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Kariyawasam R, Lau R, Valencia BM, Llanos-Cuentas A, Boggild AK. Novel detection of Leishmania RNA virus-1 (LRV-1) in clinical isolates of Leishmania Viannia panamensis. Parasitology 2024; 151:151-156. [PMID: 38031433 PMCID: PMC10941039 DOI: 10.1017/s0031182023001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/16/2023] [Accepted: 11/26/2023] [Indexed: 12/01/2023]
Abstract
American tegumentary leishmaniasis comprises a discrete set of clinical presentations endemic to Latin America. Leishmania RNA virus-1 (LRV-1) is a double-stranded RNA virus identified in 20–25% of the Leishmania Viannia braziliensis and L. V. guyanensis, however not in L. V. panamensis. This is the first report of LRV-1 in L. V. panamensis and its associations with clinical phenotypes of ATL. Unique surplus discard clinical isolates of L. V. panamensis were identified from the Public Health Ontario Laboratory (PHOL) and the Leishmania Clinic of the Instituto de Medicina Tropical ‘Alexander von Humboldt’ between 2012 and 2019 and screened for LRV-1 by real-time polymerase chain reaction. Patient isolates were stratified according to clinical phenotype. Of 30 patients with L. V. panamensis, 14 (47%) and 16 (53%) patients had severe and non-severe ATL, respectively. Five (36%) of 14 severe cases and 2 (12%) of 16 non-severe cases were positive for LRV-1, respectively. No differences in sex were observed for clinical phenotype and LRV-1 status. Although an association between LRV-1 status and clinical phenotype was not demonstrated, this is the first description of the novel detection of LRV-1 in L. V. panamensis, a species that has been documented predominantly in Central America.
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Affiliation(s)
- Ruwandi Kariyawasam
- Department of Laboratory Medicine & Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada
- Alberta Precision Laboratories-Public Health, Edmonton, AB T6G 2J2, Canada
| | - Rachel Lau
- Public Health Ontario Laboratory, Toronto, ON M5G 1M1 Canada
| | - Braulio M. Valencia
- Instituto de Medicina Tropical ‘Alejandro von Humboldt’, Lima, Peru
- Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Andrea K. Boggild
- Department of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Tropical Disease Unit, Toronto General Hospital, Toronto, ON M5G 2C4, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada
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Oliveira D, Lopes KF, de Avelar DM, Cota G, Oliveira E. Accuracy of serological tests in diagnosing mucosal leishmaniasis. Parasitol Res 2023; 122:2001-2010. [PMID: 37391643 DOI: 10.1007/s00436-023-07900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/12/2023] [Indexed: 07/02/2023]
Abstract
In this serum panel-based study, we evaluated the accuracy of serological tests originally developed for visceral leishmaniasis (VL), for diagnosis of mucosal leishmaniasis (ML). A total of five tests were evaluated, four of which are registered at the National Agency of Sanitary Surveillance (Agência Nacional de Vigilância Sanitária-ANVISA) (RIDASCREEN® Leishmania Ab from R-Biopharm AG., Leishmania ELISA IgG + IgM from Vircell S.L., IFI Leishmaniose Humana-BioManguinhos, and IT-LEISH® from Bio-Rad Laboratories, Inc.), and the other a direct agglutination test (DAT-LPC) prototype kit developed at Fiocruz. The panel was composed of 40 serum samples from patients with confirmed ML and 20 from patients with mucosal involvement and negative parasitological/molecular tests for leishmaniasis and confirmation of another etiology. All cases were treated from 2009 to 2016 in a referral center for leishmaniasis in Belo Horizonte, Minas Gerais, Brazil (Instituto René Rachou, Fiocruz). Diagnostic accuracy, based on the cut-off point for VL diagnosis, was 86.2% with RIDASCREEN® Leishmania Ab, 73.3% with Leishmania ELISA IgG + IgM, and 66.7% with IFI Leishmaniose Humana, while IT-LEISH® and DAT-LPC had the lowest accuracy (38.3%), despite high specificity (100% and 95%, respectively). New cut-off points defined with sera from ML patients improved accuracy from 86.2 to 89% (p = 0.64) and 73.3 to 88% (p = 0.04) for RIDASCREEN® Leishmania Ab and Leishmania ELISA IgG + IgM, respectively. Moreover, these tests presented greater sensitivity and immunoreactivity in patients with moderate/severe clinical ML forms. The data of this study suggest that ELISA assays can contribute to laboratory diagnosis, especially for patients with moderate or severe mucosal involvement.
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Affiliation(s)
- Diana Oliveira
- Clinical Research and Public Politics in Infectious and Parasitic Diseases, Instituto René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Karine Ferreira Lopes
- Clinical Research and Public Politics in Infectious and Parasitic Diseases, Instituto René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Daniel Moreira de Avelar
- Clinical Research and Public Politics in Infectious and Parasitic Diseases, Instituto René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil
| | - Gláucia Cota
- Clinical Research and Public Politics in Infectious and Parasitic Diseases, Instituto René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil.
| | - Edward Oliveira
- Clinical Research and Public Politics in Infectious and Parasitic Diseases, Instituto René Rachou, Oswaldo Cruz Foundation, Belo Horizonte, Minas Gerais, Brazil.
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Rahmanipour M, Mohebali M, Koosha M, Kazemirad E, Yasami-Khiabani S, Mirjalali H, Hajjaran H. Effect of Leishmania RNA virus 2 on virulence factors and cytokines gene expression in a human macrophage infected with Leishmania major: A preliminary study. Exp Parasitol 2023; 246:108459. [PMID: 36596336 DOI: 10.1016/j.exppara.2022.108459] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/30/2022] [Indexed: 01/01/2023]
Abstract
Cutaneous leishmaniasis (CL) is one of the most important infectious parasitic diseases in the world caused by the Leishmania parasite. In recent decades, the presence of a virus from the Totiviridae family has been proven in some Leishmania species. Although the existence of LRV2 in the Old world Leishmania species has been confirmed, almost no studies have been done to determine the potential impact of LRV2 on the immunopathogenicity of the Leishmania parasite. In this preliminary study, we measured the expression of target genes, including Glycoprotein 63 (gp63), Heat Shock Protein 70 (hsp70), Cysteine Protease b (cpb), Interleukin 1 beta (IL-1β), IL8 and IL-12 in LRV2 positive Leishmania major strain (LRV2+L. major) and LRV2 negative L. major strain (LRV2-L. major). We exposed THP-1, a human leukemia monocytic cell line, to promastigotes of both strains. After the initial infection, RNA was extracted at different time points, and the relative gene expression was determined using a real-time quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Findings showed that the presence of LRV2 in L. major was able to increase the expression of gp63, hsp70, and cpb genes; also, we observed lower levels of expression in cytokine genes of IL-1β, IL-8, IL-12 in the presence of LRV2+, which are critical factors in the host's immune response against leishmaniasis. These changes could suggest that the presence of LRV2 in L. major parasite may change the outcome of the disease and increase the probability of Leishmania survival; nevertheless, further studies are needed to confirm our results.
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Affiliation(s)
- Milad Rahmanipour
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohebali
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Center for Research of Endemic Parasites of Iran (CREPI), Tehran University of Medical Sciences, Tehran, Iran.
| | - Mona Koosha
- Department of Medical Entomology & Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Kazemirad
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamed Mirjalali
- Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homa Hajjaran
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Zoonoses Research Center, Ardabil University of Medical Sciences, Ardabil, Iran.
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Shita EY, Semegn EN, Wubetu GY, Abitew AM, Andualem BG, Alemneh MG. Prevalence of Leishmania RNA virus in Leishmania parasites in patients with tegumentary leishmaniasis: A systematic review and meta-analysis. PLoS Negl Trop Dis 2022; 16:e0010427. [PMID: 35675332 PMCID: PMC9236231 DOI: 10.1371/journal.pntd.0010427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 06/27/2022] [Accepted: 04/18/2022] [Indexed: 11/18/2022] Open
Abstract
Background Cutaneous leishmaniasis is caused by different protozoan parasites of the genus Leishmania. Leishmania RNA virus (LRV) was identified as the first Leishmania infecting virus in 1998. Different studies showed the presence and role of the LRV in Leishmania parasites causing cutaneous leishmaniasis (CL). However, there is limited data on the pooled prevalence of LRV in Leishmania parasites causing CL. Therefore, the aim of this systematic review and meta-analysis was to determine the pooled prevalence of LRV in Leishmania parasite isolates and/or lesion biopsies in patients with CL from the available literature globally. Methodology We retrieved the studies from different electronic databases. The studies were screened and identified based on the inclusion and exclusion criteria. We excluded studies exclusively done in experimental animals and in vitro studies. The review was conducted in line with PRISMA guidelines. The meta-analysis was performed with Stata software version 14 with metan command. The forest plot with random-effect model was used to estimate the pooled prevalence with 95% confidence interval. Inverse variance index (I2) was used to assess the heterogeneity among the included articles. Principal findings A total of 1215 samples from 25 studies were included. Of these, 40.1% (487/1215) were positive for LRV. The overall pooled prevalence of LRV globally was 37.22% (95% CI: 27.54% - 46.90%). The pooled prevalence of LRV in the New World (NW) and Old World (OW) regions was 34.18% and 45.77%, respectively. Leishmania guyanensis, L. braziliensis, L. major, and L. tropica were the most studied species for the detection of LRV. The prevalence of LRV from Leishmania isolates and lesion biopsies was 42.9% (349/813) and 34.3% (138/402), respectively. Conclusion This systematic study revealed that there is high prevalence of LRV in Leishmania parasites isolated from patients with CL. More comprehensive studies would be required to investigate the presence of the LRV in other Leishmania species such as L. aethiopica to fully understand the role of LRV in different clinical manifestations and disease pathology presented in CL patients. Cutaneous leishmaniasis (CL) is among the most neglected tropical diseases affecting a significant proportion of the world population, impacting mostly on the poorest communities. CL can present as localized, mucocutaneous or diffuse cutaneous. There are various reports on the prevalence of Leishmania RNA virus (LRV) in Leishmania parasites and/or lesion biopsies in patients with CL from both the Old World and New World regions. However, there is scarcity of comprehensive knowledge on the pooled prevalence of the virus in Leishmania parasites causing human CL. We searched different electronic databases and Google Scholar for published articles aimed to determine the presence of LRV in Leishmania parasites and/or lesion biopsies in patients with CL globally. The retrieved articles were screened according to the inclusion and exclusion parameters. Data was extracted based on the PRISMA guideline by reviewing the selected articles. Systematic review and meta-analysis would be one way to improve the level of evidence by providing pooled prevalence of the individual single studies regarding the presence of LRV in Leishmania parasites and/or lesion biopsies. This systematic review and meta-analysis revealed that a large proportion of the Leishmania parasites causing human CL harbour the endosymbiotic LRV. Further studies are needed to better understand the role of the virus in the clinical presentation of CL, as a potential target of treatment and vaccine development especially in Old World Leishmania parasites like L. aethiopica.
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Affiliation(s)
- Endalew Yizengaw Shita
- Department of Medical Laboratory Science, College of Medicine and Health science, Bahir Dar University, Bahir Dar, Ethiopia
- Institute of Biotechnology, Bahir Dar University, Bahir Dar, Ethiopia
- * E-mail:
| | - Endalkachew Nibret Semegn
- Institute of Biotechnology, Bahir Dar University, Bahir Dar, Ethiopia
- Department of Biology, College of Science, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Abaineh Munshea Abitew
- Institute of Biotechnology, Bahir Dar University, Bahir Dar, Ethiopia
- Department of Biology, College of Science, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Mekuanint Geta Alemneh
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Center for innovative Drug development and Therapeutic trials for Africa (CDT-Africa), College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
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Kariyawasam R, Lau R, Valencia BM, Llanos-Cuentas A, Boggild AK. Leishmania RNA Virus 1 (LRV-1) in Leishmania ( Viannia) braziliensis Isolates from Peru: A Description of Demographic and Clinical Correlates. Am J Trop Med Hyg 2020; 102:280-285. [PMID: 31837129 DOI: 10.4269/ajtmh.19-0147] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RNA virus 1-1 (LRV-1-1) is a dsRNA virus identified in isolates of Leishmania (Viannia) braziliensis and thought to advance localized cutaneous leishmaniasis (LCL) to mucocutaneous or mucosal leishmaniasis (MCL/ML). We examined the prevalence of LRV-1 and its correlation to phenotypes of American tegumentary leishmaniasis caused by L. (V.) braziliensis from Peru to better understand its epidemiology. Clinical isolates of L. (V.) braziliensis were screened for LRV-1 by real-time polymerase chain reaction (PCR) and stratified according to the phenotype: LCL (< 4 ulcers in number) MCL/ML; inflammatory ulcers (erythematous, purulent, painful ulcers with or without lymphatic involvement) or multifocal ulcers (≥ 4 in ≥ 2 anatomic sites). Proportionate LRV-1 positivity was compared across phenotypes. Of 78 L. (V.) braziliensis isolates, 26 (54.2%) had an inflammatory phenotype, 22 (28%) had the MCL/ML phenotype, whereas 30 (38.5%) had LCL. Mucocutaneous or mucosal leishmaniasis was found exclusively in adult male enrollees. Leishmania RNA virus 1 positivity by phenotype was as follows: 9/22 (41%) with MCL/ML; 5/26 (19%) with an inflammatory/multifocal cutaneous leishmaniasis phenotype; and 7/30 (23%) with LCL (P = 0.19). Leishmania RNA virus 1 positivity was not associated with age (P = 0.55) or gender (P = 0.49). Relative LRV-1 copy number was greater in those with MCL/ML than those with inflammatory/multifocal CL (P = 0.02). A direct association between LRV-1 status and clinical phenotype was not demonstrated; however, relative LRV-1 copy number was highest in those with MCL/ML. Future analyses to understand the relationship between viral burden and pathogenesis are required to determine if LRV-1 is truly a contributor to the MCL/ML phenotype.
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Affiliation(s)
| | - Rachel Lau
- Public Health Ontario Laboratory, Toronto, Canada
| | - Braulio M Valencia
- Viral Immunology Systems Program, Kirby Institute, University of New South Wales, Australia
| | | | - Andrea K Boggild
- Public Health Ontario Laboratory, Toronto, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Tropical Disease Unit, Toronto General Hospital, Toronto, Canada
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Saberi R, Fakhar M, Mohebali M, Anvari D, Gholami S. Global status of synchronizing Leishmania RNA virus in Leishmania parasites: A systematic review with meta-analysis. Transbound Emerg Dis 2019; 66:2244-2251. [PMID: 31376334 DOI: 10.1111/tbed.13316] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/01/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
Leishmaniasis is one of the most neglected tropical diseases caused by protozoan parasites belonging to the genus Leishmania. There is much evidence regarding prevalence of Leishmania RNAvirus (LRV) causing Old World leishmaniasis (OWL) and New World leishmaniasis (NWL); however, a combined evidence-based knowledge on this topic is not still available. The purpose of this systematic review and meta-analysis was to address the global status of synchronizing LRV in Leishmania in the available literature. The data were systematically collected from the English electronic databases up to May 2018. Then, the studies were screened based on the inclusion and exclusion criteria. The random-effect model was used by forest plot with 95% confidence interval (CI). Overall, 877 samples from 17 articles were included in this study. Given species of Leishmania, the highest prevalence of LRV belonged to Leishmania (L.) Viannia (V.) guyanensis and L. V. braziliensis. Additionally, the virus was detected also in L. V. amazonensis, L. V. panamanensis, L. V. lainsoni, L. aethiopica, L. major and L. infantum. By random-effect model, the global prevalence of LRV was estimated to be 26.2% (95% CI: 14.4% - 40.1%). The high prevalence of LRV among causative agents of NWLisolated from the metastatic clinical forms suggests potential association of LRV with metastatic clinical forms in New World endemic regions. A comprehensive investigation on experimental and clinical aspects of LRV is needed to fully appraise the role of these viruses in pathogenicity of Leishmania parasites and their drug resistance.
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Affiliation(s)
- Reza Saberi
- Student Research Committee, Mazandaran University of Medical Science, Sari, Iran.,Toxoplasmosis Research Center, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehdi Mohebali
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Davood Anvari
- Student Research Committee, Mazandaran University of Medical Science, Sari, Iran.,Department of Microbiology and Immunology, School of Medicine, Iranshahr University of Medical Sciences, Iranshahr, Iran
| | - Sara Gholami
- Toxoplasmosis Research Center, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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Kariyawasam R, Mukkala AN, Lau R, Valencia BM, Llanos-Cuentas A, Boggild AK. Virulence factor RNA transcript expression in the Leishmania Viannia subgenus: influence of species, isolate source, and Leishmania RNA virus-1. Trop Med Health 2019; 47:25. [PMID: 31007536 PMCID: PMC6458769 DOI: 10.1186/s41182-019-0153-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Leishmania RNA virus-1 (LRV1) is a double-stranded RNA virus identified in 20-25% of Viannia-species endemic to Latin America, and is believed to accelerate cutaneous to mucosal leishmaniasis over time. Our objective was to quantify known virulence factor (VF) RNA transcript expression according to LRV1 status, causative species, and isolate source. METHODS Eight cultured isolates of Leishmania were used, four of which were LRV1-positive (Leishmania Viannia braziliensis [n = 1], L. (V.) guyanensis [n = 1], L. (V.) panamensis [n = 2]), and four were LRV1-negative (L. (V.) panamensis [n = 3], L. (V.) braziliensis [n = 1]). Promastigotes were inoculated into macrophage cultures, and harvested at 24 and 48 h. RNA transcript expression of hsp23, hsp70, hsp90, hsp100, mpi, cpb, and gp63 were quantified by qPCR. RESULTS RNA transcript expression of hsp100 (p = 0.012), cpb (p = 0.016), and mpi (p = 0.022) showed significant increases from baseline pure culture expression to 24- and 48-h post-macrophage infection, whereas hsp70 (p = 0.004) was significantly decreased. A trend toward increased transcript expression of hsp100 at baseline in isolates of L. (V.) panamensis was noted. Pooled VF RNA transcript expression by L. (V.) panamensis isolates was lower than that of L. (V.) braziliensis and L. (V.) guyananesis at 24 h (p = 0.03). VF RNA transcript expression did not differ by LRV1 status, or source of cultured isolate at baseline, 24, or 48 h; however, a trend toward increased VF RNA transcript expression of 2.71- and 1.93-fold change of mpi (p = 0.11) and hsp90 (p = 0.11), respectively, in LRV1 negative isolates was noted. Similarly, a trend toward lower levels of overall VF RNA transcript expression in clinical isolates (1.15-fold change) compared to ATCC® strains at 24 h was noted (p = 0.07). CONCLUSIONS Our findings suggest that known VF RNA transcript expression may be affected by the process of macrophage infection. We were unable to demonstrate definitively that LRV-1 presence affected VF RNA transcript expression in the species and isolates studied. L. (V.) guyanensis and L. (V.) braziliensis demonstrated higher pooled VF RNA transcript expression than L. (V.) panamensis; however, further analyses of protein expression to corroborate this finding are warranted.
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Affiliation(s)
| | - Avinash N. Mukkala
- Institute of Medical Sciences, University of Toronto, Toronto, ON Canada
| | - Rachel Lau
- Public Health Ontario Laboratory, Toronto, ON Canada
| | - Braulio M. Valencia
- Instituto de Medicina Tropical “Alejandro von Humboldt”, Lima, Peru
- Viral Immunology Systems Program, Kirby Institute, University of New South Wales, Sydney, Australia
| | - Alejandro Llanos-Cuentas
- Instituto de Medicina Tropical “Alejandro von Humboldt”, Lima, Peru
- Facultad de Salud Pública y Administración, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Andrea K. Boggild
- Institute of Medical Sciences, University of Toronto, Toronto, ON Canada
- Public Health Ontario Laboratory, Toronto, ON Canada
- Department of Medicine, University of Toronto, Toronto, ON Canada
- Tropical Disease Unit, Toronto General Hospital, 200 Elizabeth Street, 13EN-218, Toronto, ON M5G 2C4 Canada
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