009] [Indexed: 02/08/2023] Open
Abstract
Trypanosomiasis is one of the major parasitic diseases for which control is still far from reality. The vaccination approaches by using dominant surface proteins have not been successful, mainly due to antigenic variation of the parasite surface coat. On the other hand, the chemotherapeutic drugs in current use for the treatment of this disease are toxic and problems of resistance are increasing (see Kennedy (2004) and Legros et al. (2002)). Therefore, alternative approaches in both treatment and vaccination against trypanosomiasis are needed at this time. To be able to design and develop such alternatives, the biology of this parasite and the host response against the pathogen need to be studied. These two aspects of this disease with few examples of alternative approaches are discussed here.
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Hainard A, Tiberti N, Robin X, Lejon V, Ngoyi DM, Matovu E, Enyaru JC, Fouda C, Ndung'u JM, Lisacek F, Müller M, Turck N, Sanchez JC. A combined CXCL10, CXCL8 and H-FABP panel for the staging of human African trypanosomiasis patients. PLoS Negl Trop Dis 2009; 3:e459. [PMID: 19554086 PMCID: PMC2696178 DOI: 10.1371/journal.pntd.0000459] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2009] [Accepted: 05/15/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Human African trypanosomiasis (HAT), also known as sleeping sickness, is a parasitic tropical disease. It progresses from the first, haemolymphatic stage to a neurological second stage due to invasion of parasites into the central nervous system (CNS). As treatment depends on the stage of disease, there is a critical need for tools that efficiently discriminate the two stages of HAT. We hypothesized that markers of brain damage discovered by proteomic strategies and inflammation-related proteins could individually or in combination indicate the CNS invasion by the parasite. METHODS Cerebrospinal fluid (CSF) originated from parasitologically confirmed Trypanosoma brucei gambiense patients. Patients were staged on the basis of CSF white blood cell (WBC) count and presence of parasites in CSF. One hundred samples were analysed: 21 from stage 1 (no trypanosomes in CSF and 5 WBC/microL) patients. The concentration of H-FABP, GSTP-1 and S100beta in CSF was measured by ELISA. The levels of thirteen inflammation-related proteins (IL-1ra, IL-1beta, IL-6, IL-9, IL-10, G-CSF, VEGF, IFN-gamma, TNF-alpha, CCL2, CCL4, CXCL8 and CXCL10) were determined by bead suspension arrays. RESULTS CXCL10 most accurately distinguished stage 1 and stage 2 patients, with a sensitivity of 84% and specificity of 100%. Rule Induction Like (RIL) analysis defined a panel characterized by CXCL10, CXCL8 and H-FABP that improved the detection of stage 2 patients to 97% sensitivity and 100% specificity. CONCLUSION This study highlights the value of CXCL10 as a single biomarker for staging T. b. gambiense-infected HAT patients. Further combination of CXCL10 with H-FABP and CXCL8 results in a panel that efficiently rules in stage 2 HAT patients. As these molecules could potentially be markers of other CNS infections and disorders, these results should be validated in a larger multi-centric cohort including other inflammatory diseases such as cerebral malaria and active tuberculosis.
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Affiliation(s)
- Alexandre Hainard
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
| | - Natalia Tiberti
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
| | - Xavier Robin
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
| | - Veerle Lejon
- Department of Parasitology, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Enock Matovu
- Department of Veterinary Parasitology and Microbiology, Faculty of Science, Makerere University, Kampala, Uganda
| | - John Charles Enyaru
- Department of Biochemistry, Faculty of Science, Makerere University, Kampala, Uganda
| | - Catherine Fouda
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
| | | | - Frédérique Lisacek
- Swiss Institute of Bioinformatics, Medical University Centre, Geneva, Switzerland
| | - Markus Müller
- Swiss Institute of Bioinformatics, Medical University Centre, Geneva, Switzerland
| | - Natacha Turck
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
| | - Jean-Charles Sanchez
- Biomedical Proteomics Research Group, Medical University Centre, Geneva, Switzerland
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Rodgers J. Human African trypanosomiasis, chemotherapy and CNS disease. J Neuroimmunol 2009; 211:16-22. [DOI: 10.1016/j.jneuroim.2009.02.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 02/05/2009] [Indexed: 11/28/2022]
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