Serodiagnostic assay for visceral leishmaniasis employing monoclonal antibodies

Systematic review on antigens for serodiagnosis of visceral leishmaniasis, with a focus on East Africa

Background

Accurate and accessible diagnosis is key for the control of visceral leishmaniasis (VL). Yet, current diagnostic tests for VL have severe limitations: they are invasive or not suitable as point of care (POC) test or their performance is suboptimal in East Africa. We analysed the antigens in the VL serodiagnostics development pipeline to identify shortcomings and to propose strategies in the development of an alternative POC test for VL in East Africa.

Objectives

The objective of this study was to identify and to analyse all antigens for VL serodiagnosis that have been published before 2018 in order to identify candidates and gaps in the pipeline for a new POC test in East Africa.

Methods

A systematic literature search was performed on PubMed for original research articles on Leishmania-specific antigens for antibody detection of VL in humans. From each article, the following information was extracted: the antigen name, test format and characteristics, its reported sensitivity and specificity and study cohort specifications.

Results

One hundred and seven articles containing information about 96 tests based on 89 different antigens were included in this study. Eighty six of these tests, comprising 80 antigens, were evaluated in phase I and II studies only. Only 20 antigens, all of which are native, contain a carbohydrate and/or lipid moiety. Twenty-four antigens, of which 7 are non-native, are composed of antigen mixtures. Nineteen tests, comprising 18 antigens, have been evaluated on East African specimens, of which only 2 (rK28 based immunochromatographic test and intact promastigote based indirect fluorescent antibody technique) consistently showed sensitivities above 94 and specificities above 97% in a phase III study and one in a phase II study (dot blot with SLA). Only rK28 is a non-native mixture of antigens which we consider suitable for further evaluation and implementation.

Conclusions

The development pipeline for an alternative serodiagnostic test for VL is almost empty. Most antigens are not sufficiently evaluated. Non-protein antigens and antigen mixtures are being neglected. We propose to expand the evaluation of existing antigen candidates and to investigate the diagnostic potential of defined non-native carbohydrate and lipid antigens for VL serodiagnosis in East Africa.

Visceral leishmaniasis is a potentially fatal disease that affects more than 20 000 people every year. Its diagnosis is difficult since the clinical symptoms are not specific and the existing diagnostic tests are not useful in limited resource countries or they a not accurate enough in East Africa. In this review we performed a systematic search of the published literature to analyse the potential candidate antigens in the pipeline for a new antibody detection test in East Africa. We found 96 tests based on 89 antigens. Eighty six of these tests were evaluated in a study design that is insufficient (phase I and II) to make conclusions on their performance in clinical practice. We found that the candidate antigens either lacked carbohydrate or lipid structures or are based on single antigens as opposed to mixtures or are extracted from the causative parasite itself, making them expensive and prone to variations. Considering that the most widely used diagnostic test does not detect all cases of visceral leishmaniasis in East Africa, we analysed how many of the candidate antigens were tested on East African specimens: We found that only 2 tests (rK28 based immunochromatographic test and the intact promastigote based indirect fluorescent antibody technique) that were tested in a phase III study and only one (dot blot with SLA) that was tested in a phase II study performed well according to our criteria. Due to the antigen characteristics we consider only the rK28 based test as suitable for further evaluation and implementation.

Bone marrow parasite burden among patients with New World kala-azar is associated with disease severity

Kala-azar or visceral leishmaniasis, found mostly throughout the Indian Subcontinent, East Africa, and Brazil, kills 20,000-40,000 persons annually. The agents, Leishmania donovani and Leishmania infantum, are obligatory intracellular protozoa of mononuclear phagocytes found principally in the spleen and bone marrow. Protracted fever, anemia, wasting, hepatosplenomegaly, hemorrhages, and bacterial co-infections are typical features. One hundred and twenty-two (122) in-hospital patients were studied to verify if higher bone marrow parasite load estimated by quantitative polymerase chain reaction is associated with severe disease. The estimated median parasite load was 5.0 parasites/10(6) human nucleated cells. It is much higher in deceased than among survivors (median 75.0 versus 4.2). Patients who lost more weight had a higher parasite burden, as well as patients with epistaxis, abdominal pain, edema, and jaundice. This study suggests that higher parasite load is influenced by wasting, which may lead to more severe disease.

Increased levels of thiols protect antimony unresponsive Leishmania donovani field isolates against reactive oxygen species generated by trivalent antimony

The current trend of antimony (Sb) unresponsiveness in the Indian subcontinent is a major impediment to effective chemotherapy of visceral leishmaniasis (VL). Although contributory mechanisms studied in laboratory-raised Sb-R parasites include an up-regulation of drug efflux pumps and increased thiols, their role in clinical isolates is not yet substantiated. Accordingly, our objectives were to study the contributory role of thiols in the generation of Sb unresponsiveness in clinical isolates. Promastigotes were isolated from VL patients who were either Sb responsive (n=2) or unresponsive (n=3). Levels of thiols as measured by HPLC and flow cytometry showed higher basal levels of thiols and a faster rate of thiol regeneration in Sb unresponsive strains as compared with sensitive strains. The effects of antimony on generation of reactive oxygen species (ROS) in normal and thiol-depleted conditions as also their H2O2 scavenging activity indicated that in unresponsive parasites, Sb-mediated ROS generation was curtailed, which could be reversed by depletion of thiols and was accompanied by a higher H2O2 scavenging activity. Higher levels of thiols in Sb-unresponsive field isolates from patients with VL protect parasites from Sb-mediated oxidative stress, thereby contributing to the antimony resistance phenotype.

Diagnosis of canine visceral leishmaniasis: biotechnological advances

Human visceral leishmaniasis (HVL) is endemic in the tropical and sub-tropical regions of Africa, Asia, the Mediterranean, Southern Europe and South and Central America, with approximately 500,000 new cases reported annually. As dogs are considered to be the major reservoirs for HVL, the accurate diagnosis of disease in these animals is important. Diagnosis of canine visceral leishmaniasis (CVL) is performed mainly by direct parasitological methods that can yield false-negative results, either because of the very low number of Leishmania spp. organisms in clinical samples (bone marrow and lymph nodes) or because morphological identification is difficult. In addition, these methods are invasive. Conventional serological techniques are limited by cross-reactivity with other parasitic diseases and because several technical procedures have not been standardised. The development of polymerase chain reaction based approaches and immunoassays based on the use of recombinant antigens aimed at improving the sensitivity and specificity of CVL diagnosis is discussed.

Development of a semi-automated colorimetric assay for screening anti-leishmanial agents

MTS or {3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl}-2H-tetrazolium, inner salt) is converted into soluble formazan by mitochondrial dehydrogenase of viable cells, thus serving as an indicator of cell viability. Accordingly, a MTS-based assay was developed to evaluate anti-leishmanial activity in Leishmania promastigotes from strains responsible for visceral, cutaneous or mucocutaneous leishmaniasis. The assay was initially optimized for the appropriate wavelength (490 nm), culture medium (M-199), incubation time (3 h) and temperature (37 degrees C). Increasing absorbance with increasing cell density confirmed linearity of the assay that was maintained up to 2.5 x 10(6) cells/200 microl. The growth kinetics of six L. donovani strains and six non-L. donovani strains consistently indicated higher absorbances in the L. donovani strains highlighting the importance of strain-specific customization of the MTS assay. The IC(50) values (i.e., the concentration at which 50% of growth was inhibited) of amphotericin B, miltefosine and pentamidine isethionate obtained by the MTS assay corroborated with previously published data. Taken together, the MTS assay thus permits a simple, reproducible and reliable semi-automated method for evaluating cell viability, effective for drug-screening and growth kinetic studies.

Immunostimulatory cellular responses of cured Leishmania-infected patients and hamsters against the integral membrane proteins and non-membranous soluble proteins of a recent clinical isolate of Leishmania donovani

Development of an effective immunoprophylactic agent for visceral leishmaniasis (VL) has become imperative due to the increasing number of cases of drug resistance and relapse. Live and killed whole parasites as well as fractionated and recombinant preparations have been evaluated for vaccine potential. However, a successful vaccine against the disease has been elusive. Because protective immunity in human and experimental leishmaniasis is predominantly of the Th1 type, immunogens with Th1 stimulatory potential would make good vaccine candidates. In the present study, the integral membrane proteins (IMPs) and non-membranous soluble proteins (NSPs), purified from promastigotes of a recent field isolate, Leishmania donovani stain 2001, were evaluated for their ability to induce cellular responses in cured patients (n = 9), endemic controls (n = 5) of visceral leishmaniasis (VL) and treated hamsters (n = 10). IMPs and NSPs induced significant proliferative responses (SI 6.3 +/- 4.1 and 5.6 +/- 2.3, respectively; P < 0.01) and IFN-gamma production (356.3 +/- 213.4 and 294.29 +/- 107.6 pg/ml, respectively) in lymphocytes isolated from cured VL patients. Significant lymphoproliferative responses against IMPs and NSPs were also noticed in cured Leishmania animals (SI 7.2 +/- 4.7 & 6.4 +/- 4.1, respectively; P < 0.01). In addition, significant NO production in response both IMPs and NSPs was also noticed in macrophages of hamsters and different cell lines (J774A-1 and THP1). These results suggest that protective, immunostimulatory molecules are present in the IMP and NSP fractions, which may be exploited for development of a subunit vaccine for VL.

Immunoblot analysis of the humoral immune response to Leishmania donovani polypeptides in cases of human visceral leishmaniasis: its usefulness in prognosis

Sera from Indian patients with parasitologically confirmed visceral leishmaniasis were studied by immunoblot analysis in order to identify a specific pattern for Leishmania infection. A soluble extract of Leishmania donovani was used as antigen. At diagnosis the sera from patients with visceral leishmaniasis specifically recognized fractions represented by bands of 201 kDa (50% of serum samples), 193 kDa (60%), 147 kDa (50%), 120 kDa (60%), 100 kDa (50%), 80 kDa (80%), 70 kDa (70%), 65 kDa (100%), 50 kDa (50%), 36 kDa (50%), 20 kDa (70%), and 18 kDa (50%). The 65-kDa band, common to all patients infected with Leishmania parasites, was found at the time of diagnosis. However, the immunoblot pattern changed after patients were treated and cured with sodium antimony gluconate (SAG; n =10) or miltefosine (n =10), as was evident from blots of sera obtained pretreatment and at 1, 3, and 6 months posttreatment. At 6 months posttreatment, immunoblots of sera from patients on the SAG regimen showed the disappearance of all bands except the 70-kDa band. Similarly, sera from those on the miltefosine regimen showed the disappearance of all bands except the 65- and 70-kDa bands. This study shows that Western blot analysis is a sensitive test for detection of anti-Leishmania antibodies. Moreover, the persistence of reactivity with the 65- and 70-kDa bands in the sera of all groups shows its promise as a diagnostic and prognostic tool.

Diagnosis of visceral leishmaniasis by enzyme-linked immunosorbent assay using urine samples

A diagnostic method has been developed to detect anti-Leishmania donovani immunoglobulin G (IgG) in urine by enzyme-linked immunosorbent assay (ELISA). In measuring anti-L. donovani IgG, IgA, and IgM in urine, the method performed best in the detection of IgG. The sensitivity and specificity of the assay were determined with panels of urine samples from 62 visceral leishmaniasis (VL) patients, 59 healthy controls from areas of endemicity, 53 healthy controls from areas of nonendemicity, 59 malaria patients, 13 tuberculosis patients, 23 cutaneous leishmaniasis patients, and 7 patients with other diseases. Using L. donovani promastigote crude antigen, the test had 93.5% sensitivity (58 positives of 62 VL patient samples) and 89.3% specificity (191 negatives of 214 non-VL patient samples). The ELISA with acetone-treated L. donovani promastigote antigen raised the sensitivity and specificity to 95.0 and 95.3%, respectively. Western blot analysis revealed that most of the samples that cross-reacted with crude antigen in ELISA did not recognize any antigenic component of L. donovani crude antigen. We also checked 40 serum samples from the same group of VL patients for anti-L. donovani IgG and got 90.0% sensitivity with both crude and acetone-treated antigens. As collection of urine is much easier than collection of serum, the detection of anti-L. donovani IgG in urine with acetone-treated antigen will be useful in epidemiological studies. It could be an adjunct of laboratory diagnosis.

Optimisation of an ELISA for the serodiagnosis of visceral leishmaniasis using in vitro derived promastigote antigens

An antibody detection ELISA was developed for diagnosis of visceral leishmaniasis. Antigens released by Leishmania donovani promastigotes into a protein-free medium were used. SDS-PAGE analysis has indicated that Ld-ESM contain several protein antigens. Titration and chequer-board analyses were performed to optimise the assay protocol. Optimal results were obtained when antigen (50 microg/ml) was coated with PBS-methyl glyoxal buffer, and wells blocked with 0.5% casein. A serum dilution of 1:500 in antigen-coated wells, blocked with 0.5% casein, generated lowest absorbance with Ref-ve sera and higher absorbance with Ref+ve sera. All steps of the ELISA were performed at room temperature. The S/N ratio, the differential absorbance between the negative sample vs. the test or Ref+ve sample, was used to quantify the specific antigen and antibody reactions. An anti-human monoclonal antibody conjugated with HRP (MAb-conjugate) outperformed a commercially available anti-human polyclonal antibody conjugate (PAb-conjugate). The MAb-conjugate gave minimal background reactions with endemic sera. Optimised final assay steps mentioned below were used to evaluate sera samples from field trials. ELISA wells were coated with 50 microg/ml Ld-ESM mixed in PBS-methyl glyoxal overnight, and after removing the antigen, blocked with 0.5% casein for 1 h at RT. Patient sera along with control sera, diluted to 1:500 in PBS/T, were reacted for 1 h at RT. After washing the plate with PBS/T, wells were reacted with MAb-conjugate for 40 min at RT, and after washing, binding of antibodies was visualized by using TMB as a chromogen substrate. The relative specific binding was quantified by the S/N ratio. A batch of n=22 endemic sera from North Africa were evaluated and resulted with 100% specificity and sensitivity, 99.99% PPV and 95.45% NPV. The specificity and sensitivity of this assay will be further evaluated in planned retrospective and prospective multi-site trials.

Diagnostic and prognostic potential of a competitive enzyme-linked immunosorbent assay for leishmaniasis in India

A Leishmania donovani species-specific monoclonal antibody (monoclonal antibody D2) was evaluated for its diagnostic and prognostic potential by a competitive enzyme-linked immunosorbent assay (C-ELISA) in sera from Indian patients with visceral leishmaniasis (VL) and seven patients with post-kala-azar dermal leishmaniasis (PKDL). These results were compared with those obtained by microscopy with Giemsa-stained tissue smears and a direct enzyme-linked immunosorbent assay (direct ELISA) with crude parasite antigen. Of 121 patients with clinically diagnosed VL examined, 103 (85.1%) were positive and 11 (9.1%) were negative by all three methods. An additional 7 (5.8%) who were negative by microscopy were positive by both C-ELISA and direct ELISA. Seven PKDL patients were also examined and were found to be positive by all three methods. Analysis of the chemotherapeutic response to sodium antimony gluconate of these 110 serologically positive VL patients showed that 57 (51.8%) were drug responsive and 53 (48.2%) were drug resistant. The C-ELISA with sera from 20 longitudinally monitored VL patients before and after chemotherapy showed a significant decrease in percent inhibition of monoclonal antibody D2 in drug-responsive patients. However, in drug-unresponsive patients, the percent inhibition of D2 was unchanged or was slightly increased. Our results therefore indicate (i) the applicability of L. donovani species-specific monoclonal antibody D2 for sensitive and specific serodiagnosis by C-ELISA, (ii) that the C-ELISA is more sensitive than microscopy, especially for early diagnosis, (iii) that L. donovani is still the main causative agent of VL, irrespective of the chemotherapeutic response, and (iv) that the C-ELISA can be used to evaluate the success of drug treatment.

Distribution of IgG subclasses in antimonial unresponsive Indian kala-azar patients

Sodium antimony gluconate (SAG) is the mainstay of treatment for visceral leishmaniasis (VL) or kala-azar. In view of the increasing incidence of refractoriness to SAG in India, we compared the levels of parasite-specific IgG and IgG subclasses in 20 longitudinally followed up kala-azar patients. In both SAG-responsive (n = 10) and unresponsive patients (n = 10), the levels of total IgG, IgG1, IgG2, IgG3 and IgG4 were increased, the rank order being IgG1 > IgG2 > IgG3 = IgG4. Following treatment, a significant decrease in total IgG and the four subclasses occurred in the SAG-responsive group, whereas in the SAG-unresponsive group these levels were unchanged or slightly increased. Therefore, monitoring of IgG1 and IgG2 levels in Indian kala-azar patients is a good serologic alternative to monitoring the disease status.

Antibody response against a Leishmania donovani amastigote-stage-specific protein in patients with visceral leishmaniasis

The antibody response against an amastigote-specific protein (A2) from Leishmania donovani was investigated. Sera from patients with trypanosomiasis and various forms of leishmaniasis were screened for anti-A2 antibodies. Sera from patients infected only with L. donovani or Leishmania mexicana specifically recognized the A2 recombinant protein. These results were consistent with karyotype analyses which revealed that the A2 gene is conserved in L. donovani and L. mexicana strains. The potential of this antigen in diagnosis was further explored by screening a series of sera obtained from patients in regions of the Sudan and India where L. donovani is endemic. The prevalence of anti-A2 antibodies was determined by Western blotting for all samples. Enzyme-linked immunosorbent assay (ELISA) and an immunoprecipitation assay were also performed on some of the samples. Anti-A2 antibodies were detected by ELISA in 82 and 60% of the samples from individuals with active visceral leishmaniasis (kala-azar) from the Sudan and India, respectively, while the immunoprecipitation assay detected the antibodies in 92% of the samples from India. These data suggest that the A2 protein may be a useful diagnostic antigen for visceral leishmaniasis.

Serological diagnosis of visceral leishmaniasis by a dot-enzyme immunoassay for the detection of a Leishmania donovani-related circulating antigen

Field medicine in tropical areas needs laboratory assays which are inexpensive and easy to perform. To meet this need a semi-quantitative dot-enzyme immunoassay (EIA) was developed for the detection of an L. donovani-related circulating antigen and tested for clinical relevance in the diagnosis of visceral leishmaniasis (VL). The dot-EIA probes serum spotted on nitrocellulose for the presence of the antigen using a monoclonal antibody raised against L. donovani promastigotes, a peroxidase-conjugated rabbit anti-mouse immunoglobulin antiserum and chloronaphthol as peroxidase substrate. The intensity of dot staining by chloronaphthol is read by eye and scored. The dot-EIA was used to test the following groups: 69 patients with VL from Brazil, Kenya, China and France, nine patients with cutaneous leishmaniasis, 38 patients with tropical diseases other than VL, five patients with rheumatoid arthritis and 40 health blood donors. The specificity of the assay was 96.7% (3/92 false positive) and the sensitivity 98.5% (1/69 false negative). A quantitative EIA for the detection of serum antibodies which makes use of a crude, soluble L. infantum promastigote extract as capture antigen and which was used as the reference method, proved to be more specific (98.9%) but similarly sensitive (98.5%). It should be possible to produce a kit, suitable for large scale application at low cost in order to facilitate routine use of the dot-EIA in the diagnosis of VL.

Monoclonal antibodies for the identification of New World Leishmania species

Monoclonal antibodies specific for selected species complexes of Leishmania have been employed for the characterization of several representative strains of Leishmania isolated from different hosts and localities in the Americas. In the past 15 years, data have been accumulated concerning (i) the specificities of a number of these monoclonal antibodies and (ii) the antigenic variation (level of the expressed antigenic determinants) occurring among New World Leishmania species or strain variants as recognized by the monoclonal antibodies. This report is an attempt to summarize in brief the data accumulated to date on these points and to indicate the directions for future applications of these specific monoclonal antibodies for identification of leishmanial isolates.

Detection of Leishmania in the blood of early kala-azar patients with the aid of the polymerase chain reaction

Samples from 39 patients with symptoms suggestive of early visceral leishmaniasis were independently assayed by microscopy of tissue smears, enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR) of blood deoxyribonucleic acid. Of these patients, 19 were confirmed as positive or negative by all 3 tests; 11 patients (28%) negative by smear were positive by ELISA and PCR; and 7 (18%) were positive by PCR alone. These results demonstrate the high sensitivity of the non-invasive PCR and, to a smaller extent, ELISA, in the early diagnosis of visceral leishmaniasis.

Leish-KIT, a stable direct agglutination test based on freeze-dried antigen for serodiagnosis of visceral leishmaniasis

In order to increase the application potential of the direct agglutination test (DAT) for the detection of anti-Leishmania antibodies in human serum samples, we developed an antigen based on stained and freeze-dried Leishmania donovani promastigotes. We describe here the evaluation of the performance of the DAT based on this freeze-dried antigen. It was shown that the freeze-dried antigen remains fully active, even after storage at 56 degrees C for 18 months. With a cutoff value of 1:1,600, the sensitivity of the DAT was shown to be 92% and the specificity of the test was 99.7%, which were comparable with the results found for the DAT based on liquid antigen. The major advantages of the freeze-dried antigen are that the production of a large batch of this antigen allows reproducible results in the DAT over a long period of time and that the freeze-dried antigen can be stored at ambient temperature, which, as was shown, makes the test a valuable diagnostic tool for use in the field.

Epitopes in the 19kDa fragment of the Plasmodium falciparum major merozoite surface protein-1 (PfMSP-1(19)) recognized by human antibodies

The antibody response to two different epitopes located in the C-terminal 19kDa fragment of the Plasmodium falciparum merozoite surface protein-1 (MSP-1(19)) has been studied using a competitive ELISA based on the inhibition of monoclonal antibody (MoAb) binding by serum samples. Sera from children aged three to eight years who suffered clinical symptoms of malaria, or were partially immune with an asymptomatic infection, and from adults all living in The Gambia, West Africa were tested. The results suggest that the antibody response to MSP-1(19) has a role in naturally-acquired immunity in Gambian individuals.

Serodiagnosis of leishmaniasis

Leishmaniasis is a spectrum of diseases ranging in severity from cutaneous (CL), post-kala-azar dermal (PKDL), and diffuse cutaneous (DCL) to mucocutaneous (MCL) and visceral (VL) infections that are endemic in 86 tropical and subtropical countries around the world, accounting for 75,000 deaths per year. Different forms of leishmaniases are generally caused by different distinct species of Leishmania having a digenetic life cycle alternating between an aflagellated amastigote form replicative within the macrophages of the host and a flagellated promastigote form that multiplies within the gut of the sandfly. VL, MCL, PKDL, DCL, and CL forms of the disease can be arranged on a priority basis in accordance with the humoral immune responses of host. Generally, the cell-mediated immunity, particularly the delayed-type hypersensitivity to leishmanial antigens, is associated with CL, MCL, PKDL, and cured VL cases. The serodiagnosis of leishmaniasis appears to be an alternative to parasite detection in biopsy samples either by the staining of amastigotes or by culturing the amastigotes, which transform to a promastigote form and replicate. A battery of immunological procedures have been developed or adapted to demonstrate either humoral or cell-mediated immune responses against Leishmania for diagnosis and epidemiological survey. The sensitivity and specificity of such diagnostic methods depend on the type, source, and purity of antigen employed, as some of the leishmanial antigens have common cross-reactive epitopes shared with other microorganisms, particularly Trypanosoma, Mycobacteria, Plasmodia, and Schistosoma. Serodiagnostic techniques for the detection of antileishmanial antibodies have been employed with about 72 to 100, 23 to 90, 83, and 33 to 100% success in VL, CL, MCL, and PKDL patients, respectively. The Leishmanin skin test (LST) is useful to detect MCL and CL, with about 100 and 84% success, respectively. In PKDL, the gradual fall of antileishmanial antibody titer to some extent and the rise of delayed hypersensitivity to the parasite antigen are the characteristic features associated with the chronicity of the disease. The use of whole promastigote as the source of antigens in the direct agglutination test (DAT) and immunofluorescent test (IFAT) gave cross-reactions with the sera of leprosy, tuberculosis, and African trypanosomiasis patients. Again, the use of cell-free extracts of promastigotes generally gave false positive results with the sera of normal human and Chagas' disease, leprosy, tuberculosis, and malaria patients in enzyme-linked immunosorbent assay (ELISA), dot ELISA, immunodiffusion, immunoelectrophoresis, and counter-current immunoelectrophoresis tests.(ABSTRACT TRUNCATED AT 400 WORDS)

Cross-reactivity studies and differential serodiagnosis of human infections caused by Trypanosoma cruzi and Leishmania spp; use of immunoblotting and ELISA with a purified antigen (Ag163B6)

Results of our studies on the reactivity of chagasic and leishmaniasic sera with the purified T. cruzi-specific antigen 163B6, as assessed by ELISA, and with complex antigenic mixtures from T. cruzi and Leishmania mexicana, by immunoblotting, are presented here. Our objective was to identify the antigens responsible for the exhibited cross-reactivity between trypanosomiasis and leishmaniasis, and to find a specific reactivity pattern corresponding to each parasitosis. In spite of the high cross-reactivity observed with the immunoblotting, the use of 7.5% A-B gels made it possible to identify a characteristic pattern for each parasitosis, that could be distinguished by the naked eye. The characteristic pattern corresponding to chagasic patients was ascribed to reactivity with T. cruzi bands of mol. wts 131, 125, 116, 111, 51-45 and 43 kD, that were not recognized by leishmaniasic sera. Trypanosoma cruzi antigens of mol. wts 85, 81, 70, 65-60, 37 and 32 kD were considered as crossing antigens, since they were recognized by leishmaniasis sera. With L. mexicana, most of the chagasic patients presented reaction with antigen of mol. wts 124, 107, 92, 59 and 32 kD, while bands of mol. wts 155, 140, 73, 56 and 48 kD were recognized only by leishmaniasic sera. In this study we found 12 out of 45 sera of patients with leishmaniasis, from a region endemic for both parasitoses, which exhibited a pattern of bands very similar to those corresponding to chagasic individuals, strongly suggesting a mixed infection. This hypothesis was verified by using a purified specific antigen of T. cruzi, Ag163B6, which would be the major cysteine proteinase of this specie (cruzipain). By ELISA, these 12 sera showed a positive reaction with this purified antigen, as those of chagasic patients, thus leading to the confirmation of the presence of a mixed infection.

Lung diseases in the tropics. Part 1: Tropical granulomatous disorders of the lung: diagnosis and management

International travel, student and cultural exchanges and changing immigration patterns are insidiously transforming the face of medicine in the United States, Europe and other developed countries. It is essential that the practising clinician be aware of the increasing prevalence of various new and exotic tropical lung diseases. The definitive diagnosis of the pulmonary granulomas that constitute the bulk of lung disorders in the tropics is important since the treatment varies significantly. At the same time, recent developments in molecular biology, immunology and biochemistry have increased the diagnostic accuracy and therapeutic effectiveness related to tropical granulomatous disorders. Clinicians in the developing countries can now supplement their clinical acumen with rapid advances in immunology and histopathology enabling them to grasp the fundamental mechanisms of granuloma formation. Mycobacterial, fungal, parasitic, spirochetal and other infections must be differentiated from a variety of non-infectious granulomas including sarcoidosis, hypersensitivity pneumonitis, drug reaction and generalized vasculitis since therapy is vastly different. The treatment, if inappropriate, may not only be worthless but, in many cases, extremely harmful and even fatal.

Leishmaniases of the New World: current concepts and implications for future research

Recent epidemiologic studies indicate that leishmaniasis in the Americas is far more abundant and of greater public health importance than was previously recognized. The disease in the New World is caused by a number of different parasite species that are capable of producing a wide variety of clinical manifestations. The outcome of leishmanial infection in humans is largely dependent on the immune responsiveness of the host and the virulence of the infecting parasite strain. This article reviews current concepts of the clinical forms, immunology, pathology, laboratory diagnosis, and treatment of the disease as well as aspects of its epidemiology and control. Recommendations for future research on the disease and its control are made.

Serodiagnosis of human paragonimiasis by ELISA-inhibition test using monoclonal antibodies

ELISA-inhibition test using Paragonimus westermani specific monoclonal antibody (Mab) was investigated to improve the diagnostic specificity of paragonimiasis. By cell fusion, one hybridoma clone secreting anti-P. westermani specific Mab was selected (Pwa-14), which reacted on bands of 28 kDa, 42.5 kDa, 89 kDa and 120.5 kDa. IFA showed Pwa-14 was located at the vitelline follicles. By micro-ELISA, 100% of 22 paragonimiasis cases were found positive, but 5 of 40 clonorchiasis cases (12.5%), 3 of 26 cysticercosis cases (7.7%) showed false positive. None of 10 sparganosis patients or 28 normal controls reacted positively. On the other hand, by ELISA-inhibition test using a P. westermani specific Mab, 100% of paragonimiasis cases were found positive, and there were no positive in cysticercosis, sparganosis cases or normal controls, except 2 (5.0%) false-positive sera of 40 clonorchiasis cases. The ELISA-inhibition test using a Mab showed higher specificity in comparison with micro-ELISA for serodiagnosis of human paragonimiasis.

Serodiagnosis of cysticercosis by ELISA-inhibition test using monoclonal antibodies

Monoclonal antibodies (Mabs) were produced against crude scolex extract of T. solium metacestodes, and applied to ELISA-inhibition test for improving the specificity of serodiagnosis of human cysticercosis. Four hybridomas secreting species-specific anticysticercal Mabs (Cya-1, Cya-7, Cya-28 and Cya-31) were selected. Each Mab reacted on antigenic components of 25.5 kDa (Cya-1), 28 kDa (Cya-7), 87.5 kDa (Cya-28), and 12.5 kDa (Cya-31). IFA showed that Cya-1 was located at the calcium corpuscles, and Cya-7 at the loose connective tissue of T. solium metacestode scolex. Cya-28 and Cya-31 reacted on the tegument of the scolex. By conventional ELISA, 23 out of 28 (82.1%) cysticercosis patients were found serologically positive, but 1 out of 9 (11.1%) sparganosis cases and 6 out of 31 (19.4%) paragonimiasis cases showed false positives. By ELISA-inhibition test using species-specific anti-cysticercal Mab Cya-7, 19 out of 28 (67.9%) cysticercosis cases were found serologically positive, but there were no false positives in other parasitic infections.

Evaluation of a monoclonal antibody-based competition ELISA for the diagnosis of human hydatidosis

An antibody competition enzyme-linked immunosorbent assay (ELISA) using 4 different monoclonal antibodies (MAb) raised against major antigens (Antigen 5 and Antigen B) of Echinococcus granulosus was evaluated for the diagnosis of human hydatidosis. The competition assay, using anti-Ag5 MAb 24.14, detected specific antibodies in 70% (131/188) of sera from patients with surgically confirmed E. granulosus infection and 38.5% (10/26) of sera from patients with E. multilocularis infection. None of the sera from patients with Taenia solium cysticercosis (10), T. saginata (2), filariasis (22), strongyloidiasis (19), fascioliasis (4), bilharziasis (4) and amoebiasis (2) tested were positive using a cut-off point established through reaction between MAb 24.14 and normal human sera. The combined use of the MAb 24.14-based competition ELISA with the conventional antibody-binding assay provides a highly sensitive (92.8%) and specific screening system for human hydatid disease diagnosis.

Serodiagnosis of parasitic diseases

In this review on serodiagnosis of parasitic diseases, antibody detection, antigen detection, use of monoclonal antibodies in parasitic serodiagnosis, molecular biological technology, and skin tests are discussed. The focus at the Centers for Disease Control on developing improved antigens, a truly quantitative FAST-enzyme-linked immunosorbent assay, and the very specific immunoblot assays for antibody detection is highlighted. The last two assays are suitable for field studies. Identification of patient response in terms of immunoglobulin class or immunoglobulin G subclass isotypes or both is discussed. Immunoglobulin isotypes may asist in defining the stage of some diseases. In other instances, use of a particular anti-isotype conjugate may increase the specificity of the assay. Monoclonal antibodies have played important roles in antigen purification and identification, in competitive antibody assays with increased sensitivity and specificity, and in assays for antigen detection in serum, body fluids, or excreta. Molecular biological technology has allowed significant advances in the production of defined parasitic serodiagnostic antigens.

Serodiagnosis of canine visceral leishmaniasis in Portugal: comparison of three methods

Sera collected in Portugal from 43 dogs were screened for specific antibodies to Leishmania donovani antigens. Three different techniques were compared: an indirect immunofluorescence assay (IFA), a direct enzyme-linked immunosorbent assay (ELISA) and a competitive-ELISA (C-ELISA) using two species-specific monoclonal antibodies, D2 and D13. By IFA, 22 of the sera examined showed positive reactions, compared with 26 by ELISA or 27 by C-ELISA. There was no direct correlation observed between the serum titre by IFA and the strength of the reaction in ELISA or inhibition in C-ELISA. However, a good correlation was observed between sera identified as positive (95.5%) by all three techniques. Western blotting on leishmanial membranes showed that common antigens with Mr of 26,000 and 70-84,000 were recognized by all infected dog sera, regardless of the serum titre. In large scale studies, ELISAs are preferred to IFA for the rapid diagnosis of canine visceral leishmaniasis because of their greater simplicity.

Immunoblot analysis of the humoral immune response to Leishmania donovani infantum polypeptides in human visceral leishmaniasis

Using the immunoblot technique, we have compared the reactions of Leishmania donovani infantum polypeptides with the immunoglobulin G of human sera from patients with parasitologically proven L. d. infantum infection, with suspected visceral leishmaniasis, and with other leishmaniases, protozoiases, helminthiases, and fungal or bacterial diseases. A 94-kDa component reacted with all L. d. infantum-infected sera and with 75% of sera from patients with clinical and serological but no parasitological diagnoses. No reaction was observed with sera from patients in the other disease groups or with control sera. Studies of eight different isolates, subspecies, and species of the genus Leishmania demonstrated that the 94-kDa component was expressed in all strains examined.

Evidence of genetic recombination in Leishmania

In the genus Leishmania there has been no convincing demonstration of genetic exchange, and it has been proposed that reproduction is clonal. However, preliminary characterization of two strains of Leishmania isolated from wild animals in a zoonotic focus of cutaneous leishmaniasis in the Eastern Province of Saudi Arabia, has suggested that they may represent hybrids of Leishmania major and Leishmania arabica. Evidence presented here strongly supports this hypothesis. Isoenzyme analysis and molecular karyotyping of cloned organisms indicated that the putative hybrids are distinct from other species of Leishmania, and possess characteristics of both L. major and L. arabica. Experiments using highly specific probes demonstrated that kinetoplast minicircle DNA from the putative hybrid contained L. major-specific, but not L. arabica-specific sequences. DNA fingerprinting data obtained using 6 genomic DNA probes were consistent in all cases with a L. major/L. arabica recombinant genotype, and implied both diploidy and allelic segregation. These observations suggest that sexual reproduction may generate genetic diversity within natural Leishmania populations.

Canine visceral leishmaniasis at Wadi Hamam, in Israel

A preliminary survey of canine leishmaniasis was made in Israel by serodiagnosis, using a direct and competitive enzyme-linked immunosorbent assay. Three (4%) of the 75 dogs surveyed were seropositive. The infected dogs came from Wadi Hamam near Tiberias in northern Israel. Parasites isolated from one dog by needle aspiration were identified as Leishmania donovani sensu lato by their excreted factor.

Purification and characterization of an 80-kilodalton membrane protein from Leishmania donovani

Visceral leishmaniasis is caused by the protozoan parasite Leishmania donovani. We previously described the development of 16 monoclonal antibodies specific for L. donovani. The epitope recognized by one of these monoclonal antibodies, D13, is present at high density on nearly all isolates of L. donovani and, along with two other monoclonal antibodies, has been used to develop a sensitive and specific competitive assay for serodiagnosis of visceral leishmaniasis. In this report, we characterize the antigens recognized by D13 by immunoprecipitation of [35S]methionine-labeled promastigotes as two proteins (apparent molecular mass, 72 and 80 kilodaltons). Pulse-chase studies showed no evidence of a precursor-product relationship for the two proteins. We purified the 80-kilodalton protein (p80) to homogeneity by detergent solubilization of promastigote membranes, immunoaffinity chromatography, and ion-exchange chromatography. The epitope on p80 recognized by D13 was completely destroyed by proteolysis but was not affected by periodic acid treatment. P80 did not bind to the radioiodinated lectins concanavalin A, wheat germ agglutinin, and Ricinus communis agglutinin. Its apparent molecular mass was not affected by tunicamycin. Thus, it does not appear to be glycosylated. This protein is highly immunogenic and may prove useful for immunoprophylaxis and serodiagnosis of visceral leishmaniasis.

Specific serodiagnosis of visceral leishmaniasis using a Leishmania donovani antigen identified by expression cloning

A lambda gt11 expression library was constructed using mRNA from the promastigote form of Leishmania donovani (African isolate MHOM/ET/67/HU3). The library was screened with serum obtained from a patient who contracted visceral leishmaniasis in the Sudan. Several cDNA clones which expressed beta-galactosidase/L. donovani antigen fusion proteins were isolated. One of these clones corresponded to a 60 kDa membrane-associated antigen. By a Western blot assay antibodies against the fusion protein were detected universally in the sera of visceral leishmaniasis patients. They were not detected in sera from patients with cutaneous leishmaniasis or other parasitic protozoan infections. The gene coding for this antigen was specific to the genus Leishmania as judged by DNA hybridisation, and its chromosomal location was conserved. A 20 kb mRNA was detected on Northern blots of promastigote RNA.

Purification of two Leishmania donovani membrane proteins recognized by sera from patients with visceral leishmaniasis

Two Leishmania donovani membrane proteins recognized by sera from patients with visceral leishmaniasis were purified using species-specific monoclonal antibodies and characterized. The molecular weights of the proteins, as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, were approximately 70,000 and approximately 72,000, respectively. The 70 kDa protein, which appears as a diffuse band on silver staining, was resolved into a doublet by Western blotting with monoclonal antibody. Though of similar molecular weight and amino acid composition, the two proteins were shown to be distinct by peptide mapping and Western blotting of the purified material. The two proteins are recognized specifically by human visceral leishmaniasis serum and not by serum from cutaneous leishmaniasis or Chagas' disease. These proteins will be useful in developing a direct serodiagnostic assay for visceral leishmaniasis.