Variation in delayed hypersensitivity in onchocerciasis

Tropical parasitic itch in returned travellers and immigrants from endemic areas

Itch is the most common skin symptom among tropical parasitic diseases (TPD), but there are limited data about its characteristics in these conditions. In dermatology practices and travellers' health clinics in the developed world, itch is a common complaint among travellers returning from endemic areas, as well among migrants arriving from endemic areas, where they may have been exposed to TPD. Studying aspects of pruritus among TPD may lead to improvements in prompt, accurate diagnosis and management of these conditions. This review examines the major itch-inducing TPDs, including schistosomiasis, echinococcosis, onchocerciasis, scabies, cutaneous larva migrans, larva currens, African trypanosomiasis, dracunculiasis and other causes of travel associated pruritus. We focus on the link between pruritus and other symptoms, aetiology, clinical staging and therapeutic options for these parasitic illnesses. Because some tropical parasitic diseases can present with significant pruritus, we attempt to identify aspects of the pruritus that are characteristic of-or unique to-specific conditions. These diagnostic insights may help clinicians create a rational and focused differential diagnosis and help determine optimal disease management pathways. In this sense, management involves treating the individual, seeking epidemiologically linked cases, preventing recurrences or relapses, and reducing spread of the disease.

Onchocerciasis (river blindness) - more than a century of research and control

This review summarises more than a century of research on onchocerciasis, also known as river blindness, and its control. River blindness is an infection caused by the tissue filaria Onchocerca volvulus affecting the skin, subcutaneous tissue and eyes and leading to blindness in a minority of infected persons. The parasite is transmitted by its intermediate hosts Simulium spp. which breed in rivers. Featured are history and milestones in onchocerciasis research and control, state-of-the-art data on the parasite, its endobacteria Wolbachia, on the vectors, previous and current prevalence of the infection, its diagnostics, the interaction between the parasite and its host, immune responses and the pathology of onchocerciasis. Detailed information is documented on the time course of control programmes in the afflicted countries in Africa and the Americas, a long road from previous programmes to current successes in control of the transmission of this infectious disease. By development, adjustment and optimization of the control measures, transmission by the vector has been interrupted in foci of countries in the Americas, in Uganda, in Sudan and elsewhere, followed by onchocerciasis eliminations. The current state and future perspectives for control, elimination and eradication within the next 20-30 years are described and discussed. This review contributes to a deeper comprehension of this disease by a tissue-dwelling filaria and it will be helpful in efforts to control and eliminate other filarial infections.

Onchocerciasis in Yemen: Time to take action against a neglected tropical parasitic disease

Onchocerciasis is a neglected parasitic disease affecting the poorest underserved people in Yemen. A national control programme with goals to eliminate onchocerciasis has yet to be launched due to the current upheaval and social unrest in the country. The disease, locally termed as sowda, is unique in its clinicopathologic pattern, being of the localized, non-blinding, hyperreactive onchocercal skin disease. Although early reports identified endemic foci along seasonal watercourses, there is a need to redefine its epidemiologic patterns as well as health and socioeconomic impacts. Laboratory diagnosis of sowda among Yemeni patients is difficult due to the low load of microfilariae in skin snips and the presence of asymptomatic itching-free microfilaria carriers. Adoption of ivermectin use at three-month intervals as a control strategy has not been evaluated because the drug is mostly used in clinics and distributed to only a few affected communities. This paper addresses key aspects of onchocerciasis in Yemen and highlights the need for screening at-risk populations using highly sensitive techniques and mapping the distributions of the parasite in human and vector populations of blackflies. The new research should be integrated with the launch of a national onchocerciasis control programme to achieve onchocerciasis elimination.

Pattern recognition receptors in microbial keratitis

Microbial keratitis is a significant cause of global visual impairment and blindness. Corneal infection can be caused by a wide variety of pathogens, each of which exhibits a range of mechanisms by which the immune system is activated. The complexity of the immune response to corneal infection is only now beginning to be elucidated. Crucial to the cornea's defences are the pattern-recognition receptors: Toll-like and Nod-like receptors and the subsequent activation of inflammatory pathways. These inflammatory pathways include the inflammasome and can lead to significant tissue destruction and corneal damage, with the potential for resultant blindness. Understanding the immune mechanisms behind this tissue destruction may enable improved identification of therapeutic targets to aid development of more specific therapies for reducing corneal damage in infectious keratitis. This review summarises current knowledge of pattern-recognition receptors and their downstream pathways in response to the major keratitis-causing organisms and alludes to potential therapeutic approaches that could alleviate corneal blindness.

Onchocerca antigens in protection, diagnosis and pathology

Characterization of the immune response to Onchocerca volvulus is important for the diagnosis, control and understanding of the disease it causes. The antibody response to surface, secreted and somatic antigens of the worm has therefore been examined at an individual immunoglobulin (Ig) class level, by using a panel of different human sera. Onchocerca-specific antigens tend to be of low molecular mass and preferentially recognized by IgG4 and IgE. There is considerable cross-reaction between O. volvulus and O. gibsoni, so that the latter may be an alternative source of material for use in diagnosis. A surface-enriched fraction of low molecular mass appears to be a most promising diagnostic tool. Amongst somatic antigens, two were uniquely recognized by IgG3 antibodies in sera from sowda patients, thereby providing a molecular correlate for a recognized pathological condition. Improved diagnosis is needed for detecting infection in both humans and the vector. Our target for detection in humans is a continuously released, nonimmunogenic product, which is ideally stage and parasite specific. The excretions of adult worms do contain components not recognized by antibodies in infected serum, but we cannot rule out that these are of host, rather than parasite origin. Excretions of Litomosoides carinii contain both host and parasite molecules and, in addition, stage-specific and sex-specific components. Unfortunately, however, the rate of production of excretions varies during the life of L. carinii. This finding may be relevant to the detection of Onchocerca excretions if they are produced at a similarly uneven rate. Finally, for detecting infective larvae in the vectors, we are currently screening a genomic library of O. volvulus for an appropriate probe. To date, one DNA sequence has been cloned that shows promising specificity.

IL-5 dominates cytokine responses during expression of protective immunity to Onchocerca lienalis microfilariae in mice

In a model of protective immunity against Onchocerca microfilariae (mf), it has been demonstrated previously that immunocompetent mice clear a primary infection and are highly resistant to re-infection. This immunity correlates with CD4+ Th2 cells, is dependent on IL-5 but not IL-4, and can be transferred adoptively with spleen cells. In the current investigation, high levels of spontaneous proliferation and of IFN gamma production were observed in splenocyte cultures from immune mice, compared with cells from naive controls. Antigen-specific proliferation also occurred in immune cells, being vigorous following stimulation with adult worm antigen, but not with antigens from developing embryos or mf. Levels of IL-4, IL-5 and IFN gamma induced by the various antigens was similar, indicating that activation of alternate T helper cell sub-sets was unlikely to explain the lack of cellular responsiveness. After a primary inoculation with mf, spleen cells from infected mice co-produced IFN gamma and IL-5. In contrast, IFN gamma production was downregulated while IL-5 levels remained high during active elimination of a challenge infection. Significant levels of IL-4 production occurred only once parasite clearance had begun. These data confirm the importance of IL-5 in protection against Onchocerca mf in mice and question the role of IFN gamma in the expression of immunity. Production of high levels of IL-5 correlated with blood and tissue eosinophil mobilization during the clearance of a challenge infection.

Delayed-type hypersensitivity reactions to Onchocerca volvulus antigens in exposed and non-exposed African individuals

Although considered of critical importance, the mode of helper T-lymphocyte function in Onchocerca volvulus infection is still unclear including the role of the Th1/Th2 dichotomy. We studied the delayed-type hypersensitivity (DTH) reaction, which is the classical Th1 response, to O. volvulus antigens in Africans exposed and not exposed to the infection. DTH reactions were found in a small percentage of patients with generalized onchocerciasis, but in a high percentage of patients with localized onchocerciasis, in putatively immune subjects, and also in non-exposed individuals, which may be due to cross-reactivity with other nematodes. These findings support the notions of (i) prenatal influence of maternal O. volvulus infection preventing development of Th1 responses and/or (ii) suppression of Th1 responses by the infection itself.

Mast cells in onchocercomas from patients with hyperreactive onchocerciasis (sowda)

In onchocerciasis, variations of the host's immune responsiveness produce a spectrum of clinical manifestations ranging from the common generalized to the rare hyperreactive form (sowda). For further characterization of the immune response, the localization and frequency of mast cells in onchocercomas from untreated and ivermectin-treated patients with hyperreactive onchocerciasis from Liberia and the Yemen were analysed and compared to the generalized form by immunohistochemistry with antibodies specific for human mast cell tryptase and chymase, histamine and IgE. The nodules were selected with special regard to only one pair of live, microfilariae-producing Onchocerca volvulus. Throughout the nodular tissue of the hyperreactive form, mast cells accumulated in the strong inflammatory infiltrates, especially near eosinophils and around cellular attacks on microfilariae as well as perivascularly. Their number was significantly higher in the whole nodular tissue compared to the generalized form. The highest numbers occurred in the nodule centre. Mast cells carried IgE and appeared activated. No mast cells were observed in the cystic parts or attached to adult worms or microfilariae. In onchocercomas, 1 and 3 days after treatment with ivermectin, microgranuloma formation by eosinophils and macrophages around damaged microfilariae was enhanced and accompanied by numerous mast cells. Attacks of neutrophils were also pronounced, but attacks by mast cells were not observed. In conclusion, hyperreactivity against microfilariae in onchocercomas clearly correlates with a strong mastocytosis and IgE production parallel to tissue eosinophilia.

Differences in eosinophil and neutrophil chemotactic responses in sowda and generalized form of onchocerciasis

Extravasation of host's leukocytes from blood vessels into inflammatory tissues represents a prerequisite for a subsequent interaction with invaded parasites. The migratory responses of eosinophilic and neutrophilic granulocytes in the polar forms of the filarial infection onchocerciasis were investigated. The hyporeactive, generalized form, the chronic hyperreactive (sowda) form and persons without signs of onchocerciasis from a hypoendemic area for onchocerciasis were compared. Eosinophils from sowda patients responded more strongly to the inflammatory mediator platelet-activating factor (PAF) than those from generalized patients and persons without onchocerciasis. The most significant differences were found between the sowda group and a subgroup of the generalized form with 16-80 microfilariae/mg skin (P<0.05) while patients with low microfilarial density exhibited chemotactic responses similar to the sowda group. In contrast to the strong eosinophil response, neutrophils from sowda patients appeared unreactive to PAF and the tripeptide activator formyl-methionyl-leucyl-phenylalanine (fMLP), thereby differing from both other groups. Laboratory data confirmed a state of hyperreactivity in sowda patients similarly found in generalized patients with low microfilarial density and contrasting with those with a microfilarial density of 16-80 mf/mg. The results revealed an inverse chemotactic responsiveness of eosinophil and neutrophil granulocytes in sowda patients and strengthened the observation of a spectrum of host's responsiveness in onchocerciasis.

Ivermectin treatment in severe asymmetric reactive onchodermatitis (sowda) in Sudan

Ivermectin efficacy and post-treatment reactions in asymmetric severe reactive ochodermatitis (sowda) were studied in 8 patients with sowda syndrome and 6 with mild generalized onchodermatitis in Sudan. Initial skin snips from 12 patients contained microfilariae (1-9 per mg skin). Patients were treated in hospital with a single oral dose of c. 150 micrograms/kg ivermectin (103-200 micrograms/kg) and monitored for frequency and severity of post-treatment reactions for 4 weeks. Serial samples of heparinized blood were collected over the first 24 h after treatment for determination of ivermectin pharmacokinetics. Skin snips from all patients on days 3 and 28 revealed no microfilariae. Post-treatment reactions were more common and severe in individuals with sowda; they consisted mainly of musculoskeletal pain, local swellings with pitting oedema, and lymph gland tenderness and enlargement. No relation was established between these reactions, the microfilarial infection intensity, or the plasma pharmacokinetic profiles. A single oral dose of ivermectin cleared the skin of microfilariae and led to improvement of symptoms and dermatological signs of sowda, but resulted in more marked reactions than in cases of generalized onchodermatitis.

Vaccine research and development for the prevention of filarial nematode infections

The development of vaccines for the prevention of filarial nematode infections is in a state of relative infancy in comparison to vaccines for other parasitic diseases, such as schistosomiasis and malaria. There are many reasons for this slow start. Some of the principal problems are: (1) the lengthy and complex life cycle of these organisms with attendant complex immune responses, (2) the unique characteristics associated with a relatively large number of different pathogens, (3) the lack of suitable model systems for study of medically important infections, (4) the paucity of parasite material for antigen discovery and recombinant library construction, (5) the lack of substantial evidence suggesting the natural occurrence of protective immune responses, and (6) the limited data on mechanisms responsible for protective immunity. As technical hurdles are considered, it is also critical to focus on the characteristics of a vaccine necessary for its eventual utility. In the case of a vaccine for D. immitis a completely successful product will need to approach a 99+% efficacy. This is because of the 99+% efficacy of competitive chemotherapeutic products and the fact that microfilaremia observed on blood examination, resulting from as few as two worms, would present as a vaccine failure. Although very low worm burdens in large dogs could be perceived as success in the context of protection from clinical disease, because of the option of virtually complete chemoprophylactic protection, the typical veterinary practitioner would probably fail to appreciate less than complete vaccine protection. In contrast, a vaccine that produced a reduction in adult worm burdens without complete protection in either lymphatic filariasis or onchocerciasis would be very important. Highly effective chemoprophylactic agents are not widely available for prevention of the human filariases, and dramatically reduced clinical disease provided by less than a completely effective vaccine could occur as the result of fewer adult worms. The importance of developing these vaccines has outweighed the obstacles to this research. There has been a great deal of epidemiological and experimental evidence to suggest a vaccine is feasible and antigen discovery has progressed relatively rapidly within just the past few years. Efforts to generate appropriate larval cDNA libraries are beginning to yield dividends and a variety of fascinating vaccine candidates have been cloned. Additional antigen discovery, research on appropriate modalities for overexpression of genes from these parasites, and the complex tasks associated with vaccinology remain as significant research and development obstacles.(ABSTRACT TRUNCATED AT 400 WORDS)

Epitopes of the Onchocerca volvulus RAL1 antigen, a member of the calreticulin family of proteins, recognized by sera from patients with onchocerciasis

RAL1 is an antigen (Ag) encoded by the filarial nematode Onchocerca volvulus, the parasite causing onchocerciasis (river blindness). RAL1 shares 64.4% identity with the autoantigen calreticulin. The striking similarity of the parasite Ag and the human autoantigen has led to the hypothesis that RAL1 may induce a cross-reactive immune response to calreticulin, which in turn may be involved in the pathogenesis of onchocerciasis. To test this hypothesis, we explored the immune response to RAL1 recombinant Ag (RAL1 rAg) and human calreticulin in patients with O. volvulus infection. A total of 86% of the O. volvulus-infected individuals produced antibodies recognizing RAL1 rAg. Antibody reactivity to RAL1 rAg in patient sera was confined primarily to the central and carboxyl-terminal parts of the molecule. No significant correlations were found to associate recognition of RAL1 rAg, or any particular portion thereof, with a particular disease state. Antibodies against RAL1 thus appear to be produced as a general immune reaction to O. volvulus infection and do not necessarily lead to a cross-reacting response with the host protein. In contrast, 33% of the patient sera tested bound recombinant human calreticulin. All of these sera also recognized a polypeptide encompassing the carboxyl-terminal portion of the RAL1 rAg. These results suggest that recognition of an epitope encoded in the carboxyl-terminal portion of RAL1 is at least in part responsible for inducing a cross-reacting immune response to the host protein.

HLA-D alleles associated with generalized disease, localized disease, and putative immunity in Onchocerca volvulus infection

Human infections with the tissue nematode Onchocerca volvulus result in a variety of clinical conditions that possibly include protective immunity. In a West African area hyperendemic for human onchocerciasis, 120 residents were classified according to clinical and laboratory findings as presenting with generalized onchocerciasis, localized onchocerciasis, or as being putatively immune. The three groups differed in the distribution of HLA-D variants as determined by DNA typing. The most pronounced differences were found among alleles of the DQ loci. The haplotype DQA1*0501-DQB1*0301 was significantly more frequent among putatively immune individuals than among patients with generalized or localized disease. Conversely, DQA1*0101-DQB1*0501 and, independently, the allele DQB1*0201 were more frequent in generalized disease than in localized disease or putative immunity. In these correlations, the frequencies of allelic variants were in localized disease intermediate to those of the two other groups. The only distinct association found with localized disease was that of the DP allele DPB1*0402. The findings indicate that HLA-D variants influence the course of O. volvulus infection and help to define a state that may reflect protective immunity.

A clinical classification and grading system of the cutaneous changes in onchocerciasis

Although onchocerciasis is one of the most important diseases of the skin and eye in the tropical world, to date there has been no formal consensus regarding the description and terminology of skin lesions. Furthermore, the contribution of cutaneous pathology to the morbidity and socio-economic effects of the disease has been largely neglected. We present a clinical classification and grading system for recording the cutaneous changes of onchocerciasis, and propose that this system be used as a standard method of description to convey clinical information between workers in all endemic areas to assist local and comparative research.

Suppression of human lymphocyte responses to specific and non-specific stimuli in human onchocerciasis

Characterization of in vitro lymphocyte responsiveness was performed on selected groups of onchocerciasis patients from Sudan and Sierra Leone. These patients manifested a very broad range of clinical signs and showed widely divergent parasite infection intensities. Lymphocyte proliferative responses to soluble Onchocerca volvulus antigen (sAg) were poor in infected persons; mitogen and PPD responses were maintained in the normal range in one group of patients from southwestern Sudan, but were profoundly depressed in a group from N.E. Sudan. Proliferative responses and interferon-gamma (INF-gamma) secretion were very significantly depressed in the presence of live microfilariae of O. volvulus or secretions/excretions (S/E) from microfilariae (mf) or from female, but not male, adult parasites. Lymphocyte responses were maintained near normal when exogenous IL-2 was added to these cultures. The results indicate that O. volvulus infection and its clinical consequences are not consistently associated with systemic deficits in immune responsiveness. However, suppression of lymphocyte reactivity by mf and S/E in vitro suggests that direct parasite intervention in host cell responses could be taking place in vivo, perhaps at the local microenvironment level; mediated by effects on cytokine production.

Immunoregulation in onchocerciasis. Functional and phenotypic abnormalities of lymphocyte subsets and changes with therapy

To help define the immunoregulatory defects in patients with onchocerciasis, flow cytometric analysis of circulating lymphocyte subpopulations was performed in parallel with functional assays. No significant differences in CD4/CD8 ratios were seen when microfilariae-positive individuals from Guatemala were compared with Guatemalan controls. However, the infected individuals had significantly increased numbers of circulating CD4+CD45RA+ lymphocytes (mean 38.3%) when compared with controls (mean 16.0%). Coexpression of the activation marker HLA-DR was significantly increased on CD4+ cells from infected individuals. In contrast, no up-regulation of HLA-DR was seen on CD8+ or CD19+ cells. At 1 year after initiation of treatment with semiannual doses of the microfilaricide ivermectin, there were significant increases (P less than 0.05) in the percentage of CD4+CD45RA- cells, the percentage of CD4+HLA-DR+ cells, and mitogen-induced lymphokine production (IL-2, IL-4). Despite these changes, parasite-specific IL-2 and IL-4 production which had been undetectable before treatment did not manifest itself even by the 2-yr follow-up. Defects in the T-cell activation pathway in Onchocerca volvulus-infected individuals may thus exist at several independent points; a state of parasite antigen-specific tolerance appears to remain even after the relative reversal of other generalized immunoregulatory defects.

Immunological crossreactivity between a cloned antigen of Onchocerca volvulus and a component of the retinal pigment epithelium

Onchocerciasis (river blindness) is a major blinding disease in Africa, Central America, and South America. Loss of vision can be due to corneal change, optic atrophy, or chorioretinal disease. It has been suggested that autoimmunological reactions resulting from crossreactivity between parasite antigens and components of eye tissues contribute to development of ocular pathology. Using sera collected from onchocerciasis patients as a screening reagent, a cDNA clone (Ov39) has been isolated from a lambda gt11 expression library of Onchocerca volvulus. This antigen exhibits immunological crossreactivity with a component of retinal pigment epithelium cells (RPE). Antiserum raised against this recombinant peptide immunoprecipitates a 22,000 Mr antigen of adult O. volvulus and recognizes a 44,000 Mr component of bovine RPE by Western blotting. A 44,000 Mr antigen of cultured human RPE metabolically labeled with 35S-methionine can be immunoprecipitated with the same antiserum. An antigen of the same size is recognized by a rabbit antiserum raised against whole O. volvulus extract. Immunocytochemical studies on cryostat sections of the bovine eye using the antirecombinant sera localizes this antigen to the RPE.

Surface antigens of male worms and microfilariae of Onchocerca gibsoni

Living adult males and microfilariae of the cattle filarial parasite Onchocerca gibsoni were externally labelled with radioactive iodine using the iodogen and Bolton-Hunter procedures. Characterization of labelled surface proteins by sodium dodecyl sulphate (SDS)-polyacrylamide gel electrophoresis revealed clear cut differences in the two life cycle stages. In addition, the two radiolabelling procedures yielded some differences in the profiles of radiolabelled surface proteins for both adults and microfilariae. Immunoprecipitation analysis revealed a number of labelled antigens recognized by antibodies in human onchocerciasis serum pools, thereby demonstrating the usefulness of O. gibsoni as a model in Onchocerca volvulus vaccine studies. The reactivity of microfilarial antigens extended to antibodies from other human nematode infections, whereas male surface antigens, particularly those of low molecular weight, were Onchocerca specific. This indicates that O. gibsoni can provide a convenient source of specific diagnostic antigen.

Serum-dependent interaction of granulocytes with Onchocerca volvulus microfilariae in generalized and chronic hyper-reactive onchocerciasis and its modulation by diethylcarbamazine

The adherence and cytotoxicity of granulocytes to microfilariae of Onchocerca volvulus were examined in vitro. Reactivity and modulation by diethylcarbamazine of isolated eosinophilic and neutrophilic granulocytes from patients with generalized and chronic hyper-reactive onchocerciasis (sowda or localized form) from endemic foci in Liberia were evaluated under varying serum conditions. In the presence of pooled sera from patients with generalized onchocerciasis granulocytes from both polar groups of patients exhibited similar adherence rates, whereas immobilization rates were higher for eosinophils than for neutrophils. In localized onchocerciasis, the use of autologous serum resulted in a significant decrease in adherence and immobilization rates for both eosinophils and neutrophils. After preincubation of eosinophils, but not of microfilariae, with diethylcarbamazine autologous serum-mediated adherence and cytotoxicity were enhanced to rates similar to those found with pooled serum from individuals with generalized onchocerciasis. These results suggest that granulocytes from both forms of onchocerciasis did not differ with respect to their anti-parasitic reactivity and that antibodies as well as additional serum factors appear to contribute to the functional activity of these effector cells. The findings indicate that predominantly eosinophils, compared to neutrophils, damage the larvae of O. volvulus and support earlier observations which suggest that diethylcarbamazine influences the effector cells rather than the parasite itself.

Antigens of parasitic helminths in diagnosis, protection and pathology

A thorough study of parasitic helminth antigens is a pre-requisite for control programmes based on accurate immunochemical diagnosis, protection by vaccination and perhaps immune modulation to diminish pathological sequelae. Studies should be directed at the identification of those stage- or age-specific surface, secreted and somatic antigens which are involved in the host-parasite interactions responsible for immunity and/or pathology. Current methods of diagnosis of parasitic infections often fail to detect low-level patent infections, which incurs the risk of having a reservoir capable of perpetuating infections. There is, then, an urgent requirement for accurate immunochemical diagnosis, to be used in association with, and for the evaluation of, drug treatment and vector elimination, in parasite control programmes. Given the high sensitivity of current immunoassay technology, the only bar to establishing the necessary immunological tests is the choice of suitably specific antigen/antibody systems. Assays designed to detect parasite products or antigens are a major priority, as they indicate current infection, whereas those which detect antibody only indicate exposure to infection, which may or may not be current. Surface and secreted antigens are the most likely targets for protective immune responses and thus form a logical focus for vaccine design. The cestodes, which present such strong evidence for immunity following natural infection, are likely to yield effective vaccines by modern procedures. Certain antigens must, however, stimulate the humoral and/or cellular responses which are responsible for the undesirable immunopathological consequences of many helminthic diseases. The nematodes and trematodes furnish some extreme examples of such pathology. The ultimate objective in identifying these particular antigens is to utilize them in the appropriate down-regulation of the immune response responsible for such pathology. As an illustration, we have presented an interesting correlation between one particular clinical condition of onchocerciasis (Sowda) and the serological response, defined both in terms of the parasite antigens and an immunoglobulin class-restricted antibody response. Finally, the complexity of these parasite systems and the host response to the parasite should not be underestimated. Modern analytical techniques allow their detailed analysis in terms of the humoral antibody responses and afford the possibility of the future development of control and disease management procedures tailored to each individual host-parasite system. However, novel systems are required to complete the analysis of the cellular components of the immune response to parasite antigens, and functional studies are needed to determine the role that these parasite antigens play in the complex interaction between parasite and host.

Parasite-specific immune responses to Onchocerca lienalis microfilariae in normal and immunodeficient mice

The model of Onchocerca lienalis microfilariae (mf) in CBA mice has been employed to examine the immunological mechanisms underlying the destruction of skin-dwelling mf in onchocerciasis. Comparative studies among immunologically intact (CBA/H) or deficient (CBA/N, T-cell-deprived) syngeneic animals demonstrated that levels of mf of a primary infection were reduced most rapidly in fully immunocompetent mice. Significant reductions in recoveries of a secondary infection were evident in CBA/H (80%) and CBA/N (44%) mice, but not in T-cell-deprived animals. The establishment of primary and secondary infections was apparently not influenced by complement, as judged by C3 depletion with Cobra Venom Factor. Eosinophilia was demonstrated to varying degrees in all infected animals; similar levels occurred in CBA/H and CBA/N mice which were greatly elevated after mf challenge. In contrast, the eosinophil response of T-cell-deprived mice was weak and not potentiated during secondary infection. Type I immediate hypersensitivity responses to soluble mf antigen (mf-Ag) were mounted by all groups, but significantly less strongly in T-cell-deprived mice. Type IV delayed responses were generally weak, although CBA/N mice reacted strongly in the early phase of primary infections. During the first 2 weeks of infection CBA/H and T-cell-deprived mice mounted rapid IgM responses to mf-Ag. Subsequently, levels of IgG2a, IgG2b and IgG1 increased in all mice. There was a potentiated IgG2a, IgG2b and IgG1 response in all groups following challenge, with levels of IgG1 highest in CBA/H mice. IgE responses were also detected by passive cutaneous anaphylaxis during primary and secondary infections. Peak levels of parasite-specific antibodies coincided with the timing of mf clearance.

Nematode antigens in protection, diagnosis and pathology

A thorough study of parasite antigens is a prerequisite for control programmes based on protection by vaccination, accurate serodiagnosis and perhaps immune modulation to diminish pathological sequelae. Stage specific surface secreted and somatic antigens may be of particular value in proceeding towards these goals. The design of vaccines is most appropriately focused on surface antigens. With respect to pathology, certain antigens must stimulate humoral and, or cellular immune responses which are responsible for the undesirable immunopathologic consequences of the disease. The ultimate objective, therefore, is identification of those particular antigens followed by appropriate down regulation of the immune system in order to delete such potentially harmful immunological reactions. The relevant illustration presented in this context is an interesting correlation between one particular clinical condition of onchocerciasis ("sowda") and the serological response, defined both in terms of the parasite antigen and an immunoglobulin class restricted antibody response. Current parasitological methods of diagnosis consistently underestimate parasite prevalence. Failure to detect low level patent infections incurs the risk of having a reservoir capable of perpetuating infections. There is, then, an urgent requirement for accurate serodiagnosis, to be used in association with, and for the evaluation of, drug treatment and vector elimination in parasite control programmes. Given the high sensitivity of current immunoassay technology, the only bar to establishing the necessary immunological tests is the choice of suitably specific antibody-antigen systems. Once these are identified, a combination of recombinant nucleic acid biochemistry and hybridoma technology should provide the necessary reagents for inexpensive, robust and specific diagnostic tests. In addition, it may not be many years before the ubiquitous RIA and ELISA technology gives way to the newly developing biosensor systems. Finally, given the sensitivity and specificity of today's nucleic acid hybridization techniques, we may soon expect to see specific identification of infective larvae in their vectors of this, a cloned DNA probe specific for Onchocerca volvulus, and with potential for the detection of infective larvae in blackflies is described.

Severe onchocercal dermatitis in the Ethiopian border region of Sudan

Onchocerca volvulus infection of the residents of two villages in the Upper Atbara River region of Sudan (63.4% prevalence) was found to be medically and socially significant with a remarkable degree of pruritus and dermal pathology present. The severest skin changes, which were often confined to certain areas of the body, were most common in the teenage group (13-19 years). Quantitation of the clinical changes showed that the most severe alterations were present in patients with the lower levels of microfilariae in the skin (0.1-6 mf mg-1) rather than in those with higher levels. Nodules containing adult O. volvulus were found in many individuals, and often in clusters in older patients. Major losses of vision due to O. volvulus were not found, although microfilariae were frequently seen in the cornea and anterior chamber. The commonest corneal change was punctate keratitis, and this was most frequently seen in the teenage group. Trachomatous changes of eyelids and corneas were also seen. The prevalence values of O. volvulus infection in the two villages were significantly increased when, in addition to microfilarial presence in skin biopsies, onchocercal signs such as punctate keratitis, nodule presence and microfilariae in the anterior chamber were taken into consideration. This illustrates the need to consider factors other than skin snip parasitology in obtaining a diagnosis. This study also emphasizes the degree of severity that onchodermatitis can reach and that low levels of dermal microfilariae can be accompanied by very extensive skin changes without any loss of vision. The necessity of considering the severity of skin changes when defining tolerable levels of onchocerciasis in a community is discussed.

Distribution pattern of peripheral lymphocyte subsets in localized and generalized form of onchocerciasis

The relationship of peripheral lymphocyte subpopulations to the generalized and localized form of onchocerciasis has been studied in 43 Liberian (West African) patients. Typing revealed a significantly increased proportion of lymphocytes expressing interleukin 2 or transferrin receptors in the localized form of onchocerciasis (African sowda) when compared to subjects with a generalized form and those without signs of onchocerciasis. Patients with African sowda showed a higher number of helper/inducer T cells, a greater ratio of helper/inducer: suppressor/cytotoxic T cells, and an increased number of DR antigen-positive cells and lymphocytes with a natural killer cell phenotype. Furthermore, the serum concentrations of immunoglobulins, particularly IgE an IgG, and antifilarial antibodies were significantly elevated in sowda patients in comparison to the generalized form and the controls. These results indicate that both forms of onchocerciasis represent different immunological types of host responsiveness and that African sowda might be associated with an increased compartment of activated T lymphocytes.

Associations between clinical disease, circulating antibodies and C1q-binding immune complexes in human onchocerciasis

Onchocerciasis is a disease where often there are high levels of serum antibodies and high parasitic loads. The role of immune complexes in the development of the disease is investigated here by studying non-specific and Onchocerca volvulus specific immune complex levels, as well as the antibody concentrations, in the sera of 372 people living in either Southern (199) or Northern (173) Sudan; sera from Sudanese individuals (31) and Caucasians (21) living outside the onchocerciasis endemic area were also tested. The levels of non-specific immune complexes (NS-IC) in these sera were measured by a solid phase radio-immunoassay and those of O. volvulus-specific immune complexes (OV-IC) by an assay measuring antibody-excess complexes using C1q-coated plates. The concentrations of O. volvulus IgG antibodies were measured by ELISA. Immune complex and antibody levels of the serum donors were compared with regard to their clinical status due to onchocerciasis. These clinical changes were classified according to onchocercal lesions related to either the active destruction of microfilariae (acute changes), or the long term tissue alterations (chronic changes). Data was analysed using the Odds Ratio method. A negative association between microfilarial load and immune complex level was found, with the higher levels of OV-IC present in patients with the lower levels of dermal microfilariae (i.e., less than 10 mf/mg). Significant associations between immune complex levels and the severity of onchocercal disease were also found. Levels of OV-IC specific immune complexes were higher in infected individuals carrying dermal onchocercal lesions than in those without such clinical changes; there was no apparent relationship between these levels and the presence of ocular lesions. OV-IC levels varied considerably within each age group and from age to age. A weak positive association was detected between microfilarial load and parasite-specific IgG antibody concentration in the sera. On average younger individuals (less than 25 years) had the higher antibody levels with a gradual reduction in mean concentrations with age. The significance of these serological findings in terms of the pathogenesis of onchocerciasis is discussed.

The Wellcome Trust lecture. Inflammatory responses to filarial connective tissue parasites

The inflammatory responses to lymphatic filariae and to Onchocerca volvulus are reviewed with particular attention to evolutionary biology; inflammatory host spectrum; non-specific components; immunoregulation; immune evasion versus immunomodulation; chronic tissue damage and scarring and disease models. Basic principles of pathogenesis are emphasized, comparisons drawn with schistosome infection, and critical items of missing information are highlighted.

A study on antigen recognition by onchocerciasis patients with different clinical forms of disease

Sera from 40 onchocerciasis patients from the Yemen Arab Republic with either mild localized forms of onchocerciasis, intermediate or severe localized forms of the disease or generalized forms of infection were studied with respect to their IgG and IgM response against Onchocerca volvulus antigens. Immunoblotting, performed with SDS-PAGE-separated proteins of female O. volvulus and quantified by densitometric scanning, revealed IgG and IgM antibodies against worm components in sera of all patients. Persons with intermediate or severe localized forms of onchocerciasis had a stronger IgG response against more proteins than individuals of the other groups. However, some antigens (Mr 21, 23, 30, 33 kDa) induced comparable quantities of IgG in all groups. The IgM response of patients with mild localized forms of onchocerciasis was more intensive and directed against more antigens than in the other groups. No antigens were detected that were recognized only by individuals with low levels of microfilaridermia. In all groups, varying concentrations of antibodies against cuticle, muscle/hypodermis layer and/or uterus of female O. volvulus were detected by the indirect immunofluorescence test using frozen worm sections as antigen. The highest mean antibody titres were found in patients with intermediate and severe localized forms of disease.

Immunomodulation by nematodes: a review

There is current evidence that infections with Trichinella spiralis, Ascaris suum, Nippostrongylus brasiliensis, Nematospiroides dubius (syn. Heligmosomoides polygyrus) and diverse filariae affect the immune responsiveness of their hosts. T. spiralis, or its extracts, can depress or enhance the heterologous humoral or cell-mediated immunities, and affect macrophage activity or the response to other invaders. These effects are induced by products of the migratory and early muscle larvae and appear to obey more than one single-mechanism. A suum acute infections or extracts depress responses involving T cell activity, but stimulate polygonal expansion of B-cells. Nippostrongylus brasiliensis causes polyclonal stimulation of IgE-producing cells, enhances immune responses during the first week of infection and inhibits them later on. Nematospiroides dubius depresses homologous and heterologous immunity and facilitates the permanence of other intestinal nematodes. Filarial worms appear to depress the homologous cell-mediated immunity and the heterologous humoral response by induction of suppressor cells and humoral factors. These phenomena are probably the result of evolutionary pressures on the parasites that facilitate their survival. In the host, they are likely to aggravate the homologous infection, facilitate intercurrent conditions and interfere with immunoprophylaxis procedures.

Immune responses in human Brugia malayi infections: serum dependent cell-mediated destruction of infective larvae in vitro

Serum dependent cell-mediated cytotoxicity of subperiodic Brugia malayi infective larvae in vitro was investigated. In vitro cellular adherence of normal human buffy coat cells to infective larvae of B. malayi was promoted by sera from patients with elephantiasis, tropical pulmonary eosinophilia (TPE) and amicrofilaraemic symptomatic filariasis, as well as by sera from normal subjects from filariasis endemic areas. However, strongest adherence was observed with TPE sera. Scanning electron microscopic (SEM) studies confirmed that the cellular adherence resulted in gross surface damage to the infective larvae. Studies with the indirect fluorescent antibody test (IFAT) suggested that IgG and/or IgM might be involved in the process of adherence. Complement did not appear to be important.

Pathogenesis and host response in subcutaneous alveolar hydatidosis. II. Intense plasmacellular infiltration in the paracortex of draining lymph nodes

Male C57L/J mice were infected subcutaneously in the left flank with 10 cysts of Echinococcus multilocularis. The draining and contralateral nodes were excised at weekly intervals, weighed, and examined histologically. Lymphoproliferation occurred in both the follicles and the paracortex (PCA) of the draining lymph nodes at one week postinfection (p.i.). Disorganization in the PCA of the draining nodes, was characterized by replacement of lymphocytes by plasma cells and the flattening of the endothelial cells lining the postcapillary venules. This began at three weeks p.i. and was completed by 12 weeks p.i. No comparable alterations occurred in the contralateral nodes during this period, but at 22 weeks p.i. these nodes were disorganized and histologically identical to the draining nodes. The growth and histogenesis of the subcutaneous alveolar cysts correlated with the expansion and disorganization of the PCA. The regulation of subcutaneous murine alveolar hydatidosis is discussed with reference to immune-deviation which is brought about by the antigenic load and plasmacellular infiltration in the draining lymph nodes.

Specific depression of cell-mediated immunity in Malayan filariasis

The possible depression of cell-mediated immunity by long-term Brugia malayi infection in jirds (Meriones unguiculatus) was investigated. Different groups of infected jirds were sensitized with dinitrofluorobenzene, sheep red blood cells, Dirofilaria immitis adult antigens and B. malayi adult antigens. The 24-hour delayed type hypersensitivity skin response to testing with antigen was measured as an in vivo correlate of cell-mediated immunity. The delayed-type hypersensitivity responses to dinitrofluorobenzene, sheep red blood cells and D. immitis antigens were normal but the response to B. malayi antigens was significantly depressed, confirming that long-term B. malayi infection depresses cell-mediated immunity and that this depression is specific to B. malayi antigens.