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Conroy AL, Datta D, Opoka RO, Batte A, Bangirana P, Gopinadhan A, Mellencamp KA, Akcan-Arikan A, Idro R, John CC. Cerebrospinal fluid biomarkers provide evidence for kidney-brain axis involvement in cerebral malaria pathogenesis. Front Hum Neurosci 2023; 17:1177242. [PMID: 37200952 PMCID: PMC10185839 DOI: 10.3389/fnhum.2023.1177242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Introduction Cerebral malaria is one of the most severe manifestations of malaria and is a leading cause of acquired neurodisability in African children. Recent studies suggest acute kidney injury (AKI) is a risk factor for brain injury in cerebral malaria. The present study evaluates potential mechanisms of brain injury in cerebral malaria by evaluating changes in cerebrospinal fluid measures of brain injury with respect to severe malaria complications. Specifically, we attempt to delineate mechanisms of injury focusing on blood-brain-barrier integrity and acute metabolic changes that may underlie kidney-brain crosstalk in severe malaria. Methods We evaluated 30 cerebrospinal fluid (CSF) markers of inflammation, oxidative stress, and brain injury in 168 Ugandan children aged 18 months to 12 years hospitalized with cerebral malaria. Eligible children were infected with Plasmodium falciparum and had unexplained coma. Acute kidney injury (AKI) on admission was defined using the Kidney Disease: Improving Global Outcomes criteria. We further evaluated blood-brain-barrier integrity and malaria retinopathy, and electrolyte and metabolic complications in serum. Results The mean age of children was 3.8 years (SD, 1.9) and 40.5% were female. The prevalence of AKI was 46.3% and multi-organ dysfunction was common with 76.2% of children having at least one organ system affected in addition to coma. AKI and elevated blood urea nitrogen, but not other measures of disease severity (severe coma, seizures, jaundice, acidosis), were associated with increases in CSF markers of impaired blood-brain-barrier function, neuronal injury (neuron-specific enolase, tau), excitatory neurotransmission (kynurenine), as well as altered nitric oxide bioavailability and oxidative stress (p < 0.05 after adjustment for multiple testing). Further evaluation of potential mechanisms suggested that AKI may mediate or be associated with CSF changes through blood-brain-barrier disruption (p = 0.0014), ischemic injury seen by indirect ophthalmoscopy (p < 0.05), altered osmolality (p = 0.0006) and through alterations in the amino acids transported into the brain. Conclusion In children with cerebral malaria, there is evidence of kidney-brain injury with multiple potential pathways identified. These changes were specific to the kidney and not observed in the context of other clinical complications.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Undergraduate Medical Education, The Aga Khan University, Nairobi, Kenya
| | - Anthony Batte
- Global Health Uganda, Kampala, Uganda
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kagan A. Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
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2
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Heme oxygenase-1, carbon monoxide, and malaria – The interplay of chemistry and biology. Coord Chem Rev 2022. [DOI: 10.1016/j.ccr.2021.214285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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3
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Bush MA, Anstey NM, Yeo TW, Florence SM, Granger DL, Mwaikambo ED, Weinberg JB. Vascular Dysfunction in Malaria: Understanding the Role of the Endothelial Glycocalyx. Front Cell Dev Biol 2021; 9:751251. [PMID: 34858979 PMCID: PMC8631294 DOI: 10.3389/fcell.2021.751251] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/27/2021] [Indexed: 01/18/2023] Open
Abstract
Malaria caused by Plasmodium falciparum results in over 400,000 deaths annually, predominantly affecting African children. In addition, non-falciparum species including vivax and knowlesi cause significant morbidity and mortality. Vascular dysfunction is a key feature in malaria pathogenesis leading to impaired blood perfusion, vascular obstruction, and tissue hypoxia. Contributing factors include adhesion of infected RBC to endothelium, endothelial activation, and reduced nitric oxide formation. Endothelial glycocalyx (eGC) protects the vasculature by maintaining vessel integrity and regulating cellular adhesion and nitric oxide signaling pathways. Breakdown of eGC is known to occur in infectious diseases such as bacterial sepsis and dengue and is associated with adverse outcomes. Emerging studies using biochemical markers and in vivo imaging suggest that eGC breakdown occurs during Plasmodium infection and is associated with markers of malaria disease severity, endothelial activation, and vascular function. In this review, we describe characteristics of eGC breakdown in malaria and discuss how these relate to vascular dysfunction and adverse outcomes. Further understanding of this process may lead to adjunctive therapy to preserve or restore damaged eGC and reduce microvascular dysfunction and the morbidity/mortality of malaria.
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Affiliation(s)
- Margaret A Bush
- Duke University School of Nursing and Durham VA Medical Centers, Durham, NC, United States
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Tsin W Yeo
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,National Centre for Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Donald L Granger
- School of Medicine, University of Utah and Salt Lake City VA Medical Centers, Salt Lake City, UT, United States
| | | | - J Brice Weinberg
- Duke University School of Medicine and Durham VA Medical Centers, Durham, NC, United States
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4
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Decreased parasite burden and altered host response in children with sickle cell anemia and severe anemia with malaria. Blood Adv 2021; 5:4710-4720. [PMID: 34470050 PMCID: PMC8759120 DOI: 10.1182/bloodadvances.2021004704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/21/2021] [Indexed: 11/20/2022] Open
Abstract
Plasmodium falciparum malaria causes morbidity and mortality in African children with sickle cell anemia (SCA), but comparisons of host responses to P falciparum between children with SCA (homozygous sickle cell disease/hemoglobin SS [HbSS]) and normal hemoglobin genotype/hemoglobin AA (HbAA) are limited. We assessed parasite biomass and plasma markers of inflammation and endothelial activation in children with HbAA (n = 208) or HbSS (n = 22) who presented with severe anemia and P falciparum parasitemia to Mulago Hospital in Kampala, Uganda. Genotyping was performed at study completion. No child had known SCA at enrollment. Children with HbSS did not differ from children with HbAA in peripheral parasite density, but had significantly lower sequestered parasite biomass. Children with HbSS had greater leukocytosis but significantly lower concentrations of several plasma inflammatory cytokines, including tumor necrosis factor α (TNF-α). In contrast, children with HbSS had threefold greater concentrations of angiopoietin-2 (Angpt-2), a marker of endothelial dysregulation associated with mortality in severe malaria. Lower TNF-α concentrations were associated with increased risk of postdischarge mortality or readmission, whereas higher Angpt-2 concentrations were associated with increased risk of recurrent clinical malaria. Children with SCA have decreased parasite sequestration and inflammation but increased endothelial dysregulation during severe anemia with P falciparum parasitemia, which may ameliorate acute infectious complications but predispose to harmful long-term sequelae.
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Knowlesi malaria: Human risk factors, clinical spectrum, and pathophysiology. ADVANCES IN PARASITOLOGY 2021; 113:1-43. [PMID: 34620381 DOI: 10.1016/bs.apar.2021.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Plasmodium knowlesi is endemic across Southeast Asia, and is the commonest cause of zoonotic malaria. The spectrum of clinical disease from P. knowlesi infection ranges from asymptomatic infection, through to severe malaria and death. Over 90% of clinical disease occurs in adults, mostly living in forest edge areas undergoing intensive land use change. With a 24-h asexual life cycle in humans, high parasite counts are possible, but most clinical cases of knowlesi malaria are uncomplicated with low parasitaemia. In co-endemic areas, median parasitaemia in knowlesi malaria is lower than that seen in vivax and falciparum malaria, suggesting a lower fever threshold. Severe malaria occurs in 6-9% of symptomatic adults. Manifestations of severe malaria from P. knowlesi are similar to those seen with falciparum malaria, with the notable absence of coma. Age, parasitaemia, cardiovascular comorbidities and delayed diagnosis are risk factors for severe disease and death, which are only seen in adults. Thrombocytopenia is near-universal in adults, likely related to platelet-red cell binding and clearance. Mechanisms underlying the microvascular sludging seen in fatal disease in non-natural primate hosts and the microvascular accumulation of parasites in fatal human disease are not clear. Marked reductions in deformability of both infected and uninfected red blood cells are associated with disease severity in both humans and other non-natural primate hosts, likely contributing to impaired microvascular perfusion and organ dysfunction. Endothelial activation, endothelial dysfunction, glycocalyx degradation and haemolysis are also associated with, and likely contribute to, severe disease and organ dysfunction, particularly acute kidney injury.
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6
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Barber BE, Grigg MJ, Piera KA, Chen Y, William T, Weinberg JB, Yeo TW, Anstey NM. Endothelial glycocalyx degradation and disease severity in Plasmodium vivax and Plasmodium knowlesi malaria. Sci Rep 2021; 11:9741. [PMID: 33963210 PMCID: PMC8105350 DOI: 10.1038/s41598-021-88962-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/13/2021] [Indexed: 02/03/2023] Open
Abstract
Degradation of the endothelial glycocalyx is associated with mortality in adult falciparum malaria. However, its role in the pathogenesis of non-falciparum malaria is unknown. In Malaysian patients with knowlesi (n = 200) and vivax (n = 61) malaria, and in healthy controls (n = 50), we measured glycocalyx breakdown products plasma syndecan-1 and urinary glycosaminoglycans, and evaluated correlations with biomarkers of disease severity. Urinary glycosaminoglycans were increased in patients with knowlesi and vivax malaria compared to healthy controls, and in knowlesi malaria were highest in those with severe disease. In knowlesi malaria, plasma syndecan-1 was also highest in those with severe disease, and correlated with markers of endothelial activation (angiopoietin-2, osteoprotegerin, ICAM-1), asymmetric dimethylarginine (ADMA) and impaired microvascular reactivity. Syndecan-1 also correlated with endothelial activation (ICAM-1, angiopoietin-2) and ADMA in vivax malaria. In knowlesi malaria increased syndecan-1 was associated with acute kidney injury, after controlling for age and parasitemia. In knowlesi malaria, the difference in median syndecan-1 between severe and non-severe disease was more marked in females than males. Endothelial glycocalyx degradation is increased in knowlesi and vivax malaria, and associated with disease severity and acute kidney injury in knowlesi malaria. Agents that inhibit glycocalyx breakdown may represent adjunctive therapeutics for severe non-falciparum malaria.
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Affiliation(s)
- Bridget E. Barber
- QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, Brisbane, QLD 4006 Australia ,Menzies School of Health Research and Charles Darwin University, Darwin, Australia ,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Malaysia
| | - Matthew J. Grigg
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia ,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Malaysia
| | - Kim A. Piera
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Youwei Chen
- Duke University and V.A. Medical Centre, Durham, USA
| | - Timothy William
- Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia ,Gleneagles Hospital, Kota Kinabalu, Malaysia
| | | | - Tsin W. Yeo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Nicholas M. Anstey
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia ,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Malaysia
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Zou Y, Tuo F, Zhang Z, Guo J, Yuan Y, Zhang H, Xu Z, Pan Z, Tang Y, Deng C, Julie N, Wu W, Guo W, Li C, Huang X, Xu Q, Song J, Wang Q. Safety and Efficacy of Adjunctive Therapy With Artesunate in the Treatment of Severe Malaria: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:596697. [PMID: 33343367 PMCID: PMC7748123 DOI: 10.3389/fphar.2020.596697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: The purpose of this meta-analysis of longitudinal studies is to determine the safety and efficacy of artesunate combined with other forms of adjunctive therapies for severe malaria. Methods: Following the PRISMA guidelines, we searched multiple databases with the search terms "artesunate" and "adjunctive therapy" and "severe malaria" in July 2020. If the search showed a randomized controlled trial, the study was included in this meta-analysis. The random-effects model was used to calculate the combined incidence rate and relative risk or risk difference. Results: This meta-analysis included nine longitudinal studies with 724 participants. We found that the mortality rates in the artesunate monotherapy group and the artesunate + adjuvant therapy group are similar (RD = -0.02, 95% confidence interval: -0.06-0.02). The incidence of adverse reactions in the artesunate monotherapy group and the artesunate + adjuvant therapy group was also similar. Conclusion: No significant differences in safety and efficacy were observed between the artesunate monotherapy group and the artesunate + adjuvant therapy group. Higher quality and rigorously designed randomized controlled studies are needed to validate our findings.
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Affiliation(s)
- Yuanyuan Zou
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fei Tuo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiqi Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jiawen Guo
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yueming Yuan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China.,Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hongying Zhang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiyong Xu
- Institute of Science and Technology, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziyi Pan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yexiao Tang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changsheng Deng
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Nadia Julie
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wanting Wu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wenfeng Guo
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Changqing Li
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xinan Huang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qin Xu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianping Song
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qi Wang
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
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Gowda SH, Anghan H, Mishra H, Chosdol K, Bhatt M, Kumar V, Ranjan P, Aggarwal P, Wig N, Soneja M. Serum Angiopoietin-1 and -2 and VEGF are associated with severe disease in vivax malaria. J Vector Borne Dis 2020; 57:285-294. [PMID: 34856707 DOI: 10.4103/0972-9062.313969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES Malaria continues to be a significant public health problem in tropical countries including India; however, there are limited tools to predict occurrence of severe disease due to malaria. This study was designed to evaluate the role of Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), Vascular endothelial growth factor (VEGF) and Asymmetric Dimethylarginine (ADMA)as disease biomarkers in uncomplicated malaria (UM) and severe malaria (SM). METHODS This is a prospective observational study carried out at All India Institute of Medical Sciences (AIIMS), tertiary referral hospital in New Delhi, India. The study population included patients diagnosed with malaria (Plasmodium falciparum or Plasmodium vivax) either by rapid diagnostic kit test or positive peripheral smear and age more than 12 years. Forty-nine patients (25 with SM, 24 with UM) and 22 controls were recruited. In addition to routine investigations, serum concentrations of Ang-1, Ang-2, VEGF and ADMA were measured using ELISA technique. RESULTS We observed Ang-1 serum levels to be significantly lower in patients with severe malaria (7775 pg/ml) compared to uncomplicated malaria (17629 pg/ml) and healthy controls (43472 pg/ml) [p <0.001]. Ang-2 levels were significantly higher in severe malaria (11100 pg/ml) compared to uncomplicated malaria (7315 pg/ml) and healthy controls (3679 pg/ml) (p <0.001). The ratio of Ang-2/Ang-1 was significantly higher in patients with severe malaria. VEGF serum levels was significantly lower in severe malaria (130.36 pg/ml) compared to uncomplicated malaria (317.3 pg/ml). The Ang-1, Ang-2 and VEGF levels were able to differentiate severe malaria from uncomplicated malaria caused by P. vivax but not with P. falciparum. INTERPRETATION & CONCLUSION We conclude that Ang-1, Ang-2 and VEGF are markers of disease severity in vivax malaria.
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Affiliation(s)
- Srinivas H Gowda
- Department of Biochemistry, Maulana Azad Medical College, New Delhi, India
| | - Hiren Anghan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Hridesh Mishra
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kunzang Chosdol
- Department of Biochemistry, All India Institute of Medical Sciences, New Delhi, India
| | - Manasvini Bhatt
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Kumar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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9
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Kingston HWF, Ghose A, Rungpradubvong V, Satitthummanid S, Herdman MT, Plewes K, Ishioka H, Leopold SJ, Sinha I, Intharabut B, Piera K, McNeil Y, Mohanty S, Maude RJ, White NJ, Day NPJ, Yeo TW, Hossain MA, Anstey NM, Dondorp AM. Cell-Free Hemoglobin Is Associated With Increased Vascular Resistance and Reduced Peripheral Perfusion in Severe Malaria. J Infect Dis 2020; 221:127-137. [PMID: 31693729 DOI: 10.1093/infdis/jiz359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In severe falciparum malaria, unlike sepsis, hypotension on admission is uncommon. We hypothesized that low nitric oxide bioavailability due to the presence of cell-free hemoglobin (CFH) increases vascular tone in severe malaria. METHODS Patients with severe malaria (n = 119), uncomplicated malaria (n = 91), or suspected bacterial sepsis (n = 56), as well as healthy participants (n = 50), were recruited. The systemic vascular resistance index (SVRI) was estimated from the echocardiographic cardiac index and the mean arterial pressure. RESULTS SVRI and hematocrit levels were lower and plasma CFH and asymmetric dimethylarginine levels were higher in patients with malaria, compared with healthy participants. In multivariate linear regression models for mean arterial pressure or SVRI in patients with severe malaria, hematocrit and CFH but not asymmetric dimethylarginine were significant predictors. The SVRI was lower in patients with suspected bacterial sepsis than in those with severe malaria, after adjustment for hematocrit and age. Plasma CFH levels correlated positively with the core-peripheral temperature gradient and plasma lactate levels and inversely with the perfusion index. Impaired peripheral perfusion, as reflected by a low perfusion index or a high core-peripheral temperature gradient, predicted mortality in patients with severe malaria. CONCLUSIONS CFH is associated with mean arterial pressure, SVRI, and peripheral perfusion in patients with severe malaria. This may be mediated through the nitric oxide scavenging potency of CFH, increasing basal vascular tone and impairing tissue perfusion.
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Affiliation(s)
- Hugh W F Kingston
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | - Voravut Rungpradubvong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sudarat Satitthummanid
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Ipsita Sinha
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Benjamas Intharabut
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University
| | - Kim Piera
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Yvette McNeil
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | | | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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10
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Hoffmeister B, Aguilar Valdez AD. Hypertension is associated with an increased risk for severe imported falciparum malaria: a tertiary care hospital based observational study from Berlin, Germany. Malar J 2019; 18:410. [PMID: 31810471 PMCID: PMC6898961 DOI: 10.1186/s12936-019-3007-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/16/2019] [Indexed: 12/19/2022] Open
Abstract
Background Increasing numbers of aging individuals with chronic co-morbidities travel to regions where falciparum malaria is endemic. Non-communicable diseases are now leading risk factors for death in such countries. Thus, the influence of chronic diseases on the outcome of falciparum malaria is an issue of major importance. Aim of the present study was to assess whether non-communicable diseases increase the risk for severe imported falciparum malaria. Methods A retrospective observational study of all adult cases with imported falciparum malaria hospitalized between 2001 and 2015 in the tertiary care Charité University Hospital, Berlin, was performed. Results A total of 536 adult patients (median age 37 years; 31.3% female) were enrolled. Of these, 329 (61.4%) originated from endemic countries, 207 patients (38.6%) from non-endemic regions. Criteria for severe malaria were fulfilled in 68 (12.7%) cases. With older age, lack of previous malaria episodes, being a tourist, and delayed presentation, well-characterized risk factors were associated with severe malaria in univariate analysis. After adjustment for these potential confounders hypertension (adjusted odds ratio aOR, 3.06 95% confidence interval, CI 1.34–7.02), cardiovascular diseases (aOR, 8.20 95% CI 2.30–29.22), and dyslipidaemia (aOR, 6.08 95% CI 1.13–32.88) were individual diseases associated with severe disease in multivariable logistic regression. Hypertension proved an independent risk factor among individuals of endemic (aOR, 4.83, 95% CI 1.44–16.22) as well as of non-endemic origin (aOR, 3.60 95% CI 1.05–12.35). Conclusions In imported falciparum malaria hypertension and its related diseases are risk factors for severe disease.
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Affiliation(s)
- Bodo Hoffmeister
- Department of Respiratory Medicine, Clinic-Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806, Bad Belzig, Germany.
| | - Abner Daniel Aguilar Valdez
- Department of Endocrinology, Clinic Group Ernst von Bergmann, Potsdam and Bad Belzig, Niemegker Straße 45, 14806, Bad Belzig, Germany
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11
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Yeo TW, Weinberg JB, Lampah DA, Kenangalem E, Bush P, Chen Y, Price RN, Young S, Zhang HY, Millington D, Granger DL, Anstey NM. Glycocalyx Breakdown Is Associated With Severe Disease and Fatal Outcome in Plasmodium falciparum Malaria. Clin Infect Dis 2019; 69:1712-1720. [PMID: 30753363 PMCID: PMC6821254 DOI: 10.1093/cid/ciz038] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/15/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Interactions between the endothelium and infected erythrocytes play a major role in the pathogenesis of falciparum malaria, with microvascular dysfunction and parasite sequestration associated with worsening outcomes. The glycocalyx is a carbohydrate-rich layer that lines the endothelium, with multiple roles in vascular homeostasis. The role of the glycocalyx in falciparum malaria and the association with disease severity has not been investigated. METHODS We prospectively enrolled Indonesian inpatients (aged ≥18 years) with severe (SM) or moderately severe (MSM) falciparum malaria, as defined by World Health Organization criteria, and healthy controls (HCs). On enrollment, blood and urine samples were collected concurrently with measurements of vascular nitric oxide (NO) bioavailability. Urine was assayed for glycocalyx breakdown products (glycosaminoglycans) using a dimethylmethylene blue (GAG-DMMB) and liquid chromatography-tandem mass spectrometry (GAG-MS) assay. RESULTS A total of 129 patients (SM = 43, MSM = 57, HC=29) were recruited. GAG-DMMB and GAG-MS (g/mol creatinine) were increased in SM (mean, 95% confidence interval: 3.98, 2.44-5.53 and 6.82, 5.19-8.44) compared to MSM patients (1.78, 1.27-2.29 and 4.87, 4.27-5.46) and HCs (0.22, 0.06-0.37 and 1.24, 0.89-1.59; P < 0.001). In SM patients, GAG-DMMB and GAG-MS were increased in those with a fatal outcome (n = 3; median, interquartile range: 6.72, 3.80-27.87 and 12.15, 7.88-17.20) compared to survivors (n = 39; 3.10, 0.46-4.5 and 4.64, 2.02-15.20; P = 0.03). Glycocalyx degradation was significantly associated with parasite biomass in both MSM (r = 0.48, GAG-DMMB and r = 0.43, GAG-MS; P < 0.001) and SM patients (r = 0.47, P = 0.002 and r = 0.33, P = 0.04) and inversely associated with endothelial NO bioavailability. CONCLUSIONS Increased endothelial glycocalyx breakdown is associated with severe disease and a fatal outcome in adults with falciparum malaria.
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Affiliation(s)
- Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - J Brice Weinberg
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | - Daniel A Lampah
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
- Mimika District Health Authority, Timika, Papua, Indonesia
| | - Peggy Bush
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | - Youwei Chen
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | - Richard N Price
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Sarah Young
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | - Hao Y Zhang
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | - David Millington
- Duke University School of Medicine and VA Medical Center, Durham, North Carolina
| | | | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
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12
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Yeo TW, Bush PA, Chen Y, Young SP, Zhang H, Millington DS, Granger DL, Mwaikambo ED, Anstey NM, Weinberg JB. Glycocalyx breakdown is increased in African children with cerebral and uncomplicated falciparum malaria. FASEB J 2019; 33:14185-14193. [PMID: 31658834 DOI: 10.1096/fj.201901048rr] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cerebral malaria (CM) from Plasmodium falciparum infection is associated with endothelial dysfunction and parasite sequestration. The glycocalyx (GCX), a carbohydrate-rich layer lining the endothelium, is crucial in vascular homeostasis. To evaluate the role of its loss in the pathogenesis of pediatric CM, we measured GCX degradation in Tanzanian children with World Health Organization-defined CM (n = 55), uncomplicated malaria (UM; n = 20), and healthy controls (HCs; n = 25). Urine GCX breakdown products [glycosaminoglycans (GAGs)] were quantified using dimethylmethylene blue (DMMB) and liquid chromatography-tandem mass spectrometry assays. DMMB-GAG and mass spectrometry (MS)-GAG (g/mol creatinine) were increased in CM and UM compared with HCs (P < 0.001), with no differences in DMMB-GAG and MS-GAG between CM and UM children or between those with and without a fatal outcome. In CM survivors, urinary GCX DMMB-GAG normalized by d 3. After adjusting for disease severity, DMMB-GAG was significantly associated with parasitemia [partial correlation coefficient (Pcorr) = 0.34; P = 0.01] and plasma TNF (Pcorr = 0.26; P = 0.04) and inversely with plasma and urine NO oxidation products [Pcorr = -0.31 (P = 0.01) and Pcorr = -0.26 (P = 0.03), respectively]. GCX breakdown is increased in children with falciparum malaria, with similar elevations in CM and UM. Endothelial GCX degradation may impair endothelial NO production, exacerbate adhesion-molecule expression, exposure, and parasite sequestration, and contribute to malaria pathogenesis.-Yeo, T. W., Bush, P. A., Chen, Y., Young, S. P., Zhang, H., Millington, D. S., Granger, D. L., Mwaikambo, E. D., Anstey, N. M., Weinberg, J. B. Glycocalyx breakdown is increased in African children with cerebral and uncomplicated falciparum malaria.
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Affiliation(s)
- Tsin W Yeo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,National Centre for Infectious Diseases, Tan Tock Seng Hospital, Singapore.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Peggy A Bush
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
| | - Youwei Chen
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
| | - Sarah P Young
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
| | - Haoyue Zhang
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
| | - David S Millington
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
| | - Donald L Granger
- University of Utah-Veterans Affairs (VA) Medical Center, Salt Lake City, Utah, USA
| | | | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - J Brice Weinberg
- Duke University-Veterans Affairs (VA) Medical Center, Durham, North Carolina, USA
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13
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Weckman AM, McDonald CR, Baxter JAB, Fawzi WW, Conroy AL, Kain KC. Perspective: L-arginine and L-citrulline Supplementation in Pregnancy: A Potential Strategy to Improve Birth Outcomes in Low-Resource Settings. Adv Nutr 2019; 10:765-777. [PMID: 31075164 PMCID: PMC6743852 DOI: 10.1093/advances/nmz015] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/19/2018] [Accepted: 01/28/2019] [Indexed: 12/22/2022] Open
Abstract
The available data support the hypothesis that L-arginine or L-citrulline supplementation would be suitable for implementation in resource-constrained settings and will enhance placental vascular development and improve birth outcomes. In resource-constrained settings, the rates of adverse birth outcomes, including fetal growth restriction, preterm birth, and low birth weight, are disproportionately high. Complications resulting from preterm birth are now the leading cause of mortality in children <5 y of age worldwide. Despite the global health burden of adverse birth outcomes, few effective interventions are currently available and new strategies are urgently needed, especially for low-resource settings. L-arginine is a nutritionally essential amino acid in pregnancy and an immediate precursor of nitric oxide. During pregnancy, placental and embryonic growth increases the demand for L-arginine, which can exceed endogenous synthesis of L-arginine from L-citrulline, necessitating increased dietary intake. In many low-resource settings, dietary intake of L-arginine in pregnancy is inadequate owing to widespread protein malnutrition and depletion of endogenous L-arginine due to maternal infections, in particular malaria. Here we examine the role of the L-arginine-nitric oxide biosynthetic pathway in pregnancy including placental vascular development and fetal growth. We review the evidence for the relations between altered L-arginine bioavailability and pregnancy outcomes, and strategies for arginine supplementation in pregnancy. Existing studies of L-arginine supplementation in pregnancy in high-resource settings have shown improved maternal and fetal hemodynamics, prevention of pre-eclampsia, and improved birth outcomes including higher birth weight and longer gestation. Arginine supplementation studies now need to be extended to pregnant women in low-resource settings, especially those at risk of malaria.
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Affiliation(s)
- Andrea M Weckman
- Laboratory Medicine and Pathobiology
- Sandra A Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Chloe R McDonald
- Sandra A Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Jo-Anna B Baxter
- Department of Nutritional Sciences
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA
| | - Andrea L Conroy
- Sandra A Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Kevin C Kain
- Laboratory Medicine and Pathobiology
- Sandra A Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
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14
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Leopold SJ, Apinan S, Ghose A, Kingston HW, Plewes KA, Hossain A, Dutta AK, Paul S, Barua A, Sattar A, Day NPJ, Tarning J, Winterberg M, White NJ, Dondorp AM. Amino acid derangements in adults with severe falciparum malaria. Sci Rep 2019; 9:6602. [PMID: 31036854 PMCID: PMC6488658 DOI: 10.1038/s41598-019-43044-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/15/2019] [Indexed: 01/10/2023] Open
Abstract
Amino acid derangements are common in severe falciparum malaria and have been associated with endothelial dysfunction (L-arginine), metabolic acidosis (alanine and lactate), and disease severity (phenylalanine and tryptophan metabolites). Whether these amino acid perturbations reflect isolated pathogenic mechanisms or if they are part of overall changes in amino acid metabolism is unclear. To investigate this, we prospectively simultaneously quantified a broad range of plasma free amino acids (PFAA) using HPLC-MRM-Mass spectrometry in relation to presenting symptoms in adults with severe malaria (n = 88), septicaemia (n = 88), uncomplicated malaria (n = 71), and healthy controls (n = 48) from Bangladesh. The total plasma concentration of measured amino acids was significantly reduced in each of the patient groups when compared to normal levels observed in healthy local controls: uncomplicated malaria -54%, severe malaria -23%, and sepsis -32%, (p = <0.001). Inspection of amino acid profiles revealed that in each group the majority of amino acids were below normal levels, except for phenylalanine. Among patients with severe malaria, L-lactate was strongly associated with an increase of the total amino acid concentration, likely because this reflects tissue hypoxia. Our data confirm previously described amino acid abnormalities, likely resulting from overall changes in the concentration of PFAA.
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Affiliation(s)
- Stije J Leopold
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Siribha Apinan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Aniruddha Ghose
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Hugh W Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Katherine A Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Amir Hossain
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Asok Kumar Dutta
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Sujat Paul
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Anupam Barua
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Abdus Sattar
- Department of Internal Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Markus Winterberg
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
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15
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Kinetic and Cross-Sectional Studies on the Genesis of Hypoargininemia in Severe Pediatric Plasmodium falciparum Malaria. Infect Immun 2019; 87:IAI.00655-18. [PMID: 30718287 DOI: 10.1128/iai.00655-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 01/05/2019] [Indexed: 12/12/2022] Open
Abstract
The low bioavailability of nitric oxide (NO) and its precursor, arginine, contributes to the microvascular pathophysiology of severe falciparum malaria. To better characterize the mechanisms underlying hypoargininemia in severe malaria, we measured the plasma concentrations of amino acids involved in de novo arginine synthesis in children with uncomplicated falciparum malaria (UM; n = 61), children with cerebral falciparum malaria (CM; n = 45), and healthy children (HC; n = 109). We also administered primed infusions of l-arginine uniformly labeled with 13C6 and 15N4 to 8 children with severe falciparum malaria (SM; age range, 4 to 9 years) and 7 healthy children (HC; age range, 4 to 8 years) to measure the metabolic flux of arginine, hypothesizing that arginine flux is increased in SM. Using two different tandem mass spectrometric methods, we measured the isotopic enrichment of arginine in plasma obtained at 0, 60, 90, 120, 150, and 180 min during the infusion. The plasma concentrations of glutamine, glutamate, proline, ornithine, citrulline, and arginine were significantly lower in UM and CM than in HC (P ≤ 0.04 for all pairwise comparisons). Of these, glutamine concentrations were the most markedly decreased: median, 457 μM (interquartile range [IQR], 400 to 508 μM) in HC, 300 μM (IQR, 256 to 365 μM) in UM, and 257 μM (IQR, 195 to 320 μM) in CM. Arginine flux during steady state was not significantly different in SM than in HC by the respective mass spectrometric methods: 93.2 μmol/h/kg of body weight (IQR, 84.4 to 129.3 μmol/h/kg) versus 88.0 μmol/h/kg (IQR, 73.0 to 102.2 μmol/h/kg) (P = 0.247) by the two mass spectrometric methods in SM and 93.7 μmol/h/kg (IQR, 79.1 to 117.8 μmol/h/kg) versus 81.0 μmol/h/kg (IQR, 75.9 to 88.6 μmol/h/kg) (P = 0.165) by the two mass spectrometric methods in HC. A limited supply of amino acid precursors for arginine synthesis likely contributes to the hypoargininemia and NO insufficiency in falciparum malaria in children.
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16
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Nagarkoti S, Sadaf S, Awasthi D, Chandra T, Jagavelu K, Kumar S, Dikshit M. L-Arginine and tetrahydrobiopterin supported nitric oxide production is crucial for the microbicidal activity of neutrophils. Free Radic Res 2019; 53:281-292. [PMID: 30621514 DOI: 10.1080/10715762.2019.1566605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 01/27/2023]
Abstract
Recent report from this lab has shown role of Rac2 in the translocation of inducible nitric oxide synthase (iNOS) to the phagosomal compartment of polymorphonuclear leukocytes (PMNs) following phagocytosis of beads. This study was undertaken to further assess the status and role of tetrahydrobiopterin (BH4), a redox-sensitive cofactor, L-arginine, and the substrate of nitric oxide synthase (NOS) in sustained nitric oxide (˙NO) production in killing of phagocytosed microbes (Escherichia coli) by human PMNs. Time-dependent study revealed consistent NO and reactive oxygen species (ROS) production in the PMNs following phagocytosis of beads. In addition, levels of L-arginine and BH4 were maintained or increased simultaneously to support the enzymatic activity of NOS in the bead activated PMNs. Moreover, translocation of nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) subunits along with iNOS was reconfirmed in the isolated phagosomes. We demonstrate that increase in the level of NO was supported by L-arginine and BH4 to kill E. coli, by using PMNs from NOS2-/- mice, human PMNs treated with biopterin inhibitor, N-acetyl serotonin (NAS), or by suspending human PMNs in L-arginine deficient medium. Altogether, this study demonstrates that following phagocytosis, sustained. NO production in the PMNs was well-maintained by redox sensitive cofactor, BH4 and substrate, and L-arginine to enable microbial killing. Further results suggest NO production in the human PMNs, along with ROS and myeloperoxidase (MPO) is important to execute antimicrobial activity.
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Affiliation(s)
- Sheela Nagarkoti
- a Pharmacology Division , CSIR-Central Drug Research Institute , Lucknow , India
| | - Samreen Sadaf
- a Pharmacology Division , CSIR-Central Drug Research Institute , Lucknow , India
| | - Deepika Awasthi
- a Pharmacology Division , CSIR-Central Drug Research Institute , Lucknow , India
| | | | - Kumaravelu Jagavelu
- a Pharmacology Division , CSIR-Central Drug Research Institute , Lucknow , India
| | - Sachin Kumar
- a Pharmacology Division , CSIR-Central Drug Research Institute , Lucknow , India
| | - Madhu Dikshit
- c Translational Health Science and Technology, NCR Biotech Science Cluster , Faridabad , India
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17
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Corbett Y, D'Alessandro S, Parapini S, Scaccabarozzi D, Kalantari P, Zava S, Giavarini F, Caruso D, Colombo I, Egan TJ, Basilico N. Interplay between Plasmodium falciparum haemozoin and L-arginine: implication for nitric oxide production. Malar J 2018; 17:456. [PMID: 30522493 PMCID: PMC6282336 DOI: 10.1186/s12936-018-2602-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 11/29/2018] [Indexed: 01/07/2023] Open
Abstract
Background Plasmodium falciparum haemozoin, a detoxification product of digested haemoglobin from infected erythrocytes, is released into the bloodstream upon schizont rupture and accumulates in leukocytes. High levels of haemozoin correlate with disease severity. Some studies have shown that concentrations of the substrate of inducible nitric oxide synthase (iNOS), l-arginine, as well as nitric oxide are low in patients infected with P. falciparum malaria. The present study investigates, in vitro, the role of P. falciparum haemozoin on nitric oxide production, iNOS expression in macrophages, and the possible interaction between l-arginine and haemozoin. Methods Plasmodium falciparum haemozoin was obtained from in vitro cultures through magnetic isolation. Phagocytosis of haemozoin by immortalized bone marrow derived macrophages was detected by confocal reflection combined with fluorescence microscopy. Nitrite concentrations in the supernatants was evaluated by Griess assay as a standard indication of nitric oxide production, while iNOS expression was detected on cell extracts by western blotting. Detection of l-arginine in haemozoin-treated or untreated media was achieved by liquid chromatography–tandem mass spectrometry (LC–MS/MS). Results Haemozoin synergizes in vitro with interferon-gamma to produce nitric oxide. However, when mouse macrophages were stimulated with haemozoin, a proportional increase of nitric oxide was observed up to 25 μM of haemozoin, followed by a decrease with doses up to 100 μM, when nitric oxide release was completely abrogated. This was not due to reactive oxygen species production, nor to an effect on iNOS activity. Interestingly, when at 24 h, haemozoin-treated macrophages were washed and incubated in fresh medium for further 24 h, the nitric oxide production was restored in a dose–response manner. Similar results were seen when l-arginine-enriched media was used in the stimulation. Moreover, muramyldipeptide, a strong nitric oxide inducer, was unable to activate macrophages to release nitric oxide in the presence of haemozoin-treated medium. By LC–MS/MS a complete depletion of l-arginine was observed in this haemozoin-treated, conditioned medium. Conclusions It is proposed that haemozoin interacts with l-arginine reducing its availability for iNOS, and thus decreasing nitric oxide production. The clinical (or pathological) implications of these results are discussed. Electronic supplementary material The online version of this article (10.1186/s12936-018-2602-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yolanda Corbett
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy. .,Dipartimento di Bioscienze, Università degli Studi di Milano, 20133, Milan, MI, Italy.
| | - Sarah D'Alessandro
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy.,Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Silvia Parapini
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy.,Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Diletta Scaccabarozzi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Parisa Kalantari
- Department of Immunology, Tufts University School of Medicine, Boston, MA, 02111, USA
| | - Stefania Zava
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Flavio Giavarini
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Donatella Caruso
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Irma Colombo
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133, Milan, MI, Italy
| | - Timothy J Egan
- Department of Chemistry, University of Cape Town, Private Bag X3, Rondebosch, 7701, South Africa
| | - Nicoletta Basilico
- Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, 20133, Milan, MI, Italy
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18
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Leligdowicz A, Richard-Greenblatt M, Wright J, Crowley VM, Kain KC. Endothelial Activation: The Ang/Tie Axis in Sepsis. Front Immunol 2018; 9:838. [PMID: 29740443 PMCID: PMC5928262 DOI: 10.3389/fimmu.2018.00838] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/05/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis, a dysregulated host response to infection that causes life-threatening organ dysfunction, is a highly heterogeneous syndrome with no specific treatment. Although sepsis can be caused by a wide variety of pathogenic organisms, endothelial dysfunction leading to vascular leak is a common mechanism of injury that contributes to the morbidity and mortality associated with the syndrome. Perturbations to the angiopoietin (Ang)/Tie2 axis cause endothelial cell activation and contribute to the pathogenesis of sepsis. In this review, we summarize how the Ang/Tie2 pathway is implicated in sepsis and describe its prognostic as well as therapeutic utility in life-threatening infections.
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Affiliation(s)
- Aleksandra Leligdowicz
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Melissa Richard-Greenblatt
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Julie Wright
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Valerie M Crowley
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, University Health Network and University of Toronto, Toronto, ON, Canada
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19
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Yacoub S, Lam PK, Huynh TT, Nguyen Ho HH, Dong Thi HT, Van NT, Lien LT, Ha QNT, Le DHT, Mongkolspaya J, Culshaw A, Yeo TW, Wertheim H, Simmons C, Screaton G, Wills B. Endothelial Nitric Oxide Pathways in the Pathophysiology of Dengue: A Prospective Observational Study. Clin Infect Dis 2017; 65:1453-1461. [PMID: 28673038 PMCID: PMC5850435 DOI: 10.1093/cid/cix567] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/20/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Dengue can cause increased vascular permeability that may lead to hypovolemic shock. Endothelial dysfunction may underlie this; however, the association of endothelial nitric oxide (NO) pathways with disease severity is unknown. METHODS We performed a prospective observational study in 2 Vietnamese hospitals, assessing patients presenting early (<72 hours of fever) and patients hospitalized with warning signs or severe dengue. The reactive hyperemic index (RHI), which measures endothelium-dependent vasodilation and is a surrogate marker of endothelial function and NO bioavailability, was evaluated using peripheral artery tonometry (EndoPAT), and plasma levels of l-arginine, arginase-1, and asymmetric dimethylarginine were measured at serial time-points. The main outcome of interest was plasma leakage severity. RESULTS Three hundred fourteen patients were enrolled; median age of the participants was 21(interquartile range, 13-30) years. No difference was found in the endothelial parameters between dengue and other febrile illness. Considering dengue patients, the RHI was significantly lower for patients with severe plasma leakage compared to those with no leakage (1.46 vs 2.00; P < .001), over acute time-points, apparent already in the early febrile phase (1.29 vs 1.75; P = .012). RHI correlated negatively with arginase-1 and positively with l-arginine (P = .001). CONCLUSIONS Endothelial dysfunction/NO bioavailability is associated with worse plasma leakage, occurs early in dengue illness and correlates with hypoargininemia and high arginase-1 levels.
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Affiliation(s)
- Sophie Yacoub
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
- Department of Medicine, Imperial College London, United Kingdom
| | - Phung Khanh Lam
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
| | | | | | - Hoai Tam Dong Thi
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
- Hospital for Tropical Diseases, Ho Chi Minh City, and
| | - Nguyen Thu Van
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
| | - Le Thi Lien
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - Quyen Nguyen Than Ha
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
| | - Duyen Huynh Thi Le
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
| | | | - Abigail Culshaw
- Department of Medicine, Imperial College London, United Kingdom
| | - Tsin Wen Yeo
- Menzies School of Health Research, Darwin, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Heiman Wertheim
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, United Kingdom; and
| | - Cameron Simmons
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
- Department of Microbiology and Immunology, University of Melbourne, Australia
| | - Gavin Screaton
- Department of Medicine, Imperial College London, United Kingdom
| | - Bridget Wills
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Hanoi and Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, University of Oxford, United Kingdom; and
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20
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S-Nitrosoglutathione Reductase Deficiency Confers Improved Survival and Neurological Outcome in Experimental Cerebral Malaria. Infect Immun 2017; 85:IAI.00371-17. [PMID: 28674030 DOI: 10.1128/iai.00371-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/26/2017] [Indexed: 11/20/2022] Open
Abstract
Artesunate remains the mainstay of treatment for cerebral malaria, but it is less effective in later stages of disease when the host inflammatory response and blood-brain barrier integrity dictate clinical outcomes. Nitric oxide (NO) is an important regulator of inflammation and microvascular integrity, and impaired NO bioactivity is associated with fatal outcomes in malaria. Endogenous NO bioactivity in mammals is largely mediated by S-nitrosothiols (SNOs). Based on these observations, we hypothesized that animals deficient in the SNO-metabolizing enzyme, S-nitrosoglutathione reductase (GSNOR), which exhibit enhanced S-nitrosylation, would have improved outcomes in a preclinical model of cerebral malaria. GSNOR knockout (KO) mice infected with Plasmodium berghei ANKA had significantly delayed mortality compared to WT animals (P < 0.0001), despite higher parasite burdens (P < 0.01), and displayed markedly enhanced survival versus the wild type (WT) when treated with the antimalarial drug artesunate (77% versus 38%; P < 0.001). Improved survival was associated with higher levels of protein-bound NO, decreased levels of CD4+ and CD8+ T cells in the brain, improved blood-brain barrier integrity, and improved coma scores, as well as higher levels of gamma interferon. GSNOR KO animals receiving WT bone marrow had significantly reduced survival following P. berghei ANKA infection compared to those receiving KO bone barrow (P < 0.001). Reciprocal transplants established that survival benefits of GSNOR deletion were attributable primarily to the T cell compartment. These data indicate a role for GSNOR in the host response to malaria infection and suggest that strategies to disrupt its activity will improve clinical outcomes by enhancing microvascular integrity and modulating T cell tissue tropism.
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21
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Winkler MS, Kluge S, Holzmann M, Moritz E, Robbe L, Bauer A, Zahrte C, Priefler M, Schwedhelm E, Böger RH, Goetz AE, Nierhaus A, Zoellner C. Markers of nitric oxide are associated with sepsis severity: an observational study. Crit Care 2017; 21:189. [PMID: 28709458 PMCID: PMC5513203 DOI: 10.1186/s13054-017-1782-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/29/2017] [Indexed: 02/23/2023] Open
Abstract
Background Nitric oxide (NO) regulates processes involved in sepsis progression, including vascular function and pathogen defense. Direct NO measurement in patients is unfeasible because of its short half-life. Surrogate markers for NO bioavailability are substrates of NO generating synthase (NOS): L-arginine (lArg) and homoarginine (hArg) together with the inhibitory competitive substrate asymmetric dimethylarginine (ADMA). In immune cells ADMA is cleaved by dimethylarginine-dimethylaminohydrolase-2 (DDAH2). The aim of this study was to investigate whether concentrations of surrogate markers for NO bioavailability are associated with sepsis severity. Method This single-center, prospective study involved 25 controls and 100 patients with surgical trauma (n = 20), sepsis (n = 63), or septic shock (n = 17) according to the Sepsis-3 definition. Plasma lArg, hArg, and ADMA concentrations were measured by mass spectrometry and peripheral blood mononuclear cells (PBMCs) were analyzed for DDAH2 expression. Results lArg concentrations did not differ between groups. Median (IQR) hArg concentrations were significantly lower in patient groups than controls, being 1.89 (1.30–2.29) μmol/L (P < 0.01), with the greatest difference in the septic shock group, being 0.74 (0.36–1.44) μmol/L. In contrast median ADMA concentrations were significantly higher in patient groups compared to controls, being 0.57 (0.46–0.65) μmol/L (P < 0.01), with the highest levels in the septic shock group, being 0.89 (0.56–1.39) μmol/L. The ratio of hArg:ADMA was inversely correlated with disease severity as determined by the Sequential Organ Failure Assessment (SOFA) score. Receiver-operating characteristic analysis for the presence or absence of septic shock revealed equally high sensitivity and specificity for the hArg:ADMA ratio compared to the SOFA score. DDAH2 expression was lower in patients than controls and lowest in the subgroup of patients with increasing SOFA. Conclusions In patients with sepsis, plasma hArg concentrations are decreased and ADMA concentrations are increased. Both metabolites affect NO metabolism and our findings suggest reduced NO bioavailability in sepsis. In addition, reduced expression of DDAH2 in immune cells was observed and may not only contribute to blunted NO signaling but also to subsequent impaired pathogen defense.
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Affiliation(s)
- Martin Sebastian Winkler
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany. .,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Maximilian Holzmann
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Eileen Moritz
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Linda Robbe
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Antonia Bauer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Corinne Zahrte
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Marion Priefler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Rainer H Böger
- Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Alwin E Goetz
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Zoellner
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.,Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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22
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Alkaitis MS, Wang H, Ikeda AK, Rowley CA, MacCormick IJC, Chertow JH, Billker O, Suffredini AF, Roberts DJ, Taylor TE, Seydel KB, Ackerman HC. Decreased Rate of Plasma Arginine Appearance in Murine Malaria May Explain Hypoargininemia in Children With Cerebral Malaria. J Infect Dis 2017; 214:1840-1849. [PMID: 27923948 DOI: 10.1093/infdis/jiw452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 09/16/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Plasmodium infection depletes arginine, the substrate for nitric oxide synthesis, and impairs endothelium-dependent vasodilation. Increased conversion of arginine to ornithine by parasites or host arginase is a proposed mechanism of arginine depletion. METHODS We used high-performance liquid chromatography to measure plasma arginine, ornithine, and citrulline levels in Malawian children with cerebral malaria and in mice infected with Plasmodium berghei ANKA with or without the arginase gene. Heavy isotope-labeled tracers measured by quadrupole time-of-flight liquid chromatography-mass spectrometry were used to quantify the in vivo rate of appearance and interconversion of plasma arginine, ornithine, and citrulline in infected mice. RESULTS Children with cerebral malaria and P. berghei-infected mice demonstrated depletion of plasma arginine, ornithine, and citrulline. Knock out of Plasmodium arginase did not alter arginine depletion in infected mice. Metabolic tracer analysis demonstrated that plasma arginase flux was unchanged by P. berghei infection. Instead, infected mice exhibited decreased rates of plasma arginine, ornithine, and citrulline appearance and decreased conversion of plasma citrulline to arginine. Notably, plasma arginine use by nitric oxide synthase was decreased in infected mice. CONCLUSIONS Simultaneous arginine and ornithine depletion in malaria parasite-infected children cannot be fully explained by plasma arginase activity. Our mouse model studies suggest that plasma arginine depletion is driven primarily by a decreased rate of appearance.
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Affiliation(s)
- Matthew S Alkaitis
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville.,Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headington
| | - Honghui Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Allison K Ikeda
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville
| | - Carol A Rowley
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville
| | - Ian J C MacCormick
- Department of Eye and Vision Science, University of Liverpool.,Centre for Clinical Brain Sciences, University of Edinburgh.,Malawi-Liverpool-Wellcome Trust Clinical Research Programme
| | - Jessica H Chertow
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville
| | | | - Anthony F Suffredini
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - David J Roberts
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headington.,National Health Service Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom
| | - Terrie E Taylor
- Michigan State University, East Lansing.,Blantyre Malaria Project, Malawi
| | - Karl B Seydel
- Michigan State University, East Lansing.,Blantyre Malaria Project, Malawi
| | - Hans C Ackerman
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville
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23
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Yeo TW, Florence SM, Kalingonji AR, Chen Y, Granger DL, Anstey NM, Mwaikambo ED, Weinberg JB. Decreased Microvascular Function in Tanzanian Children With Severe and Uncomplicated Falciparum Malaria. Open Forum Infect Dis 2017; 4:ofx079. [PMID: 28852670 PMCID: PMC5569702 DOI: 10.1093/ofid/ofx079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 04/19/2017] [Indexed: 11/13/2022] Open
Abstract
Microvascular function and oxygen consumption affect oxygen homeostasis but have not been assessed in African children with malaria. Microvascular function in Tanzanian children with severe malaria (SM) or uncomplicated malaria were 39% and 72%, respectively, of controls (P < .001). Uncomplicated malaria (P = .04), not SM (P = .06), children had increased oxygen consumption compared with controls.
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Affiliation(s)
- Tsin W Yeo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.,Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | | | | | - Youwei Chen
- Duke University and V.A. Medical Centers, Durham, North Carolina; and
| | | | - Nicholas M Anstey
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | | | - J Brice Weinberg
- Duke University and V.A. Medical Centers, Durham, North Carolina; and
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24
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Extensive alterations of blood metabolites in pediatric cerebral malaria. PLoS One 2017; 12:e0175686. [PMID: 28426698 PMCID: PMC5398544 DOI: 10.1371/journal.pone.0175686] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/29/2017] [Indexed: 12/14/2022] Open
Abstract
Cerebral malaria (CM) presents as an encephalopathy and is due to infection with Plasmodium falciparum. Patients are comatose, often with fever, recurrent seizures and this condition is associated with a high mortality rate. The etiology of the coma and seizures are poorly understood. Circulating small molecules and lipids have bioactive functions and alterations in their concentrations have been implicated in seizure disorders and other forms of encephalopathy. We carried out a comprehensive analysis of blood metabolites during CM to explore a biochemical basis of this encephalopathy. A paired metabolomics analysis was performed on the plasma samples of Malawian children (n = 11) during CM and at convalescence thirty days later, to identify differentially abundant molecules associated with CM. We also report plasma molecules associated with CM mortality (n = 4) compared to survival (n = 19). Plasma metabolites were identified through ultra high performance liquid chromatography/tandem mass spectrometry and gas chromatography/mass spectrometry to maximize compound detection and accuracy and then compared to a library for identification. We detected a total of 432 small molecules in the plasma and 247 metabolites were significantly differentially abundant between CM and convalescence (p < 0.05, FDR < 0.10). These represented global changes across many classes of molecules including lipids, amino acids and hemoglobin metabolites. We observed significant changes in molecules that could impact neurologic function during CM; these include increased levels of kynurenate and decreased indolepropionate, glutamate, arginine and glutamine. Moreover, 1-methylimidazoleacetate, kyurenate, arachidonic acid and dimethylarginine were associated with mortality (p < 0.05, fold change > 1.2). These results highlight the broad changes in blood chemistry during CM. We have identified metabolites that may impact central nervous system physiology and disease outcomes and can be further explored for their mechanistic roles into the pathophysiology of CM.
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25
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Bernabeu M, Smith JD. EPCR and Malaria Severity: The Center of a Perfect Storm. Trends Parasitol 2016; 33:295-308. [PMID: 27939609 DOI: 10.1016/j.pt.2016.11.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 12/20/2022]
Abstract
Severe malaria due to Plasmodium falciparum infection causes nearly half a million deaths per year. The different symptomatology and disease manifestations among patients have hampered understanding of severe malaria pathology and complicated efforts to develop targeted disease interventions. Infected erythrocyte sequestration in the microvasculature plays a critical role in the development of severe disease, and there is increasing evidence that cytoadherent parasites interact with host factors to enhance the damage caused by the parasite. The recent discovery that parasite binding to endothelial protein C receptor (EPCR) is associated with severe disease has suggested new mechanisms of pathology and provided new avenues for severe malaria adjunctive therapy research.
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Affiliation(s)
- Maria Bernabeu
- Center for Infectious Disease Research, Seattle, WA 98109, USA
| | - Joseph D Smith
- Center for Infectious Disease Research, Seattle, WA 98109, USA; Department of Global Health, University of Washington, Seattle, WA 98195, USA.
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26
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de Jong GM, Slager JJ, Verbon A, van Hellemond JJ, van Genderen PJJ. Systematic review of the role of angiopoietin-1 and angiopoietin-2 in Plasmodium species infections: biomarkers or therapeutic targets? Malar J 2016; 15:581. [PMID: 27905921 PMCID: PMC5134107 DOI: 10.1186/s12936-016-1624-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/19/2016] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Levels of both angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2) correlate with malaria disease severity and are proposed as biomarkers and possible therapeutic targets. To establish their role in malaria, a systematic review was performed of the literature on Ang-1 and Ang-2 with regard to their potential as biomarkers in malaria and discuss their possible place in adjuvant treatment regimens. METHODS Ten electronic databases were systematically searched to identify studies investigating Ang-1 and Ang-2 in human and murine malaria in both clinical and experimental settings. Information about the predictive value of Ang-1 and Ang-2 for disease severity and their regulatory changes in interventional studies were extracted. RESULTS Some 579 studies were screened; 26 were included for analysis. In all five studies that determined Ang-1 levels and in all 11 studies that determined Ang-2 in different disease severity states in falciparum malaria, a decline in Ang-1 and an increase of Ang-2 levels was associated with increasing disease severity. All nine studies that determined angiopoietin levels in Plasmodium falciparum patients to study their ability as biomarkers could distinguish between multiple disease severity states; the more the disease severity states differed, the better they could be distinguished. Five studies differentiating malaria survivors from non-survivors with Ang-2 as marker found an AUROC in a range of 0.71-0.83, which performed as well or better than lactate. Prophylactic administration of FTY720, rosiglitazone or inhalation of nitric oxide (NO) during malaria disease in mice resulted in an increase in Ang-1, a decrease in Ang-2 and an increased survival. For rosiglitazone, a decrease in Ang-2/Ang-1 ratio was observed after post-infection treatment in mice and humans with malaria, but for inhalation of NO, an effect on Ang-1 and survival was only observed in mice. CONCLUSION Both Ang-1 and Ang-2 levels correlate with and can distinguish between malaria disease severity states within the group of malaria-infected patients. However, distinct comparisons of disease severity states were made in distinct studies and not all distinctions made had clinical relevance. Changes in levels of Ang-1 and Ang-2 might also reflect treatment effectiveness and are promising therapeutic targets as part of multi-targeted therapy.
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Affiliation(s)
- Gerdie M. de Jong
- Institute for Tropical Diseases, Harbour Hospital, Haringvliet 2, Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Jasper J. Slager
- Institute for Tropical Diseases, Harbour Hospital, Haringvliet 2, Rotterdam, The Netherlands
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Annelies Verbon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Jaap J. van Hellemond
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
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27
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Golovliov I, Lindgren H, Eneslätt K, Conlan W, Mosnier A, Henry T, Sjöstedt A. An In Vitro Co-culture Mouse Model Demonstrates Efficient Vaccine-Mediated Control of Francisella tularensis SCHU S4 and Identifies Nitric Oxide as a Predictor of Efficacy. Front Cell Infect Microbiol 2016; 6:152. [PMID: 27933275 PMCID: PMC5122580 DOI: 10.3389/fcimb.2016.00152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/01/2016] [Indexed: 11/13/2022] Open
Abstract
Francisella tularensis is a highly virulent intracellular bacterium and cell-mediated immunity is critical for protection, but mechanisms of protection against highly virulent variants, such as the prototypic strain F. tularensis strain SCHU S4, are poorly understood. To this end, we established a co-culture system, based on splenocytes from naïve, or immunized mice and in vitro infected bone marrow-derived macrophages that allowed assessment of mechanisms controlling infection with F. tularensis. We utilized the system to understand why the clpB gene deletion mutant, ΔclpB, of SCHU S4 shows superior efficacy as a vaccine in the mouse model as compared to the existing human vaccine, the live vaccine strain (LVS). Compared to naïve splenocytes, ΔclpB-, or LVS-immune splenocytes conferred very significant control of a SCHU S4 infection and the ΔclpB-immune splenocytes were superior to the LVS-immune splenocytes. Cultures with the ΔclpB-immune splenocytes also contained higher levels of IFN-γ, IL-17, and GM-CSF and nitric oxide, and T cells expressing combinations of IFN-γ, TNF-α, and IL-17, than did cultures with LVS-immune splenocytes. There was strong inverse correlation between bacterial replication and levels of nitrite, an end product of nitric oxide, and essentially no control was observed when BMDM from iNOS-/- mice were infected. Collectively, the co-culture model identified a critical role of nitric oxide for protection against a highly virulent strain of F. tularensis.
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Affiliation(s)
- Igor Golovliov
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Clinical Bacteriology, and Umeå University Umeå, Sweden
| | - Helena Lindgren
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Clinical Bacteriology, and Umeå University Umeå, Sweden
| | - Kjell Eneslätt
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Clinical Bacteriology, and Umeå University Umeå, Sweden
| | - Wayne Conlan
- National Research Council Canada, Institute for Biological Sciences Ottawa, ON, Canada
| | - Amandine Mosnier
- Centre International de Recherche en Infectiologie, Institut national de la santé et de la recherche médicale, U1111 Lyon, France
| | - Thomas Henry
- Centre International de Recherche en Infectiologie, Institut national de la santé et de la recherche médicale, U1111 Lyon, France
| | - Anders Sjöstedt
- Laboratory for Molecular Infection Medicine Sweden, Department of Clinical Microbiology, Clinical Bacteriology, and Umeå University Umeå, Sweden
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28
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Asymmetric and Symmetric Dimethylarginine as Risk Markers for Total Mortality and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Prospective Studies. PLoS One 2016; 11:e0165811. [PMID: 27812151 PMCID: PMC5094762 DOI: 10.1371/journal.pone.0165811] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 10/18/2016] [Indexed: 02/05/2023] Open
Abstract
Background A growing number of studies linked elevated concentrations of circulating asymmetric (ADMA) and symmetric (SDMA) dimethylarginine to mortality and cardiovascular disease (CVD) events. To summarize the evidence, we conducted a systematic review and quantified associations of ADMA and SDMA with the risks of all-cause mortality and incident CVD in meta-analyses accounting for different populations and methodological approaches of the studies. Methods Relevant studies were identified in PubMed until February 2015. We used random effect models to obtain summary relative risks (RR) and 95% confidence intervals (95%CIs), comparing top versus bottom tertiles. Dose-response relations were assessed by restricted cubic spline regression models and potential non-linearity was evaluated using a likelihood ratio test. Heterogeneity between subgroups was assessed by meta-regression analysis. Results For ADMA, 34 studies (total n = 32,428) investigating associations with all-cause mortality (events = 5,035) and 30 studies (total n = 30,624) investigating the association with incident CVD (events = 3,396) were included. The summary RRs (95%CI) for all-cause mortality were 1.52 (1.37–1.68) and for CVD 1.33 (1.22–1.45), comparing high versus low ADMA concentrations. Slight differences were observed across study populations and methodological approaches, with the strongest association of ADMA being reported with all-cause mortality in critically ill patients. For SDMA, 17 studies (total n = 18,163) were included for all-cause mortality (events = 2,903), and 13 studies (total n = 16,807) for CVD (events = 1,534). High vs. low levels of SDMA, were associated with increased risk of all-cause mortality [summary RR (95%CI): 1.31 (1.18–1.46)] and CVD [summary RR (95%CI): 1.36 (1.10–1.68) Strongest associations were observed in general population samples. Conclusions The dimethylarginines ADMA and SDMA are independent risk markers for all-cause mortality and CVD across different populations and methodological approaches.
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29
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Barber BE, William T, Grigg MJ, Piera KA, Chen Y, Wang H, Weinberg JB, Yeo TW, Anstey NM. Nitric Oxide-Dependent Endothelial Dysfunction and Reduced Arginine Bioavailability in Plasmodium vivax Malaria but No Greater Increase in Intravascular Hemolysis in Severe Disease. J Infect Dis 2016; 214:1557-1564. [PMID: 27630198 DOI: 10.1093/infdis/jiw427] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/06/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pathogenesis of severe Plasmodium vivax malaria is poorly understood. Endothelial dysfunction and reduced nitric oxide (NO) bioavailability characterize severe falciparum malaria, but have not been assessed in severe vivax malaria. METHODS In patients with severe vivax malaria (n = 9), patients with nonsevere vivax malaria (n = 58), and healthy controls (n = 79), we measured NO-dependent endothelial function by using reactive hyperemia-peripheral arterial tonometry (RH-PAT) and assessed associations with arginine, asymmetric dimethylarginine (ADMA), and hemolysis. RESULTS The L-arginine level and the L-arginine to ADMA ratio (a measure of L-arginine bioavailability) were reduced in patients with severe vivax malaria and those with nonsevere vivax malaria, compared with healthy controls (median L-arginine level, 65, 66, and 98 µmol/mL, respectively [P = .0001]; median L-arginine to ADMA ratio, 115, 125, and 187, respectively [P = .0001]). Endothelial function was impaired in proportion to disease severity (median RH-PAT index, 1.49, 1.73, and 1.97 in patients with severe vivax malaria, those with nonsevere vivax malaria, and healthy controls, respectively; P = .018) and was associated with the L-arginine to ADMA ratio. While the posttreatment fall in hemoglobin level was greater in severe vivax malaria as compared to nonsevere vivax malaria (2.5 vs 1 g/dL; P = .0001), markers of intravascular hemolysis were not higher in severe disease. CONCLUSIONS Endothelial function is impaired in nonsevere and severe vivax malaria, is associated with reduced L-arginine bioavailability, and may contribute to microvascular pathogenesis. Severe disease appears to be more associated with extravascular hemolysis than with intravascular hemolysis.
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Affiliation(s)
- Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit.,Jesselton Medical Center, Kota Kinabalu, Malaysia
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit
| | - Kim A Piera
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University
| | - Youwei Chen
- Duke University Medical Center.,VA Medical Center, Durham, North Carolina
| | - Hao Wang
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University
| | - J Brice Weinberg
- Duke University Medical Center.,VA Medical Center, Durham, North Carolina
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit.,Lee Kong Chian School of Medicine, Nanyang Technological University.,Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University.,Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit
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30
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Weinberg JB, Volkheimer AD, Rubach MP, Florence SM, Mukemba JP, Kalingonji AR, Langelier C, Chen Y, Bush M, Yeo TW, Granger DL, Anstey NM, Mwaikambo ED. Monocyte polarization in children with falciparum malaria: relationship to nitric oxide insufficiency and disease severity. Sci Rep 2016; 6:29151. [PMID: 27385484 PMCID: PMC4935839 DOI: 10.1038/srep29151] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/15/2016] [Indexed: 12/23/2022] Open
Abstract
We earlier established that nitric oxide (NO) is protective against severe malaria and that arginine and NO levels are reduced in malaria patients. We now show that an M2-like blood monocyte phenotype is significantly associated with hypoargininemia, NO insufficiency, and disease severity in Tanzanian children with falciparum malaria. Compared to control children (n = 106), children with moderately severe (n = 77) and severe falciparum malaria (n = 129) had significantly higher mononuclear cell arginase 1 mRNA, protein, and enzyme activity; lower NOS2 mRNA; lower plasma arginine; and higher plasma IL-10, IL-13, and IL-4. In addition, monocyte CD206 and CD163 and plasma soluble CD163 were elevated. Multivariate logistic regression analysis revealed a significant correlation of risk of severe malaria with both plasma IL-10 and soluble CD163 levels. Monocyte M2 skewing likely contributes to NO bioinsufficiency in falciparum malaria in children. Treatments that reverse the M2 polarization may have potential as adjunctive treatment for malaria.
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Affiliation(s)
- J Brice Weinberg
- Duke University and V.A. Medical Centers, Durham, North Carolina, USA
| | | | - Matthew P Rubach
- Duke University and V.A. Medical Centers, Durham, North Carolina, USA
| | | | | | | | | | - Youwei Chen
- Duke University and V.A. Medical Centers, Durham, North Carolina, USA
| | - Margaret Bush
- Duke University and V.A. Medical Centers, Durham, North Carolina, USA
| | - Tsin W Yeo
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Donald L Granger
- University of Utah and V.A. Medical Centers, Salt Lake City, Utah, USA
| | - Nicholas M Anstey
- Menzies School of Health Research and Charles Darwin University, Darwin, Australia
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31
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Kayano ACAV, Dos-Santos JCK, Bastos MF, Carvalho LJ, Aliberti J, Costa FTM. Pathophysiological Mechanisms in Gaseous Therapies for Severe Malaria. Infect Immun 2016; 84:874-882. [PMID: 26831465 PMCID: PMC4807480 DOI: 10.1128/iai.01404-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Over 200 million people worldwide suffer from malaria every year, a disease that causes 584,000 deaths annually. In recent years, significant improvements have been achieved on the treatment of severe malaria, with intravenous artesunate proving superior to quinine. However, mortality remains high, at 8% in children and 15% in adults in clinical trials, and even worse in the case of cerebral malaria (18% and 30%, respectively). Moreover, some individuals who do not succumb to severe malaria present long-term cognitive deficits. These observations indicate that strategies focused only on parasite killing fail to prevent neurological complications and deaths associated with severe malaria, possibly because clinical complications are associated in part with a cerebrovascular dysfunction. Consequently, different adjunctive therapies aimed at modulating malaria pathophysiological processes are currently being tested. However, none of these therapies has shown unequivocal evidence in improving patient clinical status. Recently, key studies have shown that gaseous therapies based mainly on nitric oxide (NO), carbon monoxide (CO), and hyperbaric (pressurized) oxygen (HBO) alter vascular endothelium dysfunction and modulate the host immune response to infection. Considering gaseous administration as a promising adjunctive treatment against severe malaria cases, we review here the pathophysiological mechanisms and the immunological aspects of such therapies.
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Affiliation(s)
- Ana Carolina A V Kayano
- Laboratory of Tropical Diseases-Prof. Dr. Luiz Jacintho da Silva, Department of Genetics, Evolution and Bioagents, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - João Conrado K Dos-Santos
- Laboratory of Tropical Diseases-Prof. Dr. Luiz Jacintho da Silva, Department of Genetics, Evolution and Bioagents, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - Marcele F Bastos
- Laboratory of Tropical Diseases-Prof. Dr. Luiz Jacintho da Silva, Department of Genetics, Evolution and Bioagents, Institute of Biology, University of Campinas, Campinas, SP, Brazil
| | - Leonardo J Carvalho
- Laboratory of Malaria Research, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, RJ, Brazil
| | - Júlio Aliberti
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Fabio T M Costa
- Laboratory of Tropical Diseases-Prof. Dr. Luiz Jacintho da Silva, Department of Genetics, Evolution and Bioagents, Institute of Biology, University of Campinas, Campinas, SP, Brazil
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32
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Alencar-Filho AC, Ferreira JMBB, Salinas JL, Fabbri C, Monteiro WM, Siqueira AM, Okoshi K, Lacerda MVG, Okoshi MP. Cardiovascular changes in patients with non-severe Plasmodium vivax malaria. IJC HEART & VASCULATURE 2016; 11:12-16. [PMID: 28616519 PMCID: PMC5441355 DOI: 10.1016/j.ijcha.2016.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/04/2016] [Indexed: 11/19/2022]
Abstract
Background Cardiovascular system involvement in patients with Plasmodium vivax malaria has been poorly addressed. The aim of this study was to evaluate cardiac structures and function, and serum markers of cardiovascular injury in patients with the non-severe form of vivax malaria in Manaus, Amazonas State, Brazil. Methods and results We prospectively evaluated 26 patients with vivax malaria in an outpatient referral hospital and compared results with a control group of 25 gender- and age-matched healthy individuals. Patients underwent clinical evaluation, laboratory tests, and transthoracic echocardiography at first evaluation (day zero, D0) and seven days (D7) after malaria diagnosis. At D0 echocardiography showed higher left ventricular (LV) systolic diameter (28.8 ± 2.82 vs 30.9 ± 4.03 mm; p = 0.037) and LV diastolic volume (82.4 ± 12.3 vs 93.8 ± 25.9 ml; p = 0.05), and lower LV ejection fraction (Teicholz method: 73.2 ± 6.59 vs 68.4 ± 4.87%; p = 0.004) in patients compared to controls. Right ventricle (RV) fractional area change (54.7 ± 5.11 vs 50.5 ± 6.71%; p = 0.014) was lower, and RV myocardial performance index (0.21 ± 0.07 vs 0.33 ± 0.19; p = 0.007), and pulmonary vascular resistance (1.13 ± 0.25 vs 1.32 ± 0.26 Woods unit; p = 0.012) were higher in patients than controls. Patients presented higher serum levels of unconjugated bilirubin (0.24 ± 0.15 vs 1.30 ± 0.89 mg/dL; p < 0.001), soluble vascular cell adhesion molecule–1 (sVCAM-1; 453 ± 143 vs 1983 ± 880 ng/mL; p < 0.001), N-terminal prohormone brain natriuretic peptide (0.59 ± 0.86 vs 1.08 ± 0.81 pg/mL; p = 0.045), and troponin T (861 ± 338 vs 1037 ± 264 pg/mL; p = 0.045), and lower levels of plasma nitrite (13.42 ± 8.15 vs 8.98 ± 3.97 μM; p = 0.016) than controls. Most alterations had reversed by D7. Conclusion Patients with non-severe Plasmodium vivax malaria present subclinical reversible cardiovascular changes.
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Affiliation(s)
| | | | | | - Camila Fabbri
- North University Center, Pharmacy School, Manaus, Brazil
| | - Wuelton Marcelo Monteiro
- Amazonas State University (UEA), Manaus, Brazil.,Tropical Disease Center "Dr. Heitor Vieira Dourado", Manaus, Brazil
| | - Andre Machado Siqueira
- National Institute of Infectology Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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33
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Barber BE, William T, Grigg MJ, Parameswaran U, Piera KA, Yeo TW, Anstey NM. Asymmetric Dimethylarginine in Adult Falciparum Malaria: Relationships With Disease Severity, Antimalarial Treatment, Hemolysis, and Inflammation. Open Forum Infect Dis 2016; 3:ofw027. [PMID: 26985445 PMCID: PMC4789539 DOI: 10.1093/ofid/ofw027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 02/05/2016] [Indexed: 12/04/2022] Open
Abstract
Asymmetric Dimethylarginine (ADMA) and arginine bioavailability are reduced acutely in adult falciparum malaria. ADMA increases following commencement of antimalarial therapy, is associated with arginine and haemolysis, and likely contributes to reduced nitric oxide bioavailability in severe falciparum malaria. Background. Endothelial nitric oxide (NO) bioavailability is impaired in severe falciparum malaria (SM). Asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthase (NOS), contributes to endothelial dysfunction and is associated with mortality in adults with falciparum malaria. However, factors associated with ADMA in malaria, including the NOS-substrate l-arginine, hemolysis, and antimalarial treatment, are not well understood. Methods. In a prospective observational study of Malaysian adults with SM (N = 22) and non-SM (NSM; N = 124) and healthy controls (HCs), we investigated factors associated with plasma ADMA including the effects of antimalarial treatment. Results. Compared with HCs, ADMA levels were lower in NSM (0.488 µM vs 0.540 µM, P = .001) and in the subset of SM patients enrolled before commencing treatment (0.453 µM [N = 5], P = .068), but levels were higher in SM patients enrolled after commencing antimalarial treatment (0.610 µM [N = 17], P = .026). In SM and NSM, ADMA levels increased significantly to above-baseline levels by day 3. Baseline ADMA was correlated with arginine and cell-free hemoglobin in SM and NSM and inversely correlated with interleukin-10 in NSM. Arginine and the arginine/ADMA ratio (reflective of arginine bioavailability) were lower in SM and NSM compared with HCs, and the arginine/ADMA ratio was lower in SM compared with NSM. Conclusions. Pretreatment ADMA concentrations and l-arginine bioavailability are reduced in SM and NSM. Asymmetric dimethylarginine increases to above-baseline levels after commencement of antimalarial treatment. Arginine, hemolysis, and posttreatment inflammation all likely contribute to ADMA regulation, with ADMA likely contributing to the reduced NO bioavailability in SM.
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Affiliation(s)
- Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit; Jesselton Medical Centre, Kota Kinabalu, Malaysia
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit
| | - Uma Parameswaran
- Global and Tropical Health Division , Menzies School of Health Research and Charles Darwin University , Darwin , Australia
| | - Kim A Piera
- Global and Tropical Health Division , Menzies School of Health Research and Charles Darwin University , Darwin , Australia
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia; Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit; Department of Infectious Diseases, Royal Darwin Hospital, Australia
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34
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Pharmacokinetic-Pharmacodynamic Model for the Effect of l-Arginine on Endothelial Function in Patients with Moderately Severe Falciparum Malaria. Antimicrob Agents Chemother 2015; 60:198-205. [PMID: 26482311 DOI: 10.1128/aac.01479-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 10/13/2015] [Indexed: 11/20/2022] Open
Abstract
Impaired organ perfusion in severe falciparum malaria arises from microvascular sequestration of parasitized cells and endothelial dysfunction. Endothelial dysfunction in malaria is secondary to impaired nitric oxide (NO) bioavailability, in part due to decreased plasma concentrations of l-arginine, the substrate for endothelial cell NO synthase. We quantified the time course of the effects of adjunctive l-arginine treatment on endothelial function in 73 patients with moderately severe falciparum malaria derived from previous studies. Three groups of 10 different patients received 3 g, 6 g, or 12 g of l-arginine as a half-hour infusion. The remaining 43 received saline placebo. A pharmacokinetic-pharmacodynamic (PKPD) model was developed to describe the time course of changes in exhaled NO concentrations and reactive hyperemia-peripheral arterial tonometry (RH-PAT) index values describing endothelial function and then used to explore optimal dosing regimens for l-arginine. A PK model describing arginine concentrations in patients with moderately severe malaria was extended with two pharmacodynamic biomeasures, the intermediary biochemical step (NO production) and endothelial function (RH-PAT index). A linear model described the relationship between arginine concentrations and exhaled NO. NO concentrations were linearly related to RH-PAT index. Simulations of dosing schedules using this PKPD model predicted that the time within therapeutic range would increase with increasing arginine dose. However, simulations demonstrated that regimens of continuous infusion over longer periods would prolong the time within the therapeutic range even more. The optimal dosing regimen for l-arginine is likely to be administration schedule dependent. Further studies are necessary to characterize the effects of such continuous infusions of l-arginine on NO and microvascular reactivity in severe malaria.
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35
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Chertow JH, Alkaitis MS, Nardone G, Ikeda AK, Cunnington AJ, Okebe J, Ebonyi AO, Njie M, Correa S, Jayasooriya S, Casals-Pascual C, Billker O, Conway DJ, Walther M, Ackerman H. Plasmodium Infection Is Associated with Impaired Hepatic Dimethylarginine Dimethylaminohydrolase Activity and Disruption of Nitric Oxide Synthase Inhibitor/Substrate Homeostasis. PLoS Pathog 2015; 11:e1005119. [PMID: 26407009 PMCID: PMC4583463 DOI: 10.1371/journal.ppat.1005119] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 07/29/2015] [Indexed: 12/04/2022] Open
Abstract
Inhibition of nitric oxide (NO) signaling may contribute to pathological activation of the vascular endothelium during severe malaria infection. Dimethylarginine dimethylaminohydrolase (DDAH) regulates endothelial NO synthesis by maintaining homeostasis between asymmetric dimethylarginine (ADMA), an endogenous NO synthase (NOS) inhibitor, and arginine, the NOS substrate. We carried out a community-based case-control study of Gambian children to determine whether ADMA and arginine homeostasis is disrupted during severe or uncomplicated malaria infections. Circulating plasma levels of ADMA and arginine were determined at initial presentation and 28 days later. Plasma ADMA/arginine ratios were elevated in children with acute severe malaria compared to 28-day follow-up values and compared to children with uncomplicated malaria or healthy children (p<0.0001 for each comparison). To test the hypothesis that DDAH1 is inactivated during Plasmodium infection, we examined DDAH1 in a mouse model of severe malaria. Plasmodium berghei ANKA infection inactivated hepatic DDAH1 via a post-transcriptional mechanism as evidenced by stable mRNA transcript number, decreased DDAH1 protein concentration, decreased enzyme activity, elevated tissue ADMA, elevated ADMA/arginine ratio in plasma, and decreased whole blood nitrite concentration. Loss of hepatic DDAH1 activity and disruption of ADMA/arginine homeostasis may contribute to severe malaria pathogenesis by inhibiting NO synthesis. During a malaria infection, the vascular endothelium becomes more adhesive, permeable, and prone to trigger blood clotting. These changes help the parasite adhere to blood vessels, but endanger the host by obstructing blood flow through small vessels. Endothelial nitric oxide (NO) would normally counteract these pathological changes, but NO signalling is diminished malaria. NO synthesis is inhibited by asymmetric dimethylarginine (ADMA), a methylated derivative of arginine that is released during normal protein turnover. We found the ratio of ADMA to arginine to be elevated in Gambian children with severe malaria, a metabolic disturbance known to inhibit NO synthesis. ADMA was associated with markers of endothelial activation and impaired tissue perfusion. In parallel experiments using mice, the enzyme responsible for metabolizing ADMA, dimethylarginine dimethylaminohydrolase (DDAH), was inactivated after infection with a rodent malaria. Based on these studies, we propose that decreased metabolism of ADMA by DDAH might contribute to the elevated ADMA/arginine ratio observed during an acute episode of malaria. Strategies to preserve or increase DDAH activity might improve NO synthesis and help to prevent the vascular manifestations of severe malaria.
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Affiliation(s)
- Jessica H. Chertow
- Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Matthew S. Alkaitis
- Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
- Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headington Oxford, United Kingdom
| | - Glenn Nardone
- Research Technology Branch, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | - Allison K. Ikeda
- Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
| | | | | | | | | | | | | | | | - Oliver Billker
- Wellcome Trust Sanger Institute, Hinxton Cambridge, United Kingdom
| | - David J. Conway
- MRC Unit, Fajara, The Gambia
- London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Hans Ackerman
- Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, United States of America
- * E-mail:
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36
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Bertinaria M, Orjuela-Sanchez P, Marini E, Guglielmo S, Hofer A, Martins YC, Zanini GM, Frangos JA, Gasco A, Fruttero R, Carvalho LJM. NO-Donor Dihydroartemisinin Derivatives as Multitarget Agents for the Treatment of Cerebral Malaria. J Med Chem 2015; 58:7895-9. [PMID: 26367273 DOI: 10.1021/acs.jmedchem.5b01036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hybrid products in which the dihydroartemisinin scaffold is combined with NO-donor furoxan and NONOate moieties have been synthesized and studied as potential tools for the treatment of cerebral malaria (CM). The designed products were able to dilate rat aorta strips precontracted with phenylephrine with a NO-dependent mechanism. All hybrid compounds showed preserved antiplasmodial activity in vitro and in vivo against Plasmodium berghei ANKA, comparable to artesunate and artemether. Hybrid 10, selected for additional studies, was capable of increasing survival of mice with late-stage CM from 27.5% to 51.6% compared with artemether. Artemisinin-NO-donor hybrid compounds show promise as potential new drugs for treating cerebral malaria.
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Affiliation(s)
- Massimo Bertinaria
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino , Via P. Giuria 9, 10125 Torino, Italy
| | - Pamela Orjuela-Sanchez
- La Jolla Bioengineering Institute , 505 Coast Boulevard South, Suite 411, La Jolla, California 92037, United States
| | - Elisabetta Marini
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino , Via P. Giuria 9, 10125 Torino, Italy
| | - Stefano Guglielmo
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino , Via P. Giuria 9, 10125 Torino, Italy
| | - Anthony Hofer
- La Jolla Bioengineering Institute , 505 Coast Boulevard South, Suite 411, La Jolla, California 92037, United States
| | - Yuri C Martins
- La Jolla Bioengineering Institute , 505 Coast Boulevard South, Suite 411, La Jolla, California 92037, United States
| | - Graziela M Zanini
- Laboratório de Parasitologia, Instituto Nacional de Infectologia, Fiocruz, Rio de Janeiro, 21040-360, Brazil
| | - John A Frangos
- La Jolla Bioengineering Institute , 505 Coast Boulevard South, Suite 411, La Jolla, California 92037, United States
| | - Alberto Gasco
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino , Via P. Giuria 9, 10125 Torino, Italy
| | - Roberta Fruttero
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino , Via P. Giuria 9, 10125 Torino, Italy
| | - Leonardo J M Carvalho
- Laboratório de Pesquisa em Malária, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, 21040-900, Brazil
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37
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Carvalho LJDM, Moreira ADS, Daniel-Ribeiro CT, Martins YC. Vascular dysfunction as a target for adjuvant therapy in cerebral malaria. Mem Inst Oswaldo Cruz 2015; 109:577-88. [PMID: 25185000 PMCID: PMC4156451 DOI: 10.1590/0074-0276140061] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 04/02/2014] [Indexed: 12/27/2022] Open
Abstract
Cerebral malaria (CM) is a life-threatening complication of Plasmodium
falciparum malaria that continues to be a major global health problem.
Brain vascular dysfunction is a main factor underlying the pathogenesis of CM and can
be a target for the development of adjuvant therapies for the disease. Vascular
occlusion by parasitised red blood cells and vasoconstriction/vascular dysfunction
results in impaired cerebral blood flow, ischaemia, hypoxia, acidosis and death. In
this review, we discuss the mechanisms of vascular dysfunction in CM and the roles of
low nitric oxide bioavailability, high levels of endothelin-1 and dysfunction of the
angiopoietin-Tie2 axis. We also discuss the usefulness and relevance of the murine
experimental model of CM by Plasmodium berghei ANKA to identify
mechanisms of disease and to screen potential therapeutic interventions.
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Affiliation(s)
| | - Aline da Silva Moreira
- Laboratório de Pesquisas em Malária, Instituto Oswaldo Cruz-Fiocruz, Rio de Janeiro, RJ, Brasil
| | | | - Yuri Chaves Martins
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
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38
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Hanson J, Lee SJ, Hossain MA, Anstey NM, Charunwatthana P, Maude RJ, Kingston HWF, Mishra SK, Mohanty S, Plewes K, Piera K, Hassan MU, Ghose A, Faiz MA, White NJ, Day NPJ, Dondorp AM. Microvascular obstruction and endothelial activation are independently associated with the clinical manifestations of severe falciparum malaria in adults: an observational study. BMC Med 2015; 13:122. [PMID: 26018532 PMCID: PMC4453275 DOI: 10.1186/s12916-015-0365-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/12/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Microvascular obstruction and endothelial dysfunction have both been linked to tissue hypoperfusion in falciparum malaria, but their relative contributions to the disease's pathogenesis and outcome are unknown. METHODS Microvascular blood flow was quantified in adults with severe falciparum malaria on their admission to hospital; plasma biomarkers of endothelial function were measured simultaneously. The relationship between these indices and the patients' clinical findings and in-hospital course was examined. RESULTS Microvascular obstruction was observed in 119/142 (84 %) patients; a median (interquartile range (IQR)) of 14.9 % (6.6-34.9 %) of capillaries were obstructed in patients that died versus 8.3 % (1.7-26.6 %) in survivors (P = 0.039). The proportion of obstructed capillaries correlated with the estimated parasite biomass (rs = 0.25, P = 0.004) and with plasma lactate (rs = 0.38, P <0.0001), the strongest predictor of death in the series. Plasma angiopoietin-2 (Ang-2) concentrations were markedly elevated suggesting widespread endothelial activation; the median (IQR) Ang-2 concentration was 21.9 ng/mL (13.4-29.4 ng/mL) in patients that died versus 14.9 ng/mL (9.8-29.3 ng/mL) in survivors (P = 0.035). Ang-2 concentrations correlated with estimated parasite biomass (rs = 0.35, P <0.001) and plasma lactate (rs = 0.37, P <0.0001). Microvascular obstruction and Ang-2 concentrations were not significantly correlated with each other (rs = 0.17, P = 0.06), but were independently associated with plasma lactate (P <0.001 and P = 0.002, respectively). CONCLUSIONS Microvascular obstruction and systemic endothelial activation are independently associated with plasma lactate, the strongest predictor of death in adults with falciparum malaria. This supports the hypothesis that the two processes make an independent contribution to the pathogenesis and clinical manifestations of the disease.
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Affiliation(s)
- Josh Hanson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Sue J Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Md Amir Hossain
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Prakaykaew Charunwatthana
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Richard J Maude
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Hugh W F Kingston
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Saroj K Mishra
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
| | - Sanjib Mohanty
- Department of Medicine, Ispat Hospital, Rourkela, Orissa, India.
| | - Katherine Plewes
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Kim Piera
- Global Health Division, Menzies School of Health Research, Darwin, Australia.
| | - Mahtab U Hassan
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh.
| | - M Abul Faiz
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Specialized Care and Research, Chittagong, Bangladesh. .,Dev Care Foundation, Dhaka, Bangladesh.
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
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Yeo TW, Lampah DA, Kenangalem E, Tjitra E, Price RN, Weinberg JB, Hyland K, Granger DL, Anstey NM. Impaired systemic tetrahydrobiopterin bioavailability and increased dihydrobiopterin in adult falciparum malaria: association with disease severity, impaired microvascular function and increased endothelial activation. PLoS Pathog 2015; 11:e1004667. [PMID: 25764397 PMCID: PMC4357386 DOI: 10.1371/journal.ppat.1004667] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/07/2015] [Indexed: 12/22/2022] Open
Abstract
Tetrahydrobiopterin (BH₄) is a co-factor required for catalytic activity of nitric oxide synthase (NOS) and amino acid-monooxygenases, including phenylalanine hydroxylase. BH4 is unstable: during oxidative stress it is non-enzymatically oxidized to dihydrobiopterin (BH₂), which inhibits NOS. Depending on BH₄ availability, NOS oscillates between NO synthase and NADPH oxidase: as the BH₄/BH₂ ratio decreases, NO production falls and is replaced by superoxide. In African children and Asian adults with severe malaria, NO bioavailability decreases and plasma phenylalanine increases, together suggesting possible BH₄ deficiency. The primary three biopterin metabolites (BH₄, BH₂ and B₀ [biopterin]) and their association with disease severity have not been assessed in falciparum malaria. We measured pterin metabolites in urine of adults with severe falciparum malaria (SM; n=12), moderately-severe malaria (MSM, n=17), severe sepsis (SS; n=5) and healthy subjects (HC; n=20) as controls. In SM, urinary BH₄ was decreased (median 0.16 ¼mol/mmol creatinine) compared to MSM (median 0.27), SS (median 0.54), and HC (median 0.34)]; p<0.001. Conversely, BH₂ was increased in SM (median 0.91 ¼mol/mmol creatinine), compared to MSM (median 0.67), SS (median 0.39), and HC (median 0.52); p<0.001, suggesting increased oxidative stress and insufficient recycling of BH2 back to BH4 in severe malaria. Overall, the median BH₄/BH₂ ratio was lowest in SM [0.18 (IQR: 0.04-0.32)] compared to MSM (0.45, IQR 0.27-61), SS (1.03; IQR 0.54-2.38) and controls (0.66; IQR 0.43-1.07); p<0.001. In malaria, a lower BH₄/BH₂ ratio correlated with decreased microvascular reactivity (r=0.41; p=0.03) and increased ICAM-1 (r=-0.52; p=0.005). Decreased BH4 and increased BH₂ in severe malaria (but not in severe sepsis) uncouples NOS, leading to impaired NO bioavailability and potentially increased oxidative stress. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.
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Affiliation(s)
- Tsin W. Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Daniel A. Lampah
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Enny Kenangalem
- Menzies School of Health Research-National Institute of Health Research and Development Research Program, and District Ministry of Health, Timika, Papua, Indonesia
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Jakarta, Indonesia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - J. Brice Weinberg
- Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Keith Hyland
- Medical Neurogenetics LLC, Atlanta, Georgia, United States of America
| | - Donald L. Granger
- Division of Infectious Diseases, University of Utah and Veterans Affairs Medical Center, Salt Lake City, Utah, United States of America
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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Rubach MP, Mukemba J, Florence S, Lopansri BK, Hyland K, Volkheimer AD, Yeo TW, Anstey NM, Weinberg JB, Mwaikambo ED, Granger DL. Impaired systemic tetrahydrobiopterin bioavailability and increased oxidized biopterins in pediatric falciparum malaria: association with disease severity. PLoS Pathog 2015; 11:e1004655. [PMID: 25764173 PMCID: PMC4357384 DOI: 10.1371/journal.ppat.1004655] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 01/05/2015] [Indexed: 12/17/2022] Open
Abstract
Decreased bioavailability of nitric oxide (NO) is a major contributor to the pathophysiology of severe falciparum malaria. Tetrahydrobiopterin (BH4) is an enzyme cofactor required for NO synthesis from L-arginine. We hypothesized that systemic levels of BH₄ would be decreased in children with cerebral malaria, contributing to low NO bioavailability. In an observational study in Tanzania, we measured urine levels of biopterin in its various redox states (fully reduced [BH₄] and the oxidized metabolites, dihydrobiopterin [BH₂] and biopterin [B₀]) in children with uncomplicated malaria (UM, n = 55), cerebral malaria (CM, n = 45), non-malaria central nervous system conditions (NMC, n = 48), and in 111 healthy controls (HC). Median urine BH4 concentration in CM (1.10 [IQR:0.55-2.18] μmol/mmol creatinine) was significantly lower compared to each of the other three groups - UM (2.10 [IQR:1.32-3.14];p<0.001), NMC (1.52 [IQR:1.01-2.71];p = 0.002), and HC (1.60 [IQR:1.15-2.23];p = 0.005). Oxidized biopterins were increased, and the BH4:BH2 ratio markedly decreased in CM. In a multivariate logistic regression model, each Log10-unit decrease in urine BH4 was independently associated with a 3.85-fold (95% CI:1.89-7.61) increase in odds of CM (p<0.001). Low systemic BH4 levels and increased oxidized biopterins contribute to the low NO bioavailability observed in CM. Adjunctive therapy to regenerate BH4 may have a role in improving NO bioavailability and microvascular perfusion in severe falciparum malaria.
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Affiliation(s)
- Matthew P. Rubach
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Jackson Mukemba
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Salvatore Florence
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Bert K. Lopansri
- Department of Medicine, Intermountain Healthcare, Salt Lake City, Utah, United States of America
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, United States of America
| | - Keith Hyland
- Neurochemistry Division, Medical Neurogenetics, Atlanta, Georgia, United States of America
| | - Alicia D. Volkheimer
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Tsin W. Yeo
- Global and Tropical Health Division, Menzies School for Health Research and Charles Darwin University, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School for Health Research and Charles Darwin University, Darwin, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - J. Brice Weinberg
- Department of Medicine, Duke University and VA Medical Centers, Durham, North Carolina, United States of America
| | - Esther D. Mwaikambo
- Department of Pediatrics, Hubert Kairuki Memorial University, Dar es Salaam, United Republic of Tanzania
| | - Donald L. Granger
- Department of Medicine, University of Utah School of Medicine and VA Medical Center, Salt Lake City, Utah, United States of America
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Barber BE, William T, Grigg MJ, Parameswaran U, Piera KA, Price RN, Yeo TW, Anstey NM. Parasite biomass-related inflammation, endothelial activation, microvascular dysfunction and disease severity in vivax malaria. PLoS Pathog 2015; 11:e1004558. [PMID: 25569250 PMCID: PMC4287532 DOI: 10.1371/journal.ppat.1004558] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 11/06/2014] [Indexed: 12/05/2022] Open
Abstract
Plasmodium vivax can cause severe malaria, however its pathogenesis is poorly understood. In contrast to P. falciparum, circulating vivax parasitemia is low, with minimal apparent sequestration in endothelium-lined microvasculature, and pathogenesis thought unrelated to parasite biomass. However, the relationships between vivax disease-severity and total parasite biomass, endothelial autocrine activation and microvascular dysfunction are unknown. We measured circulating parasitemia and markers of total parasite biomass (plasma parasite lactate dehydrogenase [pLDH] and PvLDH) in adults with severe (n = 9) and non-severe (n = 53) vivax malaria, and examined relationships with disease-severity, endothelial activation, and microvascular function. Healthy controls and adults with non-severe and severe falciparum malaria were enrolled for comparison. Median peripheral parasitemia, PvLDH and pLDH were 2.4-fold, 3.7-fold and 6.9-fold higher in severe compared to non-severe vivax malaria (p = 0.02, p = 0.02 and p = 0.015, respectively), suggesting that, as in falciparum malaria, peripheral P. vivax parasitemia underestimates total parasite biomass, particularly in severe disease. P. vivax schizonts were under-represented in peripheral blood. Severe vivax malaria was associated with increased angiopoietin-2 and impaired microvascular reactivity. Peripheral vivax parasitemia correlated with endothelial activation (angiopoietin-2, von-Willebrand-Factor [VWF], E-selectin), whereas markers of total vivax biomass correlated only with systemic inflammation (IL-6, IL-10). Activity of the VWF-cleaving-protease, ADAMTS13, was deficient in proportion to endothelial activation, IL-6, thrombocytopenia and vivax disease-severity, and associated with impaired microvascular reactivity in severe disease. Impaired microvascular reactivity correlated with lactate in severe vivax malaria. Findings suggest that tissue accumulation of P. vivax may occur, with the hidden biomass greatest in severe disease and capable of mediating systemic inflammatory pathology. The lack of association between total parasite biomass and endothelial activation is consistent with accumulation in parts of the circulation devoid of endothelium. Endothelial activation, associated with circulating parasites, and systemic inflammation may contribute to pathology in vivax malaria, with microvascular dysfunction likely contributing to impaired tissue perfusion.
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Affiliation(s)
- Bridget E. Barber
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Queen Elizabeth Hospital, Sabah, Malaysia
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Timothy William
- Department of Infectious Diseases, Queen Elizabeth Hospital, Sabah, Malaysia
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Matthew J. Grigg
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Queen Elizabeth Hospital, Sabah, Malaysia
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Uma Parameswaran
- Department of Infectious Diseases, Queen Elizabeth Hospital, Sabah, Malaysia
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Kim A. Piera
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| | - Ric N. Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Tsin W. Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Insitute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Nicholas M. Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Royal Darwin Hospital, Darwin, Northern Territory, Australia
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43
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Lapp K, Vödisch M, Kroll K, Strassburger M, Kniemeyer O, Heinekamp T, Brakhage AA. Characterization of the Aspergillus fumigatus detoxification systems for reactive nitrogen intermediates and their impact on virulence. Front Microbiol 2014; 5:469. [PMID: 25309516 PMCID: PMC4160965 DOI: 10.3389/fmicb.2014.00469] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/18/2014] [Indexed: 01/20/2023] Open
Abstract
Aspergillus fumigatus is a saprophytic mold that can cause life-threatening infections in immunocompromised patients. In the lung, inhaled conidia are confronted with immune effector cells that attack the fungus by various mechanisms such as phagocytosis, production of antimicrobial proteins or generation of reactive oxygen intermediates. Macrophages and neutrophils can also form nitric oxide (NO) and other reactive nitrogen intermediates (RNI) that potentially also contribute to killing of the fungus. However, fungi can produce several enzymes involved in RNI detoxification. Based on genome analysis of A. fumigatus, we identified two genes encoding flavohemoglobins, FhpA, and FhpB, which have been shown to convert NO to nitrate in other fungi, and a gene encoding S-nitrosoglutathione reductase GnoA reducing S-nitrosoglutathione to ammonium and glutathione disulphide. To elucidate the role of these enzymes in detoxification of RNI, single and double deletion mutants of FhpA, FhpB, and GnoA encoding genes were generated. The analysis of mutant strains using the NO donor DETA-NO indicated that FhpA and GnoA play the major role in defense against RNI. By generating fusions with the green fluorescence protein, we showed that both FhpA-eGFP and GnoA-eGFP were located in the cytoplasm of all A. fumigatus morphotypes, from conidia to hyphae, whereas FhpB-eGFP was localized in mitochondria. Because fhpA and gnoA mRNA was also detected in the lungs of infected mice, we investigated the role of these genes in fungal pathogenicity by using a murine infection model for invasive pulmonary aspergillosis. Remarkably, all mutant strains tested displayed wild-type pathogenicity, indicating that the ability to detoxify host-derived RNI is not essential for virulence of A. fumigatus in the applied mouse infection model. Consistently, no significant differences in killing of ΔfhpA, ΔfhpB, or ΔgnoA conidia by cells of the macrophage cell line MH-S were observed when compared to the wild type.
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Affiliation(s)
- Katrin Lapp
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany
| | - Martin Vödisch
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany
| | - Kristin Kroll
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany
| | - Maria Strassburger
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany
| | - Olaf Kniemeyer
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany ; Department of Microbiology and Molecular Biology, Institute of Microbiology, Friedrich Schiller University Jena, Jena Germany ; Integrated Research Treatment-Center - Center for Sepsis Control and Care, University Hospital Jena, Jena Germany
| | - Thorsten Heinekamp
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany ; Department of Microbiology and Molecular Biology, Institute of Microbiology, Friedrich Schiller University Jena, Jena Germany
| | - Axel A Brakhage
- Department of Molecular and Applied Microbiology, Leibniz Institute for Natural Product Research and Infection Biology - Hans Knöll Institute, Jena Germany ; Department of Microbiology and Molecular Biology, Institute of Microbiology, Friedrich Schiller University Jena, Jena Germany
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Yeo TW, Lampah DA, Kenangalem E, Tjitra E, Weinberg JB, Granger DL, Price RN, Anstey NM. Decreased endothelial nitric oxide bioavailability, impaired microvascular function, and increased tissue oxygen consumption in children with falciparum malaria. J Infect Dis 2014; 210:1627-32. [PMID: 24879801 DOI: 10.1093/infdis/jiu308] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Endothelial nitric oxide (NO) bioavailability, microvascular function, and host oxygen consumption have not been assessed in pediatric malaria. We measured NO-dependent endothelial function by using peripheral artery tonometry to determine the reactive hyperemia index (RHI), and microvascular function and oxygen consumption (VO2) using near infrared resonance spectroscopy in 13 Indonesian children with severe falciparum malaria and 15 with moderately severe falciparum malaria. Compared with 19 controls, children with severe malaria and those with moderately severe malaria had lower RHIs (P = .03); 12% and 8% lower microvascular function, respectively (P = .03); and 29% and 25% higher VO2, respectively. RHIs correlated with microvascular function in all children with malaria (P < .001) and all with severe malaria (P < .001). Children with malaria have decreased endothelial and microvascular function and increased oxygen consumption, likely contributing to the pathogenesis of the disease.
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Affiliation(s)
- Tsin W Yeo
- Global Health Division, Menzies School of Health Research and Charles Darwin University Lee Kong Chian School of Medicine, Nanyang Technological University Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Daniel A Lampah
- District Ministry of Health, Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika
| | - Enny Kenangalem
- District Ministry of Health, Menzies School of Health Research-National Institute of Health Research and Development Research Program, Timika
| | - Emiliana Tjitra
- National Institute of Health Research and Development, Jakarta, Indonesia
| | - J Brice Weinberg
- Division of Hematology, Department of Medicine, School of Medicine, Duke University Division of Hematology-Oncology, Durham VA Medical Center, North Carolina
| | - Donald L Granger
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Division of Infectious Diseases, Department of Internal Medicine, VA Salt Lake Health Care System, Salt Lake City, Utah
| | - Ric N Price
- Global Health Division, Menzies School of Health Research and Charles Darwin University Division of Medicine, Royal Darwin Hospital, Australia Centre for Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas M Anstey
- Global Health Division, Menzies School of Health Research and Charles Darwin University Division of Medicine, Royal Darwin Hospital, Australia
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Weinberg JB, Yeo TW, Mukemba JP, Florence SM, Volkheimer AD, Wang H, Chen Y, Rubach M, Granger DL, Mwaikambo ED, Anstey NM. Dimethylarginines: endogenous inhibitors of nitric oxide synthesis in children with falciparum malaria. J Infect Dis 2014; 210:913-22. [PMID: 24620026 DOI: 10.1093/infdis/jiu156] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Nitric oxide (NO) bioavailability is impaired in children and adults with severe falciparum malaria (SM). Asymmetric-dimethylarginine (ADMA) limits NO production by inhibiting NO synthase and is increased in adult SM. The role of ADMA in the pathogenesis of childhood SM is unknown. METHODS We studied Tanzanian children ages 4-8 years with malaria. Plasma levels of arginine, arginase, cell-free hemoglobin, ADMA, symmetric-dimethylarginine (SDMA), histidine-rich protein-2, and angiopoietin-2 were measured. RESULTS ADMA was low in children with SM relative to controls. Nevertheless, arginine and arginine:ADMA ratios were very low in SM. SDMA was high in children with SM. With treatment, arginine and the arginine:ADMA ratio normalized, but SDMA did not. Arginine:ADMA ratios, but not arginine, were significantly and inde-pendent-ly inversely associated with lactate and angiopoietin-2. Plasma arginase was not elevated in those with malaria, and plasma free hemoglobin was elevated only in patients with cerebral malaria. CONCLUSIONS In contrast to adults, plasma ADMA is reduced in SM in children, but hypoargininemia is more severe. Arginine bioavailability (reflected by low arginine:ADMA ratios) is therefore comparably low in SM in children as in adults. Therapies to increase NO bioavailability in malaria may be useful as adjunctive treatment of severe malaria in children.
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Affiliation(s)
| | - Tsin W Yeo
- Menzies School of Health Research and Charles Darwin University, Australia
| | | | | | | | - Hao Wang
- Menzies School of Health Research and Charles Darwin University, Australia
| | - Youwei Chen
- Duke University and V.A. Medical Centers, Durham, North Carolina
| | - Matthew Rubach
- Duke University and V.A. Medical Centers, Durham, North Carolina
| | | | | | - Nicholas M Anstey
- Menzies School of Health Research and Charles Darwin University, Australia
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Abstract
Although global morbidity and mortality have decreased substantially, malaria, a parasite infection of red blood cells, still kills roughly 2000 people per day, most of whom are children in Africa. Two factors largely account for these decreases; increased deployment of insecticide-treated bednets and increased availability of highly effective artemisinin combination treatments. In large trials, parenteral artesunate (an artemisinin derivative) reduced severe malaria mortality by 22·5% in Africa and 34·7% in Asia compared with quinine, whereas adjunctive interventions have been uniformly unsuccessful. Rapid tests have been an important addition to microscopy for malaria diagnosis. Chemopreventive strategies have been increasingly deployed in Africa, notably intermittent sulfadoxine-pyrimethamine treatment in pregnancy, and monthly amodiaquine-sulfadoxine-pyrimethamine during the rainy season months in children aged between 3 months and 5 years across the sub-Sahel. Enthusiasm for malaria elimination has resurfaced. This ambitious but laudable goal faces many challenges, including the worldwide economic downturn, difficulties in elimination of vivax malaria, development of pyrethroid resistance in some anopheline mosquitoes, and the emergence of artemisinin resistance in Plasmodium falciparum in southeast Asia. We review the epidemiology, clinical features, pathology, prevention, and treatment of malaria.
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Affiliation(s)
- Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK.
| | | | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - M Abul Faiz
- Department of Medicine, Dev Care Foundation, Dhaka, Bangladesh
| | | | - Arjen M Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford, UK
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Rey J, Buffet PA, Ciceron L, Milon G, Mercereau-Puijalon O, Safeukui I. Reduced erythrocyte deformability associated with hypoargininemia during Plasmodium falciparum malaria. Sci Rep 2014; 4:3767. [PMID: 24441939 PMCID: PMC3895919 DOI: 10.1038/srep03767] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 12/20/2013] [Indexed: 11/09/2022] Open
Abstract
The mechanisms underlying reduced red blood cell (RBC) deformability during Plasmodium falciparum (Pf) malaria remain poorly understood. Here, we explore the possible involvement of the L-arginine and nitric oxide (NO) pathway on RBC deformability in Pf-infected patients and parasite cultures. RBC deformability was reduced during the acute attack (day0) and returned to normal values upon convalescence (day28). Day0 values correlated with plasma L-arginine levels (r = 0.69; p = 0.01) and weakly with parasitemia (r = −0.38; p = 0.006). In vitro, day0 patient's plasma incubated with ring-stage cultures at 41°C reduced RBC deformability, and this effect correlated strongly with plasma L-arginine levels (r = 0.89; p < 0.0001). Moreover, addition of exogenous L-arginine to the cultures increased deformability of both Pf-free and trophozoite-harboring RBCs. NO synthase activity, evidenced in Pf-infected RBCs, induced L-arginine-dependent NO production. These data show that hypoargininemia during P.falciparum malaria may altogether impair NO production and reduce RBC deformability, particularly at febrile temperature.
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Affiliation(s)
- Juliana Rey
- 1] Institut Pasteur, Immunologie Moléculaire des Parasites, Département de Parasitologie Mycologie, F- 75015 Paris, France [2] CNRS, URA2581, F- 75015 Paris, France
| | - Pierre A Buffet
- 1] INSERM - UPMC (Paris 6 University) UMRs945, F-75013 Paris, France [2] AP-HP, Department of Parasitology, Pitié Salpétrière Hospital, F-75013 Paris, France
| | - Liliane Ciceron
- 1] INSERM - UPMC (Paris 6 University) UMRs945, F-75013 Paris, France [2] AP-HP, Department of Parasitology, Pitié Salpétrière Hospital, F-75013 Paris, France
| | - Geneviève Milon
- Institut Pasteur, Immunophysiologie et Parasitisme, Département de Parasitologie Mycologie, F-75015 Paris, France
| | - Odile Mercereau-Puijalon
- 1] Institut Pasteur, Immunologie Moléculaire des Parasites, Département de Parasitologie Mycologie, F- 75015 Paris, France [2] CNRS, URA2581, F- 75015 Paris, France
| | - Innocent Safeukui
- 1] Institut Pasteur, Immunologie Moléculaire des Parasites, Département de Parasitologie Mycologie, F- 75015 Paris, France [2] CNRS, URA2581, F- 75015 Paris, France [3] Center for Rare and Neglected Diseases, and Department of Biological Sciences, University of Notre Dame, Notre Dame, Indiana, USA
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Hanson J, Lam SWK, Alam S, Pattnaik R, Mahanta KC, Uddin Hasan M, Mohanty S, Mishra S, Cohen S, Day N, White N, Dondorp A. The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study. Malar J 2013; 12:348. [PMID: 24079262 PMCID: PMC3851438 DOI: 10.1186/1475-2875-12-348] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/20/2013] [Indexed: 12/29/2022] Open
Abstract
Background Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. However, fluid must be delivered judiciously as both under- and over-hydration increase the risk of complications and, potentially, death. As most patients will be cared for in a resource-poor setting, management guidelines necessarily recommend that physical examination should guide fluid resuscitation. However, the reliability of this strategy is uncertain. Methods To determine the ability of physical examination to identify hypovolaemia, volume responsiveness, and pulmonary oedema, clinical signs and invasive measures of volume status were collected independently during an observational study of 28 adults with severe malaria. Results The physical examination defined volume status poorly. Jugular venous pressure (JVP) did not correlate with intravascular volume as determined by global end diastolic volume index (GEDVI; rs = 0.07, p = 0.19), neither did dry mucous membranes (p = 0.85), or dry axillae (p = 0.09). GEDVI was actually higher in patients with decreased tissue turgor (p < 0.001). Poor capillary return correlated with GEDVI, but was present infrequently (7% of observations) and, therefore, insensitive. Mean arterial pressure (MAP) correlated with GEDVI (rs = 0.16, p = 0.002), but even before resuscitation patients with a low GEDVI had a preserved MAP. Anuria on admission was unrelated to GEDVI and although liberal fluid resuscitation led to a median hourly urine output of 100 ml in 19 patients who were not anuric on admission, four (21%) developed clinical pulmonary oedema subsequently. MAP was unrelated to volume responsiveness (p = 0.71), while a low JVP, dry mucous membranes, dry axillae, increased tissue turgor, prolonged capillary refill, and tachycardia all had a positive predictive value for volume responsiveness of ≤50%. Extravascular lung water ≥11 ml/kg indicating pulmonary oedema was present on 99 of the 353 times that it was assessed during the study, but was identified on less than half these occasions by tachypnoea, chest auscultation, or an elevated JVP. A clear chest on auscultation and a respiratory rate <30 breaths/minute could exclude pulmonary oedema on 82% and 72% of occasions respectively. Conclusions Findings on physical examination correlate poorly with true volume status in adults with severe malaria and must be used with caution to guide fluid therapy. Trial registration Clinicaltrials.gov identifier: NCT00692627
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Affiliation(s)
- Josh Hanson
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Transdermal glyceryl trinitrate as an effective adjunctive treatment with artemether for late-stage experimental cerebral malaria. Antimicrob Agents Chemother 2013; 57:5462-71. [PMID: 23979751 DOI: 10.1128/aac.00488-13] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Cerebral malaria (CM) is associated with low nitric oxide (NO) bioavailability, cerebrovascular constriction, occlusion, and hypoperfusion. Administration of exogenous NO partially prevents the neurological syndrome and associated vascular pathology in an experimental CM (ECM) mouse model. In this study, we evaluated the effects of transdermal glyceryl trinitrate in preventing ECM and, in combination with artemether, rescuing late-stage ECM mice from mortality. The glyceryl trinitrate and/or artemether effect on survival and clinical recovery was evaluated in C57BL/6 mice infected with P. berghei ANKA. NO synthase (NOS) expression in mouse brain was determined by Western blots. Mean arterial pressure (MAP) and pial arteriolar diameter were monitored using a tail-cuff blood pressure system and a cranial window preparation, respectively. Preventative administration of glyceryl trinitrate at 0.025 mg/h decreased ECM mortality from 67 to 11% and downregulated inducible NOS expression in the brain. When administered as adjunctive rescue therapy with artemether, glyceryl trinitrate increased survival from 47 to 79%. The adjunctive therapy caused a sustained reversal of pial arteriolar vasoconstriction in ECM mice, an effect not observed with artemether alone. Glyceryl trinitrate induced a 13% decrease in MAP in uninfected mice but did not further affect MAP in hypotensive ECM mice. Glyceryl trinitrate, when combined with artemether, was an effective adjunctive rescue treatment for ECM. This treatment ameliorated pial arteriolar vasospasm and did not significantly affect MAP. These results indicate that transdermal glyceryl trinitrate has potential to be considered as a candidate for adjunctive therapy for CM.
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Yeo TW, Lampah DA, Rooslamiati I, Gitawati R, Tjitra E, Kenangalem E, Price RN, Duffull SB, Anstey NM. A randomized pilot study of L-arginine infusion in severe falciparum malaria: preliminary safety, efficacy and pharmacokinetics. PLoS One 2013; 8:e69587. [PMID: 23922746 PMCID: PMC3726665 DOI: 10.1371/journal.pone.0069587] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 06/10/2013] [Indexed: 12/11/2022] Open
Abstract
Background Decreased nitric oxide (NO) and hypoargininemia are associated with severe falciparum malaria and may contribute to severe disease. Intravenous L-arginine increases endothelial NO in moderately-severe malaria (MSM) without adverse effects. The safety, efficacy and pharmacokinetics of L-arginine or other agents to improve NO bioavailability in severe malaria have not been assessed. Methods In an open-label pilot study of L-arginine in adults with severe malaria (ARGISM-1 Study), patients were randomized to 12 g L-arginine hydrochloride or saline over 8 hours together with intravenous artesunate. Vital signs, selected biochemical measures (including blood lactate and L-arginine) and endothelial NO bioavailability (using reactive hyperemia peripheral arterial tonometry [RH-PAT]) were assessed serially. Pharmacokinetic analyses of L-arginine concentrations were performed using NONMEM. Results Six patients received L-arginine and two saline infusions. There were no deaths in either group. There were no changes in mean systolic (SBP) and diastolic blood pressure (DBP) or other vital signs with L-arginine, although a transient but clinically unimportant mean maximal decrease in SBP of 14 mmHg was noted. No significant changes in mean potassium, glucose, bicarbonate, or pH were seen, with transient mean maximal increases in plasma potassium of 0.3 mmol/L, and mean maximal decreases in blood glucose of 0.8 mmol/L and bicarbonate of 2.3 mEq/L following L-arginine administration. There was no effect on lactate clearance or RH-PAT index. Pharmacokinetic modelling (n = 4) showed L-arginine concentrations 40% lower than predicted from models developed in MSM. Conclusion In the first clinical trial of an adjunctive treatment aimed at increasing NO bioavailability in severe malaria, L-arginine infused at 12 g over 8 hours was safe, but did not improve lactate clearance or endothelial NO bioavailability. Future studies may require increased doses of L-arginine. Trial Registration ClinicalTrials.gov NTC00616304
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Affiliation(s)
- Tsin W Yeo
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.
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