The quantitative buffy coat for the diagnosis of trypanosomes

Salivarian Trypanosomes Have Adopted Intricate Host-Pathogen Interaction Mechanisms That Ensure Survival in Plain Sight of the Adaptive Immune System

Salivarian trypanosomes are extracellular parasites affecting humans, livestock and game animals. Trypanosoma brucei rhodesiense and Trypanosoma brucei gambiense are human infective sub-species of T. brucei causing human African trypanosomiasis (HAT—sleeping sickness). The related T. b. brucei parasite lacks the resistance to survive in human serum, and only inflicts animal infections. Animal trypanosomiasis (AT) is not restricted to Africa, but is present on all continents. T. congolense and T. vivax are the most widespread pathogenic trypanosomes in sub-Saharan Africa. Through mechanical transmission, T. vivax has also been introduced into South America. T. evansi is a unique animal trypanosome that is found in vast territories around the world and can cause atypical human trypanosomiasis (aHT). All salivarian trypanosomes are well adapted to survival inside the host’s immune system. This is not a hostile environment for these parasites, but the place where they thrive. Here we provide an overview of the latest insights into the host-parasite interaction and the unique survival strategies that allow trypanosomes to outsmart the immune system. In addition, we review new developments in treatment and diagnosis as well as the issues that have hampered the development of field-applicable anti-trypanosome vaccines for the implementation of sustainable disease control.

The buffy coat method: a tool for detection of blood parasites without staining procedures

BACKGROUND

Blood parasites belonging to the Apicomplexa, Trypanosomatidae and Filarioidea are widespread in birds and have been studied extensively. Microscopical examination (ME) of stained blood films remains the gold standard method for the detection of these infections in birds, particularly because co-infections predominate in wildlife. None of the available molecular tools can detect all co-infections at the same time, but ME provides opportunities for this to be achieved. However, fixation, drying and staining of blood films as well as their ME are relatively time-consuming. This limits the detection of infected hosts during fieldwork when captured animals should be released soon after sampling. It is an obstacle for quick selection of donor hosts for parasite experimental, histological and other investigations in the field. This study modified, tested and described the buffy coat method (BCM) for quick diagnostics (~ 20 min/sample) of avian blood parasites.

METHODS

Blood of 345 birds belonging to 42 species was collected, and each sample was examined using ME of stained blood films and the buffy coat, which was examined after centrifugation in capillary tubes and after being transferred to objective glass slides. Parasite detection using these methods was compared using sensitivity, specificity, positive and negative predictive values and Cohen's kappa index.

RESULTS

Haemoproteus, Leucocytozoon, Plasmodium, microfilariae, Trypanosoma and Lankesterella parasites were detected. BCM had a high sensitivity (> 90%) and specificity (> 90%) for detection of Haemoproteus and microfilariae infections. It was of moderate sensitivity (57%) and high specificity (> 90%) for Lankesterella infections, but of low sensitivity (20%) and high specificity (> 90%) for Leucocytozoon infections. Trypanosoma and Plasmodium parasites were detected only by BCM and ME, respectively. According to Cohen's kappa index, the agreement between two diagnostic tools was substantial for Haemoproteus (0.80), moderate for Lankesterella (0.46) and fair for microfilariae and Leucocytozoon (0.28) infections.

CONCLUSIONS

BCM is sensitive and recommended as a quick and reliable tool to detect Haemoproteus, Trypanosoma and microfilariae parasites during fieldwork. However, it is not suitable for detection of species of Leucocytozoon and Plasmodium. BCM is a useful tool for diagnostics of blood parasite co-infections. Its application might be extended to studies of blood parasites in other vertebrates during field studies.

Parasite specific 7SL-derived small RNA is an effective target for diagnosis of active trypanosomiasis infection

Human and animal African trypanosomiasis (HAT & AAT, respectively) remain a significant health and economic issue across much of sub-Saharan Africa. Effective control of AAT and potential eradication of HAT requires affordable, sensitive and specific diagnostic tests that can be used in the field. Small RNAs in the blood or serum are attractive disease biomarkers due to their stability, accessibility and available technologies for detection. Using RNAseq, we have identified a trypanosome specific small RNA to be present at high levels in the serum of infected cattle. The small RNA is derived from the non-coding 7SL RNA of the peptide signal recognition particle and is detected in the serum of infected cattle at significantly higher levels than in the parasite, suggesting active processing and secretion. We show effective detection of the small RNA in the serum of infected cattle using a custom RT-qPCR assay. Strikingly, the RNA can be detected before microscopy detection of parasitaemia in the blood, and it can also be detected during remission periods of infection when no parasitaemia is detectable by microscopy. However, RNA levels drop following treatment with trypanocides, demonstrating accurate prediction of active infection. While the small RNA sequence is conserved between different species of trypanosome, nucleotide differences within the sequence allow generation of highly specific assays that can distinguish between infections with Trypanosoma brucei, Trypanosoma congolense and Trypanosoma vivax. Finally, we demonstrate effective detection of the small RNA directly from serum, without the need for pre-processing, with a single step RT-qPCR assay. Our findings identify a species-specific trypanosome small RNA that can be detected at high levels in the serum of cattle with active parasite infections. This provides the basis for the development of a cheap, non-invasive and highly effective diagnostic test for trypanosomiasis.

African trypanosomes cause significant disease in humans and animals across sub-Saharan Africa. For both human and animal infections diagnostics that can accurately identify an active infection are lacking–this is particularly the case in animal disease where most diagnosis is based upon clinical signs, which is not a specific or sensitive means of detecting infection. There is therefore a significant unmet need for a pathogen marker of active infection that accurately indicates whether an animal or human is currently infected. Through analysing the blood of cattle infected with trypanosomes, we identified a short sequence of RNA that was present at very high levels. This small RNA derives from the trypanosome genome, and we could identify its presence in the genome of all three species that are responsible for human and animal disease. We were able to design species-specific tests, and showed that in samples from infected animals the assays were more sensitive than the traditional microscope-based detection, importantly the signal disappeared relatively quickly after successful treatment, and when treatment failed, the assay was able to accurately identify when infection persisted. We also demonstrated that the causative agent of human trypanosomiasis secretes the marker at similar levels to that seen in the animal-infective trypanosomes. Therefore, we have discovered a marker of trypanosome infection that is present at high levels in the blood of infected animals, disappears quickly upon successful treatment, but is effective at detecting instances of unsuccessful treatment and persistent infection. This represents a potentially powerful diagnostic tool for human and animal trypanosomiasis.

Direct blood dry LAMP: a rapid, stable, and easy diagnostic tool for Human African Trypanosomiasis

Loop-mediated isothermal amplification (LAMP) is a rapid and sensitive tool used for the diagnosis of a variety of infectious diseases. One of the advantages of this method over the polymerase chain reaction is that DNA amplification occurs at a constant temperature, usually between 60–65°C; therefore, expensive devices are unnecessary for this step. However, LAMP still requires complicated sample preparation steps and a well-equipped laboratory to produce reliable and reproducible results, which limits its use in resource-poor laboratories in most developing countries. In this study, we made several substantial modifications to the technique to carry out on-site diagnosis of Human African Trypanosomiasis (HAT) in remote areas using LAMP. The first essential improvement was that LAMP reagents were dried and stabilized in a single tube by incorporating trehalose as a cryoprotectant to prolong shelf life at ambient temperature. The second technical improvement was achieved by simplifying the sample preparation step so that DNA or RNA could be amplified directly from detergent-lysed blood samples. With these modifications, diagnosis of HAT in local clinics or villages in endemic areas becomes a reality, which could greatly impact on the application of diagnosis not only for HAT but also for other tropical diseases.

Human African trypanosomiasis (HAT) is an endemic protozoan disease affecting many African countries, predominantly in rural areas where the tsetse fly vector is present. HAT diagnosis currently relies on conventional microscopy techniques, which provide relatively low sensitivity and are often unable to distinguish between the two different HAT-causing subspecies, T. b. rhodesiense and T. b. gambiense. A delay in HAT diagnosis can result in disease progression from an early stage (hemolymphatic) to a late stage (meningoencephalitic); therefore, a rapid and sensitive diagnostic test is crucial to its successful treatment. In this study, we developed a simple and highly sensitive molecular technique for HAT diagnosis. Loop-mediated isothermal amplification (LAMP) is a method that rapidly amplifies DNA with high sensitivity under isothermal conditions. We optimized and modified the technique by stabilizing the reagents and simplifying the sample preparation for the diagnosis of HAT. The whole protocol is so simple that local staff can perform it without the need for costly equipment and expertise.

Towards Point-of-Care Diagnostic and Staging Tools for Human African Trypanosomiaisis

Human African trypanosomiasis is a debilitating disease prevalent in rural sub-Saharan Africa. Control of this disease almost exclusively relies on chemotherapy that should be driven by accurate diagnosis, given the unacceptable toxicity of the few available drugs. Unfortunately, the available diagnostics are characterised by low sensitivities due to the inherent low parasitaemia in natural infections. Demonstration of the trypanosomes in body fluids, which is a prerequisite before treatment, often follows complex algorithms. In this paper, we review the available diagnostics and explore recent advances towards development of novel point-of-care diagnostic tests.

Diagnostic accuracy of molecular amplification tests for human African trypanosomiasis--systematic review

Background

A range of molecular amplification techniques have been developed for the diagnosis of Human African Trypanosomiasis (HAT); however, careful evaluation of these tests must precede implementation to ensure their high clinical accuracy. Here, we investigated the diagnostic accuracy of molecular amplification tests for HAT, the quality of articles and reasons for variation in accuracy.

Methodology

Data from studies assessing diagnostic molecular amplification tests were extracted and pooled to calculate accuracy. Articles were included if they reported sensitivity and specificity or data whereby values could be calculated. Study quality was assessed using QUADAS and selected studies were analysed using the bivariate random effects model.

Results

16 articles evaluating molecular amplification tests fulfilled the inclusion criteria: PCR (n = 12), NASBA (n = 2), LAMP (n = 1) and a study comparing PCR and NASBA (n = 1). Fourteen articles, including 19 different studies were included in the meta-analysis. Summary sensitivity for PCR on blood was 99.0% (95% CI 92.8 to 99.9) and the specificity was 97.7% (95% CI 93.0 to 99.3). Differences in study design and readout method did not significantly change estimates although use of satellite DNA as a target significantly lowers specificity. Sensitivity and specificity of PCR on CSF for staging varied from 87.6% to 100%, and 55.6% to 82.9% respectively.

Conclusion

Here, PCR seems to have sufficient accuracy to replace microscopy where facilities allow, although this conclusion is based on multiple reference standards and a patient population that was not always representative. Future studies should, therefore, include patients for which PCR may become the test of choice and consider well designed diagnostic accuracy studies to provide extra evidence on the value of PCR in practice. Another use of PCR for control of disease could be to screen samples collected from rural areas and test in reference laboratories, to spot epidemics quickly and direct resources appropriately.

A range of molecular amplification techniques has been developed for the diagnosis of HAT, with polymerase chain reaction (PCR) at the forefront. As laboratory strengthening in endemic areas increases, it is expected that the applicability of molecular tests will increase. However, careful evaluation of these tests against the current reference standard, microscopy, must precede implementation. Therefore, we have investigated the published diagnostic accuracy of molecular amplification tests for HAT compared to microscopy for both initial diagnosis as well as for disease staging.

Here, PCR tests seem to have an acceptably high specificity and sensitivity for diagnosis of stage I HAT. This conclusion is, however, based on multiple-microscopy based techniques as reference standards, which may have low sensitivity, and a patient population that was not always representative. Future studies should, therefore, first and foremost include those patients for which PCR may become the test of choice. More certainty about the practical value of PCR tests for HAT diagnosis should come from non-accuracy design studies, like feasibility or cost-effectiveness studies.

Accuracy of five algorithms to diagnose gambiense human African trypanosomiasis

Background

Algorithms to diagnose gambiense human African trypanosomiasis (HAT, sleeping sickness) are often complex due to the unsatisfactory sensitivity and/or specificity of available tests, and typically include a screening (serological), confirmation (parasitological) and staging component. There is insufficient evidence on the relative accuracy of these algorithms. This paper presents estimates of the accuracy of five algorithms used by past Médecins Sans Frontières programmes in the Republic of Congo, Southern Sudan and Uganda.

Methodology and Principal Findings

The sequence of tests in each algorithm was programmed into a probabilistic model, informed by distributions of the sensitivity, specificity and staging accuracy of each test, constructed based on a literature review. The accuracy of algorithms was estimated in a baseline scenario and in a worst-case scenario introducing various near worst-case assumptions. In the baseline scenario, sensitivity was estimated as 85–90% in all but one algorithm, with specificity above 99.9% except for the Republic of Congo, where CATT serology was used as independent confirmation test: here, positive predictive value (PPV) was estimated at <50% in realistic active screening prevalence scenarios. Furthermore, most algorithms misclassified about one third of true stage 1 cases as stage 2, and about 10% of true stage 2 cases as stage 1. In the worst-case scenario, sensitivity was 75–90% and PPV no more than 75% at 1% prevalence, with about half of stage 1 cases misclassified as stage 2.

Conclusions

Published evidence on the accuracy of widely used tests is scanty. Algorithms should carefully weigh the use of serology alone for confirmation, and could enhance sensitivity through serological suspect follow-up and repeat parasitology. Better evidence on the frequency of low-parasitaemia infections is needed. Simulation studies should guide the tailoring of algorithms to specific scenarios of HAT prevalence and availability of control tools.

Gambiense human African trypanosomiasis (HAT, sleeping sickness) usually features low prevalence. The two stages of the disease require different treatments, and stage 2 is fatal if untreated. HAT diagnosis must therefore be highly sensitive (i.e., detect as many true cases as possible) and specific (i.e., minimize false positives). HAT diagnostic algorithms are complex and involve several tests to screen for, confirm and stage infection. We analyzed five algorithms used by Médecins Sans Frontières HAT programmes. We combined published data on the accuracy of each test in the algorithm with a computer program that simulates all possible algorithm branches. We found that all algorithms had reasonable sensitivity (85–90%); specificity was high (>99.9%) except for the Republic of Congo, where confirmation did not rely on microscopic evidence, resulting in frequent false positives (but also higher sensitivity). Algorithms misclassified about one third of stage 1 cases as stage 2, but stage 2 classification was highly accurate. The use of serology alone for confirmation merits caution. HAT diagnosis could be made more sensitively by following up serological suspects and repeating microscopic examinations. Computer simulations can help to adapt algorithms to local conditions in each HAT programme, such as the prevalence of infection and operational constraints.

Cardiac involvement with parasitic infections

Parasitic infections previously seen only in developing tropical settings can be currently diagnosed worldwide due to travel and population migration. Some parasites may directly or indirectly affect various anatomical structures of the heart, with infections manifested as myocarditis, pericarditis, pancarditis, or pulmonary hypertension. Thus, it has become quite relevant for clinicians in developed settings to consider parasitic infections in the differential diagnosis of myocardial and pericardial disease anywhere around the globe. Chagas' disease is by far the most important parasitic infection of the heart and one that it is currently considered a global parasitic infection due to the growing migration of populations from areas where these infections are highly endemic to settings where they are not endemic. Current advances in the treatment of African trypanosomiasis offer hope to prevent not only the neurological complications but also the frequently identified cardiac manifestations of this life-threatening parasitic infection. The lack of effective vaccines, optimal chemoprophylaxis, or evidence-based pharmacological therapies to control many of the parasitic diseases of the heart, in particular Chagas' disease, makes this disease one of the most important public health challenges of our time.

Cost-effectiveness of algorithms for confirmation test of human African trypanosomiasis

Algorithms that incorporate concentration techniques are more effective and efficient than the currently used algorithms.

The control of Trypanosoma brucei gambiense human African trypanosomiasis (HAT) is compromised by low sensitivity of the routinely used parasitologic confirmation tests. More sensitive alternatives, such as mini-anion exchange centrifugation technique (mAECT) or capillary tube centrifugation (CTC), are more expensive. We used formal decision analysis to assess the cost-effectiveness of alternative HAT confirmation algorithms in terms of cost per life saved. The effectiveness of the standard method, a combination of lymph node puncture (LNP), fresh blood examination (FBE), and thick blood film (TBF), was 36.8%; the LNP-FBE-CTC-mAECT sequence reached almost 80%. The cost per person examined ranged from €1.56 for LNP-FBE-TBF to €2.99 for LNP-TBF-CTC-mAECT-CATT (card agglutination test for trypanosomiasis) titration. LNP-TBF-CTC-mAECT was the most cost-effective in terms of cost per life saved. HAT confirmation algorithms that incorporate concentration techniques are more effective and efficient than the algorithms that are currently and routinely used by several T.b. gambiense control programs.

Validité, coût et faisabilité de la mAECT et CTC comme tests de confirmation dans la détection de la Trypanosomiase Humaine Africaine

OBJECTIVES

To evaluate the validity, cost and feasibility of two parasitological tests for the confirmation of Human African Trypanosomiasis (HAT): the mini Anion-exchange Centrifugation Technique (mAECT) and Capillary Tube Centrifugation (CTC).

METHODS

During a sleeping sickness screening campaign in 2004 we screened 6502 people in Kwamouth, DRC. Those with a positive result in the Card Agglutination Test for Trypanosomiasis (CATT) had a gland puncture, fresh blood examination, stained thick blood film, mAECT, CTC and CATT titration. Sensitivity and specificity of the confirmation tests were calculated using the combination of all parasitological tests as a reference standard. Each method was costed and its feasibility was assessed with structured interviews of the technicians.

RESULTS

Sensitivity of classical parasitological methods was 44.8% (36.8-53.0), of CTC 56.5% (48.3-64.5) and of mAECT 75.3% (95% CI: 67.7-81.9). Cost per test was 2.82 Euro for mAECT and 0.76 Euro for CTC. Time per test was 29.78 min for mAECT and 18.25 min for CTC. These two tests were judged feasible in field conditions.

CONCLUSION

CTC and mAECT used alone or in combination would bring a considerable improvement to HAT active case finding when used as confirmation tests in CATT-whole blood-positive persons. They proved feasible in operational conditions if a 220 V power supply can be guaranteed. As mAECT is more sensitive but also considerably more expensive, efficiency as well as feasibility considerations will have to guide the choice of the best algorithm.

The effectiveness of active population screening and treatment for sleeping sickness control in the Democratic Republic of Congo

BACKGROUND

The human African trypanosomiasis (HAT) control programme of the Democratic Republic of Congo (DRC) uses mass screening with the card agglutination test for trypanosomes (CATT). We looked at the contribution of CATT and improved parasitological confirmation to the effectiveness of screening and treatment.

METHOD

The effectiveness of the screening and treatment process is measured by the percentage of HAT cases that is effectively cured after a single round of screening. The process is analysed in five steps: (i) the attendance at the screening, (ii) the sensitivity of the screening procedure, (iii) the sensitivity of the parasitological confirmation, (iv) the proportion of the confirmed cases that effectively receive treatment and (v) the cure rate of the treatment. We used a simplified model that multiplies proportions of infected persons that go through each step. We estimated these parameters using a combination of routine data collected by the national control programme over the period January 1997 to December 1998 and published data. For varying attendance rates we compared the effectiveness of screening strategies based on CATT or on CATT combined with improved parasitological confirmation by mini anion exchange column technique (mAECT) with the previously used strategy based on palpation of neck glands and microscopy alone.

RESULTS

The model shows that overall effectiveness of the active case detection and treatment strategy is <50% under most scenarios. Attendance rates averaged 74% but showed considerable regional variability and are a major problem in some areas of DRC. The CATT and replacing traditional parasitology by mAECT increases the sensitivity of the screening but a substantial part of the gains are lost at other stages of the screening process.

CONCLUSION

Improvements of the HAT screening process such as introduction of CATT or mAECT only make sense if other parameters and attendance rate in particular are optimized at the same time.

Infectious diseases manifested in the peripheral blood

Although primary diagnosis of infectious disease is uncommonly made from morphologic examination of a blood smear in the United States, knowledge of the distinctive morphologic features of various organisms, coupled with an understanding of the clinical and epidemiologic features of various disorders, permits recognition and diagnosis of uncommonly encountered infections. Furthermore, nonspecific manifestations of infection may provide an important clue in guiding a further diagnostic work-up.

Tick-borne relapsing fever imported from West Africa: diagnosis by quantitative buffy coat analysis and in vitro culture of Borrelia crocidurae

West African tick-borne relapsing fever (TBRF) is difficult to diagnose due to the low number of spirochetes in the bloodstream of patients. Previously, the causative microorganism, Borrelia crocidurae, had never been cultured in vitro. TBRF was rapidly diagnosed for two patients returning from western Africa with fever of unknown origin by quantitative buffy coat (QBC) analysis. Diagnosis was confirmed by intraperitoneal inoculation of blood specimens from patients into laboratory mice. In vitro experiments showed that QBC analysis may be as much as 100-fold more sensitive than thick smear. Spirochetes were also cultured from blood samples from both patients in modified Kelly's medium and were identified as B. crocidurae by partial sequencing of the PCR-amplified rrs gene.

Detection of Trypanosoma brucei spp. in human blood by a nonradioactive branched DNA-based technique

We have developed a nonradioactive branched DNA (bDNA)-based assay for the diagnosis of the African trypanosomiases in simple buffy coat preparations of human blood. Two repetitive DNA sequences specific to the Trypanosoma brucei complex were chosen as targets of the bDNA assay, a technique which amplifies the signal from a target molecule rather than the target itself. Comparable sensitivities were observed with cloned target sequences, purified T. brucei DNA, procyclic trypanosomes, and bloodstream trypomastigotes. The results of bDNA analysis of human blood samples from Côte d'Ivoire (n = 50) showed excellent agreement with those of buffy coat microscopy. The bDNA technology offers certain advantages over alternative molecular biological techniques, including the simplicity of sample preparation and of the procedure itself, the stability of the reagents, the ability to process large numbers of samples simultaneously, and freedom from crosscontamination artifacts. We have successfully applied the bDNA technique to the detection of T. brucei in clinical samples from regions where T. brucei infection is endemic; to our knowledge, this is the first report of the molecular detection of T. brucei in human blood.

Isolation of Trypanosoma brucei gambiense from northern Uganda: evaluation of the kit for in vitro isolation (KIVI) in an epidemic focus

867 individuals from 3 sites near the town of Adjumani in the East Moyo region of north-west Uganda were investigated clinically and serologically for evidence of current trypanosome infections. Blood samples were taken from 94 persons with a positive card agglutination test for trypanosomiasis (CATT) and clinical suspects and inoculated into the kit for in vitro isolation of Trypanosoma brucei gambiense (KIVI). Amongst this group, 30 parasitaemic individuals were identified by microhaematocrit centrifugation and the quantitative buffy coat technique (QBC). Only 80% of these isolates, and one isolate from an aparasitaemic individual, grew in culture. The success or failure of cultures from parasitaemic patients was unrelated to the size of the trypanosome inoculum. The implications of these results and possible reasons for the failure of KIVI are discussed.