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Del Franco A, Ruggieri R, Pieroni M, Ciabatti M, Zocchi C, Biagioni G, Tavanti V, Del Pace S, Leone O, Favale S, Guaricci AI, Udelson J, Olivotto I. Atlas of Regional Left Ventricular Scar in Nonischemic Cardiomyopathies: Substrates and Etiologies. JACC. ADVANCES 2024; 3:101214. [PMID: 39246577 PMCID: PMC11380395 DOI: 10.1016/j.jacadv.2024.101214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/18/2024] [Accepted: 06/05/2024] [Indexed: 09/10/2024]
Abstract
Most acquired and inherited cardiomyopathies are characterized by regional left ventricular involvement and nonischemic myocardial scars, often with a disease-specific pattern. Irrespective of the etiology and pathophysiological mechanisms, myocardial disorders are invariably associated with cardiac fibrosis, which contributes to dysfunction and electrical instability. Accordingly, cardiac magnetic resonance plays a central role in the diagnostic work-up and prognostic risk stratification of cardiomyopathies, particularly with the increasing correlation between genetic background and specific disease phenotype. Starting from pattern and distribution of myocardial fibrosis at cardiac magnetic resonance, we provide a practical regional atlas of nonischemic myocardial scar to guide the diagnostic approach to nonischemic cardiomyopathies.
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Affiliation(s)
| | | | | | | | - Chiara Zocchi
- Cardiovascular Department, San Donato Hospital, Arezzo, Italy
| | - Giulia Biagioni
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | | | - Stefano Del Pace
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Ornella Leone
- Department of Pathology, Cardiovascular and Cardiac Transplant Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Favale
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Andrea Igoren Guaricci
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - James Udelson
- Division of Cardiology and The CardioVascular Center, Tufts Medical Center, and the Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
- Cardiology Unit, Meyer University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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2
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Seydel CM, Gonzaga BMDS, Coelho LL, Garzoni LR. Exploring the Dimensions of Pre-Clinical Research: 3D Cultures as an Investigative Model of Cardiac Fibrosis in Chagas Disease. Biomedicines 2024; 12:1410. [PMID: 39061986 PMCID: PMC11274318 DOI: 10.3390/biomedicines12071410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 07/28/2024] Open
Abstract
A three-dimensional (3D) cell culture can more precisely mimic tissues architecture and functionality, being a promising alternative model to study disease pathophysiology and drug screening. Chagas disease (CD) is a neglected parasitosis that affects 7 million people worldwide. Trypanosoma cruzi's (T. cruzi) mechanisms of invasion/persistence continue to be elucidated. Benznidazole (BZ) and Nifurtimox (NF) are trypanocidal drugs with few effects on the clinical manifestations of the chronic disease. Chronic Chagas cardiomyopathy (CCC) is the main manifestation of CD due to its frequency and severity. The development of fibrosis and hypertrophy in cardiac tissue can lead to heart failure and sudden death. Thus, there is an urgent need for novel therapeutic options. Our group has more than fifteen years of expertise using 3D primary cardiac cell cultures, being the first to reproduce fibrosis and hypertrophy induced by T. cruzi infection in vitro. These primary cardiac spheroids exhibit morphological and functional characteristics that are similar to heart tissue, making them an interesting model for studying CD cardiac fibrosis. Here, we aim to demonstrate that our primary cardiac spheroids are great preclinical models which can be used to develop new insights into CD cardiac fibrosis, presenting advances already achieved in the field, including disease modeling and drug screening.
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Affiliation(s)
| | | | | | - Luciana Ribeiro Garzoni
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro 21040-360, Brazil; (C.M.S.); (B.M.d.S.G.); (L.L.C.)
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3
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Roman-Campos D, Marin-Neto JA, Santos-Miranda A, Kong N, D’Avila A, Rassi A. Arrhythmogenic Manifestations of Chagas Disease: Perspectives From the Bench to Bedside. Circ Res 2024; 134:1379-1397. [PMID: 38723031 PMCID: PMC11081486 DOI: 10.1161/circresaha.124.324507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
Chagas cardiomyopathy caused by infection with the intracellular parasite Trypanosoma cruzi is the most common and severe expression of human Chagas disease. Heart failure, systemic and pulmonary thromboembolism, arrhythmia, and sudden cardiac death are the principal clinical manifestations of Chagas cardiomyopathy. Ventricular arrhythmias contribute significantly to morbidity and mortality and are the major cause of sudden cardiac death. Significant gaps still exist in the understanding of the pathogenesis mechanisms underlying the arrhythmogenic manifestations of Chagas cardiomyopathy. This article will review the data from experimental studies and translate those findings to draw hypotheses about clinical observations. Human- and animal-based studies at molecular, cellular, tissue, and organ levels suggest 5 main pillars of remodeling caused by the interaction of host and parasite: immunologic, electrical, autonomic, microvascular, and contractile. Integrating these 5 remodeling processes will bring insights into the current knowledge in the field, highlighting some key features for future management of this arrhythmogenic disease.
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Affiliation(s)
- Danilo Roman-Campos
- Departamento de Biofísica, Escola Paulsita de Medicina, Laboratório de Cardiobiologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil (D.R-C)
| | - José Antonio Marin-Neto
- Unidade de Hemodinâmica e Cardiologia Intervencionista, Escola de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil (J.A.M-N.)
| | - Artur Santos-Miranda
- Departamento de Fisiologia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil (A.S.-M)
| | - Nathan Kong
- Departamento de Biofísica, Escola Paulsita de Medicina, Laboratório de Cardiobiologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil (D.R-C)
- Unidade de Hemodinâmica e Cardiologia Intervencionista, Escola de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil (J.A.M-N.)
- Departamento de Fisiologia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil (A.S.-M)
- Hospital do Coração Anis Rassi, Goiânia, GO, Brazil (A.R.J.)
| | - André D’Avila
- Departamento de Biofísica, Escola Paulsita de Medicina, Laboratório de Cardiobiologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil (D.R-C)
- Unidade de Hemodinâmica e Cardiologia Intervencionista, Escola de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil (J.A.M-N.)
- Departamento de Fisiologia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil (A.S.-M)
- Hospital do Coração Anis Rassi, Goiânia, GO, Brazil (A.R.J.)
| | - Anis Rassi
- Hospital do Coração Anis Rassi, Goiânia, GO, Brazil (A.R.J.)
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4
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Jones KM, Mangin EN, Reynolds CL, Villanueva LE, Cruz JV, Versteeg L, Keegan B, Kendricks A, Pollet J, Gusovsky F, Bottazzi ME, Hotez PJ. Vaccine-linked chemotherapy improves cardiac structure and function in a mouse model of chronic Chagas disease. Front Cell Infect Microbiol 2023; 13:1106315. [PMID: 36844399 PMCID: PMC9947347 DOI: 10.3389/fcimb.2023.1106315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Chagas disease, caused by chronic infection with the protozoan parasite Trypanosoma cruzi, affects 6-7 million people worldwide. The major clinical manifestation of Chagas disease is chronic Chagasic cardiomyopathy (CCC), which encompasses a spectrum of symptoms including arrhythmias, hypertrophy, dilated cardiomyopathy, heart failure, and sudden death. Current treatment is limited to two antiparasitic drugs, benznidazole (BNZ) and nifurtimox, but both have limited efficacy to halt the progression of CCC. We developed a vaccine-linked chemotherapy strategy using our vaccine consisting of recombinant Tc24-C4 protein and a TLR-4 agonist adjuvant in a stable squalene emulsion, in combination with low dose benznidazole treatment. We previously demonstrated in acute infection models that this strategy parasite specific immune responses, and reduced parasite burdens and cardiac pathology. Here, we tested our vaccine-linked chemotherapy strategy in a mouse model of chronic T. cruzi infection to evaluate the effect on cardiac function. Methods Female BALB/c mice infected with 500 blood form T. cruzi H1 strain trypomastigotes were treated beginning 70 days after infection with a low dose of BNZ and either low or high dose of vaccine, in both sequential and concurrent treatments streams. Control mice were untreated, or administered only one treatment. Cardiac health was monitored throughout the course of treatment by echocardiography and electrocardiograms. Approximately 8 months after infection, endpoint histopathology was performed to measure cardiac fibrosis and cellular infiltration. Results Vaccine-linked chemotherapy improved cardiac function as evidenced by amelioration of altered left ventricular wall thickness, left ventricular diameter, as well as ejection fraction and fractional shortening by approximately 4 months of infection, corresponding to two months after treatment was initiated. At study endpoint, vaccine-linked chemotherapy reduced cardiac cellular infiltration, and induced significantly increased antigen specific IFN-γ and IL-10 release from splenocytes, as well as a trend toward increased IL-17A. Discussion These data suggest that vaccine-linked chemotherapy ameliorates changes in cardiac structure and function induced by infection with T. cruzi. Importantly, similar to our acute model, the vaccine-linked chemotherapy strategy induced durable antigen specific immune responses, suggesting the potential for a long lasting protective effect. Future studies will evaluate additional treatments that can further improve cardiac function during chronic infection.
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Affiliation(s)
- Kathryn M. Jones
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States,*Correspondence: Kathryn M. Jones,
| | - Elise N. Mangin
- Department of Molecular Physiology, Baylor College of Medicine, Houston, TX, United States
| | - Corey L. Reynolds
- Department of Molecular Physiology, Baylor College of Medicine, Houston, TX, United States
| | - Liliana E. Villanueva
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Laboratorio de Parasitología, Centro de Investigaciones Regionales Dr. Hideyo Noguchi, Universidad Autónoma de Yucatán, Mérida, Yucatán, Mexico
| | - Julio Vladimir Cruz
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Laboratorio de Parasitología, Centro de Investigaciones Regionales Dr. Hideyo Noguchi, Universidad Autónoma de Yucatán, Mérida, Yucatán, Mexico
| | - Leroy Versteeg
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Cell Biology and Immunology Group, Wageningen University & Research, Wageningen, Netherlands
| | - Brian Keegan
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States
| | - April Kendricks
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Jeroen Pollet
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States
| | - Fabian Gusovsky
- Global Health Research, Eisai, Inc., Cambridge, MA, United States
| | - Maria Elena Bottazzi
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States,Department of Biology, Baylor University, Waco, TX, United States
| | - Peter J. Hotez
- Texas Children’s Hospital Center for Vaccine Development, Department of Pediatrics, Division of Tropical Medicine, Baylor College of Medicine, Houston, TX, United States,Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX, United States,Department of Biology, Baylor University, Waco, TX, United States,James A. Baker III Institute for Public Policy, Rice University, Houston, TX, United States,Hagler Institute for Advanced Study at Texas A&M University, College Station, TX, United States
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Abstract
Transforming growth factor-β (TGFβ) isoforms are upregulated and activated in myocardial diseases and have an important role in cardiac repair and remodelling, regulating the phenotype and function of cardiomyocytes, fibroblasts, immune cells and vascular cells. Cardiac injury triggers the generation of bioactive TGFβ from latent stores, through mechanisms involving proteases, integrins and specialized extracellular matrix (ECM) proteins. Activated TGFβ signals through the SMAD intracellular effectors or through non-SMAD cascades. In the infarcted heart, the anti-inflammatory and fibroblast-activating actions of TGFβ have an important role in repair; however, excessive or prolonged TGFβ signalling accentuates adverse remodelling, contributing to cardiac dysfunction. Cardiac pressure overload also activates TGFβ cascades, which initially can have a protective role, promoting an ECM-preserving phenotype in fibroblasts and preventing the generation of injurious, pro-inflammatory ECM fragments. However, prolonged and overactive TGFβ signalling in pressure-overloaded cardiomyocytes and fibroblasts can promote cardiac fibrosis and dysfunction. In the atria, TGFβ-mediated fibrosis can contribute to the pathogenic substrate for atrial fibrillation. Overactive or dysregulated TGFβ responses have also been implicated in cardiac ageing and in the pathogenesis of diabetic, genetic and inflammatory cardiomyopathies. This Review summarizes the current evidence on the role of TGFβ signalling in myocardial diseases, focusing on cellular targets and molecular mechanisms, and discussing challenges and opportunities for therapeutic translation.
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Affiliation(s)
- Nikolaos G Frangogiannis
- The Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY, USA.
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6
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Rodríguez-Angulo HO, Colombet-Naranjo D, Maza MC, Poveda C, Herreros-Cabello A, Mendoza I, Perera JC, Goyo JD, Gironès N, Fresno M. Molecular Remodeling of Cardiac Sinus Node Associated with Acute Chagas Disease Myocarditis. Microorganisms 2021; 9:microorganisms9112208. [PMID: 34835334 PMCID: PMC8620628 DOI: 10.3390/microorganisms9112208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 01/04/2023] Open
Abstract
Chagas disease principally affects Latin-American people, but it currently has worldwide distribution due to migration. Death among those with Chagas disease can occur suddenly and without warning, even in those who may not have evidence of clinical or structural cardiac disease and who are younger than 60 years old. HCN4 channels, one of the principal elements responsible for pacemaker currents, are associated with cardiac fetal reprogramming and supraventricular and ventricular arrhythmias, but their role in chagasic arrhythmias is not clear. We found that a single-dose administration of ivabradine, which blocks HCN4, caused QTc and QRS enlargement and an increase in P-wave amplitude and was associated with ventricular and supraventricular arrhythmias in mice challenged with isoproterenol, a chronotropic/ionotropic positive agent. Continuous treatment with ivabradine did not alter the QTc interval, but P-wave morphology was deeply modified, generating supraventricular arrhythmias. In addition, we found that repolarization parameters improved with ivabradine treatment. These effects could have been caused by the high HCN4 expression observed in auricular and ventricular tissue in infected mice. Thus, we suggest, for the first time, that molecular remodeling by overexpression of HCN4 channels may be related to supraventricular arrhythmias in acute Chagas disease, causing ivabradine over-response. Thus, ivabradine treatment should be administered with caution, while HCN4 overexpression may be an indicator of heart failure and/or sudden death risk.
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Affiliation(s)
- Héctor O. Rodríguez-Angulo
- Instituto Venezolano de Investigaciones Científicas, Caracas 1020A, Venezuela; (H.O.R.A.); (D.C.-N.)
- Unidad de Biología Celular, Departamento de Ciencias Morfológicas, Programa de Medicina, Facultad de Ciencias de la vida, Universidad Centroccidental Lisandro Alvarado, Barquisimeto 3001, Venezuela; (J.C.P.); (J.D.G.)
| | - Diana Colombet-Naranjo
- Instituto Venezolano de Investigaciones Científicas, Caracas 1020A, Venezuela; (H.O.R.A.); (D.C.-N.)
| | - María C. Maza
- Departamento de Biología Molecular, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (M.C.M.); (C.P.); (A.-H.C.)
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, 28049 Madrid, Spain
| | - Cristina Poveda
- Departamento de Biología Molecular, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (M.C.M.); (C.P.); (A.-H.C.)
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, 28049 Madrid, Spain
| | - Alfonso Herreros-Cabello
- Departamento de Biología Molecular, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (M.C.M.); (C.P.); (A.-H.C.)
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, 28049 Madrid, Spain
| | - Iván Mendoza
- Instituto de Medicina Tropical, Universidad Central de Venezuela, Caracas 1060, Venezuela;
| | - Juan C. Perera
- Unidad de Biología Celular, Departamento de Ciencias Morfológicas, Programa de Medicina, Facultad de Ciencias de la vida, Universidad Centroccidental Lisandro Alvarado, Barquisimeto 3001, Venezuela; (J.C.P.); (J.D.G.)
| | - Juan D. Goyo
- Unidad de Biología Celular, Departamento de Ciencias Morfológicas, Programa de Medicina, Facultad de Ciencias de la vida, Universidad Centroccidental Lisandro Alvarado, Barquisimeto 3001, Venezuela; (J.C.P.); (J.D.G.)
| | - Núria Gironès
- Departamento de Biología Molecular, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (M.C.M.); (C.P.); (A.-H.C.)
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, 28049 Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de la Princesa, 28009 Madrid, Spain
- Correspondence: (N.G.); (M.F.)
| | - Manuel Fresno
- Departamento de Biología Molecular, Universidad Autónoma de Madrid, 28049 Madrid, Spain; (M.C.M.); (C.P.); (A.-H.C.)
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, 28049 Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Universitario de la Princesa, 28009 Madrid, Spain
- Correspondence: (N.G.); (M.F.)
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7
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Chagas disease: Immunology of the disease at a glance. Cytokine Growth Factor Rev 2021; 62:15-22. [PMID: 34696979 DOI: 10.1016/j.cytogfr.2021.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/12/2022]
Abstract
Chagas disease is an important neglected disease that affects 6-7 million people worldwide. The disease has two phases: acute and chronic, in which there are different clinical symptoms. Controlling the infection depends on innate and acquired immune responses, which are activated during the initial infection and are critical for host survival. Furthermore, the immune system plays an important role in the therapeutic success. Here we summarize the importance of the immune system cytokines in the pathology outcome, as well as in the treatment.
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8
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Plasma levels of soluble TNF receptors are associated with cardiac function in patients with Chagas heart disease. Int J Cardiol 2020; 316:101-103. [DOI: 10.1016/j.ijcard.2020.04.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 11/24/2022]
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9
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Rada J, Donato M, Penas FN, Alba Soto C, Cevey ÁC, Pieralisi AV, Gelpi R, Mirkin GA, Goren NB. IL-10-Dependent and -Independent Mechanisms Are Involved in the Cardiac Pathology Modulation Mediated by Fenofibrate in an Experimental Model of Chagas Heart Disease. Front Immunol 2020; 11:572178. [PMID: 33072115 PMCID: PMC7541836 DOI: 10.3389/fimmu.2020.572178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022] Open
Abstract
IL-10 is an anti-inflammatory cytokine that plays a significant role in the modulation of the immune response in many pathological conditions, including infectious diseases. Infection with Trypanosoma cruzi (T. cruzi), the etiological agent of Chagas disease, results in an ongoing inflammatory response that may cause heart dysfunction, ultimately leading to heart failure. Given its infectious and inflammatory nature, in this work we analyzed whether the lack of IL-10 hinders the anti-inflammatory effects of fenofibrate, a PPARα ligand, in a murine model of Chagas heart disease (CHD) using IL-10 knockout (IL-10 KO) mice. Our results show fenofibrate was able to restore the abnormal cardiac function displayed by T. cruzi-infected mice lacking IL-10. Treatment with fenofibrate reduced creatine kinase (CK) levels in sera of IL-10 KO mice infected with T. cruzi. Moreover, although fenofibrate could not modulate the inflammatory infiltrates developing in the heart, it was able to reduce the increased collagen deposition in infected IL-10 KO mice. Regarding pro-inflammatory mediators, the most significant finding was the increase in serum IL-17. These were reduced in IL-10 KO mice upon fenofibrate treatment. In agreement with this, the expression of RORγt was reduced. Infection of IL-10 KO mice increased the expression of YmI, FIZZ and Mannose Receptor (tissue healing markers) that remained unchanged upon treatment with fenofibrate. In conclusion, our work emphasizes the role of anti-inflammatory mechanisms to ameliorate heart function in CHD and shows, for the first time, that fenofibrate attains this through IL-10-dependent and -independent mechanisms.
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Affiliation(s)
- Jimena Rada
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y SIDA, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Martín Donato
- Departamento de Patología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Fisiopatología Cardiovascular, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Federico N Penas
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y SIDA, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Catalina Alba Soto
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones en Microbiología y Parasitología Médica, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Ágata C Cevey
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y SIDA, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Azul V Pieralisi
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y SIDA, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo Gelpi
- Departamento de Patología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Fisiopatología Cardiovascular, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Gerardo A Mirkin
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones en Microbiología y Parasitología Médica, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Nora B Goren
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto de Investigaciones Biomédicas en Retrovirus y SIDA, CONICET-Universidad de Buenos Aires, Buenos Aires, Argentina
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10
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Duran-Crane A, Rojas CA, Cooper LT, Medina HM. Cardiac magnetic resonance imaging in Chagas' disease: a parallel with electrophysiologic studies. Int J Cardiovasc Imaging 2020; 36:2209-2219. [PMID: 32613382 DOI: 10.1007/s10554-020-01925-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
Chagas' disease (CD), caused by the parasite Trypanosoma cruzi, is the leading cause of cardiac disability from infectious diseases in Central and South America. The disease progresses through an extended, asymptomatic form characterized by latency without clinical manifestations into a symptomatic form with cardiac and gastro-intestinal manifestations. In the terminal phase, chronic Chagas' myocarditis results in extensive myocardial fibrosis, chamber enlargement with aneurysms and ventricular tachycardia (VT). Cardiac magnetic resonance imaging (CMR) has proven useful in characterizing myocardial fibrosis (MF). Sub-epicardial and mid-wall fibrosis are less common patterns of MF in CHD than transmural scar, which resembles myocardial infarction. Commonly involved areas of MF include the left ventricular apex and basal infero-lateral wall, suggesting a role for watershed ischemia in the pathophysiology of MF. Electrophysiology studies have helped refine the relationship between MF and VT in this setting. This article reviews the patterns of MF in CHD and correlate these patterns with electrogram patterns to predict risk of ventricular arrhythmias and sudden death.
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Affiliation(s)
- Alejandro Duran-Crane
- Internal Medicine Residency Program, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Carlos A Rojas
- Department of Diagnostic Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hector M Medina
- Department of Cardiovascular Imaging, Fundación Cardioinfantil, Calle 163a #13B-60, 110131, Bogotá, Colombia.
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11
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Mendonça AAS, Gonçalves-Santos E, Souza-Silva TG, González-Lozano KJ, Caldas IS, Gonçalves RV, Diniz LF, Novaes RD. Thioridazine aggravates skeletal myositis, systemic and liver inflammation in Trypanosoma cruzi-infected and benznidazole-treated mice. Int Immunopharmacol 2020; 85:106611. [PMID: 32447223 DOI: 10.1016/j.intimp.2020.106611] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/27/2022]
Abstract
While thioridazine (Tio) inhibits the antioxidant defenses of Trypanosoma cruzi, the gold standard antitrypanosomal drug benznidazole (Bz) has potent anti-inflammatory and pro-oxidant properties. The combination of these drugs has never been tested to determine the effect on T. cruzi infection. Thus, we compared the impact of Tio and Bz, administered alone and in combination, on the development of skeletal myositis and liver inflammation in T. cruzi-infected mice. Swiss mice were randomized into six groups: uninfected untreated, infected untreated, treated with Tio (80 mg/kg) alone, Bz (50 or 100 mg/kg) alone, or a combination of Tio and Bz. Infected animals were inoculated with a virulent T. cruzi strain (Y) and treated by gavage for 20 days. Mice untreated or treated with Tio alone developed the most intense parasitemia, highest parasitic load, elevated IL-10, IL-17, IFN-γ, and TNF-α plasma levels, increased N-acetylglucosaminidase and myeloperoxidase activity in the liver and skeletal muscle, as well as severe myositis and liver inflammation (P < 0.05). All parameters were markedly attenuated in animals receiving Bz alone (P < 0.05). However, the co-administration of Tio impaired the response to Bz chemotherapy, causing a decrease in parasitological control (parasitemia and parasite load), skeletal muscle and liver inflammation, and increased microstructural damage, when compared to the group receiving Bz alone (P < 0.05). Altogether, our findings indicated that Tio aggravates systemic inflammation, skeletal myositis and hepatic inflammatory damage in T. cruzi-infected mice. By antagonizing the antiparasitic potential of Bz, Tio limits the anti-inflammatory, myoprotectant and hepatoprotective effects of the reference chemotherapy, aggravating the pathological remodeling of both organs. As the interaction of T. cruzi infection, Bz and Tio is potentially toxic to the liver, inducing inflammation and microvesicular steatosis; this drug combination represents a worrying pharmacological risk factor in Chagas disease.
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Affiliation(s)
- Andréa A S Mendonça
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Structural Biology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Elda Gonçalves-Santos
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Structural Biology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Thaiany G Souza-Silva
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Structural Biology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Kelly J González-Lozano
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Pathology and Parasitology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Ivo S Caldas
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Pathology and Parasitology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Reggiani V Gonçalves
- Department of Animal Biology, Federal University of Viçosa, Viçosa 36570-000, Minas Gerais, Brazil
| | - Lívia F Diniz
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Pathology and Parasitology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil
| | - Rômulo D Novaes
- Institute of Biomedical Sciences, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil; Department of Structural Biology, Federal University of Alfenas, Alfenas 37130-001, Minas Gerais, Brazil.
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Reperfusion Arrhythmias Increase after Superior Cervical Ganglionectomy Due to Conduction Disorders and Changes in Repolarization. Int J Mol Sci 2020; 21:ijms21051804. [PMID: 32155697 PMCID: PMC7084297 DOI: 10.3390/ijms21051804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/20/2020] [Accepted: 03/04/2020] [Indexed: 01/15/2023] Open
Abstract
Pharmacological concentrations of melatonin reduce reperfusion arrhythmias, but less is known about the antiarrhythmic protection of the physiological circadian rhythm of melatonin. Bilateral surgical removal of the superior cervical ganglia irreversibly suppresses melatonin rhythmicity. This study aimed to analyze the cardiac electrophysiological effects of the loss of melatonin circadian oscillation and the role played by myocardial melatonin membrane receptors, SERCA2A, TNFα, nitrotyrosine, TGFβ, KATP channels, and connexin 43. Three weeks after bilateral removal of the superior cervical ganglia or sham surgery, the hearts were isolated and submitted to ten minutes of regional ischemia followed by ten minutes of reperfusion. Arrhythmias, mainly ventricular tachycardia, increased during reperfusion in the ganglionectomy group. These hearts also suffered an epicardial electrical activation delay that increased during ischemia, action potential alternants, triggered activity, and dispersion of action potential duration. Hearts from ganglionectomized rats showed a reduction of the cardioprotective MT2 receptors, the MT1 receptors, and SERCA2A. Markers of nitroxidative stress (nitrotyrosine), inflammation (TNFα), and fibrosis (TGFβ and vimentin) did not change between groups. Connexin 43 lateralization and the pore-forming subunit (Kir6.1) of KATP channels increased in the experimental group. We conclude that the loss of the circadian rhythm of melatonin predisposes the heart to suffer cardiac arrhythmias, mainly ventricular tachycardia, due to conduction disorders and changes in repolarization.
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Sousa RCD, Deus DBD, Costa TÁD, Silva MVD, Rodrigues Junior V, Correia D. Correlation between the cytokine profile and anticongestive medication in patients with chronic chagasic cardiopathy. Rev Soc Bras Med Trop 2019; 52:e20190386. [PMID: 31800924 DOI: 10.1590/0037-8682-0386-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chronic chagasic cardiopathy (CCC) is essentially a dilated cardiomyopathy in which a subacute, but constant chronic inflammatory process causes progressive destruction of the heart tissue. The action of proinflammatory cytokines, such as tumor necrosis factor alpha (TNF-α), interferon gamma (IFN-γ), and anti-inflammatory cytokines, like interleukin IL-10 and IL-17, plays a fundamental role in the immunopathogenesis and evolution of disease. Early anti-congestive therapy, aimed at changing the morbidity and mortality rate, has been shown to reduce disease progression and to alter patients' immune response pattern. METHODS This cross-sectional study aimed to evaluate the profile of Th1 and Th17 cytokines and IL-17, TNF-α, and IFN-γ expressions in different stages of CCC. Forty patients affected by chronic Chagas disease were divided into different groups according to the stage of the pathology. In agreement with the Brazilian consensus on Chagas disease, patients were classified as presenting an undetermined form, a cardiac form and a digestive form. Serum IFN-γ, TNF-α, IL-10, and IL-17 were evaluated. RESULTS Lower serum IFN-γ concentrations were detected in patients receiving angiotensin-converting enzyme inhibitors (p = 0.0182), but not in those using angiotensin receptor blockers (p = 0.0783). Patients using amiodarone and aldosterone antagonist presented higher serum TNF-α concentrations (p = 0.0106 and 0.0187, respectively). IL-10 and IL-17 levels did not differ between the study groups (p = 0.7273 and p = 0.6697, respectively). CONCLUSIONS These results suggest that the cytokine profile and disease progression are altered by anti-congestive medications commonly prescribed for CCC.
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Affiliation(s)
- Rodrigo Cunha de Sousa
- Universidade Federal do Triângulo Mineiro, Departamento de Medicina Interna, Uberaba, MG, Brasil
| | - Diego Bernardo de Deus
- Universidade Federal do Triângulo Mineiro, Departamento de Medicina Interna, Uberaba, MG, Brasil
| | - Thiago Álvares da Costa
- Universidade Federal do Triângulo Mineiro, Departamento de Microbiologia, Imunologia e Parasitologia, Uberaba, MG, Brasil
| | - Marcos Vinícius da Silva
- Universidade Federal do Triângulo Mineiro, Departamento de Microbiologia, Imunologia e Parasitologia, Uberaba, MG, Brasil
| | - Virmondes Rodrigues Junior
- Universidade Federal do Triângulo Mineiro, Departamento de Microbiologia, Imunologia e Parasitologia, Uberaba, MG, Brasil
| | - Dalmo Correia
- Universidade Federal do Triângulo Mineiro, Departamento de Medicina Interna, Uberaba, MG, Brasil
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Duque TLA, Cascabulho CM, Oliveira GM, Henriques-Pons A, Menna-Barreto RFS. Rapamycin Treatment Reduces Acute Myocarditis Induced by Trypanosoma cruzi Infection. J Innate Immun 2019; 12:321-332. [PMID: 31801138 DOI: 10.1159/000504322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/16/2019] [Indexed: 12/15/2022] Open
Abstract
Chagas disease affects millions of people mainly in Latin America and is a protozoan illness caused by the parasite Trypanosoma cruzi. Chagasic cardiomyopathy is the leading cause of mortality of infected patients, due to compromised electrical and mechanical cardiac function induced by tissue remodeling, especially fibrosis, and lymphocytic infiltration. Some cellular biochemical pathways can be protective to the heart, and we tested if the in vivo activation of the autophagic machinery by rapamycin could reduce parasite-induced myocarditis. Regarding the expression of LC3, an autophagy marker, we observed its upregulation in the cardiac tissue of infected untreated mice. However, after rapamycin treatment, an autophagy inducer, infected mice showed reduced electrical cardiac dysfunctions, myocarditis, cardiac damage, and reduced production of pro-inflammatory cytokines by the heart. On the other hand, the parasite's life cycle was not affected, and we observed no modulations in cardiac tissue or blood parasitemia. Our data indicate that, at least partially, autophagy induction controls inflammation in the heart¸ illustrating the complexity of the pathways that concur to the development of the infection.
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Affiliation(s)
- Thabata L A Duque
- Laboratório de Biologia Celular, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil.,Laboratório de Inovações em Terapias, Ensino e Bioprodutos, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Cynthia M Cascabulho
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Gabriel M Oliveira
- Laboratório de Biologia Celular, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Andrea Henriques-Pons
- Laboratório de Inovações em Terapias, Ensino e Bioprodutos, Instituto Oswaldo Cruz, Rio de Janeiro, Brazil
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Cardiac Chagas Disease: MMPs, TIMPs, Galectins, and TGF- β as Tissue Remodelling Players. DISEASE MARKERS 2019; 2019:3632906. [PMID: 31885735 PMCID: PMC6899287 DOI: 10.1155/2019/3632906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/01/2019] [Indexed: 01/13/2023]
Abstract
A century after the discovery of Chagas disease, studies are still needed to establish the complex pathophysiology of this disease. However, it is known that several proteins and molecules are related to the establishment of this disease, its evolution, and the appearance of its different clinical forms. Metalloproteinases and their tissue inhibitors, galectins, and TGF-β are involved in the process of infection and consequently the development of myocarditis, tissue remodeling, and fibrosis upon infection with Trypanosoma cruzi. Thus, considering that the heart is one of the main target organs in Chagas disease, knowledge regarding the mechanisms of action of these molecules is essential to understand how they interact and trigger local and systemic reactions and, consequently, determine whether they contribute to the development of Chagas' heart disease. In this sense, it is believed that the inflammatory microenvironment caused by the infection alters the expression of these proteins favoring progression of the host-parasite cycle and thereby stimulating cardiac tissue remodeling mechanisms and fibrosis. The aim of this review was to gather information on metalloproteinases and their tissue inhibitors, galectins, and TGF-β and discuss how these molecules and their different interrelationships contribute to the development of Chagas' heart disease.
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16
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Souza DS, Barreto TDO, Santana MNS, Menezes-Filho JER, Cruz JS, Vasconcelos CMLD. Resident Macrophages Orchestrating Heart Rate. Arq Bras Cardiol 2019; 112:588-591. [PMID: 30843919 PMCID: PMC6555584 DOI: 10.5935/abc.20190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/14/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | - Jader Santos Cruz
- Universidade Federal de Minas Gerais - Bioquímica e Imunologia, Belo Horizonte, MG - Brazil
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17
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Ropert C. How toll-like receptors reveal monocyte plasticity: the cutting edge of antiinflammatory therapy. Cell Mol Life Sci 2019; 76:745-755. [PMID: 30413835 PMCID: PMC11105477 DOI: 10.1007/s00018-018-2959-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
Toll-like receptors (TLR)s are central in immune response by recognizing pathogen-associated molecular patterns (PAMP)s. If they are essential to eliminate pathogens in earlier stages of infection, they also might play a role in homeostasis and tissue repair. TLR versatility parallels the plasticity of monocytes, which represent an heterogeneous population of immune cells. They are rapidly recruited to sites of infection and involved in clearance of pathogens and in tissue healing. This review underlines how TLRs have proved to be an interesting tool to study the properties of monocytes and why different therapeutic strategies exploring monocyte plasticity may be relevant in the context of chronic inflammatory disorders.
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Affiliation(s)
- Catherine Ropert
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Av. Antônio Carlos 6627, Pampulha, Belo Horizonte, MG, 31270-910, Brazil.
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18
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Medeiros NI, Gomes JAS, Correa-Oliveira R. Synergic and antagonistic relationship between MMP-2 and MMP-9 with fibrosis and inflammation in Chagas' cardiomyopathy. Parasite Immunol 2017; 39. [PMID: 28543409 DOI: 10.1111/pim.12446] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/18/2017] [Indexed: 12/13/2022]
Abstract
Cardiomyopathy is the most important clinical manifestation in the chronic phase of Chagas' disease because of its frequency, severity and impact on morbidity and mortality. The extracellular matrix degradation during cardiac remodeling in Trypanosoma cruzi infection is driven by matrix metalloproteinases (MMPs), primarily the MMP-2 and MMP-9 gelatinases. MMPs also regulate some molecules related to inflammation, such as growth factors, cytokines and chemokines. The involvement of MMP-2 and MMP-9 is not yet fully understood in Chagas' disease. It has been proposed that the gelatinases may have opposite effect on inflammation/regulation and cardiac remodeling. MMP-2 would participate in regulation, offering a protective role for cardiac damage in asymptomatic patients and would be a good marker for the initiation of changes in the heart. On the other hand, MMP-9 can be used as a marker for serious changes on the heart and would be associated with inflammation and fibrosis. Here, we consolidate all characteristics involving MMP-2 and MMP-9 in Chagas' disease based on current studies to clarify their participation on the inflammation/regulation and fibrosis, and the synergistic or antagonistic role between them.
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Affiliation(s)
- N I Medeiros
- Imunologia Celular e Molecular, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brasil.,Departamento de Morfologia, Laboratório de Biologia das Interações Celulares, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - J A S Gomes
- Departamento de Morfologia, Laboratório de Biologia das Interações Celulares, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - R Correa-Oliveira
- Imunologia Celular e Molecular, Centro de Pesquisas René Rachou, Fundação Oswaldo Cruz, Belo Horizonte, Minas Gerais, Brasil
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Tanowitz HB, Garg NJ. Editorial commentary: Targeting Chagas disease. Trends Cardiovasc Med 2016; 27:92-94. [PMID: 27686273 DOI: 10.1016/j.tcm.2016.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 08/20/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Herbert B Tanowitz
- Department of Pathology and Medicine, Albert Einstein College of Medicine, Bronx, NY 10461.
| | - Nisha Jain Garg
- Department of Microbiology & Immunology, University of Texas Medical Branch, Galveston, TX, 77555-1070
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