Congenital transmission of experimental leishmaniasis in a hamster model

Visceral Leishmaniasis in a Twin Pregnancy: A Case Report and Review of the Literature

Visceral leishmaniasis (VL), often referred to as kala-azar, is quite rare in developed countries during pregnancy. Only few studies have evaluated its impact on perinatal outcome. It is caused primarily by Leishmania donovani or Leishmania infantum and presents with a wide spectrum of clinical manifestations from cutaneous ulcers to multisystem disease. Differential diagnosis is challenging as symptoms and signs are insidious, mimicking other diseases. Misdiagnosis can result in severe adverse perinatal outcomes, even maternal/neonatal death. Early treatment with liposomal amphotericin-B (LAmB) is currently the first choice with adequate effectiveness. We report a rare case of VL in a twin pregnancy with onset at the second trimester, presenting with periodic fever with rigors, right flank pain, and gradual dysregulation of all three cell lines. The positive rK39 enzyme-linked immunosorbent assay test confirmed the diagnosis. Treatment with LAmB resulted in clinical improvement within 48 h and in the delivery of two late-preterm healthy neonates with no symptoms or signs of vertical transmission. The one-year follow-up, of the mother and the neonates, was negative for recurrence. To our knowledge, this is the first reported case of VL in a twin pregnancy, and consequently treatment and perinatal outcome are of great importance.

Natural products derived steroids as potential anti-leishmanial agents; disease prevalence, underlying mechanisms and future perspectives

Leishmaniasis is a vector-borne infection caused by protozoan parasites from the genus leishmania and is among the most neglected tropical diseases. It is highly prevalent disease, affecting about 350 million population worldwide. Only limited number of anti-leishmanial agents are approved for clinical use till now and they are associated with side effects and have limited efficacy. Subsequently, natural products based discovery of more safe and effective drugs against leishmania is under scientific consideration. Various studies reported the efficacy of natural products against intracellular and extracellular forms of leishmania species. This work is aimed to evaluate current literature focused on the anti-leihmanial efficacy of steroidal moieties from natural products and their mechanism of action. Compounds including steroidal saponins, steroidal alkaloids and phytosterols were found to exhibit considerable anti-leishmanial efficacy. For instance, steroidal saponin, (25R)-spirost-5-en-3b-ol,3-O-α-rhamnopyranosyl-(1 → 4)-α-rhamnopyranosyl-(1 → 4)-[a-rhamnopyranosyl-(1 → 2)]-glucopyranoside isolated from A. paradoxum has completely eradicated Leishmania major promastigotes at 50 µg mL-1 dose. Spirostanic saponins isolated from Solanum paniculatum L. were effective against Leishmania amazonensis promastigotes. Turgidosterones isolated from Panicum turgidum exhibited high leishmanicidal potentials against Leishmania donovani promastigotes with IC50 of 4.95-8.03 µg mL-1 and even better activity against amastigotes exhibiting an IC50 of 4.50-9.29 µg mL-1. Likewise, racemoside-A from Asparagus racemosus was found effective against an antimonial sensitive (AG83) and antimonial resistant (GE1F8R) strains of the L. donovani. Moreover, steroidal alkaloids including hookerianamide-1, hookerianamide-H, hookerianamide-J, hookerianamide-K, dehydrosarsalignone, vagenine-A, sarcovagine-C, holaphylline, saracodine, holamine, 15-α hydroxyholamine, holacurtin, N-desmethyl holacurtine and elasticine has exhibited time and dose-dependent efficacy against various strains of leishmania. β-sitosterol was found active against multiple strains of leishmania. These compounds mainly exhibit their therapeutic efficacy via liberation of ROS, mitochondrial depolarization, morphological and ultra-structural changes, accumulation of lipid droplets, depletion of non-protein thiols and triggering apoptotic pathways. In conclusion, leishmaniasis is a major health problem in many countries. Plants-derived steroids moieties have reveled efficacy against leishmaniasis and is a source of lead compounds. Further detailed molecular studies are warranted for the discovery of more effective and safe anti-leishmanial drugs.

Visceral Leishmaniasis and the Skin: Dermal Parasite Transmission to Sand Flies

Visceral leishmaniasis is a parasitic disease with significant dermal tropism. The skin is an important site of infection contributing to parasite transmission to naïve sand flies, but understanding how parasitism of host skin and the related immune microenvironment supports or prevents skin parasite replication is now the focus of major investigation in the field of leishmaniasis research. Here, we review dermatoimmunology during visceral leishmaniasis (VL), dermal Leishmania parasite burden, and the role of skin parasitism in transmissibility to sand fly vectors. First, we discuss the epidemiology of VL amongst dogs, the primary zoonotic reservoir for human infection. We explore the association between spatial distribution and the burden of parasites in the skin in driving outward transmission. Factors associated with parasite persistence in the skin are examined. We discuss systemic immunity during VL and what is known about immunological correlates in the skin microenvironment. Finally, we touch on factors egested into the skin during Leishmania inoculation by sand flies. Throughout, we discuss factors associated with the early and chronic establishment of Leishmania parasites in the skin and the role of the dermal immune response.

Leishmania (L.) amazonensis infection impairs reproductive and fetal parameters in female mice

Leishmaniasis is a group of parasitic zoonotic diseases caused by intracellular protozoans belonging to the genus Leishmania. Little is known about the effects that this parasitosis may have on the reproductive parameters and pregnancy of infected humans and pets. This study aimed to evaluate the influence of chronic cutaneous leishmaniasis caused by Leishmania (Leishmania) amazonensis on reproductive and fetal parameters using a female murine model. A control group of female BALB/c mice and a group infected with L. (L.) amazonensis were mated with healthy males. Clinical parameters were monitored during the pre-mating and gestational periods. Female mice were euthanized on day 19 of gestation, when the fetuses were weighed and their length measured and embryonic resorptions and fetal death were recorded. We observed five fetal deaths and three embryonic resorptions in the infected group. Furthermore, there was a decrease in fertility in the infected group (26.32%). The weight of the offspring from infected mothers was lower than that in the control group (1.019±0.035g and 1.163±0.032g, p<0.01). Fetal length was reduced in the infected group (3.71±0.05cm in the control group and 3.40±0.06cm in the infected group p<0.001). This study shows that cutaneous leishmaniasis caused by L. (L.) amazonensis impairs reproductive and fetal parameters in mice.

Cutaneous Leishmaniasis during Pregnancy, Preterm Birth, and Neonatal Death: A Case Report

Cutaneous leishmaniasis (CL) is an emergent public health concern, particularly in tropical and subtropical regions. Reports of pregnancy complications are scarce; however, as the endemic range of CL expands in Iran, there is concern of possible detrimental effects on fetal development amongst infected mothers through placental transmission of the parasite or enhanced maternal immune responses. We herein describe the first known case of persistent anthroponotic CL, plausibly responsible for pregnancy complications, preterm birth, and neonatal death in a healthy Iranian primigravida woman. Diagnosis was based on physical examinations of the lesions on the back of both calves of the patient and laboratory analyses including direct smear, culture, and PCR. During active CL infection, the patient gave birth to a premature female neonate who passed three days post-delivery due to immature lung development and subsequent respiratory distress syndrome. This report highlights the challenges associated with CL infection during pregnancy, exacerbation of lesions, and subsequent complications.

Cutaneous Leishmaniasis: Case Series on Pregnancy Outcome

We report the pregnancy outcomes of 6 women with cutaneous leishmaniasis; 5 of these women received topical antileishmenial therapy during gestation with paromomycin plus methylbenzethonium chloride combination ointment and/or sodium stibogluconate intralesional injections. No teratogenic effects were reported. Furthermore, no vertical transmission was observed.

Status of IL-4 and IL-10 driven markers in experimental models of Visceral Leishmaniasis

AIM

Leishmania donovani, the causative agent for visceral leishmaniasis (VL), modulates host monocytes/macrophages to ensure its survival. However, knowledge regarding the host-parasite interactions underpinning the disease remains limited. As disease progression is associated with polarization of monocytes/macrophages towards M2, which is regulated by cytokines IL-4/IL-13 and IL-10, this study evaluated the status of key IL-4- and IL-10 driven markers in experimental models of VL, as also evaluated their correlation, if any, with parasite load.

METHODS

In liver and splenic tissues from L donovani-infected hamsters and BALB/c mice, the parasite burden was determined along with mRNA expression of IL-4-driven markers, that is CD206, Arginase-I, CCL17, CCL22, PPAR-γ, STAT6, KLF4, FIZZ1 and YM1 along with IL-10-driven markers, CXCL13, IL-10, TGF-β, VDR, CCR2 and CYP27A1.

RESULTS

The mRNA expression of IL-4- and IL-10-driven markers was enhanced in both models, but only in the hamster model, the splenic tissues demonstrated a positive correlation between all the IL-10-driven markers and parasite load.

CONCLUSIONS

Contrary to human VL, both models demonstrated an increased expression of IL-4- and IL-10-driven markers.

Vertical transmission may play a greater role in the spread of Leishmania infantum in synanthropic Mus musculus rodents than previously believed

Vertical transmission of Leishmania infantum was demonstrated in domestic mice captured close to the home of a patient with leishmaniasis. Leishmania infantum DNA was detected in 88.9% of synanthropic Mus musculus adult rodents and 29.2% of their unborn foetuses. Mother-to-infant transmission was observed in all females whose gestational stage was sufficiently advanced to allow foetal analysis (foetal length 2-2.5 cm). The infection rate in foetal samples ranged from 11.1% to 50.0%, with parasite loads of up to 6,481 parasites/5 mg tissue. A low density of Phlebotomus perniciosus was also found (0.2 specimen/CDC trap). Six infected mice captured in March were only 1.5 months old and could thus not have had contact with the vector. Vertical transmission thus appears to play a greater role in the spread of leishmaniasis than previously thought, particularly since rodents are natural hosts for the parasite and are prolific in nature.

Cutaneous leishmaniasis and pregnancy

We studied a 19-year-old woman, with a 4-month pregnancy who presented with four cutaneous leg ulcers of three months of evolution diagnosed by biopsy as cutaneous leishmaniasis. Direct smear and the leishmanin skin test were negative. Since all the usual medications for cutaneous leishmaniasis are contraindicated in pregnancy, she did not receive any treatment but cured spontaneously of her lesions during pregnancy. It is believed that cutaneous leishmaniasis does not carry danger for pregnant women and that there is no maternal-fetal transmission in humans, though it occurs in experimental animals. The patient gave birth without complications and both she and her son remained normal after two years of follow-up.

T-cell tolerance as a potential effect of congenital leishmaniasis on offspring immunity

Congenital transmission of leishmaniasis is recognized in cases detected by passive surveillance. Most cases are from low-resource countries, limiting the study of several important aspects of this route of infection, including the offspring's immune response. Studies on natural and experimentally infected animals suggest that parasites might be transmitted to the embryo or foetus at any time during pregnancy. As immune system undergoes sequential stages of development, an infection before the time of self-recognition could lead to central tolerance, making an individual specifically tolerant and susceptible to infection. In the alternative scenario, infection after self-recognition would allow the proper development of T-lymphocyte clones in response to Leishmania antigens, providing resistance to the disease. Newborns undergo a transient period of low expression of several immune surface molecules and a naïve adaptive immune response with no memory, which together might contribute to slow elimination of the parasite over several months. This insight is a proposed independent mechanism of the previously proven T-cell exhaustion and must be investigated. Analyses of infected placenta, cord blood and infant immunity are required for a better understanding of immunity in congenital leishmaniasis infection.

Pathophysiology of Leishmania Infection during Pregnancy

The pathological processes resulting from parasitic infection are known to have important impacts on the mother child dyad during pregnancy. The roles of parasite transmission and the maternal immune response have been described in diseases such as malaria, toxoplasmosis, and trypanosomiasis. However, the impact of parasites of the genus Leishmania, etiological agents of the neglected tropical diseases tegumentary leishmaniasis (TL) and visceral leishmaniasis (VL), is comparatively less well known, though it is an increasingly recognized concern for infected mothers and their fetuses. In this review, we first consider the pathophysiology of placental infection and transplacental transmission of this parasite, and then discuss the role and mechanisms of the maternal immune system in simultaneously mediating maternal-fetal infection and adverse pregnancy outcomes.

Epidemiological aspects of visceral leishmaniasis (kala-azar) in Ceará in the period 2007 to 2011

INTRODUCTION

Visceral leishmaniasis (VL; kala-azar) is a serious zoonosis that can be lethal, especially in untreated patients. Due to the fact that the State of Ceará is still an important area of transmission of VL, and based on the constant reports of the urbanization process of the disease in the country, it was necessary to monitor the occurrence of cases of leishmaniasis through epidemiological surveillance.

OBJECTIVES

To describe the epidemiology of leishmaniasis cases in Ceará, Brazil.

METHODS

We conducted an epidemiological survey of secondary data provided by SINAN/MS from January 2007 to December 2011.

RESULTS

VL is an endemic disease in the State of Ceará, with cases notified in approximately 88% of the municipalities, with an average of 596.8 ± 29.6 cases, an incidence of 6.1 cases/100,000 inhabitants and prevalence of 7.1 cases/100,000 inhabitants. The Metropolitan Region of Fortaleza is the microregion with the largest number of cases reported in state (51.9% of cases), with the capital, Fortaleza, being the municipality with the highest number of cases in the country. Traditionally, the main age group affected by the disease are children; however, a reversal has been observed in the profile from 2008, when the population of adult patients exceeded the pediatric population.

CONCLUSION

Ceará is still an endemic area for VL, and the city of Fortaleza reported the highest number of cases in the country. In the State, a change in the profile of patients with the disease has been observed, now affecting primarily adults.

Semi-quantitative measurement of asymptomatic L. infantum infection and symptomatic visceral leishmaniasis in dogs using Dual-Path Platform® CVL

Infection with Leishmania causes diseases with variable presentation. The most severe form is visceral leishmaniasis (VL), caused by either L. donovani or L. infantum. Despite efforts to eliminate VL, to date, molecular detection in resource-poor settings have lacked the accuracy and rapidity that would enable widespread field use and the need for accurate, sensitive assays to detect asymptomatic Leishmania infection has become apparent. The domestic dog serves as the primary reservoir host of L. infantum. Study of this reservoir population provides an opportunity to evaluate the sensitivity and specificity of diagnostics for well-defined, symptomatic, canine visceral leishmaniasis (CVL) and asymptomatic L. infantum infection. Blood samples from an L. infantum-endemic population of US hunting dogs were evaluated with Dual-Path Platform (DPP®) CVL compared to those obtained via direct detection methods (culture- and Leishmania-specific quantitative polymerase chain reaction, qPCR) and immunofluorescence anti-Leishmania antibody test (IFAT). Statistically significant correlations were found between DPP® CVL development time and clinical status, culture status, circulating DNA levels, and IFAT titer. DPP® CVL results correlated with both clinical severity of disease and serological evidence of asymptomatic L. infantum infection. By precisely documenting the minimum time required for the development of a clear positive result in DPP® CVL, this test could be used in a rapid, semi-quantitative manner for the evaluation of asymptomatic and symptomatic CVL. Our results also indicate that a similar test could be used to improve our understanding of human VL.

Immunologic progression of canine leishmaniosis following vertical transmission in United States dogs

Canine leishmaniosis (CanL) is caused by Leishmania infantum, an obligate intracellular protozoan parasite, endemic in U.S. hunting dog populations. CanL has been found in dogs in 28 states and two Canadian provinces. Previous studies by our group, (Boggiatto et al., 2011), demonstrated that vertical transmission of Leishmania was the predominant means of transmission within U.S. dogs. Very little is known regarding how this alternative means of transmission, alters the long-term immunity and clinical presentation of leishmaniosis in dogs born to a positive bitch. This study follows the immunological progression of CanL in three pups after birth to an infected bitch. During the course of the study, these dogs were tested every six months over the course of six years. Both immunologic (IFN-γ, T cell proliferation, antibody production) and parasitological parameters (qPCR) of vertically-infected dogs were measured. Within the six years after birth to an L. infantum-infected, oligosymptomatic bitch, all dogs had at least one L. infantum PCR-positive test. Interestingly, despite living in the same location for their entire lives and being full siblings, these pups demonstrate three different disease progression patterns of L. infantum infection. One dog progressed to oligosymptomatic disease, maintaining a positive titer and had intermittent positive PCR results. One asymptomatic dog had positive serological titers and demonstrated a robust CD4(+) immune response to infection. The third dog had a negligible response to L. infantum antigen and was healthy. This work demonstrates the biologic variability associated with vertically-transmitted infection similar to the variety of presentations observed during vector-borne leishmaniosis.

Vertical Transmission of Babesia microti in BALB/c Mice: Preliminary Report

Babesia spp. (Apicomplexa, Piroplasmida) are obligate parasites of many species of mammals, causing a malaria-like infection- babesiosis. Three routes of Babesia infection have been recognized to date. The main route is by a tick bite, the second is via blood transfusion. The third, vertical route of infection is poorly recognized and understood. Our study focused on vertical transmission of B. microti in a well-established mouse model. We assessed the success of this route of infection in BALB/c mice with acute and chronic infections of B. microti. In experimental groups, females were mated on the 1st day of Babesia infection (Group G0); on the 28th day post infection (dpi) in the post- acute phase of the parasite infection (G28); and on the 90th and 150th dpi (G90 and G150 group, respectively), in the chronic phase of the parasite infection. Pups were obtained from 58% of females mated in the post-acute phase (G28) and from 33% of females in groups G90 and G150. Mice mated in the pre-acute phase of infection (G0) did not deliver pups. Congenital B. microti infections were detected by PCR amplification of Babesia 18S rDNA in almost all pups (96%) from the experimental groups G28, G90 and G150. Parasitaemia in the F1 generation was low and varied between 0.01-0.001%. Vertical transmission of B. microti was demonstrated for the first time in BALB/c mice.

CXCR3 blockade protects against Listeria monocytogenes infection-induced fetal wastage

Mammalian pregnancy requires protection against immunological rejection of the developing fetus bearing discordant paternal antigens. Immune evasion in this developmental context entails silenced expression of chemoattractant proteins (chemokines), thereby preventing harmful immune cells from penetrating the maternal-fetal interface. Here, we demonstrate that fetal wastage triggered by prenatal Listeria monocytogenes infection is driven by placental recruitment of CXCL9-producing inflammatory neutrophils and macrophages that promote infiltration of fetal-specific T cells into the decidua. Maternal CD8+ T cells with fetal specificity upregulated expression of the chemokine receptor CXCR3 and, together with neutrophils and macrophages, were essential for L. monocytogenes-induced fetal resorption. Conversely, decidual accumulation of maternal T cells with fetal specificity and fetal wastage were extinguished by CXCR3 blockade or in CXCR3-deficient mice. Remarkably, protection against fetal wastage and in utero L. monocytogenes invasion was maintained even when CXCR3 neutralization was initiated after infection, and this protective effect extended to fetal resorption triggered by partial ablation of immune-suppressive maternal Tregs, which expand during pregnancy to sustain fetal tolerance. Together, our results indicate that functionally overriding chemokine silencing at the maternal-fetal interface promotes the pathogenesis of prenatal infection and suggest that therapeutically reinforcing this pathway represents a universal approach for mitigating immune-mediated pregnancy complications.

Long-term spatiotemporal stability and dynamic changes in the haemoparasite community of bank voles (Myodes glareolus) in NE Poland

Long-term field studies on parasite communities are rare but provide a powerful insight into the ecological and evolutionary processes shaping host-parasite interactions. The aim of our study was to identify the principal factors regulating long-term trends in the haemoparasite communities of bank voles, and to this end, we sampled three semi-isolated populations of bank voles (n = 880) in 1999, 2002, 2006 and 2010 in the Mazury lake district region of NE Poland. Overall, 90.8 % of the bank voles harboured at least one of the species of haemoparasites studied. Whilst overall prevalence (all species combined) did not vary significantly between the surveys, different temporal changes were detected among voles in each of the three sites. In voles from Urwitałt, prevalence increased consistently with successive surveys, whereas in Tałty, the peak years were 2002 and 2006, and in Pilchy, prevalence oscillated without a clear pattern. Across the study, bank voles harboured a mean of 1.75 ± 0.034 haemoparasite species, and species richness remained stable with no significant between-year fluctuations or trends. However, each of the five constituent species/genera showed a different pattern of spatio-temporal changes. The overall prevalence of Babesia microti was 4.9 %, but this varied significantly between years peaking in 2006 and declining again by 2010. For Bartonella spp., overall prevalence was 38.7 %, and this varied with year of study, but the temporal pattern of changes differed among the three sites. The overall prevalence of Haemobartonella (Mycoplasma) was 68.3 % with an increase in prevalence with year of study in all three sites. Hepatozoon erhardovae had an overall prevalence of 46.8 % but showed a marked reduction with each successive year of the study, and this was consistent in all three sites. The overall prevalence of Trypanosoma evotomys was 15.4 % varying significantly between sites, but showing temporal stability. While overall prevalence of all haemoparasites combined and species richness remained stable over the period of study, among the five haemoparasites, the pattern of spatiotemporal changes in prevalence and abundance of infections differed depending on parasite species. For some genera, host age was shown to play an important role, but a significant effect of host sex was found only for Haemobartonella spp.

Transplacental transmission of cutaneous Leishmania mexicana strain in BALB/c mice

The vertical transmission of leishmaniasis has been reported in species that cause visceral leishmaniasis. However, this condition has scarcely been documented in species that cause cutaneous leishmaniasis. The aim of this study was to determine experimentally whether L. mexicana is transmitted vertically. A control group of BALB/c mice and a group infected with L. mexicana were mated, the gestation was monitored, and females were killed before delivery. Four resorptions (P = 0.023) and eight fetal deaths (P = 0.010) were observed in the infected female group; furthermore, the offspring body weight of the infected group was lower than the body weight of the healthy group (P = 0.009). DNA amplification by polymerase chain reaction (PCR) revealed that all placentas and maternal spleens as well as 39 of 110 fetal spleens obtained from the offspring of infected mothers tested positive for Leishmania. In conclusion, L. mexicana is transmitted transplacentally and causes fetal death, resorption, and reduction in offspring body weight.

Determinants for the development of visceral leishmaniasis disease

Leishmaniasis is a vector-borne neglected tropical disease associated with a spectrum of clinical manifestations, ranging from self-healing cutaneous lesions to fatal visceral infections. Among the most important questions in Leishmania research is why some species like L. donovani infect visceral organs, whereas other species like L. major remain in the skin. The determinants of visceral leishmaniasis are still poorly understood, although genomic, immunologic, and animal models are beginning to provide important insight into this disease. In this review, we discuss the vector, host, and pathogen factors that mediate the development of visceral leishmaniasis. We examine the progression of the parasite from the initial site of sand fly bite to the visceral organs and its ability to survive there. The identification of visceral disease determinants is required to understand disease evolution, to understand visceral organ survival mechanisms, and potentially to develop better interventions for this largely neglected disease.