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Palmeirim MS, Hürlimann E, Knopp S, Speich B, Belizario V, Joseph SA, Vaillant M, Olliaro P, Keiser J. Efficacy and safety of co-administered ivermectin plus albendazole for treating soil-transmitted helminths: A systematic review, meta-analysis and individual patient data analysis. PLoS Negl Trop Dis 2018; 12:e0006458. [PMID: 29702653 PMCID: PMC5942849 DOI: 10.1371/journal.pntd.0006458] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 05/09/2018] [Accepted: 04/18/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The soil-transmitted helminths (STH), Ascaris lumbricoides, Trichuris trichiura and hookworms, infect 1.5 billion people worldwide and cause an estimated burden of 3.3 million disability-adjusted life years (DALYs). Current control strategies focus on morbidity reduction through preventive chemotherapy (PC) but the most commonly used recommended drugs (albendazole and mebendazole) are particularly inefficacious against T. trichiura. This, together with the threat of emerging drug resistance, calls for new control strategies, including co-administration with other anthelminthics. Ivermectin plus albendazole is widely used against lymphatic filariasis, but its efficacy and safety against STH infections has not yet been fully understood. METHODS AND FINDINGS We conducted a systematic literature review and meta-analysis on the efficacy and safety of ivermectin-albendazole co-administration in five different databases (i.e. PubMed, ISI Web of Science, ScienceDirect, CENTRAL and clinicaltrials.gov) from 1960 to January 2018. Four studies reporting efficacy of ivermectin-albendazole against STH infections and five studies on its safety met the selection criteria and were included for quantitative analysis. Ivermectin-albendazole was significantly associated with lower risk (risk ratio (RR) = 0.44, 95% confidence interval (CI) = 0.31-0.62) for T. trichiura infection after treatment compared to albendazole alone. The co-administration revealed no or only a marginal benefit on cure and egg reduction rates over albendazole alone for A. lumbricoides and hookworm infections. Adverse events (AEs) occurring after ivermectin-albendazole co-administration were mostly mild and transient. Overall, the number of individuals reporting any AE was not different (RR = 1.09, 95% CI = 0.87-1.36) in co-treated and albendazole-treated patients. However, although not statistically significant, sub-group analysis showed a tendency for slightly more AEs in patients with filariasis treated with ivermectin-albendazole compared to those treated with albendazole alone (RR = 1.29, 95% CI = 0.81-2.05). CONCLUSIONS Our findings suggest a good tolerability and higher efficacy of ivermectin-albendazole against T. trichiura compared to the current standard single-dose albendazole treatment, which supports the use of this co-administration in PC programs. Large-scale definitive randomized controlled trials are required to confirm our results.
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Affiliation(s)
- Marta S. Palmeirim
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Eveline Hürlimann
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Stefanie Knopp
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Vicente Belizario
- Department of Parasitology, College of Public Health, University of the Philippines Manila, Metro Manila, Philippines
| | | | | | - Piero Olliaro
- Special Programme for Research & Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Jennifer Keiser
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Wanji S, Eyong EEJ, Tendongfor N, Ngwa CJ, Esuka EN, Kengne-Ouafo AJ, Datchoua-Poutcheu FR, Enyong P, Agnew D, Eversole RR, Hopkins A, Mackenzie CD. Ivermectin treatment of Loa loa hyper-microfilaraemic baboons (Papio anubis): Assessment of microfilarial load reduction, haematological and biochemical parameters and histopathological changes following treatment. PLoS Negl Trop Dis 2017; 11:e0005576. [PMID: 28686693 PMCID: PMC5533442 DOI: 10.1371/journal.pntd.0005576] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 07/28/2017] [Accepted: 04/17/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Individuals with high intensity of Loa loa are at risk of developing serious adverse events (SAEs) post treatment with ivermectin. These SAEs have remained unclear and a programmatic impediment to the advancement of community directed treatment with ivermectin. The pathogenesis of these SAEs following ivermectin has never been investigated experimentally. The Loa/baboon (Papio anubis) model can be used to investigate the pathogenesis of Loa-associated encephalopathy following ivermectin treatment in humans. METHODS 12 baboons with microfilarial loads > 8,000mf/mL of blood were randomised into four groups: Group 1 (control group receiving no drug), Group 2 receiving ivermectin (IVM) alone, Group 3 receiving ivermectin plus aspirin (IVM + ASA), and Group 4 receiving ivermectin plus prednisone (IVM + PSE). Blood samples collected before treatment and at Day 5, 7 or 10 post treatment, were analysed for parasitological, hematological and biochemical parameters using standard techniques. Clinical monitoring of animals for side effects took place every 6 hours post treatment until autopsy. At autopsy free fluids and a large number of standard organs were collected, examined and tissues fixed in 10% buffered formalin and processed for standard haematoxylin-eosin staining and specific immunocytochemical staining. RESULTS Mf counts dropped significantly (p<0.05) in all animals following ivermectin treatment with reductions as high as (89.9%) recorded; while no significant drop was observed in the control animals. Apart from haemoglobin (Hb) levels which recorded a significant (p = 0.028) drop post treatment, all other haematological and biochemical parameters did not show any significant changes (p>0.05). All animals became withdrawn 48 hours after IVM administration. All treated animals recorded clinical manifestations including rashes, itching, diarrhoea, conjunctival haemorrhages, lymph node enlargement, pinkish ears, swollen face and restlessness; one animal died 5 hours after IVM administration. Macroscopic changes in post-mortem tissues observed comprised haemorrhages in the brain, lungs, heart, which seen in all groups given ivermectin but not in the untreated animals. Microscopically, the major cellular changes seen, which were present in all the ivermectin treated animals included microfilariae in varying degrees of degeneration in small vessels. These were frequently associated with fibrin deposition, endothelial changes including damage to the integrity of the blood vessel and the presence of extravascular erythrocytes (haemorrhages). There was an increased presence of eosinophils and other chronic inflammatory types in certain tissues and organs, often in large numbers and associated with microfilarial destruction. Highly vascularized organs like the brain, heart, lungs and kidneys were observed to have more microfilariae in tissue sections. The number of mf seen in the brain and kidneys of animals administered IVM alone tripled that of control animals. Co-administration of IVM + PSE caused a greater increase in mf in the brain and kidneys while the reverse was noticed with the co-administration of IVM + ASA. CONCLUSIONS The treatment of Loa hyper-microfilaraemic individuals with ivermectin produces a clinical spectrum that parallels that seen in Loa hyper-microfilaraemic humans treated with ivermectin. The utilization of this experimental model can contribute to the improved management of the adverse responses in humans.
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Affiliation(s)
- Samuel Wanji
- Parasites and Vectors Research Unit, Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, South West Region, Cameroon
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Ebanga-Echi J. Eyong
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
- Department of Biological Sciences, Faculty of Science, The University of Bamenda, Bambili, North West Region, Cameroon
- Department of Zoology and Animal Physiology, Faculty of Science, University of Buea, Buea, South West Region, Cameroon
| | - Nicholas Tendongfor
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Che J. Ngwa
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Elive N. Esuka
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Arnaud J. Kengne-Ouafo
- Parasites and Vectors Research Unit, Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, South West Region, Cameroon
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Fabrice R. Datchoua-Poutcheu
- Parasites and Vectors Research Unit, Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, South West Region, Cameroon
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Peter Enyong
- Parasites and Vectors Research Unit, Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, South West Region, Cameroon
- Research Foundation for Tropical Diseases and Environment (REFOTDE), Buea, South West Region, Cameroon
| | - Dalen Agnew
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, MI, United States of America
| | - Rob R. Eversole
- Department of Biological Sciences, Western Michigan University, Kalamazoo, Michigan, United States of America
| | - Adrian Hopkins
- Mectizan Donation Programme, 325 Swanton Way, Decatur, Atlanta, Georgia, United States of America
| | - Charles D. Mackenzie
- Filarial Programmes Support Unit, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Cloning and characterization of high mobility group box protein 1 (HMGB1) of Wuchereria bancrofti and Brugia malayi. Parasitol Res 2012; 111:619-27. [PMID: 22402610 DOI: 10.1007/s00436-012-2878-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 02/22/2012] [Indexed: 10/28/2022]
Abstract
A human homologue of high mobility group box 1 (HMGB1) protein was cloned and characterized from the human filarial parasites Wuchereria bancrofti and Brugia malayi. Sequence analysis showed that W. bancrofti HMGB1 (WbHMGB1) and B. malayi HMGB1 (BmHMGB1) proteins share 99 % sequence identity. Filarial HMGB1 showed typical architectural sequence characteristics of HMGB family of proteins and consisted of only a single HMG box domain that had significant sequence similarity to the pro-inflammatory B box domain of human HMGB1. When incubated with mouse peritoneal macrophages and human promyelocytic leukemia cells, rBmHMGB1 induced secretion of significant levels of pro-inflammatory cytokines such as TNF-α, GM-CSF, and IL-6. Functional analysis also showed that the filarial HMGB1 proteins can bind to supercoiled DNA similar to other HMG family of proteins. BmHMGB1 protein is expressed in the adult and microfilarial stages of the parasite and is found in the excretory secretions of the live parasites. These findings suggest that filarial HMGB1 may have a significant role in lymphatic pathology associated with lymphatic filariasis.
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Porksakorn C, Nuchprayoon S, Park K, Scott AL. Proinflammatory cytokine gene expression by murine macrophages in response to Brugia malayi Wolbachia surface protein. Mediators Inflamm 2008; 2007:84318. [PMID: 17641731 PMCID: PMC1906711 DOI: 10.1155/2007/84318] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 02/26/2007] [Indexed: 11/17/2022] Open
Abstract
Wolbachia, an endosymbiotic bacterium found in most species of filarial parasites, is thought to play a significant role in inducing innate inflammatory responses in lymphatic filariasis patients. However, the Wolbachia-derived molecules that are recognized by the innate immune system have not yet been identified. In this study, we exposed the murine macrophage cell line RAW 264.7 to a recombinant form of the major Wolbachia surface protein (rWSP) to determine if WSP is capable of innately inducing cytokine transcription. Interleukin (IL)-1beta, IL-6, and tumor necrosis factor (TNF) mRNAs were all upregulated by the rWSP stimulation in a dose-dependant manner. TNF transcription peaked at 3 hours, whereas IL-1beta and IL-6 transcription peaked at 6 hours post-rWSP exposure. The levels of innate cytokine expression induced by a high-dose (9.0 microg/mL) rWSP in the RAW 264.7 cells were comparable to the levels induced by 0.1 microg/mL E. coli-derived lipopolysaccharides. Pretreatment of the rWSP with proteinase-K drastically reduced IL-1beta, IL-6, and TNF transcription. However, the proinflammatory response was not inhibited by polymyxin B treatment. These results strongly suggest that the major Wolbachia surface protein molecule WSP is an important inducer of innate immune responses during filarial infections.
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Affiliation(s)
- Chantima Porksakorn
- Lymphatic Filariasis Research Unit, Department of Parasitology, and Chulalongkorn Medical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Boussinesq M, Gardon J, Gardon-Wendel N, Chippaux JP. Clinical picture, epidemiology and outcome of Loa-associated serious adverse events related to mass ivermectin treatment of onchocerciasis in Cameroon. FILARIA JOURNAL 2003; 2 Suppl 1:S4. [PMID: 14975061 PMCID: PMC2147657 DOI: 10.1186/1475-2883-2-s1-s4] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In August 2002, 65 cases of Loa-associated neurological Serious Adverse Events were reported after ivermectin treatment. The first signs, occurring within the 12-24 hours following treatment, included fatigue, generalized arthralgia, and sometimes agitation, mutism, and incontinence. Disorders of consciousness, including coma, generally appeared between 24 and 72 hours, and showed a rapid variation with time. The most frequent objective neurological signs were extrapyramidal. The patients presented with haemorrhages of the conjunctiva and of the retina. Biological examinations showed a massive Loa microfilaruria, the passage of Loa microfilariae into the cerebrospinal fluid, haematuria, and an increase in the C-reactive protein, all of which have been correlated with the high intensity of the initial Loa microfilaraemia. Eosinophil counts decreased dramatically within the first 24 hours, and then rose again rapidly. Electroencephalograms suggested the existence of a diffuse pathological process within the first weeks; the abnormalities disappearing after 3-6 months. Death may occur when patients are not properly managed, i.e. in the absence of good nursing. However, some patients who recovered showed sequelae such as aphasia, episodic amnesia, or extrapyramidal signs. The main risk factor for these encephalopathies is the intensity of the initial Loa microfilaraemia. The disorders of consciousness may occur when there are >50,000 Loa microfilariae per ml. The possible roles of co-factors, such as Loa strains, genetic predisposition of individuals, co-infestations with other parasites, or alcohol consumption, seem to be minor but they should be considered. The mechanisms of the post-ivermectin Loa-related encephalopathies should be investigated to improve the management of patients developing the condition.
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Affiliation(s)
- Michel Boussinesq
- Institut de Recherche pour le Développement (IRD), DSS, 213 rue La Fayette, 75480 Paris Cedex 10, France
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Taylor MJ, Cross HF, Bilo K. Inflammatory responses induced by the filarial nematode Brugia malayi are mediated by lipopolysaccharide-like activity from endosymbiotic Wolbachia bacteria. J Exp Med 2000; 191:1429-36. [PMID: 10770808 PMCID: PMC2193140 DOI: 10.1084/jem.191.8.1429] [Citation(s) in RCA: 175] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/1999] [Accepted: 12/22/1999] [Indexed: 12/01/2022] Open
Abstract
The pathogenesis of filarial disease is characterized by acute and chronic inflammation. Inflammatory responses are thought to be generated by either the parasite, the immune response, or opportunistic infection. We show that soluble extracts of the human filarial parasite Brugia malayi can induce potent inflammatory responses, including tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and nitric oxide (NO) from macrophages. The active component is heat stable, reacts positively in the Limulus amebocyte lysate assay, and can be inhibited by polymyxin B. TNF-alpha, IL-1beta, and NO responses were not induced in macrophages from lipopolysaccharide (LPS)-nonresponsive C3H/HeJ mice. The production of TNF-alpha after chemotherapy of microfilariae was also only detected in LPS-responsive C3H/HeN mice, suggesting that signaling through the Toll-like receptor 4 (TLR4) is necessary for these responses. We also show that CD14 is required for optimal TNF-alpha responses at low concentrations. Together, these results suggest that extracts of B. malayi contain bacterial LPS. Extracts from the rodent filaria, Acanthocheilonema viteae, which is not infected with the endosymbiotic Wolbachia bacteria found in the majority of filarial parasites, failed to induce any inflammatory responses from macrophages, suggesting that the source of bacterial LPS in extracts of B. malayi is the Wolbachia endosymbiont. Wolbachia extracts derived from a mosquito cell line induced similar LPS-dependent TNF-alpha and NO responses from C3H/HeN macrophages, which were eliminated after tetracycline treatment of the bacteria. Thus, Wolbachia LPS may be one of the major mediators of inflammatory pathogenesis in filarial nematode disease.
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Affiliation(s)
- M J Taylor
- Cellular Immunology Laboratory, Division of Molecular Biology and Immunology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, United Kingdom.
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Sartono E, Kruize YC, Partono F, Kurniawan A, Maizels RM, Yazdanbakhsh M. Specific T cell unresponsiveness in human filariasis: diversity in underlying mechanisms. Parasite Immunol 1995; 17:587-94. [PMID: 8817605 DOI: 10.1111/j.1365-3024.1995.tb01002.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In an attempt to overcome T cell unresponsiveness to filarial antigens, 65 individuals belonging to the three clinical groups of elephantiasis patients, microfilaraemics, and asymptomatic amicrofilaraemics who exhibited unresponsiveness to Brugia malayi adult worm antigen (BmA) were studied. Peripheral blood mononuclear cells were cocultured with antigen and one of the following reagents that have been reported to be effective in reconstituting T cell proliferation: interleukin-2 (IL-2), interleukin-7 (IL-7), anti-interleukin-4, anti-interleukin-10, anti-CD2, anti-CD27, anti-CD28, indomethacin, phorbol myristate acetate (PMA), or calcium ionophore (A23187). We were able to overcome antigen-specific unresponsiveness in only a minority of the individuals studied. Co-culture with IL-2, IL-7, indomethacin and PMA were the only conditions which resulted in enhanced proliferation to BmA in these individuals. In general, unresponsiveness in elephantiasis patients was easier to reverse than in other clinical groups: in 50% of elephantiasis patients, in 12.5% of microfilaraemics and in 20% of asymptomatic amicrofilaraemics. The results indicate that more than one distinct immunological mechanism may account for the antigen-specific unresponsiveness in individuals exposed to and infected with brugian filariasis.
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Affiliation(s)
- E Sartono
- Department of Parasitology, Leiden University, The Netherlands
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Bignold LP. The eosinophil leukocyte: controversies of recruitment and function. EXPERIENTIA 1995; 51:317-27. [PMID: 7729496 DOI: 10.1007/bf01928887] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Eosinophil leukocytes have been studied for over 100 years, with various theories being advanced of the mechanism of their recruitment and function, especially in relation to the lesions of allergy, asthma and parasitism. Early notions of recruitment and function depended on observations of the cells in inflammatory lesions, while later theories have used additional information from in vitro studies. Many issues are still unresolved. This review aims to cover the older and more recent literature of the mechanisms of accumulation of eosinophil leukocytes and their functions, with a view to illuminating the controversies and difficulties of research in the area.
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Affiliation(s)
- L P Bignold
- Department of Pathology, University of Adelaide, Australia
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