1
|
Kioko M, Mwangi S, Pance A, Ochola-Oyier LI, Kariuki S, Newton C, Bejon P, Rayner JC, Abdi AI. The mRNA content of plasma extracellular vesicles provides a window into molecular processes in the brain during cerebral malaria. SCIENCE ADVANCES 2024; 10:eadl2256. [PMID: 39151016 PMCID: PMC11328904 DOI: 10.1126/sciadv.adl2256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 07/10/2024] [Indexed: 08/18/2024]
Abstract
The impact of cerebral malaria on the transcriptional profiles of cerebral tissues is difficult to study using noninvasive approaches. We isolated plasma extracellular vesicles (EVs) from patients with cerebral malaria and community controls and sequenced their mRNA content. Deconvolution analysis revealed that EVs from cerebral malaria are enriched in transcripts of brain origin. We ordered the patients with cerebral malaria based on their EV-transcriptional profiles from cross-sectionally collected samples and inferred disease trajectory while using healthy community controls as a starting point. We found that neuronal transcripts in plasma EVs decreased with disease trajectory, whereas transcripts from glial, endothelial, and immune cells increased. Disease trajectory correlated positively with severity indicators like death and was associated with increased VEGFA-VEGFR and glutamatergic signaling, as well as platelet and neutrophil activation. These data suggest that brain tissue responses in cerebral malaria can be studied noninvasively using EVs circulating in peripheral blood.
Collapse
Affiliation(s)
- Mwikali Kioko
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Open University, Milton Keynes, UK
| | - Shaban Mwangi
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Alena Pance
- Pathogens and Microbes Programme, Wellcome Sanger Institute, Cambridge, UK
- School of Life and Medical Science, University of Hertfordshire, Hatfield, UK
| | - Lynette Isabella Ochola-Oyier
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Symon Kariuki
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Charles Newton
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Philip Bejon
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Julian C Rayner
- Cambridge Institute of Medical Research, University of Cambridge, Cambridge, UK
| | - Abdirahman I Abdi
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pwani University Biosciences Research Centre, Pwani University, Kilifi, Kenya
| |
Collapse
|
2
|
Hviid L, Jensen AR, Deitsch KW. PfEMP1 and var genes - Still of key importance in Plasmodium falciparum malaria pathogenesis and immunity. ADVANCES IN PARASITOLOGY 2024; 125:53-103. [PMID: 39095112 DOI: 10.1016/bs.apar.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
The most severe form of malaria, caused by infection with Plasmodium falciparum parasites, continues to be an important cause of human suffering and poverty. The P. falciparum erythrocyte membrane protein 1 (PfEMP1) family of clonally variant antigens, which mediates the adhesion of infected erythrocytes to the vascular endothelium in various tissues and organs, is a central component of the pathogenesis of the disease and a key target of the acquired immune response to malaria. Much new knowledge has accumulated since we published a systematic overview of the PfEMP1 family almost ten years ago. In this chapter, we therefore aim to summarize research progress since 2015 on the structure, function, regulation etc. of this key protein family of arguably the most important human parasite. Recent insights regarding PfEMP1-specific immune responses and PfEMP1-specific vaccination against malaria, as well as an outlook for the coming years are also covered.
Collapse
Affiliation(s)
- Lars Hviid
- Centre for translational Medicine and Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark; Department of Infectious Diseases, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
| | - Anja R Jensen
- Centre for translational Medicine and Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Kirk W Deitsch
- Department of Microbiology and Immunology, Weill Cornell Medical College, New York, NY, United States
| |
Collapse
|
3
|
Gill J, Sharma A. Structural and genomic analysis of single nucleotide polymorphisms in human host factor endothelial protein C receptor (EPCR) reveals complex interplay with malaria parasites. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 110:105413. [PMID: 36775045 DOI: 10.1016/j.meegid.2023.105413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/12/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
Plasmodium parasites responsible for malaria follow a complex life cycle of which half takes place inside the human host. Parasites present diverse antigens at different stages of their life cycle and interact with many surface molecules to attach to and enter host cells. The CIDRα1 domain of Plasmodium falciparum Erythrocyte Membrane Protein 1 (PfEMP1) in infected erythrocytes adheres to one such vascular receptor endothelial protein C receptor (EPCR). EPCR is implicated in the pathogenesis of severe malaria as preferential binding of CIDRα1 to endothelium results in widespread sequestration of infected erythrocytes leading to endothelium inflammation and severe disease. A single EPCR variant S219G is clinically reported to provide protection from severe malaria. In this work, we have collated all single nucleotide polymorphisms (SNPs) in EPCR from dbSNP. We structurally mapped the SNPs on the three-dimensional complex of EPCR and PfEMP1 CIDRα1. Analysis shows that most EPCR mutations lie on the receptor surface and are non-conservative. Of the 11 mutations in the CIDRα1-interaction region of EPCR, S88P, L96V/I, and R98L/H/P/C are seen with comparably higher occurrences in diverse populations. Our structural analysis details a framework of the interactions between the parasite ligand and host factor EPCR. These structural glimpses provide a blueprint for designing both field-based variant sequencing studies and vaccine development.
Collapse
Affiliation(s)
- Jasmita Gill
- ICMR-National Institute of Malaria Research, New Delhi, India.
| | - Amit Sharma
- ICMR-National Institute of Malaria Research, New Delhi, India; International Centre for Genetic Engineering and Biotechnology, New Delhi, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad, India.
| |
Collapse
|
4
|
Nortey LN, Anning AS, Nakotey GK, Ussif AM, Opoku YK, Osei SA, Aboagye B, Ghartey-Kwansah G. Genetics of cerebral malaria: pathogenesis, biomarkers and emerging therapeutic interventions. Cell Biosci 2022; 12:91. [PMID: 35715862 PMCID: PMC9204375 DOI: 10.1186/s13578-022-00830-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cerebral malaria (CM) is a preeminent cause of severe disease and premature deaths in Sub-Saharan Africa, where an estimated 90% of cases occur. The key features of CM are a deep, unarousable coma that persists for longer than 1 h in patients with peripheral Plasmodium falciparum and no other explanation for encephalopathy. Significant research efforts on CM in the last few decades have focused on unravelling the molecular underpinnings of the disease pathogenesis and the identification of potential targets for therapeutic or pharmacologic intervention. These efforts have been greatly aided by the generation and study of mouse models of CM, which have provided great insights into key events of CM pathogenesis, revealed an interesting interplay of host versus parasite factors that determine the progression of malaria to severe disease and exposed possible targets for therapeutic intervention in severe disease.
Main Body
This paper reviews our current understanding of the pathogenic and immunologic factors involved in CM. We present the current view of the roles of certain gene products e.g., the var gene, ABCA-1, ICAM-1, TNF-alpha, CD-36, PfEMP-1 and G6PD, in CM pathogenesis. We also present alterations in the blood–brain barrier as a consequence of disease proliferation as well as complicated host and parasite interactions, including the T-cell immune reaction, reduced deformation of erythrocytes and cytoadherence. We further looked at recent advances in cerebral malaria treatment interventions by emphasizing on biomarkers, new diagnostic tools and emerging therapeutic options.
Conclusion
Finally, we discuss how the current understanding of some of these pathogenic and immunologic factors could inform the development of novel therapeutic interventions to fight CM.
Collapse
|
5
|
Successful Profiling of Plasmodium falciparum var Gene Expression in Clinical Samples via a Custom Capture Array. mSystems 2021; 6:e0022621. [PMID: 34846163 PMCID: PMC8631312 DOI: 10.1128/msystems.00226-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
var genes encode Plasmodium falciparum erythrocyte membrane protein-1 (PfEMP1) antigens. These highly diverse antigens are displayed on the surface of infected erythrocytes and play a critical role in immune evasion and sequestration of infected erythrocytes. Studies of var expression using non-leukocyte-depleted blood are challenging because of the predominance of host genetic material and lack of conserved var segments. Our goal was to enrich for parasite RNA, allowing de novo assembly of var genes and detection of expressed novel variants. We used two overall approaches: (i) enriching for total mRNA in the sequencing library preparations and (ii) enriching for parasite RNA with a custom capture array based on Roche’s SeqCap EZ enrichment system. The capture array was designed with probes based on the whole 3D7 reference genome and an additional >4,000 full-length var gene sequences from other P. falciparum strains. We tested each method on RNA samples from Malian children with severe or uncomplicated malaria infections. All reads mapping to the human genome were removed, the remaining reads were assembled de novo into transcripts, and from these, var-like transcripts were identified and annotated. The capture array produced the longest maximum length and largest numbers of var gene transcripts in each sample, particularly in samples with low parasitemia. Identifying the most-expressed var gene sequences in whole-blood clinical samples without the need for extensive processing or generating sample-specific reference genome data is critical for understanding the role of PfEMP1s in malaria pathogenesis. IMPORTANCE Malaria parasites display antigens on the surface of infected red blood cells in the human host that facilitate attachment to blood vessels, contributing to the severity of infection. These antigens are highly variable, allowing the parasite to evade the immune system. Identifying these expressed antigens is critical to understanding the development of severe malarial disease. However, clinical samples contain limited amounts of parasite genetic material, a challenge for sequencing efforts further compounded by the extreme diversity of the parasite surface antigens. We present a method that enriches for these antigen sequences in clinical samples using a custom capture array, requiring minimal processing in the field. While our results are focused on the malaria parasite Plasmodium falciparum, this approach has broad applicability to other highly diverse antigens from other parasites and pathogens such as those that cause giardiasis and leishmaniasis.
Collapse
|
6
|
Jensen AR, Adams Y, Hviid L. Cerebral Plasmodium falciparum malaria: The role of PfEMP1 in its pathogenesis and immunity, and PfEMP1-based vaccines to prevent it. Immunol Rev 2020; 293:230-252. [PMID: 31562653 PMCID: PMC6972667 DOI: 10.1111/imr.12807] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 12/13/2022]
Abstract
Malaria, a mosquito-borne infectious disease caused by parasites of the genus Plasmodium continues to be a major health problem worldwide. The unicellular Plasmodium-parasites have the unique capacity to infect and replicate within host erythrocytes. By expressing variant surface antigens Plasmodium falciparum has evolved to avoid protective immune responses; as a result in endemic areas anti-malaria immunity develops gradually over many years of multiple and repeated infections. We are studying the role of Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) expressed by asexual stages of P. falciparum responsible for the pathogenicity of severe malaria. The immunopathology of falciparum malaria has been linked to cyto-adhesion of infected erythrocytes to specific host receptors. A greater appreciation of the PfEMP1 molecules important for the development of protective immunity and immunopathology is a prerequisite for the rational discovery and development of a safe and protective anti-disease malaria vaccine. Here we review the role of ICAM-1 and EPCR receptor adhering falciparum-parasites in the development of severe malaria; we discuss our current research to understand the factors involved in the pathogenesis of cerebral malaria and the feasibility of developing a vaccine targeted specifically to prevent this disease.
Collapse
Affiliation(s)
- Anja Ramstedt Jensen
- Centre for Medical Parasitology at Department of Immunology and MicrobiologyFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Yvonne Adams
- Centre for Medical Parasitology at Department of Immunology and MicrobiologyFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Lars Hviid
- Centre for Medical Parasitology at Department of Immunology and MicrobiologyFaculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of Infectious DiseasesRigshospitaletCopenhagenDenmark
| |
Collapse
|
7
|
Kivisi CA, Muthui M, Hunt M, Fegan G, Otto TD, Githinji G, Warimwe GM, Rance R, Marsh K, Bull PC, Abdi AI. Exploring Plasmodium falciparum Var Gene Expression to Assess Host Selection Pressure on Parasites During Infancy. Front Immunol 2019; 10:2328. [PMID: 31681266 PMCID: PMC6798654 DOI: 10.3389/fimmu.2019.02328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/16/2019] [Indexed: 11/13/2022] Open
Abstract
In sub-Saharan Africa, children below 5 years bear the greatest burden of severe malaria because they lack naturally acquired immunity that develops following repeated exposure to infections by Plasmodium falciparum. Antibodies to the surface of P. falciparum infected erythrocytes (IE) play an important role in this immunity. In children under the age of 6 months, relative protection from severe malaria is observed and this is thought to be partly due to trans-placental acquired protective maternal antibodies. However, the protective effect of maternal antibodies has not been fully established, especially the role of antibodies to variant surface antigens (VSA) expressed on IE. Here, we assessed the immune pressure on parasites infecting infants using markers associated with the acquisition of naturally acquired immunity to surface antigens. We hypothesized that, if maternal antibodies to VSA imposed a selection pressure on parasites, then the expression of a relatively conserved subset of var genes called group A var genes in infants should change with waning maternal antibodies. To test this, we compared their expression in parasites from children between 0 and 12 months and above 12 months of age. The transcript quantity and the proportional expression of group A var subgroup, including those containing domain cassette 13, were positively associated with age during the first year of life, which contrasts with above 12 months. This was accompanied by a decline in infected erythrocyte surface antibodies and an increase in parasitemia during this period. The observed increase in group A var gene expression with age in the first year of life, when the maternal antibodies are waning and before acquisition of naturally acquired antibodies with repeated exposure, is consistent with the idea that maternally acquired antibodies impose a selection pressure on parasites that infect infants and may play a role in protecting these infants against severe malaria.
Collapse
Affiliation(s)
- Cheryl A Kivisi
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya.,Pwani University Biosciences Research Centre, Pwani University, Kilifi, Kenya.,Department of Biological Sciences, Pwani University, Kilifi, Kenya
| | | | - Martin Hunt
- Wellcome Sanger Institute, Cambridge, United Kingdom
| | - Greg Fegan
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | - George M Warimwe
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Richard Rance
- Pwani University Biosciences Research Centre, Pwani University, Kilifi, Kenya
| | - Kevin Marsh
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Peter C Bull
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | - Abdirahman I Abdi
- KEMRI Wellcome Trust Research Programme, Kilifi, Kenya.,Pwani University Biosciences Research Centre, Pwani University, Kilifi, Kenya
| |
Collapse
|
8
|
Storm J, Jespersen JS, Seydel KB, Szestak T, Mbewe M, Chisala NV, Phula P, Wang CW, Taylor TE, Moxon CA, Lavstsen T, Craig AG. Cerebral malaria is associated with differential cytoadherence to brain endothelial cells. EMBO Mol Med 2019; 11:emmm.201809164. [PMID: 30610112 PMCID: PMC6365927 DOI: 10.15252/emmm.201809164] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Sequestration of Plasmodium falciparum‐infected erythrocytes (IE) within the brain microvasculature is a hallmark of cerebral malaria (CM). Using a microchannel flow adhesion assay with TNF‐activated primary human microvascular endothelial cells, we demonstrate that IE isolated from Malawian paediatric CM cases showed increased binding to brain microvascular endothelial cells compared to IE from uncomplicated malaria (UM) cases. Further, UM isolates showed significantly greater adhesion to dermal than to brain microvascular endothelial cells. The major mediator of parasite adhesion is P. falciparum erythrocyte membrane protein 1, encoded by var genes. Higher levels of var gene transcripts predicted to bind host endothelial protein C receptor (EPCR) and ICAM‐1 were detected in CM isolates. These data provide further evidence for differential tissue binding in severe and uncomplicated malaria syndromes, and give additional support to the hypothesis that CM pathology is based on increased cytoadherence of IE in the brain microvasculature.
Collapse
Affiliation(s)
- Janet Storm
- Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jakob S Jespersen
- Department of International Health, Immunology & Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Karl B Seydel
- College of Medicine, University of Malawi, Blantyre, Malawi.,Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Tadge Szestak
- Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maurice Mbewe
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Ngawina V Chisala
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Patricia Phula
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Christian W Wang
- Department of International Health, Immunology & Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Terrie E Taylor
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Christopher A Moxon
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.,Wellcome Centre for Molecular Parasitology, Institute of Infection, Immunity and Inflammation, College of Medical Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Thomas Lavstsen
- Department of International Health, Immunology & Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Alister G Craig
- Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
9
|
Lee WC, Russell B, Rénia L. Sticking for a Cause: The Falciparum Malaria Parasites Cytoadherence Paradigm. Front Immunol 2019; 10:1444. [PMID: 31316507 PMCID: PMC6610498 DOI: 10.3389/fimmu.2019.01444] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 06/10/2019] [Indexed: 12/26/2022] Open
Abstract
After a successful invasion, malaria parasite Plasmodium falciparum extensively remodels the infected erythrocyte cellular architecture, conferring cytoadhesive properties to the infected erythrocytes. Cytoadherence plays a central role in the parasite's immune-escape mechanism, at the same time contributing to the pathogenesis of severe falciparum malaria. In this review, we discuss the cytoadhesive interactions between P. falciparum infected erythrocytes and various host cell types, and how these events are linked to malaria pathogenesis. We also highlight the limitations faced by studies attempting to correlate diversity in parasite ligands and host receptors with the development of severe malaria.
Collapse
Affiliation(s)
- Wenn-Chyau Lee
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (ASTAR), Singapore, Singapore
| | - Bruce Russell
- Department of Microbiology and Immunology, University of Otago, Dunedin, New Zealand
| | - Laurent Rénia
- Singapore Immunology Network (SIgN), Agency for Science, Technology and Research (ASTAR), Singapore, Singapore
| |
Collapse
|
10
|
Immunization with Recombinant Plasmodium falciparum Erythrocyte Membrane Protein 1 CIDRα1 Domains Induces Domain Subtype Inhibitory Antibodies. Infect Immun 2018; 86:IAI.00435-18. [PMID: 30150256 DOI: 10.1128/iai.00435-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/22/2018] [Indexed: 12/19/2022] Open
Abstract
Plasmodium falciparum malaria pathogenesis is tied to the sequestration of parasites in the microvasculature. Parasite sequestration leading to severe malaria is mediated by P. falciparum erythrocyte membrane protein 1 (PfEMP1) binding to endothelial protein C receptor (EPCR) via its CIDRα1 domains. CIDRα1 domains are targets of naturally acquired immunity, and a vaccine eliciting antibodies inhibiting the EPCR binding of CIDRα1 could potentially prevent disease and death from malaria. CIDRα1 domains have diversified in sequence to escape immune recognition but preserved structure to maintain EPCR binding. The EPCR-binding CIDRα1 domains separate into six major sequence types predicted to form a conserved structure in which only the amino acids essential for EPCR binding are highly conserved. Here, we investigated whether antibodies elicited by vaccination with single or multiple recombinant CIDRα1 domains are able to bind and inhibit diverse CIDRα1 domains. We found that EPCR binding-inhibitory antibodies to CIDRα1 variants closely related to those used for vaccination are readily elicited, whereas antibodies binding distant CIDRα1 variants are sporadically generated and are rarely inhibitory. Despite this, sequence similarity correlated poorly with the ability of induced antibodies to inhibit across diverse variants, and no continuous sequence regions of importance for cross-inhibitory antibodies could be identified. This suggested that epitopes of cross-variant inhibitory antibodies were predominantly conformational. Vaccination with immunogens engineered to focus immune responses to specific epitopes or an optimal choice of multiple CIDRα1 variants may improve elicitation of broadly reactive and inhibitory antibody responses.
Collapse
|
11
|
Abstract
Human malaria is a complex disease that can show a wide array of clinical outcomes, from asymptomatic carriage and chronic infection to acute disease presenting various life-threatening pathologies. The specific outcome of an infection is believed to be determined by a multifactorial interplay between the host and the parasite but with a general trend toward disease attenuation with increasing prior exposure. Therefore, the main burden of malaria in a population can be understood as a function of transmission intensity, which itself is intricately linked to the prevalence of infected hosts and mosquito vectors, the distribution of infection outcomes, and the parasite population diversity. Predicting the long-term impact of malaria intervention measures therefore requires an in-depth understanding of how the parasite causes disease, how this relates to previous exposures, and how different infection pathologies contribute to parasite transmission. Here, we provide a brief overview of recent advances in the molecular epidemiology of clinical malaria and how these might prove to be influential in our fight against this important disease.
Collapse
Affiliation(s)
- Mario Recker
- Centre for Mathematics and the Environment, University of Exeter, Penryn Campus, Penryn, TR10 9FE, UK
| | - Peter C Bull
- Department of Pathology, University of Cambridge, Cambridge, CB2 1QP, UK
| | - Caroline O Buckee
- Center for Communicable Disease Dynamics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| |
Collapse
|
12
|
Kessler A, Campo JJ, Harawa V, Mandala WL, Rogerson SJ, Mowrey WB, Seydel KB, Kim K. Convalescent Plasmodium falciparum-specific seroreactivity does not correlate with paediatric malaria severity or Plasmodium antigen exposure. Malar J 2018; 17:178. [PMID: 29695240 PMCID: PMC5918990 DOI: 10.1186/s12936-018-2323-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/18/2018] [Indexed: 12/17/2022] Open
Abstract
Background Antibody immunity is thought to be essential to prevent severe Plasmodium falciparum infection, but the exact correlates of protection are unknown. Over time, children in endemic areas acquire non-sterile immunity to malaria that correlates with development of antibodies to merozoite invasion proteins and parasite proteins expressed on the surface of infected erythrocytes. Results A 1000 feature P. falciparum 3D7 protein microarray was used to compare P. falciparum-specific seroreactivity during acute infection and 30 days after infection in 23 children with uncomplicated malaria (UM) and 25 children with retinopathy-positive cerebral malaria (CM). All children had broad P. falciparum antibody reactivity during acute disease. IgM reactivity decreased and IgG reactivity increased in convalescence. Antibody reactivity to CIDR domains of “virulent” PfEMP1 proteins was low with robust reactivity to the highly conserved, intracellular ATS domain of PfEMP1 in both groups. Although children with UM and CM differed markedly in parasite burden and PfEMP1 exposure during acute disease, neither acute nor convalescent PfEMP1 seroreactivity differed between groups. Greater seroprevalence to a conserved Group A-associated ICAM binding extracellular domain was observed relative to linked extracellular CIDRα1 domains in both case groups. Pooled immune IgG from Malawian adults revealed greater reactivity to PfEMP1 than observed in children. Conclusions Children with uncomplicated and cerebral malaria have similar breadth and magnitude of P. falciparum antibody reactivity. The utility of protein microarrays to measure serological recognition of polymorphic PfEMP1 antigens needs to be studied further, but the study findings support the hypothesis that conserved domains of PfEMP1 are more prominent targets of cross reactive antibodies than variable domains in children with symptomatic malaria. Protein microarrays represent an additional tool to identify cross-reactive Plasmodium antigens including PfEMP1 domains that can be investigated as strain-transcendent vaccine candidates. Electronic supplementary material The online version of this article (10.1186/s12936-018-2323-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anne Kessler
- Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Visopo Harawa
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, Biomedical Department, University of Malawi, Blantyre, Malawi
| | - Wilson L Mandala
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,College of Medicine, Biomedical Department, University of Malawi, Blantyre, Malawi.,Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | | | | | - Karl B Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA. .,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.
| | - Kami Kim
- Albert Einstein College of Medicine, Bronx, NY, USA. .,Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
13
|
Kessler A, Dankwa S, Bernabeu M, Harawa V, Danziger SA, Duffy F, Kampondeni SD, Potchen MJ, Dambrauskas N, Vigdorovich V, Oliver BG, Hochman SE, Mowrey WB, MacCormick IJC, Mandala WL, Rogerson SJ, Sather DN, Aitchison JD, Taylor TE, Seydel KB, Smith JD, Kim K. Linking EPCR-Binding PfEMP1 to Brain Swelling in Pediatric Cerebral Malaria. Cell Host Microbe 2017; 22:601-614.e5. [PMID: 29107642 DOI: 10.1016/j.chom.2017.09.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/06/2017] [Accepted: 09/22/2017] [Indexed: 11/16/2022]
Abstract
Brain swelling is a major predictor of mortality in pediatric cerebral malaria (CM). However, the mechanisms leading to swelling remain poorly defined. Here, we combined neuroimaging, parasite transcript profiling, and laboratory blood profiles to develop machine-learning models of malarial retinopathy and brain swelling. We found that parasite var transcripts encoding endothelial protein C receptor (EPCR)-binding domains, in combination with high parasite biomass and low platelet levels, are strong indicators of CM cases with malarial retinopathy. Swelling cases presented low platelet levels and increased transcript abundance of parasite PfEMP1 DC8 and group A EPCR-binding domains. Remarkably, the dominant transcript in 50% of swelling cases encoded PfEMP1 group A CIDRα1.7 domains. Furthermore, a recombinant CIDRα1.7 domain from a pediatric CM brain autopsy inhibited the barrier-protective properties of EPCR in human brain endothelial cells in vitro. Together, these findings suggest a detrimental role for EPCR-binding CIDRα1 domains in brain swelling.
Collapse
Affiliation(s)
- Anne Kessler
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA
| | - Selasi Dankwa
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | - Maria Bernabeu
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | - Visopo Harawa
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre BT3, Malawi; University of Malawi, College of Medicine, Biomedical Department, Blantyre BT3, Malawi
| | | | - Fergal Duffy
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | | | - Michael J Potchen
- Department of Imaging Sciences, University of Rochester, Rochester, NY 14642, USA
| | | | | | - Brian G Oliver
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | - Sarah E Hochman
- Department of Medicine, New York University Langone Health, New York, NY 10016, USA
| | - Wenzhu B Mowrey
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA
| | - Ian J C MacCormick
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre BT3, Malawi; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH16 4SB, UK; Department of Eye and Vision Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Wilson L Mandala
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre BT3, Malawi; University of Malawi, College of Medicine, Biomedical Department, Blantyre BT3, Malawi; Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo BT3, Malawi
| | - Stephen J Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, VIC 3000, Australia
| | - D Noah Sather
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | | | - Terrie E Taylor
- Blantyre Malaria Project, Blantyre BT3, Malawi; Department of Osteopathic Medical Specialities, College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA
| | - Karl B Seydel
- Blantyre Malaria Project, Blantyre BT3, Malawi; Department of Osteopathic Medical Specialities, College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48824, USA.
| | - Joseph D Smith
- Center for Infectious Disease Research, Seattle, WA 98109, USA; Department of Global Health, University of Washington, Seattle, WA 98195, USA.
| | - Kami Kim
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10461, USA.
| |
Collapse
|
14
|
Shabani E, Hanisch B, Opoka RO, Lavstsen T, John CC. Plasmodium falciparum EPCR-binding PfEMP1 expression increases with malaria disease severity and is elevated in retinopathy negative cerebral malaria. BMC Med 2017; 15:183. [PMID: 29025399 PMCID: PMC5639490 DOI: 10.1186/s12916-017-0945-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 09/15/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Expression of group A and the A-like subset of group B Plasmodium falciparum erythrocyte membrane protein 1 (PfEMP1) is associated with severe malaria (SM). The diversity of var sequences combined with the challenges of distinct classification of patient pathologies has made studying the role of distinct PfEMP1 variants on malaria disease severity challenging. The application of retinopathy in the recent years has provided a further method to clinically evaluate children with cerebral malaria (CM). The question of whether children with clinical CM but no retinopathy represent a completely different disease process or a subgroup within the spectrum of CM remains an important question in malaria. In the current study, we use newly designed primer sets with the best coverage to date in a large cohort of children with SM to determine the role of var genes in malaria disease severity and especially CM as discriminated by retinopathy. METHODS We performed qRT-PCR targeting the different subsets of these var genes on samples from Ugandan children with CM (n = 98, of whom 50 had malarial retinopathy [RP] and 47 did not [RN]), severe malarial anemia (SMA, n = 47), and asymptomatic parasitemia (AP, n = 14). The primers used in this study were designed based on var sequences from 226 Illumina whole genome sequenced P. falciparum field isolates. RESULTS Increasing severity of illness was associated with increasing levels of endothelial protein C receptor (EPCR)-binding PfEMP1. EPCR-binding PfEMP1 transcript levels were highest in children with combined CM and SMA and then decreased by level of disease severity: RP CM > RN CM > SMA > AP. CONCLUSIONS The study findings indicate that PfEMP1 binding to EPCR is important in the pathogenesis of SM, including RN CM, and suggest that increased expression of EPCR-binding PfEMP1 is associated with progressively more severe disease. Agents that block EPCR-binding of PfEMP1 could provide novel interventions to prevent or decrease disease severity in malaria.
Collapse
Affiliation(s)
- Estela Shabani
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University, 1044 W Walnut St R4 402D, Indianapolis, Indiana, USA.,Department of Pediatrics, Division of Global Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda
| | - Thomas Lavstsen
- Centre for Medical Parasitology, Department of International Health, Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen, Denmark
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University, 1044 W Walnut St R4 402D, Indianapolis, Indiana, USA. .,Department of Pediatrics, Division of Global Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA.
| |
Collapse
|
15
|
Abdi AI, Hodgson SH, Muthui MK, Kivisi CA, Kamuyu G, Kimani D, Hoffman SL, Juma E, Ogutu B, Draper SJ, Osier F, Bejon P, Marsh K, Bull PC. Plasmodium falciparum malaria parasite var gene expression is modified by host antibodies: longitudinal evidence from controlled infections of Kenyan adults with varying natural exposure. BMC Infect Dis 2017; 17:585. [PMID: 28835215 PMCID: PMC5569527 DOI: 10.1186/s12879-017-2686-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
Background The PfEMP1 family of Plasmodium falciparum antigens play a key role in pathogenesis of severe malaria through their insertion into the surface of parasite infected erythrocytes, and adhesion to host cells. Previous studies have suggested that parasites expressing PfEMP1 subclasses group A and DC8, associated with severe malaria, may have a growth advantage in immunologically naïve individuals. However, this idea has not been tested in longitudinal studies. Methods Here we assessed expression of the var genes encoding PfEMP1, in parasites sampled from volunteers with varying prior exposure to malaria, following experimental infection by sporozoites (PfSPZ). Using qPCR, we tested for associations between the expression of various var subgroups in surviving parasite populations from each volunteer and 1) the levels of participants’ antibodies to infected erythrocytes before challenge infection and 2) the apparent in vivo parasite multiplication rate. Results We show that 1) expression of var genes encoding for group A and DC8-like PfEMP1 were associated with low levels of antibodies to infected erythrocytes (αIE) before challenge, and 2) expression of a DC8-like CIDRα1.1 domain was associated with higher apparent parasite multiplication rate in a manner that was independent of levels of prior antibodies to infected erythrocytes. Conclusions This study provides insight into the role of antibodies to infected erythrocytes surface antigens in the development of naturally acquired immunity and may help explain why specific PfEMP1 variants may be associated with severe malaria. Trial registration Pan African Clinical Trial Registry: PACTR201211000433272. Date of registration: 10th October 2012.
Collapse
Affiliation(s)
- Abdirahman I Abdi
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya. .,Pwani University, P. O. Box 195-80108, Kilifi, Kenya.
| | | | - Michelle K Muthui
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | - Cheryl A Kivisi
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya.,Pwani University, P. O. Box 195-80108, Kilifi, Kenya
| | - Gathoni Kamuyu
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | - Domtila Kimani
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | | | - Elizabeth Juma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.,Centre for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.,Centre for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya
| | | | - Faith Osier
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | - Philip Bejon
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | - Kevin Marsh
- KEMRI-Wellcome Trust Research Programme, CGMRC, P.O. Box 230-80108, Kilifi County, Kenya
| | - Peter C Bull
- Department of Pathology, University of Cambridge, 17 Tennis Court Road, Cambridge, CB2 1QP, UK.
| |
Collapse
|
16
|
The Severity of Plasmodium falciparum Infection Is Associated with Transcript Levels of var Genes Encoding Endothelial Protein C Receptor-Binding P. falciparum Erythrocyte Membrane Protein 1. Infect Immun 2017; 85:IAI.00841-16. [PMID: 28138022 DOI: 10.1128/iai.00841-16] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 01/23/2017] [Indexed: 11/20/2022] Open
Abstract
By attaching infected erythrocytes to the vascular lining, Plasmodium falciparum parasites leave blood circulation and avoid splenic clearance. This sequestration is central to pathogenesis. Severe malaria is associated with parasites expressing an antigenically distinct P. falciparum erythrocyte membrane protein 1 (PfEMP1) subset mediating binding to endothelial receptors. Previous studies indicate that PfEMP1 adhesins with so-called CIDRα1 domains capable of binding endothelial protein C receptor (EPCR) constitute the PfEMP1 subset associated with severe pediatric malaria. To analyze the relative importance of different subtypes of CIDRα1 domains, we compared Pfemp1 transcript levels in children with severe malaria (including 9 fatal and 114 surviving cases), children hospitalized with uncomplicated malaria (n = 42), children with mild malaria not requiring hospitalization (n = 10), and children with parasitemia and no ongoing fever (n = 12). High levels of transcripts encoding EPCR-binding PfEMP1 were found in patients with symptomatic infections, and the abundance of these transcripts increased with disease severity. The compositions of CIDRα1 subtype transcripts varied markedly between patients, and none of the subtypes were dominant. Transcript-level analyses targeting other domain types indicated that subtypes of DBLβ or DBLζ domains might mediate binding phenomena that, in conjunction with EPCR binding, could contribute to pathogenesis. These observations strengthen the rationale for targeting the PfEMP1-EPCR interaction by vaccines and adjunctive therapies. Interventions should target EPCR binding of all CIDRα1 subtypes.
Collapse
|
17
|
Bernabeu M, Smith JD. EPCR and Malaria Severity: The Center of a Perfect Storm. Trends Parasitol 2016; 33:295-308. [PMID: 27939609 DOI: 10.1016/j.pt.2016.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 12/20/2022]
Abstract
Severe malaria due to Plasmodium falciparum infection causes nearly half a million deaths per year. The different symptomatology and disease manifestations among patients have hampered understanding of severe malaria pathology and complicated efforts to develop targeted disease interventions. Infected erythrocyte sequestration in the microvasculature plays a critical role in the development of severe disease, and there is increasing evidence that cytoadherent parasites interact with host factors to enhance the damage caused by the parasite. The recent discovery that parasite binding to endothelial protein C receptor (EPCR) is associated with severe disease has suggested new mechanisms of pathology and provided new avenues for severe malaria adjunctive therapy research.
Collapse
Affiliation(s)
- Maria Bernabeu
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | - Joseph D Smith
- Center for Infectious Disease Research, Seattle, WA 98109, USA; Department of Global Health, University of Washington, Seattle, WA 98195, USA.
| |
Collapse
|
18
|
Jespersen JS, Wang CW, Mkumbaye SI, Minja DT, Petersen B, Turner L, Petersen JE, Lusingu JP, Theander TG, Lavstsen T. Plasmodium falciparum var genes expressed in children with severe malaria encode CIDRα1 domains. EMBO Mol Med 2016; 8:839-50. [PMID: 27354391 PMCID: PMC4967939 DOI: 10.15252/emmm.201606188] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Most severe Plasmodium falciparum infections are experienced by young children. Severe symptoms are precipitated by vascular sequestration of parasites expressing a particular subset of the polymorphic P. falciparum erythrocyte membrane protein 1 (PfEMP1) adhesion molecules. Parasites binding human endothelial protein C receptor (EPCR) through the CIDRα1 domain of certain PfEMP1 were recently associated with severe malaria in children. However, it has remained unclear to which extend the EPCR‐binding CIDRα1 domains epitomize PfEMP1 expressed in severe malaria. Here, we characterized the near full‐length transcripts dominating the var transcriptome in children with severe malaria and found that the only common feature of the encoded PfEMP1 was CIDRα1 domains. Such genes were highly and dominantly expressed in both children with severe malarial anaemia and cerebral malaria. These observations support the hypothesis that the CIDRα1‐EPCR interaction is key to the pathogenesis of severe malaria and strengthen the rationale for pursuing a vaccine or adjunctive treatment aiming at inhibiting or reducing the damaging effects of this interaction.
Collapse
Affiliation(s)
- Jakob S Jespersen
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Christian W Wang
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Sixbert I Mkumbaye
- Kilimanjaro Christian Medical University College, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Daniel Tr Minja
- National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Bent Petersen
- Centre for Biological Sequence Analysis, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Louise Turner
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Jens Ev Petersen
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - John Pa Lusingu
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark National Institute for Medical Research, Tanga Research Centre, Tanga, Tanzania
| | - Thor G Theander
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Lavstsen
- Centre for Medical Parasitology, Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|