Diffuse cutaneous leishmaniasis in Ethiopia. 3. Immunological studies. IV. Pathogenesis of diffuse cutaneous leishmaniasis

Case Report: Coinfection by Leishmania amazonensis and HIV in a Brazilian Diffuse Cutaneous Leishmaniasis Patient

Diffuse cutaneous leishmaniasis (DCL) is a rare type of leishmaniasis characterized by diffuse skin lesions. In Brazil, Leishmania (L.) amazonensis is the main etiological agent of this clinical form. The state of Maranhão has the highest prevalence of this disease in the country, as well as a high rate of HIV infection. Here, we report the first case of DCL/HIV of Brazil. A 46-year-old man from the Amazonian area of Maranhão state presented atypical lesion in the left upper limb and dissemination of diffuse erythematous nodules over his entire body. Histopathological examination confirmed the presence of intracellular amastigotes of Leishmania, and a polymerase chain reaction and molecular identification by restriction fragment profile identified L. (L.) amazonensis as the causative agent of the disease. The patient was also diagnosed with HIV virus after the leishmaniasis diagnosis. The initial treatments for leishmaniasis were liposomal amphotericin B (AmB-L) (4 mg/kg) for 10 days and prophylactic use of Glucantime^® (10 mg/Sb⁺⁵/kg) for 2 months. After unsuccessful initial treatments, he was treated with a combination of AmB-L (4 mg/kg) alternated with pentamidine (4 mg/kg) for 10 days but failed in the first therapeutic cycle. Subsequently, he had a good response to treatment with pentamidine (4 mg/kg).

What makes mucosal and anergic diffuse cutaneous leishmaniases so clinically and immunopathogically different? A review in Brazil

American cutaneous leishmaniasis (ACL) is a parasitic protozoan disease caused by different Leishmania species widely distributed throughout Latin America. Fifteen Leishmania species belonging to the subgenera Viannia, Leishmania and Mundinia are known to cause ACL. Seven of these species are found in Brazil, of which Leishmania (Viannia) braziliensis and Leishmania (Leishmania) amazonensis have the highest potential to cause mucosal (ML) and anergic diffuse cutaneous leishmaniasis (DCL), respectively, the most severe forms of ACL. The clinical and immunopathological differences between these two clinical forms are reviewed here, taking into account their different physiopathogenic mechanisms of dissemination from cutaneous lesions to mucosal tissues in the case of ML and to almost all body surfaces in the case of anergic DCL. We also discuss some immunopathogenic mechanisms of species-specific Leishmania antigens (from the subgenera Viannia and Leishmania) that are most likely associated with the clinical and immunopathological differences between ML and anergic DCL. Those discussions emphasize the pivotal importance of some surface antigens of L. (V.) braziliensis and L. (L.) amazonensis, such as lipophosphoglycan, phosphatidylserine and CD200 (an immunoregulatory molecule that inhibits macrophage activation), that have been shown to exert strong influences on the clinical and immunopathological differences between ML and anergic DCL.

Prevalence of Cutaneous Leishmaniasis in Western Highlands in Yemen

Leishmaniasis in Yemen is still not fully investigated nor well studied. Recently, outbreaks of cutaneous leishmaniasis (CL) in western highland were declared. However, there are no reports concerning the disease and the circulating species in the region. The aim of this study was to determine the prevalence of cutaneous leishmaniasis in Utmah district located in Western Highlands in Yemen. A cross-sectional survey was carried out at those highlands. For the survey, 1165 participants were subjected to Leishmanin Skin Test (LST) accompanied with direct interviews and physical examination. The overall prevalence of cutaneous leishmaniasis in the district was 18.5% and the cutaneous leishmaniasis (CL) was more frequent in the escarpments with a prevalence of 37%, including 5.5% for active lesion and 31.5% for scar of healed lesions. Children under the age of 16 years old comprised most of the CL cases (76.3%). The escarpments of western highlands in Yemen were hyperendemic areas for CL and the infection was more prevalent in children.

Depression of lymphocyte activity during cutaneous leishmaniasis: a case report

Skin leishmaniasis includes lesions of different appearance, shape, and severity, spanning from alarming diffuse lesions to an asymptomatic course. Moreover, aspecific presentation, as well as challenging differential diagnosis of cutaneous leishmaniasis, may request more in-depth investigations on the intriguing and complex pathogenesis of such infection. A 7-year case of worsening cutaneous leishmaniasis in the left frontoparietal region of the scalp, achieving omolateral eyebrow, in a 68-year-old male patient prompted us to address the immunity profile of peripheral blood lymphocytes. An increase of regulatory CD19⁺/CD38^bright/CD24^bright B cell lymphocytes was observed at the front of normal levels of other lymphocytes subpopulations, including CD4⁺/CD25^bright T cells. The total IgG and IgM, as well as proinflammatory subclasses of IgG, were below the normal range. However, IgG4 subclass was found normal. In conclusion, our data may indicate inhibition of humoral immunity associated with an increase of lymphocyte B-regulatory subpopulation.

Local increase of arginase activity in lesions of patients with cutaneous leishmaniasis in Ethiopia

Background

Cutaneous leishmaniasis is a vector-borne disease that is in Ethiopia mainly caused by the parasite Leishmania aethiopica. This neglected tropical disease is common in rural areas and causes serious morbidity. Persistent nonhealing cutaneous leishmaniasis has been associated with poor T cell mediated responses; however, the underlying mechanisms are not well understood.

Methodology/Principal Findings

We have recently shown in an experimental model of cutaneous leishmaniasis that arginase-induced L-arginine metabolism suppresses antigen-specific T cell responses at the site of pathology, but not in the periphery. To test whether these results translate to human disease, we recruited patients presenting with localized lesions of cutaneous leishmaniasis and assessed the levels of arginase activity in cells isolated from peripheral blood and from skin biopsies. Arginase activity was similar in peripheral blood mononuclear cells (PBMCs) from patients and healthy controls. In sharp contrast, arginase activity was significantly increased in lesion biopsies of patients with localized cutaneous leishmaniasis as compared with controls. Furthermore, we found that the expression levels of CD3ζ, CD4 and CD8 molecules were considerably lower at the site of pathology as compared to those observed in paired PBMCs.

Conclusion

Our results suggest that increased arginase in lesions of patients with cutaneous leishmaniasis might play a role in the pathogenesis of the disease by impairing T cell effector functions.

The leishmaniases are a complex of diseases caused by Leishmania parasites. Currently, the diseases affect an estimated 12 million people in 88 countries, and approximately 350 million more people are at risk. The leishmaniases belong to the most neglected tropical diseases, affecting the poorest populations, for whom access to diagnosis and effective treatment are often not available. Leishmania parasites infect cells of the immune system called macrophages, which have the capacity to eliminate the intracellular parasites when they receive the appropriate signals from other cells of the immune system. In nonhealing persistent leishmaniasis, lymphocytes are unable to transmit the signals to macrophages required to kill the intracellular parasites. The local upregulation of the enzyme arginase has been shown to impair lymphocyte effector functions at the site of pathology. In this study, we tested the activity of this enzyme in skin lesions of patients presenting with localized cutaneous leishmaniasis. Our results show that arginase is highly upregulated in these lesions. This increase in arginase activity coincides with lower expression of a signalling molecule in lymphocytes, which is essential for efficient activation of these cells. These results suggest that increased arginase expression in the localized cutaneous lesions might contribute to persistent disease in patients presenting with cutaneous leishmaniasis.

Systemic FasL and TRAIL neutralisation reduce leishmaniasis induced skin ulceration

Cutaneous leishmaniasis (CL) is caused by Leishmania infection of dermal macrophages and is associated with chronic inflammation of the skin. L. aethiopica infection displays two clinical manifestations, firstly ulcerative disease, correlated to a relatively low parasite load in the skin, and secondly non-ulcerative disease in which massive parasite infiltration of the dermis occurs in the absence of ulceration of epidermis. Skin ulceration is linked to a vigorous local inflammatory response within the skin towards infected macrophages. Fas ligand (FasL) and Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) expressing cells are present in dermis in ulcerative CL and both death ligands cause apoptosis of keratinocytes in the context of Leishmania infection. In the present report we show a differential expression of FasL and TRAIL in ulcerative and non-ulcerative disease caused by L. aethiopica. In vitro experiments confirmed direct FasL- and TRAIL-induced killing of human keratinocytes in the context of Leishmania-induced inflammatory microenvironment. Systemic neutralisation of FasL and TRAIL reduced ulceration in a model of murine Leishmania infection with no effect on parasitic loads or dissemination. Interestingly, FasL neutralisation reduced neutrophil infiltration into the skin during established infection, suggesting an additional proinflammatory role of FasL in addition to direct keratinocyte killing in the context of parasite-induced skin inflammation. FasL signalling resulting in recruitment of activated neutrophils into dermis may lead to destruction of the basal membrane and thus allow direct FasL mediated killing of exposed keratinocytes in vivo. Based on our results we suggest that therapeutic inhibition of FasL and TRAIL could limit skin pathology during CL.

Cutaneous leishmaniases are associated with parasite-induced inflammatory lesions of the skin. The degree of clinical pathology is not associated with parasitic burden; on the contrary, ulcerative lesions are associated with low infectious load, and non-ulcerative lesions are associated with an abundant parasite infiltration. Leishmania are intracellular parasites in mammalian hosts and reside in macrophages in the deep layers of the skin, the dermis. The exact mechanism of ulceration in CL is not known and Leishmania parasites do not directly induce destruction of keratinocytes in the most superficial layer of the skin, the epidermis. In this study we investigated if ulcerated lesions were associated with higher expression of FasL- and TRAIL-induced cell-death of keratinocytes. We found a higher expression of FasL and TRAIL in human skin samples from ulcerative as compared to non-ulcerative leishmaniasis. In a mouse model of ulcerative leishmaniasis neutralisation of FasL and TRAIL reduced ulceration. We suggest that FasL and TRAIL participate in the ulcer formation during leishmaniasis both as a chemoattractant of activated neutrophils leading to tissue destruction and through direct killing of keratinocytes. Possible approaches to use this concept in therapeutical interventions with the aim to reduce immunopathology associated with leishmaniasis are discussed.

The immune dependence of chemotherapy

In this review, Mike Doenhoff and colleagues discuss the immune dependency of chemotherapy and the consequences for drug resistance. They also consider the implications for the control of infections that are relatively unresponsive to drugs, such as opportunistic infections in immunosuppressed patients.

Tumor necrosis factor-alpha in human american tegumentary leishmaniasis

Tumor necrosis factor-alpha (TNF-alpha) is a cytokine produced by activated macrophages and other cells. In order to verify whether the serum levels of TNF-alpha in American tegumentary leishmaniasis patients are associated with the process of cure or aggravation of the disease, 41 patients were studied: 26 cases of cutaneous leishmaniasis (CL) and 15 of mucocutaneous leishmaniasis (MCL). During active disease the serum levels of TNF-alpha of MCL patients were significantly higher than those of CL patients and control subjects (healthy individuals and cutaneous lesions from other etiologies). The MCL patients had serum titers of TNF-alpha significantly lower at the end of antimonial therapy than before therapy. After a six-month follow-up, the MCL patients had serum levels of TNF-alpha similar to those observed at the end of the therapy as well as to those of CL patients and control subjects. No significant variation in the serum levels of TNF-alpha was observed in CL patients throughout the study period (before, at the end of therapy and after a six-month follow-up). The possible relationship between the high TNF-alpha serum levels and severity of the disease is discussed.

Polar and subpolar diffuse cutaneous leishmaniasis in Brazil: clinical and immunopathologic aspects

BACKGROUND

Diffuse cutaneous leishmaniasis (DCL) is a rare manifestation of human leishmaniasis, characterized by multiple, slowly progressive nodules or plaques without ulceration, involving almost the entire body. It has been suggested, that DCL results from a lack of cell-mediated immunity to leishmanial antigen, leading to uncontrolled parasite growth.

METHODS

We have performed detailed clinical, histopathologic, and immunologic investigations in six patients with DCL. Biopsies were taken from the nodules, processed, and examined for determination of the macrophagic pattern present, based on the intensity of vacuolation and the frequency of vacuolated cells, the parasite index, and the presence of eosinophils. Immunologically, patients were evaluated by their response to intradermal skin test to PPD or leishmania antigen, determination of antileishmania antibodies by immunofluorescent assay, and lymphocyte proliferation assay.

RESULTS

There seemed to be a negative relation between nodules and skin ulcerations, whereas the highest number of parasites were observed in patients with the greatest number of vacuolated macrophages. The delayed hypersensitivity skin test to leishmanial antigen was negative, and antileishmania IgG antibodies were positive in all patients.

CONCLUSIONS

Although all cases fulfill the criteria for being classified as DCL, they present a wide spectrum. Three cases were clearly at the unresponsive pole, and three other cases belonged to the subpolar form of DCL, exhibiting varying weak signs of antiparasite responsiveness.

Clinical and immunopathological aspects of disseminated cutaneous leishmaniasis

The clinico-pathological and immunological findings in eight patients from Bahia, Brazil with disseminated cutaneous leishmaniasis are described. This condition differs from anergic diffuse cutaneous leishmaniasis (DCL) and from classical American cutaneous leishmaniasis (ACL). The number of lesions in these patients ranged from 75 to 800 and were characterized by papules and an acneiform type of lesion with a few ulcers rather than nodules that are the main characteristic of DCL. On the other hand the high incidence of mucosal disease (38%) in patients with disseminated cutaneous leishmaniasis make the prevalence of mucosal involvement in this condition higher than that observed in ACL. L. amazonensis (five cases) and L. braziliensis (two cases) were the causal agents in the patients where the infecting agent was characterized. Antibody titers in disseminated cutaneous leishmaniasis were higher than those observed in ACL and patients with the highest antibody titers had mucosal involvement. Abnormalities in cellular immunity that are not observed in ACL such as decrease in CD4+ cells and absence of T cell response to leishmania antigen were observed in several patients with disseminated cutaneous leishmaniasis but restoration of these abnormalities occurred after treatment. In spite of the great number of lesions, the therapeutic response was good in six patients with disappearance of the lesions in a period shorter than that observed in ACL. In the two patients that presented therapeutic failure the causal agent was L. amazonensis. In such patients there was a predominance of ulcerated lesions, and a high titer of antibody was detected.

Endemic Kaposi's sarcoma in Africa and local volcanic soils

Endemic Kaposi's sarcoma (KS) in Africa has been attributed to a geographically-determined environmental factor. Endemic KS, a chronic nodular condition predominantly affecting the feet and legs, is believed to arise in the lymphatic endothelium and is associated with chronic lymphoedema. As such, KS bears a resemblance to podoconiosis (non-filarial elephantiasis). The prevalence of both conditions in highland areas close to volcanoes suggests a shared pathogenetic relationship to exposure to volcanic soils. The lymphatics and lymph nodes of patients with podoconiosis contain particulate alumino-silicates in macrophages consistent with the theory that ultrafine clay minerals are absorbed through the feet. The resulting chronic lymphatic irritation, inflammation, and collagenosis causes obstruction and lymphoedema. The geographical proximity of endemic KS to areas containing volcanic clay minerals, its lympho-endothelial origin, predilection for the feet and legs, and its prevalence among rural peasants and cultivators, suggest a common aetiology. Other features point to the participation of a low-grade, possibly sexually-transmitted, infective agent that becomes more pathogenic in the presence of immunosuppression. Damage to the dermal lymphatics of the feet and legs by absorbed clays could impair local immunity to such an agent. Endemic KS would then occur in exposed individuals who harbour the KS infective agent and are susceptible to the KS phenotype (males).

Inhibition of mouse lymphocyte proliferative response by glycosphingolipids from Leishmania (L.) amazonensis

The effect of a purified preparation of glycosphingolipids (GSLs) extracted from Leishmania (L.) amazonensis amastigotes on murine lymphocytes was investigated. GSLs inhibited both concanavalin A (Con A)- or lipopolysaccharide-induced [3H]thymidine uptake by normal and immunized BALB/c mouse lymph node cells. The effect of total GSLs was dose dependent. Total GSLs also suppressed the two-way mixed lymphocyte reaction of BALB/c x C57BL/6 cells and the antigen-specific response of immunized mouse cells. Six pure bands as well as a pool containing a mixture of GSLs with five to seven sugar residues separated by a combination of HPLC and preparative HPTLC were tested and shown to be inhibitors of Con A stimulation. These results suggest that parasite glycosphingolipids may play an immunologically relevant role in leishmaniasis.

Isolation and characterization of recombinant antigens from Leishmania aethiopica that react with human antibodies

A genomic expression library of Leishmania aethiopica was constructed in lambda gt11 and screened with patient sera and sera from healthy people living in an area of endemicity. Forty-five recombinant clones were isolated and partly characterized. Clone-specific antibodies were prepared and used with sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western immunoblot analysis to estimate the molecular masses of the parasite-derived antigens containing the reactive epitope(s). Antigens with apparent molecular masses of 90, 85, 63, 50, 41, 25 and 24 kDa as well as several antigens with lower molecular masses were detected. The clone-specific antibodies from patients with diffuse cutaneous leishmaniasis reacted with high-molecular-weight antigens (30,000 less than Mr less than 90,000), whereas antibodies from patients with localized cutaneous leishmaniasis recognized low-molecular-weight antigens (Mr less than 25,000). Nine different purified recombinant antigens were obtained from lysogens in Escherichia coli Y1089 by immunoaffinity chromatography on anti-beta-galactosidase columns and were subsequently tested with patient sera. It is suggested that some of these recombinant antigens might be used for immunodiagnostic purposes.

[The current status of diffuse cutaneous leishmaniasis (DCL) in the state of Maranhão. II. The epidemiological and clinico-evolutionary aspects]

The authors describe a retrospective and prospective study of 6 patients with diffuse cutaneous leishmaniasis observed in the state of Maranhão, since 1974. The patients come from different rural regions of the state and in all of them Leishmania (Leishmania) amazonensis was the cause five of the patients initiated their disease in the first decade of life. All the patients first had a solitary, nodular lesion, that after a variable period of time, disseminated and acquired other aspects. Sequentially the patients presented multiple nodular and ulcerative lesions, negative Leishmania skin tests and a refractory response to the therapeutic schedules used up to the present.

Cutaneous leishmaniasis in south-western Ethiopia: Ocholo revisited

The borough of Ocholo, on the western side of the Ethiopian Rift Valley, is an endemic focus for Leishmania aethiopica infection and has been surveyed thrice between 1987 and 1990. In 1989, 3022 inhabitants (> 95% of the population) were interviewed and examined. The overall prevalence of localized cutaneous leishmaniasis (LCL) was 3.6-4.0%, with a peak value of 8.5% in the 0-10 years old age group. In half of the patients the active disease was estimated to last for 9.6 +/- 6 months; in 10%, it exceeded 3 years. Scars of LCL were present in 34.3% of the residents. Leishmanin skin tests were positive in 54% of 120 school-children without signs of the disease. Therefore, in Ocholo a minimum of 71.6% of the population has been exposed to L. aethiopica infection. Two cases of the diffuse form of cutaneous leishmaniasis were observed. In this highland biotope, Phlebotomus pedifer was found to be the major, and possibly the only, vector for L. aethiopica.

Comparison of parasitological and immunological methods in the diagnosis of leishmaniasis in Ethiopia

The sensitivity and specificity of parasite demonstration methods (smear, culture and histology) and serological assays (enzyme-linked immunosorbent assay [ELISA], direct agglutination test and immunoblot) were compared in the diagnosis of leishmaniasis in Ethiopia. Culture was found to be the most sensitive diagnostic method, followed by ELISA, for the diagnosis of cutaneous leishmaniasis (CL). When the clinical type of CL was taken into consideration, serological and parasitological methods were equally good for the diagnosis of diffuse cutaneous leishmaniasis. Overall, the serological assays were not sensitive enough to diagnose all the parasitologically confirmed cases of localized cutaneous leishmaniasis. Both groups of diagnostic methods performed equally well in the diagnosis of visceral leishmaniasis patients. In cases of CL where clinical diagnosis was a problem and histology could not give a definitive diagnosis due to the absence of demonstrable parasites, one of the serological assays, preferably ELISA, was very useful in establishing the final diagnosis.

Serum antibody specificities to Leishmania aethiopica antigens in patients with localized and diffuse cutaneous leishmaniasis

In order to characterize the antigenic determinants of Leishmania aethiopica, we have analysed by immunoblotting the antibody reactivity of leishmaniasis patients with either the localized (LCL) or diffuse (DCL) clinical forms of disease. In this study we have compared the reactivity of antibodies from eight LCL and DCL patients to parasites isolated from each individual, or the parasite isolates of the other LCL and DCL patients studied. The immunoblot profiles of antibodies from LCL patients differed from the antibody profiles of DCL patients. Serum antibodies from LCL patients showed limited recognition of somatic antigens of less than Mr 50,000 which were recognized by antibodies present in DCL patients. A direct comparison of individual LCL and DCL patient derived promastigotes determined that the lack of antibody to these antigens in LCL patients was not due to the differential expression of these determinants by the LCL and DCL derived promastigotes. The results of this study suggest that although either LCL or DCL derived promastigotes express a wide variety of antigenic moieties which are potentially reactive with antibodies, only a subset of antibodies against these specificities develop in any individual patient, during active infection.

Profile of human T cell response to leishmanial antigens. Analysis by immunoblotting

Control and resolution of leishmanial infection depends primarily on T cell-mediated immune mechanisms. The nature of the leishmanial antigens involved in eliciting T cell immunity is unknown. We have examined the pattern of peripheral blood lymphocyte responses in patients with active, healed, or subclinical leishmanial infection to fractionated leishmanial antigens using a T cell immunoblotting method in which nitrocellulose-bound leishmanial antigen, resolved by one or two dimensional electrophoresis, are incorporated into lymphocyte cultures. The proliferative and IFN-gamma responses of cells from patients with healed mucosal or cutaneous leishmaniasis were remarkably heterogeneous and occurred to as many as 50-70 distinct antigens. In contrast, responses from subjects with active, nonhealing, diffuse cutaneous leishmaniasis were either absent or present to only a small number of antigens. Control and resolution of leishmaniasis, and resistance to reinfection, is therefore associated with a T cell response to a large and diverse pool of parasite antigens. The method of T cell immunoblotting appears to offer a powerful, rapid, and relatively simple approach to the identification of antigens involved in eliciting a T cell response in human leishmaniasis.

Responsiveness in diffuse versus local cutaneous leishmaniasis is due to parasite differences

Leishmania aethiopica infection results in two main clinical entities, diffuse disease (DCL) and localized ulcers (LCL). The lack of reactivity to leishmanial antigens has been attributed, among other things, to some inherent immunological defect of the host or considered as a consequence of the initial site of infection. Properties unique to the infecting parasite have been said to contribute little if anything to the differences between DCL and LCL found in the same areas of Ethiopia. Data are given to show that infected individuals respond by higher production of IL-2 to antigens from LCL isolates (lcl antigen), than to antigens derived from DCL isolates (dcl antigen). Furthermore, dcl antigen induced less gamma interferon from lymphocytes of all individuals tested than did lcl antigen. Lymphocytic proliferation of cells from control individuals working in the endemic area was higher in response to lcl isolates than to dcl isolates. These findings suggest that some differences in the parasites may contribute to the clinical outcome of infection with L. aethiopica.

Induction of delayed-type hypersensitivity to Leishmania major and the concomitant acceleration of disease development in progressive murine cutaneous leishmaniasis

BALB/c mice injected intradermally with 10(5) or higher doses of formaldehyde-fixed promastigotes (FFP) of Leishmania major developed strong delayed-type hypersensitivity (DTH) to leishmanial antigens injected into the hind footpad 3 to 10 days later. The DTH peaked 15 to 18 h after footpad injection and disappeared by 48 h. This specific DTH correlated with the homing of 51Cr-labeled syngeneic bone marrow cells and the infiltration of proliferating cells to the site of antigen administration. Spleen cells from FFP-sensitized mice also gave significant proliferative response to FFP in vitro. The DTH was adoptively transferable by Lyt-1+2-L3T4+ T cells and was H-2 restricted. DTH could be substantially enhanced by pretreatment with cyclophosphamide or pertussigen. Such DTH enhancement was accompanied by concomitant exacerbation of disease progression after L. major infection. Mice injected intravenously with FFP developed substantial immunity to cutaneous leishmaniasis but specifically suppressed DTH reactivity. Treatment of mice with pertussigen before intravenous immunization, however, abolished the protection and reversed the suppression of DTH. These results therefore demonstrate that the early-appearing type of DTH is not involved in host protection but that it actually facilitates disease progression in cutaneous leishmaniasis. Further evidence, which also shows the nonspecific nature of this disease exacerbation, is provided by local cell transfer experiments. Splenic T cells from mice sensitized to keyhole limpet hemocyanin or FFP induced significantly larger lesions compared with normal T cells when they were transferred into the footpad together with specific antigen and L. major promastigotes.

Specific suppressor T cells for delayed-type hypersensitivity in susceptible mice immunized against cutaneous leishmaniasis

BALB/c mice injected intravenously with 10(6) or higher doses of formaldehyde-fixed promastigotes (ffp) of Leishmania major developed significantly lower levels of delayed-type hypersensitivity (DTH) compared with uninjected control mice when they were subsequently immunized intradermally with ffp. The suppression of DTH was antigen specific and was also inducible with lethally irradiated promastigotes or soluble parasite antigens. The suppressive effect was adoptively transferable with splenic T cells which express the Lyt-1+2+ and L3T4+ phenotypes. These specific suppressor T cells were active against both the inductive and expressive phases of DTH. They were sensitive to 200 rads of gamma-irradiation in vitro and appeared to manifest the suppressive activity via soluble factors. In spite of this profound suppression of DTH, BALB/c mice injected intravenously with 4 X 10(7) ffp were substantially protected against a challenge infection with L. major promastigotes. The possible relationship between the suppressor T cells for DTH and prophylactic immunization against fatal cutaneous leishmanial infection in susceptible BALB/c mice is discussed.

Impaired macrophage leishmanicidal activity at cutaneous temperature

Temperature is one of the primary influences upon the pathogenesis of cutaneous leishmaniasis. In this study, we measured the temperature of murine leishmanial lesions and determined the ability of lymphokine (LK) activated macrophages to kill Leishmania major at these temperatures. The temperature of leishmanial lesions in BALB/c and C3H/HeN mice ranged from 27 degrees C to 32 degrees C. We found that LK activated resident or inflammatory macrophages exhibited significantly less leishmanicidal activity in vitro at temperatures closer to those measured in vivo. The decrease in microbicidal activity was not due to the enhanced growth of the parasites at lower temperatures, since impaired killing was also observed against non-replicating radiation attenuated amastigotes. Finally, the tumoricidal activity of macrophages was found to be significantly depressed at temperatures below 37 degrees C, indicating a generalized impairment of macrophage function at these temperatures. These findings suggest that impaired macrophage microbicidal activity at cutaneous temperatures may contribute to parasite survival, and imply that healing of leishmanial lesions, as well as other cutaneous infections, may require an exceptionally potent local LK response.

Chemotherapy and the immune response in parasitic infections

There are comparatively few studies concerned specifically with chemotherapy of parasitic infections and its relationship with the immune status of the host being treated. In one sense this is hardly surprising. The disciplines of chemotherapy and immunology have developed independently, and the search for effective drugs has for the most part been an empirical process; when a compound showing some activity has emerged the tendency has been to look for analogues with even greater parasiticidal properties rather than to consider whether effectiveness of the parent compound could be improved if the immune status of the host were different. In many cases, test systems for drug development have actually been selected to reduce as far as possible the complications f an immune response. Thus acute, fatal infections are commonly used for the screens, and questions such as the level of specific resistance at the time of treatment, immunodepression by the parasite, and increased resistance to challenge following chemotherapy are generally irrelevant.

Immunoregulation of genetically controlled acquired responses to Leishmania donovani infection in mice: the effects of parasite dose, cyclophosphamide and sublethal irradiation

On a B10 (Lshs) genetic background, the development of acquired T cell mediated immunity to Leishmania donovani infection in mice is under H-2 linked genetic control. Following intravenous inoculation of 10(7) amastigotes three phenotypic patterns of recovery have been described: 'early cure' (H-2r,s), 'cure' (H-2b) and 'non-cure' (H-2d,q,f). In an attempt to determine the immunological basis for this H-2 linked genetic control the effects of varying parasite dose (5 x 10(3) to 5 x 10(7) amastigotes) and of pre-treatments with cyclophosphamide (50 or 200 mg/kg body weight CY) or sublethal irradiation (100 or 550 rad) on the course of infection, and on circulating anti-leishmanial IgG levels, were examined in strains representative of the three phenotypes: B10.D2/n (H-2d), C57BL/10ScSn (H-2b) and B10.RIII (H-2r). It was found that with low parasite doses (5 x 10(3) or 5 x 10(4)) 'non-cure' mice presented a 'cure' profile whilst raising the dose (5 x 10(7)) caused some perturbation of the normal self-curing response in 'cure' (but not 'early cure') mice. The highest dose did not, however, lead to progressive disease in the genetically non-cure strain. For the parasite dose experiments circulating anti-leishmanial IgG levels were higher in the early cure and cure strains than in the H-2d non-cure strain. The higher doses of CY and sublethal irradiation administered prior to infection had a clear prophylactic effect on the non-cure strain with some effect also observed in cure and early cure strains. This was thought to be due to deletion of the precursors of T suppressor (TS) cells suppressing cell-mediated immunity. Resolution of the liver parasite load in pre-treated mice took place despite minimal or undetectable levels of circulating anti-leishmanial IgG. Similarly, the earlier resolution of parasite load in pre-treated cure and early cure mice occurred even though the antibody response was severely reduced. This suggests that the high antibody responses observed in early cure and cure strains do not normally mediate cure and may simply reflect the independent effect of H-2 on T helper function or the humoral response.

Leishmania braziliensis: effects of bacteria (Staphylococcus aureus and Pasteurella multocida) on the developing cutaneous leishmaniasis lesion in the golden hamster

Experimentally induced lesions of cutaneous leishmaniasis and the effect of concurrent bacterial infection on the development of these lesions were studied in the golden hamster. Male outbred golden hamsters received intradermal injections at the base of the tail with approximately 10(7) promastigotes of Leishmania braziliensis panamensis, or promastigotes combined with Staphylococcus aureus or Pasteurella multocida or both, bacteria only, or sterile Eagle's minimal essential medium (MEME). The size of the resulting lesions was measured at least twice each week. Hamsters were killed at postinoculation Days 6, 13, 20, 27, 41, or 48, and each lesion was measured, aseptically excised, and bisected; half was used for bacteriologic culture and the other half was prepared for light microscopic examination. Lesions resulting from L. b. panamensis alone progressed from initial erythema to a granulomatous nodule and finally to a necrotic granuloma, often capped by a crateriform ulcer. Lesions resulting from a suspension of L. b. panamensis with added S. aureus or S. aureus and P. multocida, were initially larger, more erythemic and contained a greater proportion of neutrophils up to postinoculation Days 14-21 than did lesions resulting from L. b. panamensis alone. Concurrent infections with bacteria such as S. aureus and P. multocida had little effect on the development of ulcerating characteristics of lesions, but when S. aureus was present it appeared to enhance the severity of the early lesions. Between postinoculation Days 14-28, lesions produced by L. b. panamensis, with or without added bacteria had similar developmental progression of sufficient size for optimal testing of antileishmanial compounds.

Cell-mediated killing of protozoa

Cell-mediated immunity represents an important host defence mechanism against protozoal infections. The effector cells directly involved are neutrophils, macrophages and, ultimately, activated macrophages. Within this simple scheme there are, however, considerable variations in activity. Effector cells from different animal species, and even from different strains of the same species, may be more or less effective in controlling a certain protozoal infection. Different protozoa differ in their susceptibility to cell-mediated killing according to genus, species, strain and morphological form. The most susceptible morphological form is that which occurs in the insect vector, and which has not yet adapted to protect itself from the vertebrate host. Epimastigotes of Trypanosoma and promastigotes of Leishmania are readily killed by phagocytic cells, while the corresponding trypomastigote and amastigote forms are considerably more resistant. Protozoa which live in macrophages, such as amastigotes of Leishmania, endozoites (tachyzoites) of Toxoplasma and amastigotes of reticulotropic strains of T. cruzi, have developed a remarkable resistance to the microbicidal activity of the host cell. Conversely, amastigotes of myotropic strains of T. cruzi, which live in muscle cells, have not developed this resistance to cell-mediated killing by macrophages. Readily accessible protozoa, such as T. brucei trypomastigotes and Plasmodium merozoites in the bloodstream, while they lack the marked resistance developed by reticulotropic protozoa, have a partial protection since they are attacked by phagocytic cells only when specific antibody is present. Granulocyte-mediated killing can be largely attributed to neutrophils. Eosinophils appear to play only a minor role and compete ineffectually when neutrophils are also present. The only group of protozoal species which may be significantly controlled by eosinophils are the stercorarian species of Trypanosoma. In vitro experiments show that antibody-coated trypomastigotes of T. cruzi can be killed by eosinophils, although there is little evidence that this occurs in vivo. Interestingly, this is the only species that has been reported to be susceptible to the major basic protein of eosinophils, a toxic component of the lysosomal granules which is very active against helminths. Neutrophils are not very active against endozoites of Toxoplasma gondii, Trypanosoma, trypomastigotes of salivarian Trypanosoma, free merozoites of Plasmodium, and promastigotes and amastigotes of Leishmania.(ABSTRACT TRUNCATED AT 400 WORDS)

On the identity of the parasite causing diffuse cutaneous leishmaniasis in the Dominican Republic

Three isolates from disseminated cutaneous leishmaniasis (DCL) patients from an unusual focus in the Dominican Republic were studied and typed according to their behaviour in culture and experimental animals, their malate dehydrogenase (MDH) electrophoretic variant type, and excretory factor (EF) serotype. They were compared with parasites known to cause DCL in other parts of the world. On the basis of these characteristics, this parasite appears to be different from Leishmania aethiopica which causes DCL in the Old World and from both L. mexicana pifanoi and L. m. amazonensis, which are associated with DCL in the New World. However, it appeared to have some relationship to the L. mexicana-complex.

Specific inhibition of lymphocyte-proliferation responses by adherent suppressor cells in diffuse cutaneous leishmaniasis

Diffuse cutaneous leishmaniasis is characterized by multiple nonulcerative skin lesions. Histologically, these lesions are dominated by vacuolated, heavily infected macrophages, with only a few lymphocytes present. A unique focus of diffuse cutaneous leishmaniasis is present in the Dominican Republic. We studied four patients with this disease. None had a delayed reaction to leishmanial antigen on skin tests. The total numbers of lymphocytes and T cells were normal. None of these patients had a lymphocyte-proliferation response to leishmanial antigens, although their responses to other antigens were normal. Adding indomethacin to cultures or decreasing the number of adherent cells by passage of cells over nylon wool reconstituted the lymphocyte responses to leishmanial antigens. Thus, our studies demonstrate that patients with diffuse cutaneous leishmaniasis have a selective anergy to leishmanial antigen, and that an adherent suppressor cell is one mechanism by which this selective immunosuppressive state is modulated.

Immunological regulation of experimental cutaneous leishmaniasis. III. Nature and significance of specific suppression of cell-mediated immunity in mice highly susceptible to Leishmania tropica

BALB/c mice have been an exceptional susceptibility to Leishmania tropica infection such that cutaneous lesions grow without restraint in all cases leading to fatal metastasis and visceralization in normal and x-irradiated, bone-marrow reconstituted (XBM) animals. Adult thymectomized, x-irradiated, bone marrow-reconstituted (ATxXBM) BALB/c mice, however, show pronounced retardation of lesion growth leading to some survival and even cures. A similar trend was also found in moderately susceptible (BALB/c X C57BL/6)F1 mice, in contrast with the "resistant" CBA strain, in which, as previously known, ATxXBM animals showed impairment of normal, spontaneous self-healing. These convere effects are paralleled by respective leishmania-specific delayed-type hypersensitivity (DTH) reactivities, prior thymectomy leading to diminution in CBA and augmentation in BALB/c and (BALB/c X C57BL/6)F1. Anti-leishmanial DTH responses, amplfiable by cyclophosphamide pretreatment, can be detected in BALB/c mice within 10 d of infection with 2 X 10(7) promastigotes, but becomes near-totally suppressed by day 25-35. No such suppressin is found in CBA, C57BL/6, or (BALB/c X C57BL/6)F1 mice together with varying degrees of immune control of lesion development or regression. Suppression of DTH in BALB/c mice is leishmania specific and does not extent to 2,4-dinitrofluorobenzene (DNFB) or sheep erythrocytes specificities. Spleen cells from suppressed L. tropica-infected mice when transferred to normal BALB/c mice impaired the induction of DTH to leishmanial antigen. This property resided in the T cell-enriched fraction and not in the T cell-depleted fraction. It is concluded that a major component of the striking inability of BALB/c mice to control L. tropica infection involves profound impairment of a potentially curative cell-mediated immune response by suppressor T cell generation. The possibility is discussed that this may be secondary to rapid amastigote (antigen) accumulation in macrophages expressing the primary genetic "defect."

Comparative study of American cutaneous leishmaniasis and diffuse cutaneous leishmaniasis in two strains of inbred mice

Two Leishmania strains, AZV (isolated from a typical case of American cutaneous leishmaniasis) and AMP (from a case of diffuse cutaneous leishmaniasis), were studied in C57BL/6 and BALB/c mice. After infection with 10(4) amastigotes of either strain, C57BL/6 mice developed self-resolving lesions lasting 20 to 23 weeks and showed both delayed hypersensitivity response to leishmanial antigen and specific agglutinating antibodies. On the other hand, BALB/c mice infected with 10(4) AZV or AMP amastigotes developed chronic, large, ulcerated lesions and showed impaired cellular and humoral responses to the parasite. When BALB/c and C57BL/6 mice received 10(2) AMP amastigotes, patterns of infection were similar to those observed after inoculation of 10(4) amastigotes. In vitro studies revealed that spleen cells from AZV- or AMP-infected C57BL/6 mice showed an increased DNA-synthetic response to leishmanial antigen, concanavalin A, and phytohemagglutinin. Spleen cells from AZV- or AMP-infected BALB/c mice showed an increased response to concanavalin A and diminished responses to leishmanial antigen, phytohemagglutinin, and lipopolysaccharide.

[Immunologic reaction in parasitic invasion (author's transl)]

Among the manifold immunologic events which take place during parasitic invasions, production of autoantibodies and immune complexes can play a serious role during infections with African and American trypanosomes. The importance of complement deserves new attention. The increasing level of IgE induced by helminthic infections on a humoral basis seems to be caused by separate worm allergens; its involvement in self-cure phenomena together with processes on cellular levels is discussed. Destructive processes on various development stages of schistosoma and immunological events during cutaneous leishmaniasis are also cell mediated. Variations in the antigenic behaviour of parasites and their immunological mimicry by uptake of substances from the host and their immunosuppressive action are discussed. As reasons for absence of immunity against animal parasites this action can disturb either humoral or cellular immunological procedures or both.

Suppression of cell-mediated immunity in experimental Chagas' disease

The effect of acute infection with the Tulahuén strain of Trypanosoma cruzi on the cellular immune response in Swiss mice was studied. Mice were immunized with either Freund's complete adjuvant or oxazolone, a skin sensitizing agent, and subsequently skin-tested with either BCG protoplasm or oxazolone to detect delayed hypersensitivity. Depression of the response to these antigens was observed in infected mice during the stage of marked parasitemia. Mice which were responsive to oxazolone before infection lost their ability to respond as the infection progressed. When immunized with live attenuated T. cruzi before infection with virulent organisms, mice developed a greater than normal sensitivity to oxazolone and survived infection. These experiments do not conclude whether immunosuppression due to infection with T. cruzi is directed toward induction or expression of the cell-mediated immune response to the antigens employed.

Aspectos imunológicos da Leishmaniose Cutis Difusa

Um caso de Leishmaniose Cutis Difusa é estudado quanto aos seus aspectos imunológicos. A imunidade celular foi investigada com testes intradérmicos, sensibilização artificia! do DNCB e dosagem de fator de inibição do macrófago (MIF). Embora alguns antígenos injetados tivessem dado reação positiva, a leishmanina foi não reatora evidenciando uma anergia específica. As imunoglobulinas G e M estavam elevadas. 0 encontro de anticorpos circulantes por alguns autores associando ao fato de que o complemento C3 era baixo em nosso paciente, levou-nos a considerar o consumo deste que fixado a complexos Ag-Ac circulantes poderiam explicar os surtos de febre e artralgias. Por fim são considerados os pontos de vista de autores diferentes em relação ao fato de que a LCD seria causada por espécie diferente de leishmânia, ou por defeito imunológico do paciente, destacando-se o trabalho de Convit³ em favor desta útlima hipótese.