Parasitic diseases of the central nervous system

Involvement of ectonucleotidases and purinergic receptor expression during acute Chagas disease in the cortex of mice treated with resveratrol and benznidazole

Chagas disease (CD) is caused by the parasite Trypanosoma cruzi. CD affects people worldwide, primarily in tropical areas. The central nervous system (CNS) is an essential site for T. cruzi persistence during infection. The protozoan may pass through the blood-brain barrier and may cause motor and cognitive neuronal damage. Once in the CNS, T. cruzi triggers immune responses that the purinergic system can regulate. Treatment for CD is based on benznidazole (BNZ); however, this agent has negative side-effects and is toxic to the host. For this reason, we investigated whether resveratrol (RSV), a potent antioxidant and neuroprotective molecule, would modulate purinergic signaling and RSV alone or in combination with BNZ would prevent changes in purinergic signaling and oxidative damage caused by T. cruzi. We infected mice with T. cruzi and treated them with RSV or BNZ for 8 days. Increases in ATP and ADP hydrolysis by NTPDase in the total cortex of infected animals were observed. The treatment with RSV in infected group diminished ATP, ADP, and AMP hydrolysis compared to infected group. The combination of RSV + BNZ decreased AMP hydrolysis in infected animals compared to the INF group, exerting an anti-inflammatory effect. RSV acted as a neuroprotector, decreasing adenosine levels. Infected animals presented an increase of P2X₇ and A_2A density of purine receptors. RSV reduced P2X₇ and A_2A and increased A1 density receptors in infected animals. In addition, infected animals showed higher TBARS and reactive oxygen species (ROS) levels than control. RSV diminished ROS levels in infected mice, possibly due to antioxidant properties. In short, we conclude that resveratrol could act as a neuroprotective molecule, probably preventing inflammatory changes caused by infection by T. cruzi, even though the mice experienced high levels of parasitemia.

Infektionen

In diesem Kapitel werden zunächst die für die Neurointensivmedizin wesentlichen bakteriellen Infektionen (Meningitis, spinale und Hirnabszesse, Spondylodiszitis, septisch-embolische Herdenzephalitis) abgehandelt, die trotz gezielt eingesetzter Antibiotika und neurochirurgischer Therapieoptionen noch mit einer erheblichen Morbidität und Mortalität behaftet sind. Besonderheiten wie neurovaskuläre Komplikationen, die Tuberkulose des Nervensystems, Neuroborreliose, Neurosyphilis und opportunistische Infektionen bei Immunsuppressionszuständen finden hierbei besondere Berücksichtigung. Der zweite Teil dieses Kapitels behandelt akute und chronische Virusinfektionen des ZNS sowie in einem gesonderten Abschnitt die HIVInfektion und HIV-assoziierte Krankheitsbilder sowie Parasitosen und Pilzinfektionen, die in Industrieländern seit Einführung der HAART bei HIV zwar eher seltener, aber mit zunehmender Globalisierung auch in unseren Breiten immer noch anzutreffen sind.

Neurological and ocular fascioliasis in humans

Fascioliasis is a food-borne parasitic disease caused by the trematode species Fasciola hepatica, distributed worldwide, and Fasciola gigantica, restricted to given regions of Africa and Asia. This disease in humans shows an increasing importance, which relies on its recent widespread emergence related to climate and global changes and also on its pathogenicity in the invasive, biliary, and advanced chronic phases in the human endemic areas, mainly of developing countries. In spite of the large neurological affection capacity of Fasciola, this important pathogenic aspect of the disease has been pronouncedly overlooked in the past decades and has not even appear within the numerous reviews on the parasitic diseases of the central nervous system. The aim of this wide retrospective review is an in-depth analysis of the characteristics of neurological and ocular fascioliasis caused by these two fasciolid species. The terms of neurofascioliasis and ophthalmofascioliasis are restricted to cases in which the direct affection of the central nervous system or the eye by a migrant ectopic fasciolid fluke is demonstrated by an aetiological diagnosis of recovered flukes after surgery or spontaneous moving-out of the fluke through the orbit. Cases in which the ectopic fluke is not recovered and the symptoms cannot be explained by an indirect affection at distance may also be included in these terms. Neurofascioliasis and ophthalmofascioliasis cases are reviewed and discussed. With regard to fascioliasis infection giving an indirect rise to neurological affection, the distribution and frequency of cases are analysed according to geography, sex, and age. Minor symptoms and major manifestations are discussed. Three main types of cases are distinguished depending on the characteristics of their manifestations: genuine neurological, meningeal, and psychiatric or neuropsychic. The impressive symptoms and signs appearing in each type of these cases are included. Brain examination techniques and neuroimaging useful for the diagnosis of neurological cases are exposed. Within fascioliasis infection indirectly causing ocular manifestations, case distribution and frequency are similarly analysed. A short analysis is devoted to clarify the first reports of a human eye infection. The affection of related and close organs is discussed by differentiating between cases of the dorsal spine, pulmonary manifestations, heart and vessel affection, findings in blood vessels, skin and dermatologic reactions, cases of ectopic mature flukes, and upper body locations. The clinical complexity of the puzzling polymorphisms, the disconcerting multifocality of the manifestations, and their changes along the evolution of the disease in the same patient, as well as the differences between the clinical pictures shown by different patients, are highlighted. The many syndromes involved are enumerated. The pathogenic and physiological mechanisms underlying neurofascioliasis and ophthalmofascioliasis caused by ectopic flukes and the physiopathogenic processes indirectly affecting the central nervous system and causing genuine neurological, meningeal, psychiatric, and ocular manifestations are discussed. The diagnosis of neurological and ophthalmologic fascioliasis is analysed in depth, including clinical and paraclinical diagnosis, eosinophilia in the blood and cerebrospinal fluid, differential diagnosis from other parasitic infections such as helminthiases and myiases, an update of human fascioliasis diagnosis, and fluke and/or fluke egg recovery by surgery. Diagnostic analyses with faecal and blood samples for fascioliasis patients are updated. Therapy for patients with major neurological manifestations includes both antiparasitic treatments and anti-inflammatory therapeutics. Prognosis in fascioliasis patients with neurological manifestations is discussed, with emphasis on sequelae and fatal cases, and the care of patients with ophthalmologic manifestations is added. Conclusions indicate that neurological cases are overlooked in human fascioliasis endemic areas and also in developing countries in general. In remote zones, rural health centres and small hospitals in or near the human endemic areas do not dispose of the appropriate equipments for neurological analyses. Moreover, physicians may not be aware about the potential relationship between liver fluke infection and neurological implications, and such cases may therefore remain misdiagnosed, even in developed countries. Priority should henceforth be given to the consideration of neurological and ocular affection in human endemic areas, and efforts should be implemented to assess their characteristics and frequency. Their impact should also be considered when estimating the global burden of fascioliasis.

Pathology of CNS parasitic infections

Parasitic infections of the central nervous system (CNS) include two broad categories of infectious organisms: single-celled protozoa and multicellular metazoa. The protozoal infections include malaria, American trypanosomiasis, human African trypanosomiasis, toxoplasmosis, amebiasis, microsporidiasis, and leishmaniasis. The metazoal infections are grouped into flatworms, which include trematoda and cestoda, and roundworms or nematoda. Trematoda infections include schistosomiasis and paragonimiasis. Cestoda infections include cysticercosis, coenurosis, hydatidosis, and sparganosis. Nematoda infections include gnathostomiasis, angiostrongyliasis, toxocariasis, strongyloidiasis, filariasis, baylisascariasis, dracunculiasis, micronemiasis, and lagochilascariasis. The most common route of CNS invasion is through the blood. In some cases, the parasite invades the olfactory neuroepithelium in the nasal mucosa and penetrates the brain via the subarachnoid space or reaches the CNS through neural foramina of the skull base around the cranial nerves or vessels. The neuropathological changes vary greatly, depending on the type and size of the parasite, geographical strain variations in parasitic virulence, immune evasion by the parasite, and differences in host immune response. Congestion of the leptomeninges, cerebral edema, hemorrhage, thrombosis, vasculitis, necrosis, calcification, abscesses, meningeal and perivascular polymorphonuclear and mononuclear inflammatory infiltrate, microglial nodules, gliosis, granulomas, and fibrosis can be found affecting isolated or multiple regions of the CNS, or even diffusely spread. Some infections may be present as an expanding mass lesion. The parasites can be identified by conventional histology, immunohistochemistry, in situ hybridization, and PCR.

Co-infection of HIV and tropical infectious agents that affect the nervous system

Tropical infections refer to a group of diseases usually located in regions with a warm climate, particularly affecting developing countries, partly because of the conditions that allow them to thrive. However, due to the increased international travel, infectious agents that were previously limited to tropical regions pose an increasing threat to populations at risk for opportunistic infection (OI), especially those infected with the HIV. Tropical infections can facilitate HIV transmission and accelerate the progression of asymptomatic HIV infection to AIDS. Some have the potential to alter the epidemiology, natural history, and/or response to treatment of the other. The introduction of highly active antiretroviral therapy has provided a huge benefit for the vast majority of patients infected with the HIV, by allowing the immune system to recover, improving the clinical and radiological results and reducing the number of OI. On the other hand, some patients have developed various disorders of immune reconstitution, resulting in either hyper-immune inflammatory response to an exogenous antigen or autoimmunity. A significant proportion of these cases have been reported in immigrants from tropical countries to high-income countries, therefore awareness of these phenomena is needed since clinical presentations are often atypical and pose diagnostic challenges. This article reviews some of the key diagnostic aspects of tropical infections associated with HIV infection.

Infektionen

Trotz Weiterentwicklung moderner Antibiotika in den letzten Jahren sind die Letalitätszahlen der bakteriellen (eitrigen) Meningitis weiterhin hoch; Überlebende haben häufig neurologische Residuen. Die ungünstigen klinischen Verläufe der bakteriellen Meningitis sind meist Folge intrakranieller Komplikationen, wie z. B. eines generalisierten Hirnödems, einer zerebrovaskulären arteriellen oder venösen Beteiligung oder eines Hydrozephalus.

A morphological approach to the diagnosis of protozoal infections of the central nervous system

Protozoal infections, though endemic to certain regions, can be seen all around the world, because of the increase in travel and migration. In addition, immunosuppression associated with various conditions, particularly with HIV infection, favors the occurrence of more severe manifestations and failure to respond to treatments. The CNS may be the only affected system; when not, it is often the most severely affected. Despite information obtained from clinical, laboratory, and imaging procedures that help to narrow the differential diagnosis of intracranial infections, there are cases that need confirmation with biopsy or autopsy. Predominant presentations are meningoencephalitis (trypanosomiasis), encephalopathy (cerebral malaria), or as single or multiple pseudotumoral enhancing lesions (toxoplasmosis, reactivated Chagas' disease). The immune reconstitution disease, resulting from enhancement of pathogen-specific immune responses after HAART, has altered the typical presentation of toxoplasmosis and microsporidiosis. In this paper, a morphological approach for the diagnosis of protozoal infections affecting the CNS (amoebiasis, cerebral malaria, toxoplasmosis, trypanosomiasis, and microsporidiosis) is presented.