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Haley MJ, Barroso R, Jasim DA, Haigh M, Green J, Dickie B, Craig AG, Brough D, Couper KN. Lymphatic network drainage resolves cerebral edema and facilitates recovery from experimental cerebral malaria. Cell Rep 2024; 43:114217. [PMID: 38728141 DOI: 10.1016/j.celrep.2024.114217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 11/29/2023] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
While brain swelling, associated with fluid accumulation, is a known feature of pediatric cerebral malaria (CM), how fluid and macromolecules are drained from the brain during recovery from CM is unknown. Using the experimental CM (ECM) model, we show that fluid accumulation in the brain during CM is driven by vasogenic edema and not by perivascular cerebrospinal fluid (CSF) influx. We identify that fluid and molecules are removed from the brain extremely quickly in mice with ECM to the deep cervical lymph nodes (dcLNs), predominantly through basal routes and across the cribriform plate and the nasal lymphatics. In agreement, we demonstrate that ligation of the afferent lymphatic vessels draining to the dcLNs significantly impairs fluid drainage from the brain and lowers anti-malarial drug recovery from the ECM syndrome. Collectively, our results provide insight into the pathways that coordinate recovery from CM.
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Affiliation(s)
- Michael J Haley
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Ruben Barroso
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Dhifaf A Jasim
- Nanomedicine Lab, National Graphene Institute and Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester M13 9PT, UK; Medicines Discovery Catapult (MDC), Alderley Park, Macclesfield SK10 4TG, UK
| | - Megan Haigh
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Jack Green
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK; Division of Neuroscience, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Ben Dickie
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; Division of Informatics, Imaging & Data Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Alister G Craig
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - David Brough
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK; Division of Neuroscience, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Kevin N Couper
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.
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Gopinadhan A, Hughes JM, Conroy AL, John CC, Canfield SG, Datta D. A human pluripotent stem cell-derived in vitro model of the blood-brain barrier in cerebral malaria. Fluids Barriers CNS 2024; 21:38. [PMID: 38693577 PMCID: PMC11064301 DOI: 10.1186/s12987-024-00541-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/18/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Blood-brain barrier (BBB) disruption is a central feature of cerebral malaria (CM), a severe complication of Plasmodium falciparum (Pf) infections. In CM, sequestration of Pf-infected red blood cells (Pf-iRBCs) to brain endothelial cells combined with inflammation, hemolysis, microvasculature obstruction and endothelial dysfunction mediates BBB disruption, resulting in severe neurologic symptoms including coma and seizures, potentially leading to death or long-term sequelae. In vitro models have advanced our knowledge of CM-mediated BBB disruption, but their physiological relevance remains uncertain. Using human induced pluripotent stem cell-derived brain microvascular endothelial cells (hiPSC-BMECs), we aimed to develop a novel in vitro model of the BBB in CM, exhibiting enhanced barrier properties. METHODS hiPSC-BMECs were co-cultured with HB3var03 strain Pf-iRBCs up to 9 h. Barrier integrity was measured using transendothelial electrical resistance (TEER) and sodium fluorescein permeability assays. Localization and expression of tight junction (TJ) proteins (occludin, zonula occludens-1, claudin-5), cellular adhesion molecules (ICAM-1, VCAM-1), and endothelial surface markers (EPCR) were determined using immunofluorescence imaging (IF) and western blotting (WB). Expression of angiogenic and cell stress markers were measured using multiplex proteome profiler arrays. RESULTS After 6-h of co-culture with Pf-iRBCs, hiPSC-BMECs showed reduced TEER and increased sodium fluorescein permeability compared to co-culture with uninfected RBCs, indicative of a leaky barrier. We observed disruptions in localization of occludin, zonula occludens-1, and claudin-5 by IF, but no change in protein expression by WB in Pf-iRBC co-cultures. Expression of ICAM-1 and VCAM-1 but not EPCR was elevated in hiPSC-BMECs with Pf-iRBC co-culture compared to uninfected RBC co-culture. In addition, there was an increase in expression of angiogenin, platelet factor-4, and phospho-heat shock protein-27 in the Pf-iRBCs co-culture compared to uninfected RBC co-culture. CONCLUSION These findings demonstrate the validity of our hiPSC-BMECs based model of the BBB, that displays enhanced barrier integrity and appropriate TJ protein localization. In the hiPSC-BMEC co-culture with Pf-iRBCs, reduced TEER, increased paracellular permeability, changes in TJ protein localization, increase in expression of adhesion molecules, and markers of angiogenesis and cellular stress all point towards a novel model with enhanced barrier properties, suitable for investigating pathogenic mechanisms underlying BBB disruption in CM.
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Affiliation(s)
- Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4-402D 1044 W. Walnut St., Indianapolis, IN, 46202, USA
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Jason M Hughes
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, 620 Chestnut Street, Terre Haute, IN, 47809, USA
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4-402D 1044 W. Walnut St., Indianapolis, IN, 46202, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4-402D 1044 W. Walnut St., Indianapolis, IN, 46202, USA
| | - Scott G Canfield
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, 620 Chestnut Street, Terre Haute, IN, 47809, USA.
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4-402D 1044 W. Walnut St., Indianapolis, IN, 46202, USA.
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3
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Raees MQ, Gushu MB, Taylor TE, Seydel KB, Wynkoop HJ, O’Brien NF. Optic nerve sheath diameter and its association with brain swelling in pediatric cerebral malaria: a retrospective study. Front Pediatr 2024; 12:1295254. [PMID: 38425660 PMCID: PMC10902095 DOI: 10.3389/fped.2024.1295254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/09/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Mortality in pediatric cerebral malaria (CM) in low- and middle-income countries (LMICs) is associated with brain swelling on magnetic resonance imaging (MRI); however, MRI is unavailable in most LMICs. Optic nerve sheath diameter (ONSD) measurement is an inexpensive method of detecting increased intracranial pressure compared with the invasive opening pressure (OP). Our primary objective was to determine if increased ONSD correlated with brain swelling on MRI in pediatric CM. Our secondary objective was to determine if increased ONSD correlated with increased OP and/or poor neurological outcome in pediatric CM. We hypothesized that increased ONSD would correlate with brain swelling on MRI and increased OP and that ONSD would be higher in survivors with sequelae and non-survivors. Methods We performed a retrospective chart review of children aged 0-12 years in Blantyre, Malawi, from 2013 to 2022 with CM as defined by the World Health Organization. Brain swelling on admission MRI was characterized by brain volume scores (BVS); severe swelling was scored as 7-8, mild-to-moderate as 4-6, normal as 3. The admission ONSD was measured via ultrasound; it was defined as abnormal if it was >4.5 mm in children >1 year and >4 mm in children <1 year. Favorable outcome was defined as a normal neurological exam on discharge in survivors. The primary and secondary objectives were evaluated using Spearman's correlation; and the demographics were compared using chi-square and the Kruskal-Wallis test (Stata, College Station, TX, USA). Results Median age of the 207-patients cohort was 50 months [interquartile range (IQR) 35-75]; 49% (n = 102) were female. Of those, 73% (n = 152) had a favorable outcome, and 14% (n = 30) died. Twenty-nine (14%) had a normal BVS, 134 (65%) had mild-to-moderate swelling, and 44 (21%) had severe swelling. ONSD was elevated in 86% (n = 178) of patients, while 12% of patients had increased OP. There was a weakly positive correlation between BVS and ONSD (r = 0.14, p = 0.05). The median ONSD was not significantly different compared by discharge outcome (p = 0.11) or by BVS (p = 0.18). Conclusion ONSD was not a reliable tool to correlate with BVS, neurological outcome, or OP in children with CM. Future studies to identify alternative methods of early identification of CM patients at highest risk for morbidity and mortality are urgently needed.
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Affiliation(s)
- Madiha Q. Raees
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Terrie E. Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States
| | - Hunter J. Wynkoop
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Nicole F. O’Brien
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
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Nampota-Nkomba N, Nyirenda OM, Mallewa J, Chimalizeni Y, Dzabala N, Fay MP, Gopalakrishnan M, Laurens MB, O'Brien NF, Miller LH, Pierce SK, Riggle BA, Postels DG. DON in pediatric cerebral malaria, a phase I/IIA dose-escalation safety study: study protocol for a clinical trial. Trials 2024; 25:87. [PMID: 38279124 PMCID: PMC10811809 DOI: 10.1186/s13063-023-07808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/16/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Despite treatment with highly effective antimalarial drugs, malaria annually claims the lives of over half a million children under 5-years of age in sub-Saharan Africa. Cerebral malaria (CM), defined as Plasmodium falciparum infection with coma, is the severe malaria syndrome with the highest mortality. Studies in the CM mouse model suggest that a T cell-mediated response underlies CM pathology, opening a new target for therapy in humans. This trial aims to establish the preliminary safety of one such novel therapy, the glutamine antagonist 6-diazo-5-oxo-L-norleucine (DON). METHODS In this phase I/IIa dose-escalation clinical trial, a single dose of intravenous (IV) DON is administered to three participants groups-healthy adults and adults with uncomplicated malaria, then pediatric participants with CM-to primarily assess safety. The secondary objective of this trial is to assess pharmacokinetics of DON over a range of doses. The open-label adult portion of the trial enrolls 40 healthy adults concurrently with 40 adults with uncomplicated malaria. Cohorts of 10 participants receive a single IV dose of DON with doses escalating between cohorts from 0.1 mg/kg, 1.0 mg/kg, 5.0 mg/kg, to 10 mg/kg. Following subsequent safety review, a randomized, double-blind, and placebo-controlled pediatric study enrolls 72 participants aged 6 months to 14 years with CM. The pediatric portion of the study minimally spans three malaria seasons including a planned interim analysis after 50% of pediatric enrollments. The first half of pediatric participants receive DON 0.1 mg/kg, 1.0 mg/kg, or placebo. Dosing for the second half of pediatric participants is informed by the safety and preliminary efficacy results of those previously enrolled. The pediatric portion of the study has an exploratory outcome evaluating the preliminary efficacy of DON. Efficacy is assessed by diagnostics predictive of CM outcome: electroencephalography (EEG), magnetic resonance imaging (MRI), and transcranial doppler (TCD), measured before and after DON administration. All participants with malaria receive standard of care antimalarials in accordance with local guidelines, regardless of study drug dose group. DISCUSSION This preliminary safety and efficacy study evaluates DON, a candidate adjunctive therapy for pediatric CM. If results support DON preliminary safety and efficacy, follow-up phase II and III clinical trials will be indicated. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov on 28 July 2022 (NCT05478720).
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Affiliation(s)
| | - Osward M Nyirenda
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jane Mallewa
- Department of Internal Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nettie Dzabala
- Department of Pharmacy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael P Fay
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Louis H Miller
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Susan K Pierce
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Brittany A Riggle
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA.
| | - Douglas G Postels
- Division of Neurology, The George Washington University/ Children's National Medical Center, Washington, DC, USA.
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5
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O'Brien NF, Chetcuti K, Fonseca Y, Vidal L, Raghavan P, Postels DG, Chimalizeni Y, Ray S, Seydel KB, Taylor TE. Cerebral Metabolic Crisis in Pediatric Cerebral Malaria. J Pediatr Intensive Care 2023; 12:278-288. [PMID: 37970136 PMCID: PMC10631841 DOI: 10.1055/s-0041-1732444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022] Open
Abstract
Cerebral metabolic energy crisis (CMEC), often defined as a cerebrospinal fluid (CSF) lactate: pyruvate ratio (LPR) >40, occurs in various diseases and is associated with poor neurologic outcomes. Cerebral malaria (CM) causes significant mortality and neurodisability in children worldwide. Multiple factors that could lead to CMEC are plausible in these patients, but its frequency has not been explored. Fifty-three children with CM were enrolled and underwent analysis of CSF lactate and pyruvate levels. All 53 patients met criteria for a CMEC (median CSF LPR of 72.9 [interquartile range [IQR]: 58.5-93.3]). Half of children met criteria for an ischemic CMEC (median LPR of 85 [IQR: 73-184]) and half met criteria for a nonischemic CMEC (median LPR of 60 [IQR: 54-79]. Children also underwent transcranial doppler ultrasound investigation. Cerebral blood flow velocities were more likely to meet diagnostic criteria for low flow (<2 standard deviation from normal) or vasospasm in children with an ischemic CMEC (73%) than in children with a nonischemic CMEC (20%, p = 0.04). Children with an ischemic CMEC had poorer outcomes (pediatric cerebral performance category of 3-6) than those with a nonischemic CMEC (46 vs. 22%, p = 0.03). CMEC was ubiquitous in this patient population and the processes underlying the two subtypes (ischemic and nonischemic) may represent targets for future adjunctive therapies.
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Affiliation(s)
- Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Karen Chetcuti
- Department of Radiology, College of Medicine, Chichiri, Blantyre, Malawi
| | - Yudy Fonseca
- Division of Critical Care Medicine, Department of Pediatrics, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Lorenna Vidal
- Division of Neuroradiology, Department of Radiology Children's Hospital of Philadelphia, Clinical Instructor at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Douglas G. Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, District of Columbia, United States
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, University of Malawi, Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Stephen Ray
- Department of Paediatric, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Karl B. Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
- Blantyre Malaria Project, Blantyre, Malawi
| | - Terrie E. Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
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Smith RL, Ikeda AK, Rowley CA, Khandhadia A, Gorbach AM, Chimalizeni Y, Taylor TE, Seydel K, Ackerman HC. Increased brain microvascular hemoglobin concentrations in children with cerebral malaria. Sci Transl Med 2023; 15:eadh4293. [PMID: 37703350 DOI: 10.1126/scitranslmed.adh4293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023]
Abstract
Brain swelling is associated with death from cerebral malaria, but it is unclear whether brain swelling is caused by cerebral edema or vascular congestion-two pathological conditions with distinct effects on tissue hemoglobin concentrations. We used near-infrared spectroscopy (NIRS) to noninvasively study cerebral microvascular hemoglobin concentrations in 46 Malawian children with cerebral malaria. Cerebral malaria was defined by the presence of the malaria parasite Plasmodium falciparum on a blood smear, a Blantyre coma score of 2 or less, and retinopathy. Children with uncomplicated malaria (n = 33) and healthy children (n = 29) were enrolled as comparators. Cerebral microvascular hemoglobin concentrations were higher among children with cerebral malaria compared with those with uncomplicated malaria [median (25th, 75th): 145.2 (95.2, 190.0) μM versus 82.9 (65.7, 105.4) μM, P = 0.008]. Cerebral microvascular hemoglobin concentrations correlated with brain swelling score determined by MRI (r = 0.37, P = 0.03). Fluctuations in cerebral microvascular hemoglobin concentrations over a 30-min time period were characterized using detrended fluctuation analysis (DFA). DFA determined self-similarity of the cerebral microvascular hemoglobin concentration signal to be lower among children with cerebral malaria compared with those with uncomplicated malaria [0.63 (0.54, 0.70) versus 0.91 (0.82, 0.94), P < 0.0001]. The lower self-similarity of the hemoglobin concentration signal in children with cerebral malaria suggested impaired regulation of cerebral blood flow. The elevated cerebral tissue hemoglobin concentration and its correlation with brain swelling suggested that excess blood volume, potentially due to vascular congestion, may contribute to brain swelling in cerebral malaria.
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Affiliation(s)
- Rachel L Smith
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Allison K Ikeda
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Carol A Rowley
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Amit Khandhadia
- Infrared Imaging and Thermometry Unit, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Alexander M Gorbach
- Infrared Imaging and Thermometry Unit, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Yamikani Chimalizeni
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Terrie E Taylor
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Karl Seydel
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Hans C Ackerman
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
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Douglas-Vail M, Fah J, Cotran-Lenrow A, Pintwala RC. Optic Disc Elevation Secondary to Cerebral Malaria Resolves Completely With Mannitol Administration and Corresponds to Clinical Improvement. Cureus 2023; 15:e40639. [PMID: 37476140 PMCID: PMC10355342 DOI: 10.7759/cureus.40639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
This case report describes a 14-year-old boy presenting with cerebral malaria in a resource-limited setting. The patient exhibited optic disc elevation, indicating increased intracranial pressure (ICP). Due to the unavailability of advanced neuroimaging, point-of-care ultrasound (POCUS) was employed to assess the optic disc. After administration of a weight-based dose of mannitol, optic disc elevation resolved completely, accompanied by clinical improvement. This case highlights the potential of POCUS as a valuable tool for the assessment and management of cerebral malaria in resource-limited settings.
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Affiliation(s)
- Matthew Douglas-Vail
- Department of Emergency Medicine, The University of British Columbia, Vancouver, CAN
- Emergency Medicine, Partners In Health Liberia, Harper, LBR
| | - James Fah
- Emergency Medicine, J.J. Dosen Hospital, Ministry of Health, Harper, LBR
| | | | - Robert C Pintwala
- Department of Ophthalmology and Vision Science, The University of British Columbia, Vancouver, CAN
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8
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Pais TF, Penha-Gonçalves C. In vitro model of brain endothelial cell barrier reveals alterations induced by Plasmodium blood stage factors. Parasitol Res 2023; 122:729-737. [PMID: 36694092 PMCID: PMC9988999 DOI: 10.1007/s00436-023-07782-x] [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: 09/19/2022] [Accepted: 11/25/2022] [Indexed: 01/26/2023]
Abstract
Cerebral malaria (CM) is a severe neurological condition caused by Plasmodium falciparum. Disruption of the brain-blood barrier (BBB) is a key pathological event leading to brain edema and vascular leakage in both humans and in the mouse model of CM. Interactions of brain endothelial cells with infected red blood cells (iRBCs) and with circulating inflammatory mediators and immune cells contribute to BBB dysfunction in CM. Adjunctive therapies for CM aim at preserving the BBB to prevent neurologic deficits. Experimental animal and cellular models are essential to develop new therapeutic strategies. However, in mice, the disease develops rapidly, which offers a very narrow time window for testing the therapeutic potential of drugs acting in the BBB. Here, we establish a brain endothelial cell barrier whose disturbance can be monitored by several parameters. Using this system, we found that incubation with iRBCs and with extracellular particles (EPs) released by iRBCs changes endothelial cell morphology, decreases the tight junction protein zonula occludens-1 (ZO-1), increases the gene expression of the intercellular adhesion molecule 1 (ICAM-1), and induces a significant reduction in transendothelial electrical resistance (TEER) with increased permeability. We propose this in vitro experimental setup as a straightforward tool to investigate molecular interactions and pathways causing endothelial barrier dysfunction and to test compounds that may target BBB and be effective against CM. A pre-selection of the effective compounds that strengthen the resistance of the brain endothelial cell barrier to Plasmodium-induced blood factors in vitro may increase the likelihood of their efficacy in preclinical disease mouse models of CM and in subsequent clinical trials with patients.
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Affiliation(s)
- Teresa F Pais
- Instituto Gulbenkian de Ciência, Rua da Quinta Grande, 6, 2780-156, Oeiras, Portugal.
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9
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Akide Ndunge OB, Kilian N, Salman MM. Cerebral Malaria and Neuronal Implications of Plasmodium Falciparum Infection: From Mechanisms to Advanced Models. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2202944. [PMID: 36300890 PMCID: PMC9798991 DOI: 10.1002/advs.202202944] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/22/2022] [Indexed: 06/01/2023]
Abstract
Reorganization of host red blood cells by the malaria parasite Plasmodium falciparum enables their sequestration via attachment to the microvasculature. This artificially increases the dwelling time of the infected red blood cells within inner organs such as the brain, which can lead to cerebral malaria. Cerebral malaria is the deadliest complication patients infected with P. falciparum can experience and still remains a major public health concern despite effective antimalarial therapies. Here, the current understanding of the effect of P. falciparum cytoadherence and their secreted proteins on structural features of the human blood-brain barrier and their involvement in the pathogenesis of cerebral malaria are highlighted. Advanced 2D and 3D in vitro models are further assessed to study this devastating interaction between parasite and host. A better understanding of the molecular mechanisms leading to neuronal and cognitive deficits in cerebral malaria will be pivotal in devising new strategies to treat and prevent blood-brain barrier dysfunction and subsequent neurological damage in patients with cerebral malaria.
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Affiliation(s)
- Oscar Bate Akide Ndunge
- Department of Internal MedicineSection of Infectious DiseasesYale University School of Medicine300 Cedar StreetNew HavenCT06510USA
| | - Nicole Kilian
- Centre for Infectious Diseases, ParasitologyHeidelberg University HospitalIm Neuenheimer Feld 32469120HeidelbergGermany
| | - Mootaz M. Salman
- Department of PhysiologyAnatomy and GeneticsUniversity of OxfordOxfordOX1 3QUUK
- Kavli Institute for NanoScience DiscoveryUniversity of OxfordOxfordUK
- Oxford Parkinson's Disease CentreUniversity of OxfordOxfordUK
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Tu Z, Gormley J, Sheth V, Seydel KB, Taylor T, Beare N, Barrera V, Proudlock FA, Manda C, Harding S, Gottlob I. Cerebral malaria: insight into pathology from optical coherence tomography. Sci Rep 2021; 11:15722. [PMID: 34344903 PMCID: PMC8333417 DOI: 10.1038/s41598-021-94495-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/08/2021] [Indexed: 01/25/2023] Open
Abstract
We aimed to investigate structural retinal changes in malarial retinopathy (MR) using hand-held optical coherence tomography (HH-OCT) to assess its diagnostic potential. Children with MR (n = 43) underwent ophthalmoscopy, fluorescein angiography and HH-OCT during admission, 1-month (n = 31) and 1-year (n = 8) post-discharge. Controls were comatose patients without malaria (n = 6) and age/sex-matched healthy children (n = 43). OCT changes and retinal layer thicknesses were compared. On HH-OCT, hyper-reflective areas (HRAs) were seen in the inner retina of 81% of MR patients, corresponding to ischaemic retinal whitening on fundus photography. Cotton wool spots were present in 37% and abnormal hyper-reflective dots, co-localized to capillary plexus, in 93%. Hyper-reflective vessel walls were present in 84%, and intra-retinal cysts in 9%. Vascular changes and cysts resolved within 48 h. HRAs developed into retinal thinning at 1 month (p = 0.027) which was more pronounced after 1 year (p = 0.009). Ischaemic retinal whitening is located within inner retinal layers, distinguishing it from cotton wool spots. Vascular hyper-reflectivity may represent the sequestration of parasitized erythrocytes in vessels, a key CM feature. The mechanisms of post-ischemic retinal atrophy and cerebral atrophy with cognitive impairment may be similar in CM survivors. HH-OCT has the potential for monitoring patients, treatment response and predicting neurological deficits.
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Affiliation(s)
- Zhanhan Tu
- Department of Neuroscience, Psychology and Behaviour, Ulverscroft Eye Unit, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Jack Gormley
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Viral Sheth
- Department of Neuroscience, Psychology and Behaviour, Ulverscroft Eye Unit, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Terrie Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Nicholas Beare
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Valentina Barrera
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Frank A Proudlock
- Department of Neuroscience, Psychology and Behaviour, Ulverscroft Eye Unit, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, UK
| | - Chatonda Manda
- University of Malawi College of Medicine, Blantyre, Malawi
| | - Simon Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Member of Liverpool Health Partners, Liverpool, UK
| | - Irene Gottlob
- Department of Neuroscience, Psychology and Behaviour, Ulverscroft Eye Unit, University of Leicester, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, LE2 7LX, UK.
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11
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Riggle BA, Manglani M, Maric D, Johnson KR, Lee MH, Neto OLA, Taylor TE, Seydel KB, Nath A, Miller LH, McGavern DB, Pierce SK. CD8+ T cells target cerebrovasculature in children with cerebral malaria. J Clin Invest 2020; 130:1128-1138. [PMID: 31821175 DOI: 10.1172/jci133474] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/05/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUNDCerebral malaria (CM) accounts for nearly 400,000 deaths annually in African children. Current dogma suggests that CM results from infected RBC (iRBC) sequestration in the brain microvasculature and resulting sequelae. Therapies targeting these events have been unsuccessful; findings in experimental models suggest that CD8+ T cells drive disease pathogenesis. However, these data have largely been ignored because corroborating evidence in humans is lacking. This work fills a critical gap in our understanding of CM pathogenesis that is impeding development of therapeutics.METHODSUsing multiplex immunohistochemistry, we characterized cerebrovascular immune cells in brain sections from 34 children who died from CM or other causes. Children were grouped by clinical diagnosis (CM+ or CM-), iRBC sequestration (Seqhi, Seqlo, Seq0) and HIV status (HIV+ or HIV-).RESULTSWe identified effector CD3+CD8+ T cells engaged on the cerebrovasculature in 69% of CM+ HIV- children. The number of intravascular CD3+CD8+ T cells was influenced by CM status (CM+ > CM-, P = 0.004) and sequestration level (Seqhi > Seqlo, P = 0.010). HIV coinfection significantly increased T cell numbers (P = 0.017) and shifted cells from an intravascular (P = 0.004) to perivascular (P < 0.0001) distribution.CONCLUSIONWithin the studied cohort, CM is associated with cerebrovascular engagement of CD3+CD8+ T cells, which is exacerbated by HIV coinfection. Thus, CD3+CD8+ T cells are highly promising targets for CM adjunctive therapy, opening new avenues for the treatment of this deadly disease.FUNDINGThis research was supported by the Intramural Research Program of the National Institutes of Health.
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Affiliation(s)
- Brittany A Riggle
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Rockville, Maryland, USA
| | - Monica Manglani
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA.,Medical Scientist Training Program, Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA
| | | | - Kory R Johnson
- Information Technology Program, Division of Intramural Research, and
| | - Myoung-Hwa Lee
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, and
| | | | - Terrie E Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi, Africa
| | - Karl B Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA.,Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi, Africa
| | - Avindra Nath
- Section of Infections of the Nervous System, National Institute of Neurological Disorders and Stroke, and
| | - Louis H Miller
- Laboratory of Malaria Vector Research, National Institute of Allergy and Infectious Diseases, NIH, Rockville, Maryland, USA
| | - Dorian B McGavern
- Viral Immunology and Intravital Imaging Section, National Institute of Neurological Disorders and Stroke (NINDS), NIH, Bethesda, Maryland, USA
| | - Susan K Pierce
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases (NIAID), NIH, Rockville, Maryland, USA
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12
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Nwokocha CR, Bafor EE, Ajayi OI, Ebeigbe AB. The Malaria-High Blood Pressure Hypothesis: Revisited. Am J Hypertens 2020; 33:695-702. [PMID: 32211753 DOI: 10.1093/ajh/hpaa051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/24/2020] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Abstract
Malaria etiologies with pathophysiological similarities to hypertension currently constitute a major subject of research. The malaria-high blood pressure hypothesis is strongly supported by observations of the increasing incidence of hypertension in malaria-endemic, low- and middle-income countries with poor socioeconomic conditions, particularly in sub-Saharan African countries. Malnutrition and low birth weight with persistent symptomatic malaria presentations in pregnancy correlate strongly with the development of preeclampsia, gestational hypertension and subsequent hypertension in adult life. Evidence suggest that the link between malaria infection and high blood pressure involves interactions between malaria parasites and erythrocytes, the inflammatory process, effects of the infection during pregnancy; effects on renal and vascular functions as well as effects in sickle cell disease. Possible mechanisms which provide justification for the malaria-high blood pressure hypothesis include the following: endothelial dysfunction (reduced nitric oxide (NO) levels), impaired release of local neurotransmitters and cytokines, decrease in vascular smooth muscle cell viability and/or alterations in cellular calcium signaling leading to enhanced vascular reactivity, remodeling, and cardiomyopathies, deranged homeostasis through dehydration, elevated intracellular mediators and proinflammatory cytokine responses, possible genetic regulations, activation of the renin-angiotensin-aldosterone system mechanisms and renal derangements, severe anemia and hemolysis, renal failure, and end organ damage. Two key mediators of the malaria-high blood pressure association are: endothelial dysfunction (reduced NO) and increased angiotensin-converting enzyme activity/angiotensin II levels. Sickle cell disease is associated with protection against malaria infection and reduced blood pressure. In this review, we present the state of knowledge about the malaria-blood pressure hypothesis and suggest insights for future studies.
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Affiliation(s)
| | - Enitome E Bafor
- Department of Pharmacology and Toxicology, University of Benin, Benin City, Nigeria
| | - Olutayo I Ajayi
- Department of Physiology, College of Medical Sciences, University of Benin, Benin City, Nigeria
| | - Anthony B Ebeigbe
- Department of Physiology, College of Medical Sciences, University of Benin, Benin City, Nigeria
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13
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Lang SS, Paden W, Steenhoff AP, Hines K, Storm PB, Huh J. Intracranial Pressure and Brain Tissue Oxygen Neuromonitoring in Pediatric Cerebral Malaria. World Neurosurg 2020; 141:115-118. [PMID: 32526359 DOI: 10.1016/j.wneu.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pediatric cerebral malaria (CM) is a severe complication of Plasmodium falciparum that often leaves survivors with severe neurologic impairment. Increased intracranial pressure (ICP) as a result of cerebral edema has been identified as a major predictor of morbidity and mortality in CM. Past studies have demonstrated that survivors are more likely to have resolution of elevated ICP and that efficient management of ICP crises may lead to better outcomes. However, data on invasive brain tissue oxygen monitoring are unknown. CASE DESCRIPTION We report a case of a pediatric patient with cerebral malaria who developed encephalopathy and cerebral edema and describe the pathophysiology of this disease process with invasive ICP and brain tissue oxygen multimodality neuromonitoring. The utilization of both ICP and brain tissue oxygen monitoring allowed prompt diagnosis and successful treatment of severe intracranial hypertension and low brain tissue oxygenation crisis. The patient was discharged to home in good neurologic condition. CONCLUSIONS Multimodality neuromonitoring may be considered in pediatric patients who have cerebral edema and encephalopathy from CM.
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Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
| | - William Paden
- Drexel University, College of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew P Steenhoff
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Phillip B Storm
- Division of Neurosurgery, Department of Neurosurgery, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jimmy Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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14
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Siddiqui AJ, Adnan M, Jahan S, Redman W, Saeed M, Patel M. Neurological disorder and psychosocial aspects of cerebral malaria: what is new on its pathogenesis and complications? A minireview. Folia Parasitol (Praha) 2020; 67. [PMID: 32636351 DOI: 10.14411/fp.2020.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 03/06/2020] [Indexed: 01/21/2023]
Abstract
Recently, malaria is remain considered as the most prevalent infectious disease, affecting the human health globally. High morbidity and mortality worldwide is often allied with cerebral malaria (CM) based disorders of the central nervous system, especially across many tropical and sub-tropical regions. These disorders are characterised by the infection of Plasmodium species, which leads to acute or chronic neurological disorders, even after having active/effective antimalarial drugs. Furthermore, even during the treatment, individual remain sensitive for neurological impairments in the form of decrease blood flow and vascular obstruction in brain including many more other changes. This review briefly explains and update on the epidemiology, burden of disease, pathogenesis and role of CM in neurological disorders with behaviour and function in mouse and human models. Moreover, the social stigma, which plays an important role in neurological disorders and a factor for assessing CM, is also discussed in this review.
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Affiliation(s)
| | | | - Sadaf Jahan
- Department of Medical Laboratory, College of Applied Medical Sciences, Majmaah University, Majmaah city, Saudi Arabia
| | - Whitni Redman
- Surgery Department, Division of Biomedical Research, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Mοhd Saeed
- Department of Biology, College of Science, University of Hail, Hail, PO Box 2440, Saudi Arabia
| | - Mitesh Patel
- Bapalal Vaidya Botanical Research Centre, Department of Biosciences, Veer Narmad South Gujarat University, Surat, Gujarat, India
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15
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Abstract
BACKGROUND Cerebral malaria (CM) remains a leading cause of mortality and morbidity in children in sub-Saharan Africa. Recent studies using brain magnetic resonance imaging have revealed increased brain volume as a major predictor of death. Similar morphometric predictors of morbidity at discharge are lacking. The aim of this study was to investigate the utility of serial cranial cisternal cerebrospinal fluid (CSF) volume measurements in predicting morbidity at discharge in pediatric CM survivors. METHODS In this case-control study, 54 Malawian pediatric CM survivors with neurologic sequelae evident at discharge who underwent serial magnetic resonance imaging scans while comatose were matched to concurrently admitted children with serial imaging who made full recoveries. Serial cranial cisternal CSF volume quantified by radiologists blinded to outcome was evaluated as a predictor of neurologic deficits at discharge. The probability of neurologic sequelae was determined using a model that included coma duration and changes in cisternal CSF volume over time. RESULTS Coma duration before admission was similar between cases and controls (16.1 vs. 15.3; P = 0.81), but overall coma was longer among children with sequelae (60 vs. 38 hours; P < 0.01). Lower initial CSF volumes and decreased volumes over time were both associated with a higher probability of neurologic sequelae at discharge. CONCLUSIONS Among pediatric CM survivors with prolonged coma, lower initial CSF volume and decreasing volume during coma is associated with neurologic sequelae at discharge. These findings suggest that cerebral edema is an underlying contributor to both morbidity and mortality in pediatric CM.
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16
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Liu F, Liu Q, Yuan F, Guo S, Liu J, Sun Z, Gao P, Wang Y, Yan S, Liu J. Erg mediates downregulation of claudin-5 in the brain endothelium of a murine experimental model of cerebral malaria. FEBS Lett 2019; 593:2585-2595. [PMID: 31271645 DOI: 10.1002/1873-3468.13526] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/19/2019] [Accepted: 06/20/2019] [Indexed: 12/17/2022]
Abstract
Cerebral malaria (CM) is a severe complication with brain vascular hyperpermeability. Claudin-5 is the major component of tight junctions. To investigate the expression of claudin-5 in CM, we established a murine experimental cerebral malaria (ECM) model and an in vitro model by treating murine brain endothelial cells (bEnd3) with plasma from ECM mice. Expression of claudin-5 and the ETS transcription factor Erg was reduced in the brain endothelium of ECM mice. In bEnd3 cells exposed to ECM plasma, decreased expression of claudin-5 and Erg, and increased permeability were observed. Silencing of Erg significantly reduced Cldn5 expression. ChIP assays indicated that Erg binds to the -813 ETS motif of the murine Cldn5 gene promoter, and the binding is decreased by treatment with ECM plasma.
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Affiliation(s)
- Fuhong Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Qiang Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Fangshu Yuan
- Department of Human Parasitology, School of Medicine, Shandong University, Jinan, China
| | - Shuling Guo
- Department of Human Parasitology, School of Medicine, Shandong University, Jinan, China
| | - Jinzhi Liu
- Department of Neurology, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Zongguo Sun
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Peng Gao
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Yu Wang
- School of Medicine, Shandong University, Jinan, China
| | - Suhua Yan
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Ju Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
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17
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Levin M, Cunnington AJ, Wilson C, Nadel S, Lang HJ, Ninis N, McCulloch M, Argent A, Buys H, Moxon CA, Best A, Nijman RG, Hoggart CJ. Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial. THE LANCET. RESPIRATORY MEDICINE 2019; 7:581-593. [PMID: 31196803 PMCID: PMC6593355 DOI: 10.1016/s2213-2600(19)30114-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Fluid resuscitation is the recommended management of shock, but increased mortality in febrile African children in the FEAST trial. We hypothesised that fluid bolus-induced deaths in FEAST would be associated with detectable changes in cardiovascular, neurological, or respiratory function, oxygen carrying capacity, and blood biochemistry. METHODS We developed composite scores for respiratory, cardiovascular, and neurological function using vital sign data from the FEAST trial, and used them to compare participants from FEAST with those from four other cohorts and to identify differences between the bolus (n=2097) and no bolus (n=1044) groups of FEAST. We calculated the odds of adverse outcome for each ten-unit increase in baseline score using logistic regression for each cohort. Within FEAST participants, we also compared haemoglobin and plasma biochemistry between bolus and non-bolus patients, assessed the effects of these factors along with the vital sign scores on the contribution of bolus to mortality using Cox proportional hazard models, and used Bayesian clustering to identify subgroups that differed in response to bolus. The FEAST trial is registered with ISRCTN, number ISRCTN69856593. FINDINGS Increasing respiratory (odds ratio 1·09, 95% CI 1·07-1·11), neurological (1·26, 1·21-1·31), and cardiovascular scores (1·09, 1·05-1·14) were associated with death in FEAST (all p<0·0001), and with adverse outcomes for specific scores in the four other cohorts. In FEAST, fluid bolus increased respiratory and neurological scores and decreased cardiovascular score at 1 h after commencement of the infusion. Fluid bolus recipients had mean 0·33 g/dL (95% CI 0·20-0·46) reduction in haemoglobin concentration after 8 h (p<0·0001), and at 24 h had a decrease of 1·41 mEq/L (95% CI 0·76-2·06; p=0·0002) in mean base excess and increase of 1·65 mmol/L (0·47-2·8; p=0·0070) in mean chloride, and a decrease of 0·96 mmol/L (0·45 to 1·47; p=0·0003) in bicarbonate. There were similar effects of fluid bolus in three patient subgroups, identified on the basis of their baseline characteristics. Hyperchloraemic acidosis and respiratory and neurological dysfunction induced by saline or albumin bolus explained the excess mortality due to bolus in Cox survival models. INTERPRETATION In the resuscitation of febrile children, albumin and saline boluses can cause respiratory and neurological dysfunction, hyperchloraemic acidosis, and reduction in haemoglobin concentration. The findings support the notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned. The effects of lower volumes of buffered solutions should be evaluated further. FUNDING Medical Research Council, Department for International Development, National Institute for Health Research, Imperial College Biomedical Research Centre.
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Affiliation(s)
- Michael Levin
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK.
| | - Aubrey J Cunnington
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Clare Wilson
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Simon Nadel
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Hans Joerg Lang
- Paediatric Referent, Médecins sans Frontières, Brussels, Belgium
| | - Nelly Ninis
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Andrew Argent
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Heloise Buys
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Christopher A Moxon
- Wellcome Centre for Integrative Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Abigail Best
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ruud G Nijman
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Emergency Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clive J Hoggart
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
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18
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Pais TF, Penha-Gonçalves C. Brain Endothelium: The "Innate Immunity Response Hypothesis" in Cerebral Malaria Pathogenesis. Front Immunol 2019; 9:3100. [PMID: 30761156 PMCID: PMC6361776 DOI: 10.3389/fimmu.2018.03100] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023] Open
Abstract
Cerebral malaria (CM) is a life-threatening neurological syndrome caused by Plasmodium falciparum infection afflicting mainly children in Africa. Current pathogenesis models implicate parasite and host-derived factors in impairing brain vascular endothelium (BVE) integrity. Sequestration of Plasmodium-infected red blood cells (iRBCs) in brain microvessels is a hallmark of CM pathology. However, the precise mechanisms driving loss of blood-brain barrier (BBB) function with consequent brain injury are still unsettled and it is plausible that distinct pathophysiology trajectories are involved. Studies in humans and in the mouse model of CM indicate that inflammatory reactions intertwined with microcirculatory and coagulation disturbances induce alterations in vascular permeability and impair BBB integrity. Yet, the role of BVE as initiator of immune responses against parasite molecules and iRBCs is largely unexplored. Brain endothelial cells express pattern recognition receptors (PRR) and are privileged sensors of blood-borne infections. Here, we focus on the hypothesis that innate responses initiated by BVE and subsequent interactions with immune cells are critical to trigger local effector immune functions and induce BBB damage. Uncovering mechanisms of BVE involvement in sensing Plasmodium infection, recruiting of immune cells and directing immune effector functions could reveal pharmacological targets to promote BBB protection with potential applications in CM clinical management.
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19
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Harawa V, Njie M, Kessler A, Choko A, Kumwenda B, Kampondeni S, Potchen M, Kim K, Jaworowski A, Taylor T, Mandala W, Seydel K, Rogerson S. Brain swelling is independent of peripheral plasma cytokine levels in Malawian children with cerebral malaria. Malar J 2018; 17:435. [PMID: 30477519 PMCID: PMC6260579 DOI: 10.1186/s12936-018-2590-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 11/22/2018] [Indexed: 11/26/2022] Open
Abstract
Background Cerebral malaria (CM) is often fatal, and severe brain swelling is a predictor of CM-related mortality. CM is characterized by elevated circulating pro-inflammatory cytokines TNF and IFN-γ and anti-inflammatory cytokine IL-10, however whether cytokine levels correlate with brain swelling severity is unknown. This study therefore was conducted to investigate the relationship between cytokine levels and brain swelling severity in children presenting with CM. Methods A total of 195 Malawian children presenting with CM were recruited and had the concentrations of plasma cytokines determined and compared to brain swelling severity, determined by MRI examination, and graded as severe, moderate, mild or none. Results Levels of IL-1β, IL-6, IL-8 and IL-10 did not differ between CM patients with and without severe brain swelling. Compared to children without brain swelling, IL-12 levels were higher in children with severe swelling (p < 0.01, no swelling 1 pg/mL, IQR [1] vs. severe swelling 18.7 pg/mL, IQR [1–27]), whereas TNF concentrations were higher in children with moderate brain swelling compared to children with no swelling (p < 0.01, no swelling 3 pg/mL, IQR [1–20] vs. moderate swelling 24 pg/mL, IQR [8–58]. Multivariate analysis showed that no single cytokine independently predicted brain swelling. Conclusion Severe brain swelling in paediatric CM was independent of tested blood pro-inflammatory and anti-inflammatory cytokines which are markers of systemic inflammation. Electronic supplementary material The online version of this article (10.1186/s12936-018-2590-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Visopo Harawa
- Biomedical Sciences Department, College of Medicine, University of Malawi, Blantyre, Malawi. .,Malawi-Liverpool Wellcome Trust Clinical Programme, Blantyre, Malawi.
| | - Madi Njie
- Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Australia
| | - Anne Kessler
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Augustine Choko
- Biomedical Sciences Department, College of Medicine, University of Malawi, Blantyre, Malawi.,London School of Hygiene & Tropical Medicine, London, UK
| | - Benjamin Kumwenda
- Biomedical Sciences Department, College of Medicine, University of Malawi, Blantyre, Malawi.,Malawi-Liverpool Wellcome Trust Clinical Programme, Blantyre, Malawi
| | - Sam Kampondeni
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Kami Kim
- Albert Einstein College of Medicine, Bronx, NY, USA.,University of South Florida, Tampa, FL, USA
| | - Anthony Jaworowski
- Life Sciences Program, Burnet Institute, Melbourne, Australia.,Health and Biomedical Sciences, RMIT University, Melbourne, Australia
| | - Terrie Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, E. Lansing, MI, USA
| | - Wilson Mandala
- Biomedical Sciences Department, College of Medicine, University of Malawi, Blantyre, Malawi. .,Malawi-Liverpool Wellcome Trust Clinical Programme, Blantyre, Malawi. .,Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi.
| | - Karl Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, E. Lansing, MI, USA
| | - Stephen Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Australia
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Kampondeni SD, Birbeck GL, Seydel KB, Beare NA, Glover SJ, Hammond CA, Chilingulo CA, Taylor TE, Potchen MJ. Noninvasive measures of brain edema predict outcome in pediatric cerebral malaria. Surg Neurol Int 2018; 9:53. [PMID: 29576904 PMCID: PMC5858047 DOI: 10.4103/sni.sni_297_17] [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: 08/10/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022] Open
Abstract
Background: Increased brain volume (BV) and subsequent herniation are strongly associated with death in pediatric cerebral malaria (PCM), a leading killer of children in developing countries. Accurate noninvasive measures of BV are needed for optimal clinical trial design. Our objectives were to examine the performance of six different magnetic resonance imaging (MRI) BV quantification measures for predicting mortality in PCM and to review the advantages and disadvantages of each method. Methods: Receiver operator characteristics were generated from BV measures of MRIs of children admitted to an ongoing research project with PCM between 2009 and 2014. Fatal cases were matched to the next available survivor. A total of 78 MRIs of children aged 5 months to 13 years (mean 4.0 years), of which 45% were males, were included. Results: Areas under the curve (AUC) with 95% confidence interval on measures from the initial MRIs were: Radiologist-derived score = 0.69 (0.58–0.79; P = 0.0037); prepontine cistern anteroposterior (AP) dimension = 0.70 (0.56–0.78; P = 0.0133); SamKam ratio [Rt. parietal lobe height/(prepontine AP dimension + fourth ventricle AP dimension)] = 0.74 (0.63–0.83; P = 0.0002); and global cerebrospinal fluid (CSF) space ascertained by ClearCanvas = 0.67 (0.55–0.77; P = 0.0137). For patients with serial MRIs (n = 37), the day 2 global CSF space AUC was 0.87 (0.71–0.96; P < 0.001) and the recovery factor (CSF volume day 2/CSF volume day 1) was 0.91 (0.76–0.98; P < 0.0001). Poor prognosis is associated with radiologist score of ≥7; prepontine cistern dimension ≤3 mm; cisternal CSF volume ≤7.5 ml; SamKam ratio ≥6.5; and recovery factor ≤0.75. Conclusion: All noninvasive measures of BV performed well in predicting death and providing a proxy measure for brain volume. Initial MRI assessment may inform future clinical trials for subject selection, risk adjustment, or stratification. Measures of temporal change may be used to stage PCM.
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Affiliation(s)
- Samuel D Kampondeni
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Imaging Sciences, Division of Diagnostic and Interventional Neuroradiology, University of Rochester Medical Center, Rochester, New York
| | - Gretchen L Birbeck
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Strong Epilepsy Center, University of Rochester, Rochester, New York, USA
| | - Karl B Seydel
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University, Michigan, USA
| | - Nicholas A Beare
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon J Glover
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, UK
| | | | - Cowles A Chilingulo
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Osteopathic Medical Specialties, Michigan State University, Michigan, USA
| | - Michael J Potchen
- Blantyre Malaria Project, University of Malawi College of Medicine, Chichiri, Blantyre, Malawi.,Department of Imaging Sciences, Division of Diagnostic and Interventional Neuroradiology, University of Rochester Medical Center, Rochester, New York
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21
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Cariaco Y, Lima WR, Sousa R, Nascimento LAC, Briceño MP, Fotoran WL, Wunderlich G, Dos Santos JL, Silva NM. Ethanolic extract of the fungus Trichoderma stromaticum decreases inflammation and ameliorates experimental cerebral malaria in C57BL/6 mice. Sci Rep 2018; 8:1547. [PMID: 29367729 PMCID: PMC5784021 DOI: 10.1038/s41598-018-19840-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 01/05/2018] [Indexed: 01/31/2023] Open
Abstract
Increased resistance to the first-line treatment against P. falciparum malaria, artemisinin-based combination therapies, has been reported. Here, we tested the effect of crude ethanolic extract of the fungus Trichoderma stromaticum (Ext-Ts) on the growth of P. falciparum NF54 in infected human red blood cells (ihRBCs) and its anti-malarial and anti-inflammatory properties in a mouse model of experimental cerebral malaria. For this purpose, ihRBCs were treated with Ext-Ts and analysed for parasitaemia; C57BL/6 mice were infected with P. berghei ANKA (PbA), treated daily with Ext-Ts, and clinical, biochemical, histological and immunological features of the disease were monitored. It was observed that Ext-Ts presented a dose-dependent ability to control P. falciparum in ihRBCs. In addition, it was demonstrated that Ext-Ts treatment of PbA-infected mice was able to increase survival, prevent neurological signs and decrease parasitaemia at the beginning of infection. These effects were associated with systemically decreased levels of lipids and IFN-γ, ICAM-1, VCAM-1 and CCR5 cerebral expression, preserving blood brain barrier integrity and attenuating the inflammatory lesions in the brain, liver and lungs. These results suggest that Ext-Ts could be a source of immunomodulatory and antimalarial compounds that could improve the treatment of cerebral malaria.
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Affiliation(s)
- Yusmaris Cariaco
- Laboratory of Immunopathology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, 38400-902, Minas Gerais, Brazil
| | - Wânia Rezende Lima
- Institute of Exact and Natural Sciences, Federal University of Mato Grosso, Rondonópolis, 78735-901, Mato Grosso, Brazil
| | - Romulo Sousa
- Laboratory of Immunopathology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, 38400-902, Minas Gerais, Brazil
| | - Layane Alencar Costa Nascimento
- Laboratory of Immunopathology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, 38400-902, Minas Gerais, Brazil
| | - Marisol Pallete Briceño
- Laboratory of Immunopathology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, 38400-902, Minas Gerais, Brazil
| | | | - Gerhard Wunderlich
- Department of Parasitology, University of São Paulo, São Paulo, 05508-900, Brazil
| | | | - Neide Maria Silva
- Laboratory of Immunopathology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia, 38400-902, Minas Gerais, Brazil.
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22
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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23
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Keita Alassane S, Nicolau-Travers ML, Menard S, Andreoletti O, Cambus JP, Gaudre N, Wlodarczyk M, Blanchard N, Berry A, Abbes S, Colongo D, Faye B, Augereau JM, Lacroux C, Iriart X, Benoit-Vical F. Young Sprague Dawley rats infected by Plasmodium berghei: A relevant experimental model to study cerebral malaria. PLoS One 2017; 12:e0181300. [PMID: 28742109 PMCID: PMC5524346 DOI: 10.1371/journal.pone.0181300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 06/14/2017] [Indexed: 02/06/2023] Open
Abstract
Cerebral malaria (CM) is the most severe manifestation of human malaria yet is still poorly understood. Mouse models have been developed to address the subject. However, their relevance to mimic human pathogenesis is largely debated. Here we study an alternative cerebral malaria model with an experimental Plasmodium berghei Keyberg 173 (K173) infection in Sprague Dawley rats. As in Human, not all infected subjects showed cerebral malaria, with 45% of the rats exhibiting Experimental Cerebral Malaria (ECM) symptoms while the majority (55%) of the remaining rats developed severe anemia and hyperparasitemia (NoECM). These results allow, within the same population, a comparison of the noxious effects of the infection between ECM and severe malaria without ECM. Among the ECM rats, 77.8% died between day 5 and day 12 post-infection, while the remaining rats were spontaneously cured of neurological signs within 24-48 hours. The clinical ECM signs observed were paresis quickly evolving to limb paralysis, global paralysis associated with respiratory distress, and coma. The red blood cell (RBC) count remained normal but a drastic decrease of platelet count and an increase of white blood cell numbers were noted. ECM rats also showed a decrease of glucose and total CO2 levels and an increase of creatinine levels compared to control rats or rats with no ECM. Assessment of the blood-brain barrier revealed loss of integrity, and interestingly histopathological analysis highlighted cyto-adherence and sequestration of infected RBCs in brain vessels from ECM rats only. Overall, this ECM rat model showed numerous clinical and histopathological features similar to Human CM and appears to be a promising model to achieve further understanding the CM pathophysiology in Humans and to evaluate the activity of specific antimalarial drugs in avoiding/limiting cerebral damages from malaria.
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Affiliation(s)
- Sokhna Keita Alassane
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
- UFR Sciences de la Santé, Université Gaston Berger, St Louis, Sénégal
| | - Marie-Laure Nicolau-Travers
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | - Sandie Menard
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Olivier Andreoletti
- UMR INRA ENVT 1225, Interactions Hôte Agent Pathogène, Ecole Nationale Vétérinaire de Toulouse, 23 Chemin des Capelles, Toulouse, France
| | - Jean-Pierre Cambus
- Laboratoire Hématologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Noémie Gaudre
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Myriam Wlodarczyk
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Nicolas Blanchard
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
| | - Antoine Berry
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Sarah Abbes
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | | | - Babacar Faye
- UFR Sciences de la Santé, Université Gaston Berger, St Louis, Sénégal
| | - Jean-Michel Augereau
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
| | - Caroline Lacroux
- UMR INRA ENVT 1225, Interactions Hôte Agent Pathogène, Ecole Nationale Vétérinaire de Toulouse, 23 Chemin des Capelles, Toulouse, France
| | - Xavier Iriart
- CPTP (Centre de Physiopathologie de Toulouse Purpan), INSERM U1043, CNRS UMR5282, Université de Toulouse III, Toulouse, France
- Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Françoise Benoit-Vical
- CNRS, LCC (Laboratoire de Chimie de Coordination), 205 route de Narbonne, Toulouse, France
- Université de Toulouse, UPS, INPT, Toulouse, France
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24
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Strangward P, Haley MJ, Shaw TN, Schwartz JM, Greig R, Mironov A, de Souza JB, Cruickshank SM, Craig AG, Milner DA, Allan SM, Couper KN. A quantitative brain map of experimental cerebral malaria pathology. PLoS Pathog 2017; 13:e1006267. [PMID: 28273147 PMCID: PMC5358898 DOI: 10.1371/journal.ppat.1006267] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 03/20/2017] [Accepted: 03/01/2017] [Indexed: 11/19/2022] Open
Abstract
The murine model of experimental cerebral malaria (ECM) has been utilised extensively in recent years to study the pathogenesis of human cerebral malaria (HCM). However, it has been proposed that the aetiologies of ECM and HCM are distinct, and, consequently, no useful mechanistic insights into the pathogenesis of HCM can be obtained from studying the ECM model. Therefore, in order to determine the similarities and differences in the pathology of ECM and HCM, we have performed the first spatial and quantitative histopathological assessment of the ECM syndrome. We demonstrate that the accumulation of parasitised red blood cells (pRBCs) in brain capillaries is a specific feature of ECM that is not observed during mild murine malaria infections. Critically, we show that individual pRBCs appear to occlude murine brain capillaries during ECM. As pRBC-mediated congestion of brain microvessels is a hallmark of HCM, this suggests that the impact of parasite accumulation on cerebral blood flow may ultimately be similar in mice and humans during ECM and HCM, respectively. Additionally, we demonstrate that cerebrovascular CD8+ T-cells appear to co-localise with accumulated pRBCs, an event that corresponds with development of widespread vascular leakage. As in HCM, we show that vascular leakage is not dependent on extensive vascular destruction. Instead, we show that vascular leakage is associated with alterations in transcellular and paracellular transport mechanisms. Finally, as in HCM, we observed axonal injury and demyelination in ECM adjacent to diverse vasculopathies. Collectively, our data therefore shows that, despite very different presentation, and apparently distinct mechanisms, of parasite accumulation, there appear to be a number of comparable features of cerebral pathology in mice and in humans during ECM and HCM, respectively. Thus, when used appropriately, the ECM model may be useful for studying specific pathological features of HCM.
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Affiliation(s)
- Patrick Strangward
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Michael J. Haley
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Tovah N. Shaw
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Jean-Marc Schwartz
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Rachel Greig
- Immunology Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Aleksandr Mironov
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - J. Brian de Souza
- Immunology Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sheena M. Cruickshank
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alister G. Craig
- Department of Molecular and Biochemical Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Danny A. Milner
- Department of Pathology, The Brigham & Women’s Hospital, Boston, Massachusetts, United States of America
| | - Stuart M. Allan
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Kevin N. Couper
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- * E-mail:
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25
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Hora R, Kapoor P, Thind KK, Mishra PC. Cerebral malaria--clinical manifestations and pathogenesis. Metab Brain Dis 2016; 31:225-37. [PMID: 26746434 DOI: 10.1007/s11011-015-9787-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/22/2015] [Indexed: 01/28/2023]
Abstract
One of the most common central nervous system diseases in tropical countries is cerebral malaria (CM). Malaria is a common protozoan infection that is responsible for enormous worldwide mortality and economic burden on the society. Episodes of Plasmodium falciparum (Pf) caused CM may be lethal, while survivors are likely to suffer from persistent debilitating neurological deficits, especially common in children. In this review article, we have summarized the various symptoms and manifestations of CM in children and adults, and entailed the molecular basis of the disease. We have also emphasized how pathogenesis of the disease is effected by the parasite and host responses including blood brain barrier (BBB) disruption, endothelial cell activation and apoptosis, nitric oxide bioavailability, platelet activation and apoptosis, and neuroinflammation. Based on a few recent studies carried out in experimental mouse malaria models, we propose a basis for the neurological deficits and sequelae observed in human cerebral malaria, and summarize how existing drugs may improve prognosis in affected individuals.
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Affiliation(s)
- Rachna Hora
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India.
| | - Payal Kapoor
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India
| | - Kirandeep Kaur Thind
- Department of Molecular Biology and Biochemistry, Guru Nanak Dev University, Amritsar, 143005, India
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26
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Deroost K, Pham TT, Opdenakker G, Van den Steen PE. The immunological balance between host and parasite in malaria. FEMS Microbiol Rev 2015; 40:208-57. [PMID: 26657789 DOI: 10.1093/femsre/fuv046] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 12/16/2022] Open
Abstract
Coevolution of humans and malaria parasites has generated an intricate balance between the immune system of the host and virulence factors of the parasite, equilibrating maximal parasite transmission with limited host damage. Focusing on the blood stage of the disease, we discuss how the balance between anti-parasite immunity versus immunomodulatory and evasion mechanisms of the parasite may result in parasite clearance or chronic infection without major symptoms, whereas imbalances characterized by excessive parasite growth, exaggerated immune reactions or a combination of both cause severe pathology and death, which is detrimental for both parasite and host. A thorough understanding of the immunological balance of malaria and its relation to other physiological balances in the body is of crucial importance for developing effective interventions to reduce malaria-related morbidity and to diminish fatal outcomes due to severe complications. Therefore, we discuss in this review the detailed mechanisms of anti-malarial immunity, parasite virulence factors including immune evasion mechanisms and pathogenesis. Furthermore, we propose a comprehensive classification of malaria complications according to the different types of imbalances.
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Affiliation(s)
- Katrien Deroost
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium The Francis Crick Institute, Mill Hill Laboratory, London, NW71AA, UK
| | - Thao-Thy Pham
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
| | - Ghislain Opdenakker
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
| | - Philippe E Van den Steen
- Laboratory of Immunobiology, Rega Institute for Medical Research, KU Leuven - University of Leuven, 3000 Leuven, Belgium
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27
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Govil D, Srinivasan S. Optic nerve sheath diameter measurement using bedside ultrasound: Is it accurate? Indian J Crit Care Med 2015; 19:443-5. [PMID: 26321801 PMCID: PMC4548411 DOI: 10.4103/0972-5229.162456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Deepak Govil
- Institute of Critical Care Medicine, Medanta The Medicity, Gurgaon, India
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28
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Shirodkar CG, Munta K, Rao SM, Mahesh MU. Correlation of measurement of optic nerve sheath diameter using ultrasound with magnetic resonance imaging. Indian J Crit Care Med 2015; 19:466-70. [PMID: 26321806 PMCID: PMC4548416 DOI: 10.4103/0972-5229.162465] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Analysis to correlate the measurements of optic nerve sheath diameter (ONSD) obtained by using ultrasound to magnetic resonance imaging (MRI) techniques in order to establish the accuracy of ocular sonography as a noninvasive modality for detecting raised intracranial pressure (ICP). Materials and Methods: A prospective, observational study was performed in 100 cases of adult meningoencephalitis patients admitted to Intensive Care Unit in whom MRI was performed for neurodiagnosis. ONSD was measured in such patients, 3 mm behind the globe in each eye. A mean binocular ONSD >4.6 mm in female and 4.8 mm in male was taken as cut-off values for diagnosing raised ICP. This was compared with ONSD measured on T2-weighted MRI image measured 3 mm behind the globe. The reading obtained from both the methods were compared with Bland–Altman analysis for correlation and the findings were tabulated. Results: The mean ONSD values measured with ultrasonography (USG) and MRI for female were 5.48 ± 0.43 mm and 5.68 ± 0.44 mm and for male were 5.40 ± 0.37 mm and 5.56 ± 0.38 mm, respectively. The mean age of the female and male was 53.90 ± 17.84 and 56.06 ± 15.67 years, respectively. On comparing ultrasound with MRI-derived ONSD values, we found acceptable agreement between both methods for measurements at a depth of 3 mm (r = 0.02, P < 0.001). Conclusion: In our study, we have found a good correlation between ocular USG and MRI of ONSD. The study has shown agreement with the fact that ocular sonography can be used as a noninvasive tool for detecting raised ICP with accuracy.
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Affiliation(s)
- Chetan G Shirodkar
- Department of Critical Care Medicine, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
| | - Kartik Munta
- Department of Critical Care Medicine, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
| | - S Manimala Rao
- Department of Critical Care Medicine, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
| | - M Uma Mahesh
- Department of Radiology, Yashoda Super Speciality Hospital, Hyderabad, Telangana, India
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29
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Seydel KB, Kampondeni SD, Valim C, Potchen MJ, Milner DA, Muwalo FW, Birbeck GL, Bradley WG, Fox LL, Glover SJ, Hammond CA, Heyderman RS, Chilingulo CA, Molyneux ME, Taylor TE. Brain swelling and death in children with cerebral malaria. N Engl J Med 2015; 372:1126-37. [PMID: 25785970 PMCID: PMC4450675 DOI: 10.1056/nejmoa1400116] [Citation(s) in RCA: 269] [Impact Index Per Article: 29.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Case fatality rates among African children with cerebral malaria remain in the range of 15 to 25%. The key pathogenetic processes and causes of death are unknown, but a combination of clinical observations and pathological findings suggests that increased brain volume leading to raised intracranial pressure may play a role. Magnetic resonance imaging (MRI) became available in Malawi in 2009, and we used it to investigate the role of brain swelling in the pathogenesis of fatal cerebral malaria in African children. METHODS We enrolled children who met a stringent definition of cerebral malaria (one that included the presence of retinopathy), characterized them in detail clinically, and obtained MRI scans on admission and daily thereafter while coma persisted. RESULTS Of 348 children admitted with cerebral malaria (as defined by the World Health Organization), 168 met the inclusion criteria, underwent all investigations, and were included in the analysis. A total of 25 children (15%) died, 21 of whom (84%) had evidence of severe brain swelling on MRI at admission. In contrast, evidence of severe brain swelling was seen on MRI in 39 of 143 survivors (27%). Serial MRI scans showed evidence of decreasing brain volume in the survivors who had had brain swelling initially. CONCLUSIONS Increased brain volume was seen in children who died from cerebral malaria but was uncommon in those who did not die from the disease, a finding that suggests that raised intracranial pressure may contribute to a fatal outcome. The natural history indicates that increased intracranial pressure is transient in survivors. (Funded by the National Institutes of Health and Wellcome Trust U.K.).
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Affiliation(s)
- Karl B Seydel
- From the Department of Osteopathic Medical Specialties, College of Osteopathic Medicine (K.B.S., L.L.F., T.E.T.), Department of Radiology (M.J.P., C.A.H.), and Department of Neurology and Ophthalmology, International Neurologic and Psychiatric Epidemiology Program (G.L.B.), Michigan State University, East Lansing; the Blantyre Malaria Project (K.B.S., S.D.K., D.A.M., F.W.M., L.L.F., T.E.T.) and Malawi-Liverpool-Wellcome Trust Clinical Research Programme (R.S.H., M.E.M.), Queen Elizabeth Central Hospital (S.D.K., C.A.C.) and the Department of Anatomy (S.J.G.), University of Malawi College of Medicine - both in Blantyre, Malawi; the Department of Immunology and Infectious Diseases, Harvard School of Public Health (C.V., D.A.M.), and the Department of Pathology, Brigham and Women's Hospital (D.A.M.) - both in Boston; the Department of Radiology, University of California San Diego, San Diego (W.G.B.); and the Liverpool School of Tropical Medicine, Liverpool, United Kingdom (M.E.M.)
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Abstract
Over 90% of the world's severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the publication of the AQUAMAT trial in 2010, involving 5,425 children at 11 centres across 9 African countries, showing that in artesunate-treated children, the relative risk of death was 22.5% (95% confidence interval (CI) 8.1 to 36.9) lower than in those receiving quinine. Human trials of supportive therapies carried out on the basis of pathophysiology studies, have so far made little progress on reducing mortality; despite appearing to reduce morbidity endpoints, more often than not they have led to an excess of adverse outcomes. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
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Taylor TE, Molyneux ME. The pathogenesis of pediatric cerebral malaria: eye exams, autopsies, and neuroimaging. Ann N Y Acad Sci 2015; 1342:44-52. [PMID: 25708306 DOI: 10.1111/nyas.12690] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/02/2014] [Accepted: 12/18/2014] [Indexed: 12/23/2022]
Abstract
Several advances in our understanding of pediatric cerebral malaria (CM) have been made over the past 25 years. Accurate clinical diagnosis is enhanced by the identification of a characteristic retinopathy, visible by direct or indirect ophthalmoscopy, the retinal changes (retinal whitening, vessel color changes, white-centered hemorrhages) being consistently associated with intracerebral sequestration of parasites in autopsy studies. Autopsies have yielded information at tissue levels in fatal CM, but new insights into critical pathogenetic processes have emerged from neuroimaging studies, which, unlike autopsy-based studies, permit serial observations over time and allow comparisons between fatal cases and survivors. Brain swelling has emerged as the major risk factor for death, and, among survivors, brain volume diminishes spontaneously over 24-48 hours. Studies of life-threatening and fatal malaria are suggesting new approaches to identifying and caring for those at highest risk; potential adjuvants should be evaluated and implemented where they are most needed.
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Affiliation(s)
- Terrie E Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI; Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
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Nacer A, Movila A, Sohet F, Girgis NM, Gundra UM, Loke P, Daneman R, Frevert U. Experimental cerebral malaria pathogenesis--hemodynamics at the blood brain barrier. PLoS Pathog 2014; 10:e1004528. [PMID: 25474413 PMCID: PMC4256476 DOI: 10.1371/journal.ppat.1004528] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/17/2014] [Indexed: 12/16/2022] Open
Abstract
Cerebral malaria claims the lives of over 600,000 African children every year. To better understand the pathogenesis of this devastating disease, we compared the cellular dynamics in the cortical microvasculature between two infection models, Plasmodium berghei ANKA (PbA) infected CBA/CaJ mice, which develop experimental cerebral malaria (ECM), and P. yoelii 17XL (PyXL) infected mice, which succumb to malarial hyperparasitemia without neurological impairment. Using a combination of intravital imaging and flow cytometry, we show that significantly more CD8(+) T cells, neutrophils, and macrophages are recruited to postcapillary venules during ECM compared to hyperparasitemia. ECM correlated with ICAM-1 upregulation on macrophages, while vascular endothelia upregulated ICAM-1 during ECM and hyperparasitemia. The arrest of large numbers of leukocytes in postcapillary and larger venules caused microrheological alterations that significantly restricted the venous blood flow. Treatment with FTY720, which inhibits vascular leakage, neurological signs, and death from ECM, prevented the recruitment of a subpopulation of CD45(hi) CD8(+) T cells, ICAM-1(+) macrophages, and neutrophils to postcapillary venules. FTY720 had no effect on the ECM-associated expression of the pattern recognition receptor CD14 in postcapillary venules suggesting that endothelial activation is insufficient to cause vascular pathology. Expression of the endothelial tight junction proteins claudin-5, occludin, and ZO-1 in the cerebral cortex and cerebellum of PbA-infected mice with ECM was unaltered compared to FTY720-treated PbA-infected mice or PyXL-infected mice with hyperparasitemia. Thus, blood brain barrier opening does not involve endothelial injury and is likely reversible, consistent with the rapid recovery of many patients with CM. We conclude that the ECM-associated recruitment of large numbers of activated leukocytes, in particular CD8(+) T cells and ICAM(+) macrophages, causes a severe restriction in the venous blood efflux from the brain, which exacerbates the vasogenic edema and increases the intracranial pressure. Thus, death from ECM could potentially occur as a consequence of intracranial hypertension.
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Affiliation(s)
- Adéla Nacer
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
| | - Alexandru Movila
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
| | - Fabien Sohet
- Department of Anatomy, University of California San Francisco, San Francisco, California, United States of America
| | - Natasha M. Girgis
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
| | - Uma Mahesh Gundra
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
| | - P'ng Loke
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
| | - Richard Daneman
- Department of Anatomy, University of California San Francisco, San Francisco, California, United States of America
| | - Ute Frevert
- Department of Microbiology, Division of Medical Parasitology, New York University School of Medicine, New York, New York, United States of America
- * E-mail:
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Frevert U, Nacer A. Fatal cerebral malaria: a venous efflux problem. Front Cell Infect Microbiol 2014; 4:155. [PMID: 25414834 PMCID: PMC4222339 DOI: 10.3389/fcimb.2014.00155] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 10/13/2014] [Indexed: 12/20/2022] Open
Abstract
Most Plasmodium falciparum-infected children with cerebral malaria (CM) die from respiratory arrest, but the underlying pathology is unclear. Here we present a model in which the ultimate cause of death from CM is severe intracranial hypertension. Dynamic imaging of mice infected with P. berghei ANKA, an accepted model for experimental CM, revealed that leukocyte adhesion impairs the venous blood flow by reducing the functional lumen of postcapillary venules (PCV). The resulting increase in intracranial pressure (ICP) exacerbates cerebral edema formation, a hallmark of both murine and pediatric CM. We propose that two entirely different pathogenetic mechanisms-cytoadherence of P. falciparum-infected erythrocytes in pediatric CM and leukocyte arrest in murine CM-result in the same pathological outcome: a severe increase in ICP leading to brainstem herniation and death from respiratory arrest. The intracranial hypertension (IH) model unifies previous hypotheses, applies to human and experimental CM alike, eliminates the need to explain any selective recognition mechanism Plasmodium might use to target multiple sensitive sites in the brain, and explains how an intravascular parasite can cause so much neuronal dysfunction.
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Affiliation(s)
- Ute Frevert
- Division of Medical Parasitology, Department of Microbiology, New York University School of Medicine New York, NY, USA
| | - Adéla Nacer
- Unité de Biologie des Interactions Hôte-Parasite, Département de Parasitologie et Mycologie, Institut Pasteur Paris, France
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Shirodkar CG, Rao SM, Mutkule DP, Harde YR, Venkategowda PM, Mahesh MU. Optic nerve sheath diameter as a marker for evaluation and prognostication of intracranial pressure in Indian patients: An observational study. Indian J Crit Care Med 2014; 18:728-34. [PMID: 25425840 PMCID: PMC4238090 DOI: 10.4103/0972-5229.144015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND AIMS The aim was to evaluate efficacy of optic nerve sheath diameter (ONSD) by ultrasound as a noninvasive method for detecting raised intracranial pressure (ICP) in intensive care unit, to compare with computed tomography/magnetic resonance imaging (MRI) findings of raised ICP and to prognosticate ONSD value with treatment. MATERIALS AND METHODS We conducted a prospective, observational study on 101 adults by including 41 healthy individuals in group A as control and 60 patients in group B admitted with fever, headache, vomiting, and altered sensorium. We examined them in supine position using 10 MHz linear array probe on closed eyelid. ONSD was measured 3 mm behind the globe in each eye. A mean binocular ONSD > 4.6 mm in female and 4.8 mm in male was considered abnormal. Midline shift, edema, effacement or ONSD > 5.0 mm on T2 MRI suggestive of elevated ICP was used to evaluate ONSD accuracy. RESULTS Group A mean ONSD was 4.6 mm in females and 4.8 mm in males. Group B mean ONSD for 17 females was 5.103 ± 0.6221 mm (P = 0.002) and for 43 males 5.081 ± 0.5799 mm (P = 0.032). Radiological sign of raised ICP was confirmed in 35 patients (females = 11 and males = 24) with high ONSD value. Sensitivity of detecting raised ICP by ONSD was 84.6% in females and 75% in males while specificity was 100% in both genders. Out of 25 patients without radiological signs of raised ICP 10 patients showed high ONSD (females = 4.735 mm and males = 4.907 mm). ONSD was well prognosticated with treatment modalities. CONCLUSION Bedside ocular ultrasonography for measuring ONSD can be used an early test for diagnosing raised ICP as it is a noninvasive, cost effective bedside test, which can be repeated for re-evaluation.
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Affiliation(s)
- Chetan G. Shirodkar
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - S. Manimala Rao
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - Dnyaneshwar P. Mutkule
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - Yogesh R. Harde
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - Pradeep M. Venkategowda
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
| | - M. Uma Mahesh
- From: Department of Critical Care Medicine and Department of Radiology, Yashoda Multi-Speciality Hospital, Somajiguda, Hyderabad, Telangana, India
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Mariga ST, Kolko M, Gjedde A, Bergersen LH. Lactate transport and receptor actions in cerebral malaria. Front Neurosci 2014; 8:125. [PMID: 24904266 PMCID: PMC4032900 DOI: 10.3389/fnins.2014.00125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 04/22/2014] [Indexed: 01/09/2023] Open
Abstract
Cerebral malaria (CM), caused by Plasmodium falciparum infection, is a prevalent neurological disorder in the tropics. Most of the patients are children, typically with intractable seizures and high mortality. Current treatment is unsatisfactory. Understanding the pathogenesis of CM is required in order to identify therapeutic targets. Here, we argue that cerebral energy metabolic defects are probable etiological factors in CM pathogenesis, because malaria parasites consume large amounts of glucose metabolized mostly to lactate. Monocarboxylate transporters (MCTs) mediate facilitated transfer, which serves to equalize lactate concentrations across cell membranes in the direction of the concentration gradient. The equalizing action of MCTs is the basis for lactate’s role as a volume transmitter of metabolic signals in the brain. Lactate binds to the lactate receptor GPR81, recently discovered on brain cells and cerebral blood vessels, causing inhibition of adenylyl cyclase. High levels of lactate delivered by the parasite at the vascular endothelium may damage the blood–brain barrier, disrupt lactate homeostasis in the brain, and imply MCTs and the lactate receptor as novel therapeutic targets in CM.
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Affiliation(s)
- Shelton T Mariga
- Department of Neuroscience and Pharmacology, University of Copenhagen Copenhagen, Denmark
| | - Miriam Kolko
- Department of Neuroscience and Pharmacology, University of Copenhagen Copenhagen, Denmark ; Department of Ophthalmology, Roskilde Hospital Roskilde, Denmark
| | - Albert Gjedde
- Department of Neuroscience and Pharmacology, University of Copenhagen Copenhagen, Denmark
| | - Linda H Bergersen
- Department of Neuroscience and Pharmacology, University of Copenhagen Copenhagen, Denmark ; The Brain and Muscle Energy Group and SN-Lab, Department of Anatomy and Department of Oral Biology, Institute of Basic Medical Sciences and Centre for Molecular Biology and Neuroscience/SERTA Healthy Brain Aging Centre, University of Oslo Oslo, Norway
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Monteiro MC, Oliveira FR, Oliveira GB, Romao PRT, Maia CSF. Neurological and behavioral manifestations of cerebral malaria: An update. World J Transl Med 2014; 3:9-16. [DOI: 10.5528/wjtm.v3.i1.9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 02/28/2014] [Accepted: 03/14/2014] [Indexed: 02/05/2023] Open
Abstract
Neglected tropical diseases are a group of tropical diseases endemic in poor countries even though medical treatment and cures are available. They are considered a global health problem due to the severity of the physiological changes they induce in their hosts. Malaria is a disease caused by Plasmodium sp. that in its cerebral form may lead to acute or long-term neurological deficits, even with effective antimalarial therapy, causing vascular obstruction, reduced cerebral blood flow and many other changes. However, Plasmodium falciparum infection can also develop into a cerebral malaria (CM) disease that can produce neurological damage. This review will discuss the mechanisms involved in the neuropathology caused by CM, focusing on alterations in cognitive, behavior and neurological functions in human and experimental models.
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Merceron S, Geeraerts T. Ocular sonography for the detection of raised intracranial pressure. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.3.5.497] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Jain K, Sood S, Gowthamarajan K. Modulation of cerebral malaria by curcumin as an adjunctive therapy. Braz J Infect Dis 2013; 17:579-91. [PMID: 23906771 PMCID: PMC9425129 DOI: 10.1016/j.bjid.2013.03.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 03/20/2013] [Accepted: 03/21/2013] [Indexed: 12/31/2022] Open
Abstract
Cerebral malaria is the most severe and rapidly fatal neurological complication of Plasmodium falciparum infection and responsible for more than two million deaths annually. The current therapy is inadequate in terms of reducing mortality or post-treatment symptoms such as neurological and cognitive deficits. The pathophysiology of cerebral malaria is quite complex and offers a variety of targets which remain to be exploited for better therapeutic outcome. The present review discusses on the pathophysiology of cerebral malaria with particular emphasis on scope and promises of curcumin as an adjunctive therapy to improve survival and overcome neurological deficits.
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Affiliation(s)
- Kunal Jain
- Department of Pharmaceutics, J.S.S. College of Pharmacy, Udhagamandalam, Tamilnadu 643001, India.
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Preventing intensive care admissions for sepsis in tropical Africa (PICASTA): an extension of the international pediatric global sepsis initiative: an African perspective. Pediatr Crit Care Med 2013; 14:561-70. [PMID: 23823191 DOI: 10.1097/pcc.0b013e318291774b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Global Sepsis Initiative recommends prevention of sepsis through immunizations, vitamins, breast feeding, and other important interventions. In our study, we consider a second set of proposals for preventing intensive care admissions for sepsis in tropical Africa, which have been specifically designed to further prevent ICU admissions for sepsis in the group A nation hospital setting. OBJECTIVES To reduce admissions with severe sepsis in an ICU of a group A nation through the identification of challenges leading to preventable, foreseeable, or nosocomial sepsis specific to our setting. METHODS Malawi is one of the poorest countries in the world. Lacking the ability to comply with standard sepsis treatment, we conducted over 4 years several studies, audits, and surveys to identify challenges leading to preventable pediatric sepsis in our setting. We developed a method to identify malnourished children through a "gatekeeper" in the theaters without any equipment, tried to implement the World Health Organization's Safe Surgery Campaign checklist, evaluated our educational courses for the districts to improve the quality of referrals, looked into the extreme fasting times discovered in our hospital, trained different cadres in the districts to deal with peripartal and posttraumatic sepsis, and identified the needs in human resources to deal with pediatric sepsis in our setting. RESULTS Six foci were identified as promising to work on in future. Focus 1: Preventing elective operations and procedures in malnourished children in the hospital and in the district: 134 of 145 nurses (92.4%) and even 25 of 31 African laymen (80.6%) were able to identify malnourished children with their own fingers. Focus 2: Preventing sepsis-related problems in emergencies through the implementation of the Safe Surgery Campaign checklist: only 100 of 689 forms (14.5%) were filled in due to challenges in ownership, communication responsibility, and time constraints. Focus 3: Preventing sepsis through the reduction of unwise referrals: our courses toward this topic reached 82-100% satisfaction of the 391 participants for relevance, presentation applicability, content, and teaching technique. Focus 4: Preventing sepsis-related problems through reduction of excessive fasting times in our hospital: necessity for action was documented by a mean fasting time of 10.2 hours (SD, 4.4 hr). Focus 5: Concentration on two extremely sepsis-relevant health challenges for children in Malawian districts, trauma and peripartal complications: numbers after our courses in the trained two districts showed a reduction in the maternal mortality rate (from 150.3 to 55 and 234.2 to 75.2), an inconclusive result for posttraumatic deaths and the identification of 44 future instructors. Focus 6: Implementation of a Master in Medicine (anesthesia and intensive care) and improvement of training in anesthesia for all cadres resulted in the first five anesthetic registrars in training and enhanced numbers in all other cadres in anesthesia dealing in own responsibility with pediatric sepsis. CONCLUSIONS Every hospital can try to improve sepsis prevention on a local level by the Preventing Intensive Care Admissions for Sepsis in Tropical Africa approach. This will help support the promotion of the regionally adjusted Global Sepsis Initiative guidelines and the future global implementation of feasible bundles as a gold standard for resource-poor countries.
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Nwokocha CR, Nwokocha MI, Owu DU, Ajayi IO, Ebeigbe AB. Experimental malaria: the in vitro and in vivo blood pressure paradox. Cardiovasc J Afr 2013; 23:98-102. [PMID: 22447479 PMCID: PMC3721815 DOI: 10.5830/cvja-2011-059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Accepted: 06/06/2011] [Indexed: 11/07/2022] Open
Abstract
Objective Malaria causes more deaths worldwide than any other parasitic disease. Many aspects of the biology that governs the pathogenesis of this parasite are still unclear. Therefore insight into the complexity of the pathogenesis of malaria is vital to understand the disease, particularly as it relates to blood pressure. Methods In vivo and in vitro experimental models were used for this study. In the in vivo study, mean arterial pressure, pulse rates and heart rates were recorded by cannulation of the carotid artery of rats. In the in vitro study, ring preparations of blood vessels from the rat aorta were studied using standard organ bath techniques. Dose–response curves for phenylepherine (PE)- and acetylcholine (Ach)-induced relaxation were constructed for rings pre-contracted with PE. Results Our results showed a significant (p < 0.05) reduction in the mean arterial pressure and pulse rates, while the heart rates remained unaltered in rats with malaria parasites, compared with the controls. Incubation of rat aortic rings with parasitised blood resulted in a significant (p < 0.05) increase in maximum contractile response to phenylephrine in the rat aortic rings but there was no effect on the baseline. The dose–response curve showed a significant (p < 0.05) leftward shift following the addition of parasitised blood and the EC70 (M) values increased from 7 × 10-7 to 5 × 10-6 M. Following exposure to parasitised blood, the magnitude of Ach-induced relaxation responses reduced significantly (p < 0.05) from 73 ± 3.6 to 24.75 ± 7.25% in the rat aortic rings. Conclusions The results suggest that malaria parasitaemia caused in vivo reduction in blood pressure, and enhanced the responses to contractile agents and reduced relaxation responses to acetylcholine in vitro. This appears to be a paradox but is explainable by the complex cardiovascular control mechanisms in vivo. This may be independent of direct action on vascular smooth muscle.
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Affiliation(s)
- C R Nwokocha
- Department of Basic Medical Sciences, University of the West Indies, Kingston, Jamaica.
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Gwer S, Sheward V, Birch A, Marchbanks R, Idro R, Newton CR, Kirkham FJ, Lin JP, Lim M. The tympanic membrane displacement analyser for monitoring intracranial pressure in children. Childs Nerv Syst 2013; 29:927-33. [PMID: 23361337 PMCID: PMC3657347 DOI: 10.1007/s00381-013-2036-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 01/15/2013] [Indexed: 12/23/2022]
Abstract
PURPOSE Raised intracranial pressure (ICP) is a potentially treatable cause of morbidity and mortality but tools for monitoring are invasive. We sought to investigate the utility of the tympanic membrane displacement (TMD) analyser for non-invasive measurement of ICP in children. METHODS We made TMD observations on normal and acutely comatose children presenting to Kilifi District Hospital (KDH) at the rural coast of Kenya and on children on follow-up for idiopathic intracranial hypertension at Evelina Children's Hospital (ECH), in London, UK. RESULTS We recruited 63 patients (median age 3.3 (inter-quartile range (IQR) 2.0-4.3) years) at KDH and 14 children (median age 10 (IQR 5-11) years) at ECH. We observed significantly higher (more negative) TMD measurements in KDH children presenting with coma compared to normal children seen at the hospital's outpatient department, in both semi-recumbent [mean -61.3 (95 % confidence interval (95 % CI) -93.5 to 29.1) nl versus mean -7.1 (95 % CI -54.0 to 68.3) nl, respectively; P = 0.03] and recumbent postures [mean -61.4 (95 % CI -93.4 to -29.3) nl, n = 59) versus mean -25.9 (95 % CI -71.4 to 123.2) nl, respectively; P = 0.03]. We also observed higher TMD measurements in ECH children with raised ICP measurements, as indicated by lumbar puncture manometry, compared to those with normal ICP, in both semi-recumbent [mean -259.3 (95 % CI -363.8 to -154.8) nl versus mean 26.7 (95 % CI -52.3 to 105.7) nl, respectively; P < 0.01] and recumbent postures [mean -137.5 (95 % CI -260.6 to -14.4) nl versus mean 96.6 (95 % CI 6.5 to 186.6) nl, respectively; P < 0.01]. CONCLUSION The TMD analyser has a potential utility in monitoring ICP in a variety of clinical circumstances.
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Affiliation(s)
- Samson Gwer
- Department of Medical Physiology, School of Health Sciences, Kenyatta University, Nairobi, Kenya.
| | - Victoria Sheward
- Paediatric Neurosciences, Evelina Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners AHSC, London, UK
| | - Anthony Birch
- Neurological Physics Group, Department of Medical Physics and Bioengineering, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert Marchbanks
- Neurological Physics Group, Department of Medical Physics and Bioengineering, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard Idro
- Centre For Geographic Medicine Research, Kenya Medical Research Institute, Kilifi, Kenya ,Department of Paediatrics and Child Health, Mulago Hospital, Makerere University College of Health Sciences, Kampala, Uganda
| | - Charles R. Newton
- Centre For Geographic Medicine Research, Kenya Medical Research Institute, Kilifi, Kenya ,Department of Psychiatry, Oxford University, Oxford, UK ,Neurosciences Unit, The Wolfson Centre, Institute of Child Health, University College of London, London, UK
| | - Fenella J. Kirkham
- Neurosciences Unit, The Wolfson Centre, Institute of Child Health, University College of London, London, UK ,Department of Child Health, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jean-Pierre Lin
- Paediatric Neurosciences, Evelina Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners AHSC, London, UK
| | - Ming Lim
- Paediatric Neurosciences, Evelina Children’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, King’s Health Partners AHSC, London, UK
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Gaieski DF, Goldman JD, Holtzman DL, Shoff WH, Shepherd SM, Mehta N, Goyal M. Algid malaria treated with early goal-directed therapy. Am J Emerg Med 2013; 31:263.e5-10. [DOI: 10.1016/j.ajem.2012.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022] Open
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Protective role of brain water channel AQP4 in murine cerebral malaria. Proc Natl Acad Sci U S A 2012; 110:1035-40. [PMID: 23277579 DOI: 10.1073/pnas.1220566110] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Tragically common among children in sub-Saharan Africa, cerebral malaria is characterized by rapid progression to coma and death. In this study, we used a model of cerebral malaria appearing in C57BL/6 WT mice after infection with the rodent malaria parasite Plasmodium berghei ANKA. Expression and cellular localization of the brain water channel aquaporin-4 (AQP4) was investigated during the neurological syndrome. Semiquantitative real-time PCR comparing uninfected and infected mice showed a reduction of brain AQP4 transcript in cerebral malaria, and immunoblots revealed reduction of brain AQP4 protein. Reduction of brain AQP4 protein was confirmed in cerebral malaria by quantitative immunogold EM; however, polarized distribution of AQP4 at the perivascular and subpial astrocyte membranes was not altered. To further examine the role of AQP4 in cerebral malaria, WT mice and littermates genetically deficient in AQP4 were infected with P. berghei. Upon development of cerebral malaria, WT and AQP4-null mice exhibited similar increases in width of perivascular astroglial end-feet in brain. Nevertheless, the AQP4-null mice exhibited more severe signs of cerebral malaria with greater brain edema, although disruption of the blood-brain barrier was similar in both groups. In longitudinal studies, cerebral malaria appeared nearly 1 d earlier in the AQP4-null mice, and reduced survival was noted when chloroquine rescue was attempted. We conclude that the water channel AQP4 confers partial protection against cerebral malaria.
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Beare NAV, Glover SJ, Lewallen S, Taylor TE, Harding SP, Molyneux ME. Prevalence of raised intracranial pressure in cerebral malaria detected by optic nerve sheath ultrasound. Am J Trop Med Hyg 2012; 87:985-8. [PMID: 23033398 DOI: 10.4269/ajtmh.2012.11-0459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We aimed to use optic nerve sheath (ONS) ultrasound to determine the prevalence of raised intracranial pressure (ICP) in African children with cerebral malaria (CM); and if increased ONS diameter is associated with poor outcome. We measured ONS diameter in 101 children with CM and 11 children with malaria and impaired consciousness in Malawi. The prevalence of raised ICP detected by increased ONS diameter was 49%. Case fatality was similar in children with increased ONS diameter on admission (9/55) and those children without increased ONS diameter (11/57). Neurological sequelae were more common in those children with increased ONS diameter (7/46 versus 2/46, P < 0.05). Lumbar puncture (LP) opening pressure was elevated in 95% of 46 children who underwent LP. In Malawian children with CM, raised ICP is less commonly detected by ONS ultrasound than LP. This study suggests that raised ICP is not universal in CM and that other mechanisms may account for coma.
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Affiliation(s)
- Nicholas A V Beare
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom.
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Abstract
Worldwide, arboviral illnesses constitute the most important international infectious threat to human neurological health and welfare. Before the availability of effective immunizations, approximately 50,000 cases of Japanese encephalitis occurred in the world each year, one-fifth of which cases proved lethal and a much larger number were left with severe neurological handicaps. With global climate change and perhaps other factors, the prevalences of some arboviral illnesses appear to be increasing. Arboviral illnesses, including Japanese encephalitis, tick-borne encephalitis, Yellow fever, and others, are emerging as possible global health care threats because of biological warfare. This chapter will review ecology, pathophysiology, diagnosis, management, and outcome of the forms of arboviral encephalitis that are of greatest importance in North America, together with some of the most important arboviral encephalitides prevalent in other parts of the world.
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Dubost C, Motuel J, Geeraerts T. [Non-invasive evaluation of intracranial pressure: how and for whom?]. ACTA ACUST UNITED AC 2012; 31:e125-32. [PMID: 22683401 DOI: 10.1016/j.annfar.2012.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.
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Affiliation(s)
- C Dubost
- Département d'anesthésie-réanimation, HIA Val-de-Grâce, 74, boulevard de Port-Royal, 75230 Paris 05, France
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Hochman S, Kim K. The Impact of HIV Coinfection on Cerebral Malaria Pathogenesis. JOURNAL OF NEUROPARASITOLOGY 2012; 3:235547. [PMID: 22545215 PMCID: PMC3336366 DOI: 10.4303/jnp/235547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
HIV infection is widespread throughout the world and is especially prevalent in sub-Saharan Africa and Asia. Similarly, Plasmodium falciparum, the most common cause of severe malaria, affects large areas of sub-Saharan Africa, the Indian subcontinent, and Southeast Asia. Although initial studies suggested that HIV and malaria had independent impact upon patient outcomes, recent studies have indicated a more significant interaction. Clinical studies have shown that people infected with HIV have more frequent and severe episodes of malaria, and parameters of HIV disease progression worsen in individuals during acute malaria episodes. However, the effect of HIV on development of cerebral malaria, a manifestation of P. falciparum infection that is frequently fatal, has not been characterized. We review clinical and basic science studies pertaining to HIV and malaria coinfection and cerebral malaria in particular in order to highlight the likely role HIV plays in exacerbating cerebral malaria pathogenesis.
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Affiliation(s)
- Sarah Hochman
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, USA
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Gay F, Zougbédé S, N’Dilimabaka N, Rebollo A, Mazier D, Moreno A. Cerebral malaria: What is known and what is on research. Rev Neurol (Paris) 2012; 168:239-56. [DOI: 10.1016/j.neurol.2012.01.582] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 01/27/2012] [Indexed: 01/21/2023]
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Mohanty S, Mishra SK, Patnaik R, Dutt AK, Pradhan S, Das B, Patnaik J, Mohanty AK, Lee SJ, Dondorp AM. Brain swelling and mannitol therapy in adult cerebral malaria: a randomized trial. Clin Infect Dis 2012; 53:349-55. [PMID: 21810747 PMCID: PMC3148260 DOI: 10.1093/cid/cir405] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Mild cerebral swelling on CT-scan was common in adult patients with cerebral malaria, but severity of swelling was not correlated with coma depth or survival. Mannitol as adjunctive treatment for cerebral malaria prolonged coma duration and may be harmful. Background. Coma is a frequent presentation of severe malaria in adults and an important cause of death. The role of cerebral swelling in its pathogenesis, and the possible benefit of intravenous mannitol therapy to treat this, is uncertain. Methods. A computed tomographic (CT) scan of the cerebrum and lumbar puncture with measurement of cerebrospinal fluid (CSF) pressure were performed on admission for 126 consecutive adult Indian patients with cerebral malaria. Patients with brain swelling on CT scan were randomized to adjunctive treatment with intravenous mannitol (1.5 g/kg followed by 0.5 g/kg every 8 hours; n = 30) or no adjunctive therapy (n = 31). Results. On CT scan 80 (63%) of 126 patients had cerebral swelling, of whom 36 (29%) had moderate or severe swelling. Extent of brain swelling was not related to coma depth or mortality. CSF pressures were elevated (≥200 mm H2O) in 43 (36%) of 120 patients and correlated with CT scan findings (P for trend = .001). Mortality with mannitol therapy was 9 (30%) of 30 versus 4 (13%) of 31 without adjunctive therapy (hazard ratio, 2.4 [95% confidence interval, 0.8–7.3]; P = .11). Median coma recovery time was 90 hours (range, 22–380 hours) with mannitol versus 32 hours (range, 5–168 hours) without (P = .02). Conclusions. Brain swelling on CT scan is a common finding in adult patients with cerebral malaria but is not related to coma depth or survival. Mannitol therapy as adjunctive treatment for brain swelling in adult cerebral malaria prolongs coma duration and may be harmful.
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Affiliation(s)
- Sanjib Mohanty
- Depatment of Medicine and Radiology, Ispat General Hospital, Rourkela, Orissa, India
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