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Granger DL, Ansong D, Agbenyega T, Liddle MS, Brinton BA, Hale DC, Lopansri BK, Reithinger R, Bisanzio D. Longitudinal associations of plasma amino acid levels with recovery from malarial coma. Malar J 2024; 23:253. [PMID: 39180112 PMCID: PMC11342642 DOI: 10.1186/s12936-024-05077-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/13/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Disordered amino acid metabolism is observed in cerebral malaria (CM). This study sought to determine whether abnormal amino acid concentrations were associated with level of consciousness in children recovering from coma. Twenty-one amino acids and coma scores were quantified longitudinally and the data were analysed for associations. METHODS In a prospective observational study, 42 children with CM were enrolled. Amino acid levels were measured at entry and at frequent intervals thereafter and consciousness was assessed by Blantyre Coma Scores (BCS). Thirty-six healthy children served as controls for in-country normal amino acid ranges. Logistic regression was employed using a generalized linear mixed-effects model to assess associations between out-of-range amino acid levels and BCS. RESULTS At entry 16/21 amino acid levels were out-of-range. Longitudinal analysis revealed 10/21 out-of-range amino acids were significantly associated with BCS. Elevated phenylalanine levels showed the highest association with low BCS. This finding held when out-of-normal-range data were analysed at each sampling time. CONCLUSION Longitudinal data is provided for associations between abnormal amino acid levels and recovery from CM. Of 10 amino acids significantly associated with BCS, elevated phenylalanine may be a surrogate for impaired clearance of ether lipid mediators of inflammation and may contribute to CM pathogenesis.
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Affiliation(s)
- Donald L Granger
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, 2761 E. Swasont Way, Holladay, Salt Lake City, UT, 84117, USA.
- George H. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT, USA.
| | - Daniel Ansong
- Department of Pediatrics, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Tsiri Agbenyega
- Department of Pediatrics, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Benjamin A Brinton
- Department of Psychiatry, North Shore University Hospital, Glen Oaks, NY, USA
| | - Devon C Hale
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, 2761 E. Swasont Way, Holladay, Salt Lake City, UT, 84117, USA
| | | | | | - Donal Bisanzio
- Research Triangle Institute International, Washington, DC, USA
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2
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Kioko M, Mwangi S, Pance A, Ochola-Oyier LI, Kariuki S, Newton C, Bejon P, Rayner JC, Abdi AI. The mRNA content of plasma extracellular vesicles provides a window into molecular processes in the brain during cerebral malaria. SCIENCE ADVANCES 2024; 10:eadl2256. [PMID: 39151016 PMCID: PMC11328904 DOI: 10.1126/sciadv.adl2256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 07/10/2024] [Indexed: 08/18/2024]
Abstract
The impact of cerebral malaria on the transcriptional profiles of cerebral tissues is difficult to study using noninvasive approaches. We isolated plasma extracellular vesicles (EVs) from patients with cerebral malaria and community controls and sequenced their mRNA content. Deconvolution analysis revealed that EVs from cerebral malaria are enriched in transcripts of brain origin. We ordered the patients with cerebral malaria based on their EV-transcriptional profiles from cross-sectionally collected samples and inferred disease trajectory while using healthy community controls as a starting point. We found that neuronal transcripts in plasma EVs decreased with disease trajectory, whereas transcripts from glial, endothelial, and immune cells increased. Disease trajectory correlated positively with severity indicators like death and was associated with increased VEGFA-VEGFR and glutamatergic signaling, as well as platelet and neutrophil activation. These data suggest that brain tissue responses in cerebral malaria can be studied noninvasively using EVs circulating in peripheral blood.
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Affiliation(s)
- Mwikali Kioko
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Open University, Milton Keynes, UK
| | - Shaban Mwangi
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Alena Pance
- Pathogens and Microbes Programme, Wellcome Sanger Institute, Cambridge, UK
- School of Life and Medical Science, University of Hertfordshire, Hatfield, UK
| | - Lynette Isabella Ochola-Oyier
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Symon Kariuki
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Charles Newton
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Philip Bejon
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Julian C Rayner
- Cambridge Institute of Medical Research, University of Cambridge, Cambridge, UK
| | - Abdirahman I Abdi
- Bioscience Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Pwani University Biosciences Research Centre, Pwani University, Kilifi, Kenya
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3
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Jin Z, Pang W, Zhao Y, Min H, Yao S, Bian Z, Wen Y, Peng C, Cao Y, Zheng L. Oral administration of IPI549 protects mice from neuropathology and an overwhelming inflammatory response during experimental cerebral malaria. Int J Parasitol Drugs Drug Resist 2024; 25:100539. [PMID: 38621317 PMCID: PMC11021959 DOI: 10.1016/j.ijpddr.2024.100539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/17/2024]
Abstract
Infection with Plasmodium falciparum is often deadly when it results in cerebral malaria, which is associated with neuropathology described as an overwhelming inflammatory response and mechanical obstruction of cerebral microvascular. PI3Kγ is a critical component of intracellular signal transduction and plays a central role in regulating cell chemotaxis, migration, and activation. The purpose of this study was to examine the relationship between inhibiting the PI3Kγ pathway and the outcome of experimental cerebral malaria (ECM) in C57BL/6J mice infected with the mouse malaria parasite, Plasmodium berghei ANKA. We observed that oral administration of the PI3Kγ inhibitor IPI549 after infection completely protected mice from ECM. IPI549 treatment significantly dampened the magnitude of inflammatory responses, with reduced production of pro-inflammatory factors, decreased T cell activation, and altered differentiation of antigen-presenting cells. IPI549 treatment protected the infected mice from neuropathology, as assessed by an observed reduction of pathogenic T cells in the brain. Treating the infected mice with IPI549 three days after parasite inoculation improved the murine blood brain barrier (BBB) integrity and helped the mice pass the onset of ECM. Together, these data indicate that oral administration of the PI3Kγ inhibitor IPI549 has a suppressive role in host inflammation and alleviates cerebral pathology, which supports IPI549 as a new malaria treatment option with potential therapeutic implications for cerebral malaria.
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Affiliation(s)
- Zhuoru Jin
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China; Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wei Pang
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Yan Zhao
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Hui Min
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Shijie Yao
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Zhifang Bian
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Yixin Wen
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China
| | - Chuanyang Peng
- Liaoning Provincial Key Laboratory of Oral Diseases, Shenyang, Liaoning, China; Department of Emergency and Oral Medicine, School and Hospital of Stomatology, China Medical University, Shenyang, Liaoning, China
| | - Yaming Cao
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China.
| | - Li Zheng
- Department of Immunology, College of Basic Medical Sciences, China Medical University, Shenyang, Liaoning, China.
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4
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Askonas C, Storm J, Camarda G, Craig A, Pain A. Transcriptional responses of brain endothelium to Plasmodium falciparum patient-derived isolates in vitro. Microbiol Spectr 2024; 12:e0072724. [PMID: 38864616 PMCID: PMC11218514 DOI: 10.1128/spectrum.00727-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/29/2024] [Indexed: 06/13/2024] Open
Abstract
A hallmark of cerebral malaria (CM) is sequestration of Plasmodium falciparum-infected erythrocytes (IE) within the brain microvasculature. Binding of IE to endothelium reduces microvascular flow and, combined with an inflammatory response, perturbs endothelial barrier function, resulting in breakdown of the blood-brain barrier (BBB). Cytoadherence leads to activation of the endothelium and alters a range of cell processes affecting signaling pathways, receptor expression, coagulation, and disruption of BBB integrity. Here, we investigated whether CM-derived parasites elicit differential effects on human brain microvascular endothelial cells (HBMECs), as compared to uncomplicated malaria (UM)-derived parasites. Patient-derived IE from UM and CM clinical cases, as well as non-binding skeleton-binding protein 1 knockout parasites, were overlaid onto tumour necrosis factor (TNF)-activated HBMECs. Gene expression analysis of endothelial responses was performed using probe-based assays of a panel of genes involved in inflammation, apoptosis, endothelial barrier function, and prostacyclin synthesis pathway. We observed a significant effect on endothelial transcriptional responses in the presence of IE, yet there was no significant correlation between HBMEC responses and type of clinical syndrome (UM or CM). Furthermore, there was no correlation between HBMEC gene expression and both binding itself and level of IE binding to HBMECs, as we detected the same change in endothelial responses when employing both binding and non-binding parasites. Our results suggest that interaction of IE with endothelial cells in this co-culture model induces some endothelial responses that are independent of clinical origin and independent of the expression of the major variant antigen Plasmodium falciparum erythrocyte membrane protein 1 on the IE surface. IMPORTANCE Cerebral malaria (CM) is the most prevalent and deadly complication of severe Plasmodium falciparum infection. A hallmark of this disease is sequestration of P. falciparum-infected erythrocytes (IE) in brain microvasculature that ultimately results in breakdown of the blood-brain barrier. Here, we compared the effect of P. falciparum parasites derived from uncomplicated malaria (UM) and CM cases on the relative gene expression of human brain microvascular endothelial cells (HBMECs) for a panel of genes. We observed a significant effect on the endothelial transcriptional response in the presence of IE, yet there is no significant correlation between HBMEC responses and the type of clinical syndrome (UM or CM). Furthermore, there was no correlation between HBMEC gene expression and both binding itself and the level of IE binding to HBMECs. Our results suggest that interaction of IE with endothelial cells induces endothelial responses that are independent of clinical origin and not entirely driven by surface Plasmodium falciparum erythrocyte membrane protein 1 expression.
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Affiliation(s)
- Caroline Askonas
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - Janet Storm
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Grazia Camarda
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Alister Craig
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Arnab Pain
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
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5
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Taylor TE. Murine model captures evolution of edema in experimental cerebral malaria. Trends Parasitol 2024; 40:544-545. [PMID: 38797655 DOI: 10.1016/j.pt.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/14/2024] [Indexed: 05/29/2024]
Abstract
A complex series of studies by Oelschlegel et al. in a murine model of cerebral malaria establishes a temporal sequence of events linking decreased venous efflux to impaired perfusion, edema, and neuroinflammation. The relevance to human cerebral malaria is discussed, including the heterogeneity recognized in recent investigations of cerebrovascular hemodynamics.
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Affiliation(s)
- Terrie E Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA; Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi.
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6
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Joof F, Hu R, Saidi A, Seydel KB, Cohee LM, Zheng Y, Smith JD. Plasma from older children in Malawi inhibits Plasmodium falciparum binding in 3D brain microvessels. J Infect Dis 2024:jiae315. [PMID: 38875153 DOI: 10.1093/infdis/jiae315] [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: 03/06/2024] [Revised: 05/02/2024] [Accepted: 06/12/2024] [Indexed: 06/16/2024] Open
Abstract
A hallmark of cerebral malaria is sequestration of Plasmodium falciparum-infected erythrocytes (IEs) in the brain microcirculation. Antibodies contribute to malaria immunity, but it remains unclear whether functional antibodies targeting parasite-expressed ligand can block cytoadhesion in the brain. Here, we screened the plasma of older children and young adults in Malawi to characterize the antibody response against the P. falciparum-IE surface and used a bioengineered 3D human brain microvessel model incorporating variable flow dynamics to measure adhesion blocking responses. We found a strong correlation between surface antibody reactivity by flow cytometry and reduced P. falciparum-IE binding in 3D microvessels. Moreover, there was a threshold of surface antibody reactivity necessary to achieve robust inhibitory activity. Our findings provide evidence of the acquisition of adhesion blocking antibodies against cerebral binding variants in people exposed to stable P. falciparum transmission and suggest the quality of the inhibitory response can be influenced by flow dynamics.
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Affiliation(s)
- Fatou Joof
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA USA
| | - Ruoqian Hu
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Alex Saidi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Karl B Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Lauren M Cohee
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | - Joseph D Smith
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
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7
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Haley MJ, Barroso R, Jasim DA, Haigh M, Green J, Dickie B, Craig AG, Brough D, Couper KN. Lymphatic network drainage resolves cerebral edema and facilitates recovery from experimental cerebral malaria. Cell Rep 2024; 43:114217. [PMID: 38728141 DOI: 10.1016/j.celrep.2024.114217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 11/29/2023] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
While brain swelling, associated with fluid accumulation, is a known feature of pediatric cerebral malaria (CM), how fluid and macromolecules are drained from the brain during recovery from CM is unknown. Using the experimental CM (ECM) model, we show that fluid accumulation in the brain during CM is driven by vasogenic edema and not by perivascular cerebrospinal fluid (CSF) influx. We identify that fluid and molecules are removed from the brain extremely quickly in mice with ECM to the deep cervical lymph nodes (dcLNs), predominantly through basal routes and across the cribriform plate and the nasal lymphatics. In agreement, we demonstrate that ligation of the afferent lymphatic vessels draining to the dcLNs significantly impairs fluid drainage from the brain and lowers anti-malarial drug recovery from the ECM syndrome. Collectively, our results provide insight into the pathways that coordinate recovery from CM.
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Affiliation(s)
- Michael J Haley
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Ruben Barroso
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
| | - Dhifaf A Jasim
- Nanomedicine Lab, National Graphene Institute and Faculty of Biology, Medicine & Health, The University of Manchester, AV Hill Building, Manchester M13 9PT, UK; Medicines Discovery Catapult (MDC), Alderley Park, Macclesfield SK10 4TG, UK
| | - Megan Haigh
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Jack Green
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK; Division of Neuroscience, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Ben Dickie
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; Division of Informatics, Imaging & Data Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Alister G Craig
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - David Brough
- Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK; Division of Neuroscience, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK
| | - Kevin N Couper
- Division of Immunology, Immunity to Infection & Respiratory Medicine, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, UK; Geoffrey Jefferson Brain Research Centre, The Manchester Academic Health Science Centre, Northern Care Alliance NHS Group, University of Manchester, Manchester, UK; The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.
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8
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Granger DL, Ansong D, Agbenyega T, Liddle MS, Brinton BA, Hale DC, Lopansri BK, Reithinger R, Bisanzio D. Longitudinal associations of plasma amino acid levels with recovery from malarial coma. RESEARCH SQUARE 2024:rs.3.rs-4421190. [PMID: 38826416 PMCID: PMC11142354 DOI: 10.21203/rs.3.rs-4421190/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Background Disordered amino acid metabolism is observed in cerebral malaria (CM). We sought to determine whether abnormal amino acid concentrations were associated with level of consciousness in children recovering from coma. We quantified 21 amino acids and coma scores longitudinally and analyzed data for associations. Methods In a prospective observational study, we enrolled 42 children with CM. We measured amino acid levels at entry and at frequent intervals thereafter and assessed consciousness by Blantyre Coma Scores (BCS). Thirty-six healthy children served as controls for in-country normal amino acid ranges. We employed logistic regression using a generalized linear mixed-effects model to assess associations between out-of-range amino acid levels and BCS. Results At entry 16/21 amino acid levels were out-of-range. Longitudinal analysis revealed 10/21 out-of-range amino acids were significantly associated with BCS. Elevated phenylalanine levels showed the highest association with low BCS. This finding held when out-of-normal-range data were analyzed at each sampling time. Discussion We provide longitudinal data for associations between abnormal amino acid levels and recovery from CM. Of 10 amino acids significantly associated with BCS, we propose that elevated phenylalanine may be a surrogate for impaired clearance of ether lipid mediators of inflammation contributing to CM pathogenesis.
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Affiliation(s)
- Donald L. Granger
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT USA
- George H. Wahlen Veterans Affairs Medical Center, Salt Lake City, UT USA
| | - Daniel Ansong
- Department of Pediatrics, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Tsiri Agbenyega
- Department of Pediatrics, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Benjamin A. Brinton
- Department of Psychiatry, North Shore University Hospital, Glen Oaks, NY USA
| | - Devon C. Hale
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT USA
| | | | - Richard Reithinger
- International Development Group, Research Triangle Institute International, Washington, DC USA
| | - Donal Bisanzio
- International Development Group, Research Triangle Institute International, Washington, DC USA
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9
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Vera IM, Kessler A, Harawa V, Ahmadu A, Keller TE, Ray ST, Taylor TE, Rogerson SJ, Mandala WL, Reyes Gil M, Seydel KB, Kim K. Prothrombotic autoantibodies targeting platelet factor 4/polyanion are associated with pediatric cerebral malaria. J Clin Invest 2024; 134:e176466. [PMID: 38652559 PMCID: PMC11142751 DOI: 10.1172/jci176466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUNDFeatures of consumptive coagulopathy and thromboinflammation are prominent in cerebral malaria (CM). We hypothesized that thrombogenic autoantibodies contribute to a procoagulant state in CM.METHODSPlasma from children with uncomplicated malaria (UM) (n = 124) and CM (n = 136) was analyzed by ELISA for a panel of 8 autoantibodies including anti-platelet factor 4/polyanion (anti-PF4/P), anti-phospholipid, anti-phosphatidylserine, anti-myeloperoxidase, anti-proteinase 3, anti-dsDNA, anti-β-2-glycoprotein I, and anti-cardiolipin. Plasma samples from individuals with nonmalarial coma (NMC) (n = 49) and healthy controls (HCs) (n = 56) were assayed for comparison. Associations with clinical and immune biomarkers were determined using univariate and logistic regression analyses.RESULTSMedian anti-PF4/P and anti-PS IgG levels were elevated in individuals with malaria infection relative to levels in HCs (P < 0.001) and patients with NMC (PF4/P: P < 0.001). Anti-PF4/P IgG levels were elevated in children with CM (median = 0.27, IQR: 0.19-0.41) compared with those with UM (median = 0.19, IQR: 0.14-0.22, P < 0.0001). Anti-PS IgG levels did not differ between patients with UM and those with CM (P = 0.39). When patients with CM were stratified by malaria retinopathy (Ret) status, the levels of anti-PF4/P IgG correlated negatively with the peripheral platelet count in patients with Ret+ CM (Spearman's rho [Rs] = 0.201, P = 0.04) and associated positively with mortality (OR = 15.2, 95% CI: 1.02-275, P = 0.048). Plasma from patients with CM induced greater platelet activation in an ex vivo assay relative to plasma from patients with UM (P = 0.02), and the observed platelet activation was associated with anti-PF4/P IgG levels (Rs= 0.293, P = 0.035).CONCLUSIONSThrombosis mediated by elevated anti-PF4/P autoantibodies may be one mechanism contributing to the clinical complications of CM.
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Affiliation(s)
- Iset M. Vera
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Anne Kessler
- Center for Genomics and Systems Biology, Department of Biology, New York University, New York, New York, USA
| | - Visopo Harawa
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Biomedical Department, University of Malawi College of Medicine, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ajisa Ahmadu
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Thomas E. Keller
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Stephen T.J. Ray
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Terrie E. Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, USA
| | - Stephen J. Rogerson
- Department of Medicine (RMH), and
- Department of Infectious Diseases, Doherty Institute, The University of Melbourne, Melbourne, Australia
| | - Wilson L. Mandala
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Biomedical Department, University of Malawi College of Medicine, Blantyre, Malawi
- Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Morayma Reyes Gil
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan, USA
| | - Kami Kim
- Division of Infectious Disease and International Medicine, Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
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10
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Oelschlegel AM, Bhattacharjee R, Wenk P, Harit K, Rothkötter HJ, Koch SP, Boehm-Sturm P, Matuschewski K, Budinger E, Schlüter D, Goldschmidt J, Nishanth G. Beyond the microcirculation: sequestration of infected red blood cells and reduced flow in large draining veins in experimental cerebral malaria. Nat Commun 2024; 15:2396. [PMID: 38493187 PMCID: PMC10944460 DOI: 10.1038/s41467-024-46617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/29/2024] [Indexed: 03/18/2024] Open
Abstract
Sequestration of infected red blood cells (iRBCs) in the microcirculation is a hallmark of cerebral malaria (CM) in post-mortem human brains. It remains controversial how this might be linked to the different disease manifestations, in particular brain swelling leading to brain herniation and death. The main hypotheses focus on iRBC-triggered inflammation and mechanical obstruction of blood flow. Here, we test these hypotheses using murine models of experimental CM (ECM), SPECT-imaging of radiolabeled iRBCs and cerebral perfusion, MR-angiography, q-PCR, and immunohistochemistry. We show that iRBC accumulation and reduced flow precede inflammation. Unexpectedly, we find that iRBCs accumulate not only in the microcirculation but also in large draining veins and sinuses, particularly at the rostral confluence. We identify two parallel venous streams from the superior sagittal sinus that open into the rostral rhinal veins and are partially connected to infected skull bone marrow. The flow in these vessels is reduced early, and the spatial patterns of pathology correspond to venous drainage territories. Our data suggest that venous efflux reductions downstream of the microcirculation are causally linked to ECM pathology, and that the different spatiotemporal patterns of edema development in mice and humans could be related to anatomical differences in venous anatomy.
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Affiliation(s)
- A M Oelschlegel
- Combinatorial NeuroImaging Core Facility, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany
- Research group Neuroplasticity, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany
| | - R Bhattacharjee
- Combinatorial NeuroImaging Core Facility, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, 30625, Hannover, Germany
| | - P Wenk
- Combinatorial NeuroImaging Core Facility, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany
| | - K Harit
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, 30625, Hannover, Germany
| | - H-J Rothkötter
- Institute of Anatomy, Medical Faculty, Otto-von-Guericke-University Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - S P Koch
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Experimental Neurology and Center for Stroke Research, Charitéplatz 1, 10117, Berlin, Germany
- Charité-Universitätsmedizin Berlin, NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, 10117, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Charité 3R | Replace, Reduce, Refine, Charitéplatz 1, 10117, Berlin, Germany
| | - P Boehm-Sturm
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Experimental Neurology and Center for Stroke Research, Charitéplatz 1, 10117, Berlin, Germany
- Charité-Universitätsmedizin Berlin, NeuroCure Cluster of Excellence and Charité Core Facility 7T Experimental MRIs, 10117, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Charité 3R | Replace, Reduce, Refine, Charitéplatz 1, 10117, Berlin, Germany
| | - K Matuschewski
- Department of Molecular Parasitology, Institute of Biology, Humboldt University, 10115, Berlin, Germany
| | - E Budinger
- Combinatorial NeuroImaging Core Facility, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany
- Center of Behavioural Brain Sciences, Universitätsplatz 2, 39106, Magdeburg, Germany
| | - D Schlüter
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, 30625, Hannover, Germany
| | - J Goldschmidt
- Combinatorial NeuroImaging Core Facility, Leibniz Institute for Neurobiology, 39118, Magdeburg, Germany.
- Center of Behavioural Brain Sciences, Universitätsplatz 2, 39106, Magdeburg, Germany.
| | - G Nishanth
- Institute of Medical Microbiology and Hospital Epidemiology, Hannover Medical School, 30625, Hannover, Germany.
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11
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Wang J, Zhu Q, Shen Y, Liang J, Wang Y, Huang Y, Tong G, Wang X, Zhang N, Yu K, Li Y, Zhao Y. CD8 + T cell infiltration and proliferation in the brainstem during experimental cerebral malaria. CNS Neurosci Ther 2024; 30:e14431. [PMID: 37697956 PMCID: PMC10916431 DOI: 10.1111/cns.14431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/06/2023] [Accepted: 07/16/2023] [Indexed: 09/13/2023] Open
Abstract
INTRODUCTION Cerebral malaria (CM) is a lethal neuroinflammatory disease caused by Plasmodium infection. Immune cells and brain parenchyma cells contribute to the pathogenesis of CM. However, a systematic examination of the changes that occur in the brain parenchyma region during CM at the single-cell resolution is still poorly studied. AIMS To explore cell composition and CD8+ T cell infiltration, single-cell RNA sequencing (scRNA-seq) was performed on the brainstems of healthy and experimental cerebral malaria (ECM) mice. Then CD8+ T cell infiltration was confirmed by flow cytometry and immunofluorescence assays. Subsequently, the characteristics of the brain-infiltrated CD8+ T cells were analyzed. Finally, the interactions between parenchyma cells and brain-infiltrated CD8+ T cells were studied with an astrocytes-CD8+ T cell cocultured model. RESULTS The brainstem is the most severely damaged site during ECM. ScRNA-seq revealed a large number of CD8+ T cells infiltrating into the brainstem in ECM mice. Brain-infiltrated CD8+ T cells were highly activated according to scRNA-seq, immunofluorescence, and flow cytometry assays. Further analysis found a subset of ki-67+ CD8+ T cells that have a higher transcriptional level of genes related to T cell function, activation, and proliferation, suggesting that they were exposed to specific antigens presented by brain parenchyma cells. Brain-infiltrated CD8+ T cells were the only prominent source of IFN-γ in this single-cell analysis. Astrocytes, which have a high interferon response, act as cross-presenting cells to recruit and re-activate brain-infiltrated CD8+ T cells. We also found that brain-infiltrated CD8+ T cells were highly expressed immune checkpoint molecule PD-1, while parenchyma cells showed up-regulation of PD-L1 after infection. CONCLUSIONS These findings reveal a novel interaction between brain-infiltrated CD8+ T cells and parenchyma cells in the ECM brainstem, suggesting that the PD-1/PD-L1 signal pathway is a promising adjunctive therapeutic strategy for ECM targeting over-activated CD8+ T cells.
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Affiliation(s)
- Jun Wang
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Qinghao Zhu
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Yan Shen
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Jiao Liang
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Yi Wang
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Yuxiao Huang
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Guodong Tong
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
- College of Life SciencesNorthwest UniversityXi'anChina
| | - Xu Wang
- School of Basic Medical SciencesFourth Military Medical UniversityXi'anChina
| | - Ningning Zhang
- School of Basic Medical SciencesFourth Military Medical UniversityXi'anChina
| | - Kangjie Yu
- Department of PathologyAir Force Hospital of Eastern TheaterNanjingChina
| | - Yinghui Li
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
| | - Ya Zhao
- Department of Medical Microbiology and ParasitologyFourth Military Medical UniversityXi'anChina
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12
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Long B, MacDonald A, Liang SY, Brady WJ, Koyfman A, Gottlieb M, Chavez S. Malaria: A focused review for the emergency medicine clinician. Am J Emerg Med 2024; 77:7-16. [PMID: 38096639 DOI: 10.1016/j.ajem.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Malaria is a potentially fatal parasitic disease transmitted by the Anopheles mosquito. A resurgence in locally acquired infections has been reported in the U.S. OBJECTIVE This narrative review provides a focused overview of malaria for the emergency clinician, including the epidemiology, presentation, diagnosis, and management of the disease. DISCUSSION Malaria is caused by Plasmodium and is transmitted by the Anopheles mosquito. Disease severity can range from mild to severe. Malaria should be considered in any returning traveler from an endemic region, as well as those with unexplained cyclical, paroxysms of symptoms or unexplained fever. Patients most commonly present with fever and rigors but may also experience cough, myalgias, abdominal pain, fatigue, vomiting, and diarrhea. Hepatomegaly, splenomegaly, pallor, and jaundice are findings associated with malaria. Although less common, severe malaria is precipitated by microvascular obstruction with complications of anemia, acidosis, hypoglycemia, multiorgan failure, and cerebral malaria. Peripheral blood smears remain the gold standard for diagnosis, but rapid diagnostic tests are available. Treatment includes specialist consultation and antimalarial drugs tailored depending on chloroquine resistance, geographic region of travel, and patient comorbidities. Supportive care may be required, and patients with severe malaria will require resuscitation. Most patients will require admission for treatment and further monitoring. CONCLUSION Emergency medicine clinicians should be aware of the presentation, diagnosis, evaluation, and management of malaria to ensure optimal outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Austin MacDonald
- Department of Emergency Medicine, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Stephen Y Liang
- Divisions of Emergency Medicine and Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO, USA.
| | - William J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, USA
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Summer Chavez
- Department of Health Systems and Population Health Sciences, Tilman J. Fertitta Family College of Medicine, USA.
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13
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Coughlan C, Jäger HR, Brealey D, Carletti F, Hyare H, Pattnaik R, Sahu PK, Mohanty S, Logan S, Hoffmann A, Wassmer SC, Checkley AM. Adult Cerebral Malaria: Acute and Subacute Imaging Findings, Long-term Clinical Consequences. Clin Infect Dis 2024; 78:457-460. [PMID: 37897407 PMCID: PMC10874268 DOI: 10.1093/cid/ciad651] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 09/28/2023] [Accepted: 10/27/2023] [Indexed: 10/30/2023] Open
Abstract
Cerebral malaria is an important cause of mortality and neurodisability in endemic regions. We show magnetic resonance imaging (MRI) features suggestive of cytotoxic and vasogenic cerebral edema followed by microhemorrhages in 2 adult UK cases, comparing them with an Indian cohort. Long-term follow-up images correlate ongoing changes with residual functional impairment.
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Affiliation(s)
- Charles Coughlan
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Hans Rolf Jäger
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Neuroradiological Academic Unit, Queen Square Institute of Neurology, London, United Kingdom
| | - David Brealey
- Department of Intensive Care Medicine, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Francesco Carletti
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Harpreet Hyare
- Department of Radiology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Praveen K Sahu
- Center for the Study of Complex Malaria in India, Community Welfare Society Hospital, Rourkela, India
| | - Sanjib Mohanty
- Center for the Study of Complex Malaria in India, Community Welfare Society Hospital, Rourkela, India
| | - Sarah Logan
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Angelika Hoffmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Samuel C Wassmer
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna M Checkley
- Department of Infectious Diseses, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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14
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Raees MQ, Gushu MB, Taylor TE, Seydel KB, Wynkoop HJ, O’Brien NF. Optic nerve sheath diameter and its association with brain swelling in pediatric cerebral malaria: a retrospective study. Front Pediatr 2024; 12:1295254. [PMID: 38425660 PMCID: PMC10902095 DOI: 10.3389/fped.2024.1295254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/09/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Mortality in pediatric cerebral malaria (CM) in low- and middle-income countries (LMICs) is associated with brain swelling on magnetic resonance imaging (MRI); however, MRI is unavailable in most LMICs. Optic nerve sheath diameter (ONSD) measurement is an inexpensive method of detecting increased intracranial pressure compared with the invasive opening pressure (OP). Our primary objective was to determine if increased ONSD correlated with brain swelling on MRI in pediatric CM. Our secondary objective was to determine if increased ONSD correlated with increased OP and/or poor neurological outcome in pediatric CM. We hypothesized that increased ONSD would correlate with brain swelling on MRI and increased OP and that ONSD would be higher in survivors with sequelae and non-survivors. Methods We performed a retrospective chart review of children aged 0-12 years in Blantyre, Malawi, from 2013 to 2022 with CM as defined by the World Health Organization. Brain swelling on admission MRI was characterized by brain volume scores (BVS); severe swelling was scored as 7-8, mild-to-moderate as 4-6, normal as 3. The admission ONSD was measured via ultrasound; it was defined as abnormal if it was >4.5 mm in children >1 year and >4 mm in children <1 year. Favorable outcome was defined as a normal neurological exam on discharge in survivors. The primary and secondary objectives were evaluated using Spearman's correlation; and the demographics were compared using chi-square and the Kruskal-Wallis test (Stata, College Station, TX, USA). Results Median age of the 207-patients cohort was 50 months [interquartile range (IQR) 35-75]; 49% (n = 102) were female. Of those, 73% (n = 152) had a favorable outcome, and 14% (n = 30) died. Twenty-nine (14%) had a normal BVS, 134 (65%) had mild-to-moderate swelling, and 44 (21%) had severe swelling. ONSD was elevated in 86% (n = 178) of patients, while 12% of patients had increased OP. There was a weakly positive correlation between BVS and ONSD (r = 0.14, p = 0.05). The median ONSD was not significantly different compared by discharge outcome (p = 0.11) or by BVS (p = 0.18). Conclusion ONSD was not a reliable tool to correlate with BVS, neurological outcome, or OP in children with CM. Future studies to identify alternative methods of early identification of CM patients at highest risk for morbidity and mortality are urgently needed.
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Affiliation(s)
- Madiha Q. Raees
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Terrie E. Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States
| | - Karl B. Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, United States
| | - Hunter J. Wynkoop
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
| | - Nicole F. O’Brien
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, United States
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15
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Goyal MS, Vidal L, Chetcuti K, Chilingulo C, Ibrahim K, Zhang J, Small DS, Seydel KB, O'Brien N, Taylor TE, Postels DG. MRI-Based Brain Volume Scoring in Cerebral Malaria Is Externally Valid and Applicable to Lower-Resolution Images. AJNR Am J Neuroradiol 2024; 45:205-210. [PMID: 38216302 DOI: 10.3174/ajnr.a8098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/06/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND PURPOSE Children with cerebral malaria have an elevated risk of mortality and neurologic morbidity. Both mortality and morbidity are associated with initially increased brain volume on MR imaging, as graded by the Brain Volume Score, a subjective ordinal rating scale created specifically for brain MRIs in children with cerebral malaria. For the Brain Volume Score to be more widely clinically useful, we aimed to determine its independent reproducibility and whether it can be applicable to lower-resolution MRIs. MATERIALS AND METHODS To assess the independent reproducibility of the Brain Volume Score, radiologists not associated with the initial study were trained to score MRIs from a new cohort of patients with cerebral malaria. These scores were then compared with survival and neurologic outcomes. To assess the applicability to lower-resolution MRI, we assigned Brain Volume Scores to brain MRIs degraded to simulate a very-low-field (64 mT) portable scanner and compared these with the original scores assigned to the original nondegraded MRIs. RESULTS Brain Volume Scores on the new cohort of patients with cerebral malaria were highly associated with outcomes (OR for mortality = 16, P < .001). Scoring of the simulated degraded images remained consistent with the Brain Volume Scores assigned to the original higher-quality (0.35 T) images (intraclass coefficients > 0.86). CONCLUSIONS Our findings demonstrate that the Brain Volume Score is externally valid in reproducibly predicting outcomes and can be reliably assigned to lower-resolution images.
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Affiliation(s)
- Manu S Goyal
- From the Mallinckrodt Institute of Radiology (M.S.G.), Washington University School of Medicine, St. Louis, Missouri
| | - Lorenna Vidal
- Children's Hospital of Philadelphia (L.V.), Philadelphia, Pennsylvania
| | - Karen Chetcuti
- Department of Radiology (K.C.), Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Radiology (K.C., C.C.), Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Cowles Chilingulo
- Department of Radiology (K.C., C.C.), Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Khalid Ibrahim
- College of Osteopathic Medicine (K.B.S., T.E.T., K.I.), Michigan State University, East Lansing, Michigan
| | - Jeffrey Zhang
- Department of Statistics and Data Science (J.Z., D.S.S.), The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dylan S Small
- Department of Statistics and Data Science (J.Z., D.S.S.), The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl B Seydel
- College of Osteopathic Medicine (K.B.S., T.E.T., K.I.), Michigan State University, East Lansing, Michigan
- Blantyre Malaria Project, (K.B.S., N.O., T.E.T., D.G.P.) Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicole O'Brien
- Blantyre Malaria Project, (K.B.S., N.O., T.E.T., D.G.P.) Kamuzu University of Health Sciences, Blantyre, Malawi
- Nationwide Children's Hospital (N.O.), Division of Pediatric Critical Care, Columbus, Ohio
| | - Terrie E Taylor
- College of Osteopathic Medicine (K.B.S., T.E.T., K.I.), Michigan State University, East Lansing, Michigan
- Blantyre Malaria Project, (K.B.S., N.O., T.E.T., D.G.P.) Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Douglas G Postels
- Blantyre Malaria Project, (K.B.S., N.O., T.E.T., D.G.P.) Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Neurology (D.G.P.), The George Washington University, Children's National Medical Center, Washington, DC
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16
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Fraering J, Salnot V, Gautier EF, Ezinmegnon S, Argy N, Peoc'h K, Manceau H, Alao J, Guillonneau F, Migot-Nabias F, Bertin GI, Kamaliddin C. Infected erythrocytes and plasma proteomics reveal a specific protein signature of severe malaria. EMBO Mol Med 2024; 16:319-333. [PMID: 38297098 PMCID: PMC10897182 DOI: 10.1038/s44321-023-00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/18/2023] [Accepted: 11/22/2023] [Indexed: 02/02/2024] Open
Abstract
Cerebral malaria (CM), the most lethal complication of Plasmodium falciparum severe malaria (SM), remains fatal for 15-25% of affected children despite the availability of treatment. P. falciparum infects and multiplies in erythrocytes, contributing to anemia, parasite sequestration, and inflammation. An unbiased proteomic assessment of infected erythrocytes and plasma samples from 24 Beninese children was performed to study the complex mechanisms underlying CM. A significant down-regulation of proteins from the ubiquitin-proteasome pathway and an up-regulation of the erythroid precursor marker transferrin receptor protein 1 (TFRC) were associated with infected erythrocytes from CM patients. At the plasma level, the samples clustered according to clinical presentation. Significantly, increased levels of the 20S proteasome components were associated with SM. Targeted quantification assays confirmed these findings on a larger cohort (n = 340). These findings suggest that parasites causing CM preferentially infect reticulocytes or erythroblasts and alter their maturation. Importantly, the host plasma proteome serves as a specific signature of SM and presents a remarkable opportunity for developing innovative diagnostic and prognostic biomarkers.
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Affiliation(s)
- Jeremy Fraering
- UMR261 MERIT, Université Paris Cité, IRD, F-75006, Paris, France
- Plateforme Proteom'IC, Institut Cochin, Université Paris Cité, INSERM U-1016, CNRS UMR8104, Paris, France
| | - Virginie Salnot
- Plateforme Proteom'IC, Institut Cochin, Université Paris Cité, INSERM U-1016, CNRS UMR8104, Paris, France
| | - Emilie-Fleur Gautier
- Plateforme Proteom'IC, Institut Cochin, Université Paris Cité, INSERM U-1016, CNRS UMR8104, Paris, France
- Institut Imagine-INSERM U1163, Hôpital Necker, Université Paris Cité, F-75015, Paris, France
- Laboratoire d'Excellence GR-Ex, F-75015, Paris, France
| | - Sem Ezinmegnon
- Groupe de Recherche Action en Santé, Ouagadougou, Burkina Faso
| | - Nicolas Argy
- UMR261 MERIT, Université Paris Cité, IRD, F-75006, Paris, France
- Laboratoire de parasitologie, Hôpital Bichat-Claude Bernard, APHP, Paris, France
| | - Katell Peoc'h
- Laboratoire d'Excellence GR-Ex, F-75015, Paris, France
- Biochimie Métabolique et Cellulaire, Hôpital Bichat-Claude Bernard, APHP, Paris, France
- Centre de Recherche sur l'Inflammation, UFR de Médecine Xavier Bichat, Université Paris Cité, INSERM UMR1149, Paris, France
| | - Hana Manceau
- Laboratoire d'Excellence GR-Ex, F-75015, Paris, France
- Biochimie Métabolique et Cellulaire, Hôpital Bichat-Claude Bernard, APHP, Paris, France
- Département de Biochimie, Hôpital Universitaire Beaujon, APHP, Clichy, France
| | - Jules Alao
- Service de Pédiatrie, Centre Hospitalier Universitaire de la Mère et de l'Enfant-Lagune de Cotonou, Cotonou, Benin
| | - François Guillonneau
- Plateforme Proteom'IC, Institut Cochin, Université Paris Cité, INSERM U-1016, CNRS UMR8104, Paris, France
- Unité OncoProtéomique, Institut de Cancérologie de l'Ouest, F-49055, Angers, France
- Université d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, F-49000, Angers, France
| | | | - Gwladys I Bertin
- UMR261 MERIT, Université Paris Cité, IRD, F-75006, Paris, France.
| | - Claire Kamaliddin
- UMR261 MERIT, Université Paris Cité, IRD, F-75006, Paris, France.
- Cumming School of Medicine, The University of Calgary, Calgary, AB, Canada.
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17
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Fain CE, Zheng J, Jin F, Ayasoufi K, Wu Y, Lilley MT, Dropik AR, Wolf DM, Rodriguez RC, Aibaidula A, Tritz ZP, Bouchal SM, Pewe LL, Urban SL, Chen Y, Chang SY, Hansen MJ, Kachergus JM, Shi J, Thompson EA, Jensen HE, Harty JT, Parney IF, Sun J, Wu LJ, Johnson AJ. Discrete class I molecules on brain endothelium differentially regulate neuropathology in experimental cerebral malaria. Brain 2024; 147:566-589. [PMID: 37776513 DOI: 10.1093/brain/awad319] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/15/2023] [Accepted: 08/31/2023] [Indexed: 10/02/2023] Open
Abstract
Cerebral malaria is the deadliest complication that can arise from Plasmodium infection. CD8 T-cell engagement of brain vasculature is a putative mechanism of neuropathology in cerebral malaria. To define contributions of brain endothelial cell major histocompatibility complex (MHC) class I antigen-presentation to CD8 T cells in establishing cerebral malaria pathology, we developed novel H-2Kb LoxP and H-2Db LoxP mice crossed with Cdh5-Cre mice to achieve targeted deletion of discrete class I molecules, specifically from brain endothelium. This strategy allowed us to avoid off-target effects on iron homeostasis and class I-like molecules, which are known to perturb Plasmodium infection. This is the first endothelial-specific ablation of individual class-I molecules enabling us to interrogate these molecular interactions. In these studies, we interrogated human and mouse transcriptomics data to compare antigen presentation capacity during cerebral malaria. Using the Plasmodium berghei ANKA model of experimental cerebral malaria (ECM), we observed that H-2Kb and H-2Db class I molecules regulate distinct patterns of disease onset, CD8 T-cell infiltration, targeted cell death and regional blood-brain barrier disruption. Strikingly, ablation of either molecule from brain endothelial cells resulted in reduced CD8 T-cell activation, attenuated T-cell interaction with brain vasculature, lessened targeted cell death, preserved blood-brain barrier integrity and prevention of ECM and the death of the animal. We were able to show that these events were brain-specific through the use of parabiosis and created the novel technique of dual small animal MRI to simultaneously scan conjoined parabionts during infection. These data demonstrate that interactions of CD8 T cells with discrete MHC class I molecules on brain endothelium differentially regulate development of ECM neuropathology. Therefore, targeting MHC class I interactions therapeutically may hold potential for treatment of cases of severe malaria.
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Affiliation(s)
- Cori E Fain
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Jiaying Zheng
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN 55905USA
| | - Fang Jin
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
| | | | - Yue Wu
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Meredith T Lilley
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Abigail R Dropik
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Delaney M Wolf
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
| | | | - Abudumijiti Aibaidula
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905USA
| | - Zachariah P Tritz
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Samantha M Bouchal
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Lecia L Pewe
- Department of Pathology, University of Iowa, Iowa City, IA 52242USA
| | - Stina L Urban
- Department of Pathology, University of Iowa, Iowa City, IA 52242USA
| | - Yin Chen
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905USA
| | - Su-Youne Chang
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905USA
| | | | | | - Ji Shi
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224USA
| | - E Aubrey Thompson
- Department of Cancer Biology, Mayo Clinic, Jacksonville, FL 32224USA
| | - Hadley E Jensen
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
| | - John T Harty
- Department of Pathology, University of Iowa, Iowa City, IA 52242USA
| | - Ian F Parney
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905USA
| | - Jie Sun
- Department of Medicine, University of Virginia, Charlottesville, VA 22903USA
| | - Long-Jun Wu
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Department of Neurology, Mayo Clinic, Rochester, MN 55905USA
| | - Aaron J Johnson
- Department of Immunology, Mayo Clinic, Rochester, MN 55905USA
- Department of Molecular Medicine, Mayo Clinic, Rochester, MN 55905USA
- Department of Neurology, Mayo Clinic, Rochester, MN 55905USA
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18
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Nampota-Nkomba N, Nyirenda OM, Mallewa J, Chimalizeni Y, Dzabala N, Fay MP, Gopalakrishnan M, Laurens MB, O'Brien NF, Miller LH, Pierce SK, Riggle BA, Postels DG. DON in pediatric cerebral malaria, a phase I/IIA dose-escalation safety study: study protocol for a clinical trial. Trials 2024; 25:87. [PMID: 38279124 PMCID: PMC10811809 DOI: 10.1186/s13063-023-07808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/16/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Despite treatment with highly effective antimalarial drugs, malaria annually claims the lives of over half a million children under 5-years of age in sub-Saharan Africa. Cerebral malaria (CM), defined as Plasmodium falciparum infection with coma, is the severe malaria syndrome with the highest mortality. Studies in the CM mouse model suggest that a T cell-mediated response underlies CM pathology, opening a new target for therapy in humans. This trial aims to establish the preliminary safety of one such novel therapy, the glutamine antagonist 6-diazo-5-oxo-L-norleucine (DON). METHODS In this phase I/IIa dose-escalation clinical trial, a single dose of intravenous (IV) DON is administered to three participants groups-healthy adults and adults with uncomplicated malaria, then pediatric participants with CM-to primarily assess safety. The secondary objective of this trial is to assess pharmacokinetics of DON over a range of doses. The open-label adult portion of the trial enrolls 40 healthy adults concurrently with 40 adults with uncomplicated malaria. Cohorts of 10 participants receive a single IV dose of DON with doses escalating between cohorts from 0.1 mg/kg, 1.0 mg/kg, 5.0 mg/kg, to 10 mg/kg. Following subsequent safety review, a randomized, double-blind, and placebo-controlled pediatric study enrolls 72 participants aged 6 months to 14 years with CM. The pediatric portion of the study minimally spans three malaria seasons including a planned interim analysis after 50% of pediatric enrollments. The first half of pediatric participants receive DON 0.1 mg/kg, 1.0 mg/kg, or placebo. Dosing for the second half of pediatric participants is informed by the safety and preliminary efficacy results of those previously enrolled. The pediatric portion of the study has an exploratory outcome evaluating the preliminary efficacy of DON. Efficacy is assessed by diagnostics predictive of CM outcome: electroencephalography (EEG), magnetic resonance imaging (MRI), and transcranial doppler (TCD), measured before and after DON administration. All participants with malaria receive standard of care antimalarials in accordance with local guidelines, regardless of study drug dose group. DISCUSSION This preliminary safety and efficacy study evaluates DON, a candidate adjunctive therapy for pediatric CM. If results support DON preliminary safety and efficacy, follow-up phase II and III clinical trials will be indicated. TRIAL REGISTRATION This trial was registered on ClinicalTrials.gov on 28 July 2022 (NCT05478720).
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Affiliation(s)
| | - Osward M Nyirenda
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jane Mallewa
- Department of Internal Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nettie Dzabala
- Department of Pharmacy, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael P Fay
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicole F O'Brien
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Louis H Miller
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Susan K Pierce
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA
| | - Brittany A Riggle
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, MD, USA.
| | - Douglas G Postels
- Division of Neurology, The George Washington University/ Children's National Medical Center, Washington, DC, USA.
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19
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Evbuomwan IO, Alejolowo OO, Elebiyo TC, Nwonuma CO, Ojo OA, Edosomwan EU, Chikwendu JI, Elosiuba NV, Akulue JC, Dogunro FA, Rotimi DE, Osemwegie OO, Ojo AB, Ademowo OG, Adeyemi OS, Oluba OM. In silico modeling revealed phytomolecules derived from Cymbopogon citratus (DC.) leaf extract as promising candidates for malaria therapy. J Biomol Struct Dyn 2024; 42:101-118. [PMID: 36974933 DOI: 10.1080/07391102.2023.2192799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
The emergence of varying levels of resistance to currently available antimalarial drugs significantly threatens global health. This factor heightens the urgency to explore bioactive compounds from natural products with a view to discovering and developing newer antimalarial drugs with novel mode of actions. Therefore, we evaluated the inhibitory effects of sixteen phytocompounds from Cymbopogon citratus leaf extract against Plasmodium falciparum drug targets such as P. falciparum circumsporozoite protein (PfCSP), P. falciparum merozoite surface protein 1 (PfMSP1) and P. falciparum erythrocyte membrane protein 1 (PfEMP1). In silico approaches including molecular docking, pharmacophore modeling and 3D-QSAR were adopted to analyze the inhibitory activity of the compounds under consideration. The molecular docking results indicated that a compound swertiajaponin from C. citratus exhibited a higher binding affinity (-7.8 kcal/mol) to PfMSP1 as against the standard artesunate-amodiaquine (-6.6 kcal/mol). Swertiajaponin also formed strong hydrogen bond interactions with LYS29, CYS30, TYR34, ASN52, GLY55 and CYS28 amino acid residues. In addition, quercetin another compound from C. citratus exhibited significant binding energies -6.8 and -8.3 kcal/mol with PfCSP and PfEMP1, respectively but slightly lower than the standard artemether-lumefantrine with binding energies of -7.4 kcal/mol against PfCSP and -8.7 kcal/mol against PfEMP1. Overall, the present study provides evidence that swertiajaponin and other phytomolecules from C. citratus have modulatory properties toward P. falciparum drug targets and thus may warrant further exploration in early drug discovery efforts against malaria. Furthermore, these findings lend credence to the folkloric use of C. citratus for malaria treatment.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Ikponmwosa Owen Evbuomwan
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
- Department of Food Science and Microbiology, Landmark University, Omu-Aran, Nigeria
| | - Omokolade Oluwaseyi Alejolowo
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
| | | | - Charles Obiora Nwonuma
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
| | - Oluwafemi Adeleke Ojo
- Phytomedicine, Molecular Toxicology and Computational Biochemistry Research Group, Department of Biochemistry, Bowen University, Iwo, Nigeria
| | - Evelyn Uwa Edosomwan
- Department of Animal and Environmental Biology, University of Benin, Benin City, Nigeria
| | | | | | | | | | - Damilare Emmanuel Rotimi
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
| | | | | | - Olusegun George Ademowo
- Department of Pharmacology and Therapeutics, Faculty of Basic Medical Sciences, University of Ibadan, Ibadan, Nigeria
- Drug Research Laboratory, Institute of Advanced Medical Research and Training (IMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oluyomi Stephen Adeyemi
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
- Laboratory of Sustainable Animal Environment, Graduate School of Agricultural Science, Tohoku University, Osaki, Miyagi, Japan
| | - Olarewaju Michael Oluba
- SDG #03 Group - Good Health and Well-Being Research Cluster, Landmark University, Omu-Aran, Nigeria
- Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
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20
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Wassmer SC, de Koning-Ward TF, Grau GER, Pai S. Unravelling mysteries at the perivascular space: a new rationale for cerebral malaria pathogenesis. Trends Parasitol 2024; 40:28-44. [PMID: 38065791 PMCID: PMC11072469 DOI: 10.1016/j.pt.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 01/06/2024]
Abstract
Cerebral malaria (CM) is a severe neurological complication caused by Plasmodium falciparum parasites; it is characterized by the sequestration of infected red blood cells within the cerebral microvasculature. New findings, combined with a better understanding of the central nervous system (CNS) barriers, have provided greater insight into the players and events involved in CM, including site-specific T cell responses in the human brain. Here, we review the updated roles of innate and adaptive immune responses in CM, with a focus on the role of the perivascular macrophage-endothelium unit in antigen presentation, in the vascular and perivascular compartments. We suggest that these events may be pivotal in the development of CM.
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Affiliation(s)
- Samuel C Wassmer
- Department of Infection Biology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Tania F de Koning-Ward
- School of Medicine, Deakin University, Waurn Ponds, Victoria, Australia; Institute of Mental and Physical Health and Clinical Translation, Deakin University, Geelong, Victoria, Australia
| | - Georges E R Grau
- Vascular Immunology Unit, Discipline of Pathology, School of Medical Sciences, University of Sydney, Camperdown, New South Wales, Australia
| | - Saparna Pai
- Centre for Molecular Therapeutics, Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, Queensland, Australia.
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21
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Carpinter BA, Renhe DC, Bellei JCB, Vieira CD, Rodolphi CM, Ferreira MVR, de Freitas CS, Neto AFDS, Coelho EAF, Mietto BDS, Gomes FLR, Rocha VN, Scopel KKG. DHA-rich fish oil plays a protective role against experimental cerebral malaria by controlling inflammatory and mechanical events from infection. J Nutr Biochem 2024; 123:109492. [PMID: 37866427 DOI: 10.1016/j.jnutbio.2023.109492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/17/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
Every year, thousands of children, particularly those under 5 years old, die because of cerebral malaria (CM). Following conventional treatment, approximately 25% of surviving individuals have lifelong severe neurocognitive sequelae. Therefore, improved conventional therapies or effective alternative therapies that prevent the severe infection are crucial. Omega-3 (Ω-3) polyunsaturated fatty acids (PUFAs) are known to have antioxidative and anti-inflammatory effects and protect against diverse neurological disorders, including Alzheimer's and Parkinson's diseases. However, little is known regarding the effects of Ω-3 PUFAs against parasitic infections. In this study, C57BL/6 mice received supplemental treatment of a fish oil rich in the Ω-3 PUFA, docosahexaenoic acid (DHA), which was started 15 days prior to infection with Plasmodium berghei ANKA and was maintained until the end of the study. Animals treated with the highest doses of DHA, 3.0 and 6.0 g/kg body weight, had 60 and 80% chance of survival, respectively, while all nontreated mice died by the 7th day postinfection due to CM. Furthermore, the parasite load during the critical period for CM development (5th to 11th day postinfection) was controlled in treated mice. However, after this period all animals developed high levels of parasitemia until the 20th day of infection. DHA treatment also effectively reduced blood-brain barrier (BBB) damage and brain edema and completely prevented brain hemorrhage and vascular occlusion. A strong anti-inflammatory profile was observed in the brains of DHA-treated mice, as well as, an increased number of neutrophil and reduced number of CD8+ T leukocytes in the spleen. Thus, this is the first study to demonstrate that the prophylactic use of DHA-rich fish oil exerts protective effects against experimental CM, reducing the mechanical and immunological events caused by the P. berghei ANKA infection.
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Affiliation(s)
- Bárbara Albuquerque Carpinter
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Daniela Chaves Renhe
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Jéssica Correa Bezerra Bellei
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Carolina David Vieira
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Cinthia Magalhães Rodolphi
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | | | - Camila Simões de Freitas
- Post-graduation Program in Health Sciences, Infectology and Tropical Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Adolfo Firmino da Silva Neto
- Department of Biology, Research Centre of Cellular Biology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Eduardo Antônio Ferraz Coelho
- Post-graduation Program in Health Sciences, Infectology and Tropical Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bruno de Siqueira Mietto
- Department of Biology, Research Centre of Cellular Biology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | | | - Vinicius Novaes Rocha
- Department of Veterinary Medicine, Research Centre of Pathology and Veterinary Histology, Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | - Kézia Katiani Gorza Scopel
- Department of Parasitology, Microbiology and Immunology and Post-Graduation Program in Biological Science, Research Centre of Parasitology, Federal University of Juiz de Fora, Juiz de Fora, Brazil.
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22
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Poespoprodjo JR, Douglas NM, Ansong D, Kho S, Anstey NM. Malaria. Lancet 2023; 402:2328-2345. [PMID: 37924827 DOI: 10.1016/s0140-6736(23)01249-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 05/22/2023] [Accepted: 06/16/2023] [Indexed: 11/06/2023]
Abstract
Malaria is resurging in many African and South American countries, exacerbated by COVID-19-related health service disruption. In 2021, there were an estimated 247 million malaria cases and 619 000 deaths in 84 endemic countries. Plasmodium falciparum strains partly resistant to artemisinins are entrenched in the Greater Mekong region and have emerged in Africa, while Anopheles mosquito vectors continue to evolve physiological and behavioural resistance to insecticides. Elimination of Plasmodium vivax malaria is hindered by impractical and potentially toxic antirelapse regimens. Parasitological diagnosis and treatment with oral or parenteral artemisinin-based therapy is the mainstay of patient management. Timely blood transfusion, renal replacement therapy, and restrictive fluid therapy can improve survival in severe malaria. Rigorous use of intermittent preventive treatment in pregnancy and infancy and seasonal chemoprevention, potentially combined with pre-erythrocytic vaccines endorsed by WHO in 2021 and 2023, can substantially reduce malaria morbidity. Improved surveillance, better access to effective treatment, more labour-efficient vector control, continued drug development, targeted mass drug administration, and sustained political commitment are required to achieve targets for malaria reduction by the end of this decade.
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Affiliation(s)
- Jeanne Rini Poespoprodjo
- Centre for Child Health and Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia; Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Mimika District Hospital and District Health Authority, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Nicholas M Douglas
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Christchurch Hospital, Te Whatu Ora Waitaha, Christchurch, New Zealand; Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Daniel Ansong
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Steven Kho
- Timika Malaria Research Facility, Papuan Health and Community Development Foundation, Timika, Indonesia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Infectious Diseases, Royal Darwin Hospital, Darwin, NT, Australia
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23
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O'Brien NF, Chetcuti K, Fonseca Y, Vidal L, Raghavan P, Postels DG, Chimalizeni Y, Ray S, Seydel KB, Taylor TE. Cerebral Metabolic Crisis in Pediatric Cerebral Malaria. J Pediatr Intensive Care 2023; 12:278-288. [PMID: 37970136 PMCID: PMC10631841 DOI: 10.1055/s-0041-1732444] [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: 03/23/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022] Open
Abstract
Cerebral metabolic energy crisis (CMEC), often defined as a cerebrospinal fluid (CSF) lactate: pyruvate ratio (LPR) >40, occurs in various diseases and is associated with poor neurologic outcomes. Cerebral malaria (CM) causes significant mortality and neurodisability in children worldwide. Multiple factors that could lead to CMEC are plausible in these patients, but its frequency has not been explored. Fifty-three children with CM were enrolled and underwent analysis of CSF lactate and pyruvate levels. All 53 patients met criteria for a CMEC (median CSF LPR of 72.9 [interquartile range [IQR]: 58.5-93.3]). Half of children met criteria for an ischemic CMEC (median LPR of 85 [IQR: 73-184]) and half met criteria for a nonischemic CMEC (median LPR of 60 [IQR: 54-79]. Children also underwent transcranial doppler ultrasound investigation. Cerebral blood flow velocities were more likely to meet diagnostic criteria for low flow (<2 standard deviation from normal) or vasospasm in children with an ischemic CMEC (73%) than in children with a nonischemic CMEC (20%, p = 0.04). Children with an ischemic CMEC had poorer outcomes (pediatric cerebral performance category of 3-6) than those with a nonischemic CMEC (46 vs. 22%, p = 0.03). CMEC was ubiquitous in this patient population and the processes underlying the two subtypes (ischemic and nonischemic) may represent targets for future adjunctive therapies.
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Affiliation(s)
- Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Karen Chetcuti
- Department of Radiology, College of Medicine, Chichiri, Blantyre, Malawi
| | - Yudy Fonseca
- Division of Critical Care Medicine, Department of Pediatrics, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Lorenna Vidal
- Division of Neuroradiology, Department of Radiology Children's Hospital of Philadelphia, Clinical Instructor at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Douglas G. Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, District of Columbia, United States
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, University of Malawi, Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Stephen Ray
- Department of Paediatric, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Karl B. Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
- Blantyre Malaria Project, Blantyre, Malawi
| | - Terrie E. Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
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24
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Walker IS, Rogerson SJ. Pathogenicity and virulence of malaria: Sticky problems and tricky solutions. Virulence 2023; 14:2150456. [PMID: 36419237 PMCID: PMC9815252 DOI: 10.1080/21505594.2022.2150456] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 11/25/2022] Open
Abstract
Infections with Plasmodium falciparum and Plasmodium vivax cause over 600,000 deaths each year, concentrated in Africa and in young children, but much of the world's population remain at risk of infection. In this article, we review the latest developments in the immunogenicity and pathogenesis of malaria, with a particular focus on P. falciparum, the leading malaria killer. Pathogenic factors include parasite-derived toxins and variant surface antigens on infected erythrocytes that mediate sequestration in the deep vasculature. Host response to parasite toxins and to variant antigens is an important determinant of disease severity. Understanding how parasites sequester, and how antibody to variant antigens could prevent sequestration, may lead to new approaches to treat and prevent disease. Difficulties in malaria diagnosis, drug resistance, and specific challenges of treating P. vivax pose challenges to malaria elimination, but vaccines and other preventive strategies may offer improved disease control.
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Affiliation(s)
- Isobel S Walker
- Department of Infectious Diseases, The University of Melbourne, The Doherty Institute, Melbourne, Australia
| | - Stephen J Rogerson
- Department of Infectious Diseases, The University of Melbourne, The Doherty Institute, Melbourne, Australia
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25
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Othman B, Zeef L, Szestak T, Rchiad Z, Storm J, Askonas C, Satyam R, Madkhali A, Haley M, Wagstaff S, Couper K, Pain A, Craig A. Different PfEMP1-expressing Plasmodium falciparum variants induce divergent endothelial transcriptional responses during co-culture. PLoS One 2023; 18:e0295053. [PMID: 38033133 PMCID: PMC10688957 DOI: 10.1371/journal.pone.0295053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
The human malaria parasite Plasmodium falciparum is responsible for the majority of mortality and morbidity caused by malaria infection and differs from other human malaria species in the degree of accumulation of parasite-infected red blood cells in the microvasculature, known as cytoadherence or sequestration. In P. falciparum, cytoadherence is mediated by a protein called PfEMP1 which, due to its exposure to the host immune system, undergoes antigenic variation resulting in the expression of different PfEMP1 variants on the infected erythrocyte membrane. These PfEMP1s contain various combinations of adhesive domains, which allow for the differential engagement of a repertoire of endothelial receptors on the host microvasculature, with specific receptor usage associated with severe disease. We used a co-culture model of cytoadherence incubating human brain microvascular endothelial cells with erythrocytes infected with two parasite lines expressing different PfEMP1s that demonstrate different binding profiles to vascular endothelium. We determined the transcriptional profile of human brain microvascular endothelial cells (HBMEC) following different incubation periods with infected erythrocytes, identifying different transcriptional profiles of pathways previously found to be involved in the pathology of severe malaria, such as inflammation, apoptosis and barrier integrity, induced by the two PfEMP1 variants.
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Affiliation(s)
- Basim Othman
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Leo Zeef
- Faculty of Biology, Medicine and Health, The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - Tadge Szestak
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Zineb Rchiad
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, KSA
| | - Janet Storm
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Caroline Askonas
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, KSA
| | - Rohit Satyam
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, KSA
| | - Aymen Madkhali
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Michael Haley
- Faculty of Biology, Medicine and Health, The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - Simon Wagstaff
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Kevin Couper
- Faculty of Biology, Medicine and Health, The Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - Arnab Pain
- Pathogen Genomics Laboratory, Bioscience Program, Biological and Environmental Sciences and Engineering (BESE) Division, King Abdullah University of Science and Technology, Thuwal, KSA
| | - Alister Craig
- Tropical Disease Biology, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
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26
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Hadjilaou A, Brandi J, Riehn M, Friese MA, Jacobs T. Pathogenetic mechanisms and treatment targets in cerebral malaria. Nat Rev Neurol 2023; 19:688-709. [PMID: 37857843 DOI: 10.1038/s41582-023-00881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
Malaria, the most prevalent mosquito-borne infectious disease worldwide, has accompanied humanity for millennia and remains an important public health issue despite advances in its prevention and treatment. Most infections are asymptomatic, but a small percentage of individuals with a heavy parasite burden develop severe malaria, a group of clinical syndromes attributable to organ dysfunction. Cerebral malaria is an infrequent but life-threatening complication of severe malaria that presents as an acute cerebrovascular encephalopathy characterized by unarousable coma. Despite effective antiparasite drug treatment, 20% of patients with cerebral malaria die from this disease, and many survivors of cerebral malaria have neurocognitive impairment. Thus, an important unmet clinical need is to rapidly identify people with malaria who are at risk of developing cerebral malaria and to develop preventive, adjunctive and neuroprotective treatments for cerebral malaria. This Review describes important advances in the understanding of cerebral malaria over the past two decades and discusses how these mechanistic insights could be translated into new therapies.
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Affiliation(s)
- Alexandros Hadjilaou
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany.
- Institut für Neuroimmunologie und Multiple Sklerose, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Johannes Brandi
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
| | - Mathias Riehn
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
| | - Manuel A Friese
- Institut für Neuroimmunologie und Multiple Sklerose, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Jacobs
- Protozoen Immunologie, Bernhard-Nocht-Institut für Tropenmedizin (BNITM), Hamburg, Germany
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Howard C, Joof F, Hu R, Smith JD, Zheng Y. Probing cerebral malaria inflammation in 3D human brain microvessels. Cell Rep 2023; 42:113253. [PMID: 37819760 DOI: 10.1016/j.celrep.2023.113253] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023] Open
Abstract
Sequestration of Plasmodium falciparum-infected erythrocytes (IEs) in the brain microcirculation is a hallmark of cerebral malaria (CM), which leads to endothelial activation, brain swelling, and death. Here, we probed CM inflammation in a perfusable 3D human brain microvessel model. 3D brain microvessels supported in vivo-like capacities for parasite binding and maturation in situ, leading to a distinct inflammatory response from the pro-inflammatory cytokine tumor necrosis factor α (TNF-α). By combining transcriptional analysis, imaging, and leukocyte perfusion, we showed that whereas TNF-α promotes a reversible inflammatory phenotype with widespread leukocyte recruitment, parasites induce unique stress response pathways and cause localized cell adhesivity changes, focal endothelial disruptions, and apoptosis. Furthermore, parasites modified the temporal kinetics of the TNF transcriptional response, suggesting augmented inflammatory damage with the two sequential stimuli. Our findings offer mechanistic insights into CM biology in a 3D brain microvessel mimetic platform and suggest that multiple events intersect to promote brain barrier inflammation in CM.
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Affiliation(s)
- Caitlin Howard
- Department of Bioengineering, University of Washington, Seattle, WA, USA; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA 98109, USA
| | - Fatou Joof
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA 98109, USA
| | - Ruoqian Hu
- Department of Bioengineering, University of Washington, Seattle, WA, USA; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA 98109, USA
| | - Joseph D Smith
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, WA 98109, USA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Ying Zheng
- Department of Bioengineering, University of Washington, Seattle, WA, USA; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA 98109, USA.
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Rajan Raghavan SS, Turner L, Jensen RW, Johansen NT, Jensen DS, Gourdon P, Zhang J, Wang Y, Theander TG, Wang K, Lavstsen T. Endothelial protein C receptor binding induces conformational changes to severe malaria-associated group A PfEMP1. Structure 2023; 31:1174-1183.e4. [PMID: 37582356 DOI: 10.1016/j.str.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/16/2023] [Accepted: 07/20/2023] [Indexed: 08/17/2023]
Abstract
Severe Plasmodium falciparum malaria infections are caused by microvascular sequestration of parasites binding to the human endothelial protein C receptor (EPCR) via the multi-domain P. falciparum erythrocyte membrane protein 1 (PfEMP1) adhesion ligands. Using cryogenic electron microscopy (Cryo-EM) and PfEMP1 sequence diversity analysis, we found that group A PfEMP1 CIDRα1 domains interact with the adjacent DBLα1 domain through central, conserved residues of the EPCR-binding site to adopt a compact conformation. Upon EPCR binding, the DBLα1 domain is displaced, and the EPCR-binding helix of CIDRα1 is turned, kinked, and twisted to reach a rearranged, stable EPCR-bound conformation. The unbound conformation and the required transition to the EPCR-bound conformation may represent a conformational masking mechanism of immune evasion for the PfEMP1 family.
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Affiliation(s)
- Sai Sundar Rajan Raghavan
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Louise Turner
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Rasmus W Jensen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Nicolai Tidemand Johansen
- Section for Transport Biology, Department of Plant and Environmental Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Skjold Jensen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Pontus Gourdon
- Department of Experimental Medical Science, Lund University, Lund, Sweden; Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jinqiu Zhang
- The Provincial International Science and Technology Cooperation Base on Engineering Biology, International Campus of Zhejiang University, Haining, China
| | - Yong Wang
- The Provincial International Science and Technology Cooperation Base on Engineering Biology, International Campus of Zhejiang University, Haining, China
| | - Thor Grundtvig Theander
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Kaituo Wang
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Thomas Lavstsen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, and Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.
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29
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Clark DJ, Bond C, Andrews A, Muller DJ, Sarkisian A, Opoka RO, Idro R, Bangirana P, Witten A, Sausen NJ, Birbeck GL, John CC, Postels DG. Admission Clinical and EEG Features Associated With Mortality and Long-term Neurologic and Cognitive Outcomes in Pediatric Cerebral Malaria. Neurology 2023; 101:e1307-e1318. [PMID: 37541845 PMCID: PMC10558167 DOI: 10.1212/wnl.0000000000207657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 06/02/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES For children with cerebral malaria, mortality is high, and in survivors, long-term neurologic and cognitive dysfunctions are common. While specific clinical factors are associated with death or long-term neurocognitive morbidity in cerebral malaria, the association of EEG features with these outcomes, particularly neurocognitive outcomes, is less well characterized. METHODS In this prospective cohort study of 149 children age 6 months to 12 years who survived cerebral malaria in Kampala, Uganda, we evaluated whether depth of coma, number of clinical seizures, or EEG features during hospitalization were associated with mortality during hospitalization, short-term and long-term neurologic deficits, or long-term cognitive outcomes (overall cognition, attention, memory) over the 2-year follow-up. RESULTS Higher Blantyre or Glasgow Coma Scores (BCS and GCS, respectively), higher background voltage, and presence of normal reactivity on EEG were each associated with lower mortality. Among clinical and EEG features, the presence of >4 seizures on admission had the best combination of negative and positive predictive values for neurologic deficits in follow-up. In multivariable modeling of cognitive outcomes, the number of seizures and specific EEG features showed independent association with better outcomes. In children younger than 5 years throughout the study, seizure number and presence of vertex sharp waves were independently associated with better posthospitalization cognitive performance, faster dominant frequency with better attention, and higher average background voltage and faster dominant background frequency with better associative memory. In children younger than 5 years at CM episode but 5 years or older at cognitive testing, seizure number, background dominant frequency, and the presence of vertex sharp waves were each associated with changes in cognition, seizure number and variability with attention, and seizure number with working memory. DISCUSSION In children with cerebral malaria, seizure number is strongly associated with the risk of long-term neurologic deficits, while seizure number and specific EEG features (average background voltage, dominant rhythm frequency, presence of vertex sharp waves, presence of variability) are independently associated with cognitive outcomes. Future studies should evaluate the predictive value of these findings.
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Affiliation(s)
- Daniel J Clark
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi.
| | - Caitlin Bond
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Alexander Andrews
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Daniel J Muller
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Angela Sarkisian
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Robert O Opoka
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Richard Idro
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Bangirana
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andy Witten
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicholas J Sausen
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Gretchen L Birbeck
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Chandy C John
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Douglas G Postels
- From the Division of Neurology (D.J.C.), Nationwide Children's Hospital, Columbus, OH; Ryan White Center for Pediatric Infectious Diseases & Global Health (C.B., C.C.J.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (A.A.), MedStar Georgetown University Hospital; The George Washington University School of Medicine and Health Sciences (D.J.M., A.S., D.G.P.), Washington, DC; Department of Paediatrics and Child Health (R.O.O., R.I.), Makerere University College of Health Sciences; Department of Psychiatry (P.B.), Makerere University College of Health Sciences, Kampala, Uganda; Department of Neurosurgery (A.W.), Indiana University School of Medicine, Indianapolis; Department of Pediatrics (N.J.S.), Division of Emergency Medicine, University of Minnesota, Minneapolis; Department of Neurology (G.L.B.), University of Rochester, NY; University of Zambia (G.L.B.), School of Medicine, Lusaka; University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia; Children's National Medical Center (D.G.P.), Washington, DC; and Blantyre Malaria Project (D.G.P.), Kamuzu University of Health Sciences, Blantyre, Malawi
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30
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Smith RL, Ikeda AK, Rowley CA, Khandhadia A, Gorbach AM, Chimalizeni Y, Taylor TE, Seydel K, Ackerman HC. Increased brain microvascular hemoglobin concentrations in children with cerebral malaria. Sci Transl Med 2023; 15:eadh4293. [PMID: 37703350 DOI: 10.1126/scitranslmed.adh4293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023]
Abstract
Brain swelling is associated with death from cerebral malaria, but it is unclear whether brain swelling is caused by cerebral edema or vascular congestion-two pathological conditions with distinct effects on tissue hemoglobin concentrations. We used near-infrared spectroscopy (NIRS) to noninvasively study cerebral microvascular hemoglobin concentrations in 46 Malawian children with cerebral malaria. Cerebral malaria was defined by the presence of the malaria parasite Plasmodium falciparum on a blood smear, a Blantyre coma score of 2 or less, and retinopathy. Children with uncomplicated malaria (n = 33) and healthy children (n = 29) were enrolled as comparators. Cerebral microvascular hemoglobin concentrations were higher among children with cerebral malaria compared with those with uncomplicated malaria [median (25th, 75th): 145.2 (95.2, 190.0) μM versus 82.9 (65.7, 105.4) μM, P = 0.008]. Cerebral microvascular hemoglobin concentrations correlated with brain swelling score determined by MRI (r = 0.37, P = 0.03). Fluctuations in cerebral microvascular hemoglobin concentrations over a 30-min time period were characterized using detrended fluctuation analysis (DFA). DFA determined self-similarity of the cerebral microvascular hemoglobin concentration signal to be lower among children with cerebral malaria compared with those with uncomplicated malaria [0.63 (0.54, 0.70) versus 0.91 (0.82, 0.94), P < 0.0001]. The lower self-similarity of the hemoglobin concentration signal in children with cerebral malaria suggested impaired regulation of cerebral blood flow. The elevated cerebral tissue hemoglobin concentration and its correlation with brain swelling suggested that excess blood volume, potentially due to vascular congestion, may contribute to brain swelling in cerebral malaria.
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Affiliation(s)
- Rachel L Smith
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Allison K Ikeda
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Carol A Rowley
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
| | - Amit Khandhadia
- Infrared Imaging and Thermometry Unit, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Alexander M Gorbach
- Infrared Imaging and Thermometry Unit, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Yamikani Chimalizeni
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Terrie E Taylor
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Karl Seydel
- Queen Elizabeth Central Hospital and Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Hans C Ackerman
- Physiology Unit, Laboratory of Malaria and Vector Research, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Rockville, MD, USA
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31
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Tu D, Goyal MS, Dworkin JD, Kampondeni S, Vidal L, Biondo-Savin E, Juvvadi S, Raghavan P, Nicholas J, Chetcuti K, Clark K, Robert-Fitzgerald T, Satterthwaite TD, Yushkevich P, Davatzikos C, Erus G, Tustison NJ, Postels DG, Taylor TE, Small DS, Shinohara RT. Automated analysis of low-field brain MRI in cerebral malaria. Biometrics 2023; 79:2417-2429. [PMID: 35731973 PMCID: PMC10267853 DOI: 10.1111/biom.13708] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/08/2022] [Indexed: 11/26/2022]
Abstract
A central challenge of medical imaging studies is to extract biomarkers that characterize disease pathology or outcomes. Modern automated approaches have found tremendous success in high-resolution, high-quality magnetic resonance images. These methods, however, may not translate to low-resolution images acquired on magnetic resonance imaging (MRI) scanners with lower magnetic field strength. In low-resource settings where low-field scanners are more common and there is a shortage of radiologists to manually interpret MRI scans, it is critical to develop automated methods that can augment or replace manual interpretation, while accommodating reduced image quality. We present a fully automated framework for translating radiological diagnostic criteria into image-based biomarkers, inspired by a project in which children with cerebral malaria (CM) were imaged using low-field 0.35 Tesla MRI. We integrate multiatlas label fusion, which leverages high-resolution images from another sample as prior spatial information, with parametric Gaussian hidden Markov models based on image intensities, to create a robust method for determining ventricular cerebrospinal fluid volume. We also propose normalized image intensity and texture measurements to determine the loss of gray-to-white matter tissue differentiation and sulcal effacement. These integrated biomarkers have excellent classification performance for determining severe brain swelling due to CM.
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Affiliation(s)
- Danni Tu
- The Penn Statistics in Imaging and Visualization Endeavor (PennSIVE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Manu S. Goyal
- Mallinckrodt Institute of Radiology, Washington University in St. Louis
| | | | | | - Lorenna Vidal
- Department of Radiology, Children’s Hospital of Philadelphia
| | | | | | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine
| | - Jennifer Nicholas
- University Hospitals Cleveland Medical Center, Department of Radiology, Case Western Reserve University
| | - Karen Chetcuti
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences
| | - Kelly Clark
- The Penn Statistics in Imaging and Visualization Endeavor (PennSIVE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | - Timothy Robert-Fitzgerald
- The Penn Statistics in Imaging and Visualization Endeavor (PennSIVE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
| | | | | | | | - Guray Erus
- Center for Biomedical Image Computing and Analysis (CBICA), Department of Radiology, University of Pennsylvania
| | | | - Douglas G. Postels
- Division of Neurology, George Washington University/Children’s National Medical Center
| | - Terrie E. Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences
- College of Osteopathic Medicine, Michigan State University
| | | | - Russell T. Shinohara
- The Penn Statistics in Imaging and Visualization Endeavor (PennSIVE), Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania
- Center for Biomedical Image Computing and Analysis (CBICA), Department of Radiology, University of Pennsylvania
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Pinheiro ADS, Kazura JW, Pinheiro AA, Schmaier AH. Is there a role for bradykinin in cerebral malaria pathogenesis? Front Cell Infect Microbiol 2023; 13:1184896. [PMID: 37637466 PMCID: PMC10448822 DOI: 10.3389/fcimb.2023.1184896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Malaria is a parasitic disease of global health significance and a leading cause of death in children living in endemic regions. Although various Plasmodium species are responsible for the disease, Plasmodium falciparum infection accounts for most severe cases of the disease in humans. The mechanisms of cerebral malaria pathogenesis have been studied extensively in humans and animal malaria models; however, it is far from being fully understood. Recent discoveries indicate a potential role of bradykinin and the kallikrein kinin system in the pathogenesis of cerebral malaria. The aim of this review is to highlight how bradykinin is formed in cerebral malaria and how it may impact cerebral blood-brain barrier function. Areas of interest in this context include Plasmodium parasite enzymes that directly generate bradykinin from plasma protein precursors, cytoadhesion of P. falciparum infected red blood cells to brain endothelial cells, and endothelial cell blood-brain barrier disruption.
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Affiliation(s)
- Alessandro de Sa Pinheiro
- Department of Medicine, Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - James W. Kazura
- Center for Global Health and Diseases, Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - Ana Acacia Pinheiro
- Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Alvin H. Schmaier
- Department of Medicine, Hematology and Oncology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, United States
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Raees MQ, Chimalizeni Y, Liomba AWM, Pensulo P, Gushu MB, Tebulo A, Malenga A, Sikorski MJ, Holloway AJ, Bhutta AT, Doctor A, Remy KE, O’Brien NF, Postels DG, Taylor TE. Capacity Building in Pediatric Critical Care-Global Health Research and Education: The Blantyre Experience. Am J Trop Med Hyg 2023; 109:225-227. [PMID: 37308102 PMCID: PMC10397452 DOI: 10.4269/ajtmh.22-0445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/23/2023] [Indexed: 06/14/2023] Open
Abstract
Pediatric critical care medicine (PCCM), as it is practiced in high-income countries, is focused on specialized medical care for the most vulnerable pediatric patient populations. However, best practices for provision of that care globally are lacking. Thus, PCCM research and education programming can potentially fill significant knowledge gaps by facilitating the development of evidence-based clinical guidelines that reduce child mortality on a global scale. Malaria remains a leading cause of pediatric mortality worldwide. The Blantyre Malaria Project (BMP) is a research and clinical care collaborative that has focused on reducing the public health burden of pediatric cerebral malaria in Malawi since 1986. In 2017, the requirements of a new research study led to the creation of PCCM services in Blantyre, creating the opportunity to establish a PCCM-Global Health Research Fellowship by BMP in collaboration with the University of Maryland School of Medicine. In this perspective piece, we reflect on the evolution of the PCCM-Global Health research fellowship. Although the specifics of this fellowship are out of the scope of this perspective, we discuss the context allowing for the development of this program and explore some early lessons learned to consider for future capacity-building efforts in the future of PCCM-Global Health research.
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Affiliation(s)
- Madiha Q. Raees
- Division of Critical Care, Department of Critical Care and Anesthesia, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yamikani Chimalizeni
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Alice W. Muiruri Liomba
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Paul Pensulo
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Montfort Benard Gushu
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Andrew Tebulo
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Albert Malenga
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Michael J. Sikorski
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Adrian J. Holloway
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Adnan T. Bhutta
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allan Doctor
- Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
- Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kenneth E. Remy
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Division of Pulmonary and Critical Care, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Nicole F. O’Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - Douglas G. Postels
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Division of Neurology, Children’s National Medical Center, George Washington University, Washington, District of Columbia
| | - Terrie E. Taylor
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
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Beare NAV. Cerebral malaria-using the retina to study the brain. Eye (Lond) 2023; 37:2379-2384. [PMID: 36788363 PMCID: PMC10397347 DOI: 10.1038/s41433-023-02432-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Cerebral malaria (CM) remains a common cause of death of children in Africa with annual mortality of 400 000. Malarial retinopathy is a unique set of fundus signs which has diagnostic and prognostic value in CM. Assessment of malarial retinopathy is now widely utilised in clinical care, and routinely incorporated into clinical studies to refine entry criteria. As a visible part of the central nervous system, the retina provides insights into the pathophysiology of this infectious small-vessel vasculitis with adherent parasitised red blood cells. Fluorescein angiography and optical coherence tomography (OCT) have shown that patchy capillary non-perfusion is common and causes ischaemic changes in the retina in CM. It is likely this is mirrored in the brain and may cause global neurological impairments evident on developmental follow up. Three types of blood-retina barrier breakdown are evident: large focal, punctate, and vessel leak. Punctate and large focal leak (haemorrhage in formation) are associated with severe brain swelling and fatal outcome. Vessel leak and capillary non-perfusion are associated with moderate brain swelling and neurological sequelae. These findings imply that death and neurological sequelae have separate mechanisms and are not a continuum of severity. Each haemorrhage causes a temporary uncontrolled outflow of fluid into the tissue. The rapid accumulation of haemorrhages, as evidenced by multiple focal leaks, is a proposed mechanism of severe brain swelling, and death. Current studies aim to use optic nerve head OCT to identify patients with severe brain swelling, and macula OCT to identify those at risk of neurological sequelae.
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Affiliation(s)
- Nicholas A V Beare
- Department of Eye and Vision Science, University of Liverpool, Liverpool, L7 8TX, UK.
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Saleki K, Mohamadi MH, Alijanizadeh P, Rezaei N. Neurological adverse effects of chimeric antigen receptor T-cell therapy. Expert Rev Clin Immunol 2023; 19:1361-1383. [PMID: 37578341 DOI: 10.1080/1744666x.2023.2248390] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Chimeric antigen receptor (CAR) T-cell is among the most prevalent approaches that act by directing T-cells toward cancer; however, they need to be optimized to minimize side effects and maximize efficacy before being used as standard treatment for malignancies. Neurotoxicity associated with CAR T-cell therapy has been well-documented in recent works. AREAS COVERED In this regard, two established syndromes exist. Immune effector cell-associated neurotoxicity syndrome (ICANS), previously called cytokine release encephalopathy syndrome (CRES), is a neuropsychiatric condition which can occur after therapy by immune effector cells (IEC) and T-lymphocytes utilizing treatments. Another syndrome is cytokine release syndrome (CRS), which may overlap with ICANS. EXPERT OPINION ICANS clinical manifestations include cerebral edema, mild lethargy, aphasia, and seizures. Notably, ICANS is associated with changes to EEG and neuroradiological findings. Therefore, it is necessary to make a timely and accurate diagnosis of neurological complications of CAR T-cells by clinical presentations, neuroimaging, and EEG. Since neurological events by different CAR T-cell products are heterogeneous, guides should be developed according to each product. Here, we provide an updated review of general information on CAR T-cell therapies and applications, neurological syndromes associated with their use, and risk factors contributing to ICANS.
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Affiliation(s)
- Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
- Department of e-Learning, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences(SBMU), Tehran, Iran
| | | | - Parsa Alijanizadeh
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
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Brodeur KRN, Herculano A, Oliveira K. Clinical aspects of malarial retinopathy: a critical review. Pathog Glob Health 2023; 117:450-461. [PMID: 36262019 PMCID: PMC10262785 DOI: 10.1080/20477724.2022.2128568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
This review will provide a better understanding of a set of signs known as malarial retinopathy. The discovery of this retinopathy in association with cerebral malaria is important because it best distinguishes patients with true cerebral malaria from those with coma due to other causes and incidental Plasmodium falciparum parasitemia. Identifying a comatose patient with malarial retinopathy increases the likelihood of an accurate severe or cerebral malaria diagnosis. As the World Health Organization does not specify that malarial retinopathy is one of the factors included in determining a cerebral malaria diagnosis, there are significant false-positive diagnoses of cerebral malaria. Once a cerebral malaria diagnosis is assigned, other possibilities and treatments are often excluded making an incorrect diagnosis of cerebral malaria potentially fatal. However, Plasmodium falciparum may also contribute to coma in some children with retinopathy-negative cerebral malaria, as this group is still not clinically well characterized, so all children with the WHO definition of cerebral malaria should be treated for severe malaria. Nevertheless, by raising awareness about malarial retinopathy, there could be a greater potential to accurately diagnose cerebral malaria and thus achieve more positive patient outcomes in the future. This literary review aims to raise awareness of the retinopathy by defining what it is to non-experts, explaining its pathology, clarifying the techniques needed to accurately diagnose malarial retinopathy, as well as the barriers that prevent clinicians from providing a proper diagnosis in malaria-endemic regions; and finally, discuss future directions to continue the study of malarial retinopathy.
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Affiliation(s)
- Ketan Raymond Nair Brodeur
- Laboratory of Experimental Neuropharmacology, Federal University of Pará, Belém, Pará, Brazil
- Fulbright US Student Program
- University of Michigan – Ann Arbor, Michigan, USA
| | - Anderson Herculano
- Laboratory of Experimental Neuropharmacology, Federal University of Pará, Belém, Pará, Brazil
| | - Karen Oliveira
- Laboratory of Experimental Neuropharmacology, Federal University of Pará, Belém, Pará, Brazil
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Conroy AL, Datta D, Opoka RO, Batte A, Bangirana P, Gopinadhan A, Mellencamp KA, Akcan-Arikan A, Idro R, John CC. Cerebrospinal fluid biomarkers provide evidence for kidney-brain axis involvement in cerebral malaria pathogenesis. Front Hum Neurosci 2023; 17:1177242. [PMID: 37200952 PMCID: PMC10185839 DOI: 10.3389/fnhum.2023.1177242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Introduction Cerebral malaria is one of the most severe manifestations of malaria and is a leading cause of acquired neurodisability in African children. Recent studies suggest acute kidney injury (AKI) is a risk factor for brain injury in cerebral malaria. The present study evaluates potential mechanisms of brain injury in cerebral malaria by evaluating changes in cerebrospinal fluid measures of brain injury with respect to severe malaria complications. Specifically, we attempt to delineate mechanisms of injury focusing on blood-brain-barrier integrity and acute metabolic changes that may underlie kidney-brain crosstalk in severe malaria. Methods We evaluated 30 cerebrospinal fluid (CSF) markers of inflammation, oxidative stress, and brain injury in 168 Ugandan children aged 18 months to 12 years hospitalized with cerebral malaria. Eligible children were infected with Plasmodium falciparum and had unexplained coma. Acute kidney injury (AKI) on admission was defined using the Kidney Disease: Improving Global Outcomes criteria. We further evaluated blood-brain-barrier integrity and malaria retinopathy, and electrolyte and metabolic complications in serum. Results The mean age of children was 3.8 years (SD, 1.9) and 40.5% were female. The prevalence of AKI was 46.3% and multi-organ dysfunction was common with 76.2% of children having at least one organ system affected in addition to coma. AKI and elevated blood urea nitrogen, but not other measures of disease severity (severe coma, seizures, jaundice, acidosis), were associated with increases in CSF markers of impaired blood-brain-barrier function, neuronal injury (neuron-specific enolase, tau), excitatory neurotransmission (kynurenine), as well as altered nitric oxide bioavailability and oxidative stress (p < 0.05 after adjustment for multiple testing). Further evaluation of potential mechanisms suggested that AKI may mediate or be associated with CSF changes through blood-brain-barrier disruption (p = 0.0014), ischemic injury seen by indirect ophthalmoscopy (p < 0.05), altered osmolality (p = 0.0006) and through alterations in the amino acids transported into the brain. Conclusion In children with cerebral malaria, there is evidence of kidney-brain injury with multiple potential pathways identified. These changes were specific to the kidney and not observed in the context of other clinical complications.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Undergraduate Medical Education, The Aga Khan University, Nairobi, Kenya
| | - Anthony Batte
- Global Health Uganda, Kampala, Uganda
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Global Health Uganda, Kampala, Uganda
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adnan Gopinadhan
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Kagan A. Mellencamp
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, United States
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Wilson KJ, Dhalla A, Meng Y, Tu Z, Zheng Y, Mhango P, Seydel KB, Beare NAV. Retinal imaging technologies in cerebral malaria: a systematic review. Malar J 2023; 22:139. [PMID: 37101295 PMCID: PMC10131356 DOI: 10.1186/s12936-023-04566-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 04/20/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Cerebral malaria (CM) continues to present a major health challenge, particularly in sub-Saharan Africa. CM is associated with a characteristic malarial retinopathy (MR) with diagnostic and prognostic significance. Advances in retinal imaging have allowed researchers to better characterize the changes seen in MR and to make inferences about the pathophysiology of the disease. The study aimed to explore the role of retinal imaging in diagnosis and prognostication in CM; establish insights into pathophysiology of CM from retinal imaging; establish future research directions. METHODS The literature was systematically reviewed using the African Index Medicus, MEDLINE, Scopus and Web of Science databases. A total of 35 full texts were included in the final analysis. The descriptive nature of the included studies and heterogeneity precluded meta-analysis. RESULTS Available research clearly shows retinal imaging is useful both as a clinical tool for the assessment of CM and as a scientific instrument to aid the understanding of the condition. Modalities which can be performed at the bedside, such as fundus photography and optical coherence tomography, are best positioned to take advantage of artificial intelligence-assisted image analysis, unlocking the clinical potential of retinal imaging for real-time diagnosis in low-resource environments where extensively trained clinicians may be few in number, and for guiding adjunctive therapies as they develop. CONCLUSIONS Further research into retinal imaging technologies in CM is justified. In particular, co-ordinated interdisciplinary work shows promise in unpicking the pathophysiology of a complex disease.
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Affiliation(s)
- Kyle J Wilson
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK.
- Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi.
| | - Amit Dhalla
- Department of Ophthalmology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Yanda Meng
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK
| | - Zhanhan Tu
- School of Psychology and Vision Sciences, College of Life Science, The University of Leicester Ulverscroft Eye Unit, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK
| | - Yalin Zheng
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK
- St. Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Priscilla Mhango
- Department of Ophthalmology, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Karl B Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nicholas A V Beare
- Department of Eye & Vision Sciences, University of Liverpool, Liverpool, UK.
- St. Paul's Eye Unit, Royal Liverpool University Hospitals, Liverpool, UK.
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Cimperman CK, Pena M, Gokcek SM, Theall BP, Patel MV, Sharma A, Qi C, Sturdevant D, Miller LH, Collins PL, Pierce SK, Akkaya M. Cerebral Malaria Is Regulated by Host-Mediated Changes in Plasmodium Gene Expression. mBio 2023; 14:e0339122. [PMID: 36852995 PMCID: PMC10127683 DOI: 10.1128/mbio.03391-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 03/01/2023] Open
Abstract
Cerebral malaria (CM), the deadliest complication of Plasmodium infection, is a complex and unpredictable disease. However, our understanding of the host and parasite factors that cause CM is limited. Using a mouse model of CM, experimental CM (ECM), we performed a three-way comparison between ECM-susceptible C57BL/6 mice infected with ECM-causing Plasmodium ANKA parasites [ANKA(C57BL/6)], ECM-resistant BALB/c mice infected with Plasmodium ANKA [ANKA(BALB/c)], and C57BL/6 mice infected with Plasmodium NK65 that does not cause ECM [NK65(C57BL/6)]. All ANKA(C57BL/6) mice developed CM. In contrast, in ANKA(BALB/c) and NK65(C57BL/6), infections do not result in CM and proceed similarly in terms of parasite growth, disease course, and host immune response. However, parasite gene expression in ANKA(BALB/c) was remarkably different than that in ANKA(C57BL/6) but similar to the gene expression in NK65(C57BL/6). Thus, Plasmodium ANKA has an ECM-specific gene expression profile that is activated only in susceptible hosts, providing evidence that the host has a critical influence on the outcome of infection. IMPORTANCE Hundreds of thousands of lives are lost each year due to the brain damage caused by malaria disease. The overwhelming majority of these deaths occur in young children living in sub-Saharan Africa. Thus far, there are no vaccines against this deadly disease, and we still do not know why fatal brain damage occurs in some children while others have milder, self-limiting disease progression. Our research provides an important clue to this problem. Here, we showed that the genetic background of the host has an important role in determining the course and the outcome of the disease. Our research also identified parasite molecules that can potentially be targeted in vaccination and therapy approaches.
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Affiliation(s)
- Clare K. Cimperman
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Mirna Pena
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Sohret M. Gokcek
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Microbial Infection and Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Pelotonia Institute for Immuno-Oncology, The James Comprehensive Cancer Center, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Brandon P. Theall
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Meha V. Patel
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Anisha Sharma
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - ChenFeng Qi
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Daniel Sturdevant
- Research Technologies Branch, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, Hamilton, Montana, USA
| | - Louis H. Miller
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Patrick L. Collins
- Department of Microbial Infection and Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Pelotonia Institute for Immuno-Oncology, The James Comprehensive Cancer Center, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Susan K. Pierce
- Laboratory of Immunogenetics, National Institute of Allergy and Infectious Diseases, Rockville, Maryland, USA
| | - Munir Akkaya
- Division of Rheumatology and Immunology, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Microbial Infection and Immunity, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Pelotonia Institute for Immuno-Oncology, The James Comprehensive Cancer Center, College of Medicine, The Ohio State University, Columbus, Ohio, USA
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Wilson KJ, Tu Z, Mbale E, Mhango PP, Kayange P, Gladstone MJ, Harding S, Gottlob I, Garcia-Finana M, Shen Y, Taylor TE, Seydel KB, Zheng Y, Beare NAV. Predicting Acute and Post-Recovery Outcomes in Cerebral Malaria and Other Comas by Optical Coherence Tomography (OCT in CM) - A protocol for an observational cohort study of Malawian children. Wellcome Open Res 2023; 8:172. [PMID: 37663790 PMCID: PMC10468659 DOI: 10.12688/wellcomeopenres.19166.1] [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] [Accepted: 03/14/2023] [Indexed: 09/05/2023] Open
Abstract
Cerebral malaria (CM) remains a significant global health challenge with high morbidity and mortality. Malarial retinopathy has been shown to be diagnostically and prognostically significant in the assessment of CM. The major mechanism of death in paediatric CM is brain swelling. Long term morbidity is typically characterised by neurological and neurodevelopmental sequelae. Optical coherence tomography can be used to quantify papilloedema and macular ischaemia, identified as hyperreflectivity. Here we describe a protocol to test the hypotheses that quantification of optic nerve head swelling using optical coherence tomography can identify severe brain swelling in CM, and that quantification of hyperreflectivity in the macula predicts neurodevelopmental outcomes post-recovery. Additionally, our protocol includes the development of a novel, low-cost, handheld optical coherence tomography machine and artificial intelligence tools to assist in image analysis.
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Affiliation(s)
- Kyle J Wilson
- Eye & Vision Science, University of Liverpool, Liverpool, England, L69 7TX, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Southern Region, PO Box 30096, Malawi
| | - Zhanhan Tu
- Ulverscroft Eye Unit, University of Leicester, Leicester, England, LE2 7LX, UK
| | - Emmie Mbale
- Department of Paediatrics, Kamuzu University of Health Sciences, Blantyre, Southern Region, P/Bag 360, Malawi
| | - Priscilla P Mhango
- Department of Ophthalmology, Kamuzu University of Health Sciences, Blantyre, Southern Region, P/Bag 360, Malawi
| | - Petros Kayange
- Department of Ophthalmology, Kamuzu University of Health Sciences, Blantyre, Southern Region, P/Bag 360, Malawi
| | - Melissa J. Gladstone
- Women’s and Children’s Health, University of Liverpool, Liverpool, England, L69 7TX, UK
| | - Simon Harding
- Eye & Vision Science, University of Liverpool, Liverpool, England, L69 7TX, UK
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8YA, UK
| | - Irene Gottlob
- Cooper Neurological Institute, Cherry Hill, New Jersey, 08002, USA
| | - Marta Garcia-Finana
- Department of Health Data Science, University of Liverpool, Liverpool, England, L69 3GF, UK
| | - Yaochun Shen
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, England, L69 3GJ, UK
| | - Terrie E Taylor
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, 4882, USA
- Blantyre Malaria Project, Blantyre, Southern Region, P/Bag 360, Malawi
| | - Karl B Seydel
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, 4882, USA
- Blantyre Malaria Project, Blantyre, Southern Region, P/Bag 360, Malawi
| | - Yalin Zheng
- Eye & Vision Science, University of Liverpool, Liverpool, England, L69 7TX, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, England, L69 7TX, UK
| | - Nicholas AV Beare
- Eye & Vision Science, University of Liverpool, Liverpool, England, L69 7TX, UK
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8YA, UK
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41
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Huang W, Hua C, Guo Y, Gao W, Li Y, Zheng Y. Super resolution imaging reconstruction reveals that gold standard methods may not correctly conclude neural/brain functional recovery. Comput Med Imaging Graph 2023; 105:102198. [PMID: 36805708 DOI: 10.1016/j.compmedimag.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/17/2022] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
The status of cerebral perfusion and its restoration level play a vital role in the prognosis and clinical decision making of many neurosurgical diseases. As such, gold standard methods including CT, MR and ICP monitoring, which can indicate and measure cerebral perfusion and restoration, have been widely adopted to evaluate whether or not a patient has recovered from neurofunctional disabilities. This robust combination of methods, however, is confronted with a growing number of contradictions in recent years due to its inability to measure the status of cerebral reperfusion in microvasculature level, even though this has been shown to determine neurofunctional restoration as well or even better. To this date, nevertheless, we have very limited imaging methods that could evaluate human cerebral microperfusion both safely and accurately under most neurosurgical conditions. We herein report a new method of acquiring a patient's cerebral microperfusion status noninvasively which could display the precise distribution of microvasculature in deep cerebral regions with a resolution of ∼30 µm, using everyday bed-side ultrasonography combined with a computerized super-resolution reconstruction algorithm. Using this imaging modality, we found that a patient's cerebral microperfusion might not be improved by some routine administrations even though the gold standard method had yielded the opposite conclusions. Our imaging modality retains the safe, portable feature of ordinary ultrasonography while possesses the extraordinary super-resolution nature, which enables an efficient, precise diagnosis of cerebral perfusion. Most importantly, the super resolution nature of this method may also facilitate early-stage evaluation of a patient's neurofunctional restoration level and avoid overoptimistic conclusions from conventional angiography or ICP monitoring.
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Affiliation(s)
- Weifeng Huang
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Hua
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Center for Brain Science, Shanghai, China.
| | - Yan Guo
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenwei Gao
- Department of Neurosurgery, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchuan Li
- Department of Critical Care Medicine, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Yuanyi Zheng
- Department of Ultrasound, The Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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42
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Sahu PK, Mohanty S. Pathogenesis of Cerebral Malaria: New Trends and Insights for Developing Adjunctive Therapies. Pathogens 2023; 12:pathogens12040522. [PMID: 37111408 PMCID: PMC10142940 DOI: 10.3390/pathogens12040522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
No specific or adjunctive therapies exist to treat cerebral malaria (CM) as of date. CM is a neuropathological manifestation of the malaria infection in humans, caused by the hemoparasitic pathogen Plasmodium falciparum. Driven through a multitude of virulence factors, varied immune responses, variations in brain swelling with regard to the age of patients, parasite biomass, and parasite-typing, the essential pathogenetic mechanisms underlying clinical CM have remained elusive. However, a recent series of studies based on molecular, immunologic, and advanced neuroradiologic and machine-learning approaches have unraveled new trends and insights to better understand and focus on the key determinants of CM in humans. This could possibly be the beginning of the design of new and effective adjunctive therapies that may not be common or applicable to the entire malarious world, but that could, rather, be specific to the variations in the determinants of CM.
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43
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Shafi AM, Végvári Á, Zubarev RA, Penha-Gonçalves C. Brain endothelial cells exposure to malaria parasites links type I interferon signalling to antigen presentation, immunoproteasome activation, endothelium disruption, and cellular metabolism. Front Immunol 2023; 14:1149107. [PMID: 36993973 PMCID: PMC10042232 DOI: 10.3389/fimmu.2023.1149107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
IntroductionCerebral malaria (CM) lethality is attributable to induction of brain edema induction but the cellular mechanisms involving brain microvascular endothelium in CM pathogenesis are unexplored.ResultsActivation of the STING-INFb-CXCL10 axis in brain endothelial cells (BECs) is a prominent component of the innate immune response in CM development in mouse models. Using a T cell-reporter system, we show that Type 1 IFN signaling in BECs exposed to Plasmodium berghei-infected erythrocytes (PbA-IE), functionally enhances MHC Class-I antigen presentation through gamma-interferon independent immunoproteasome activation and impacted the proteome functionally related to vesicle trafficking, protein processing/folding and antigen presentation. In vitro assays showed that Type 1 IFN signaling and immunoproteasome activation are also involved in the dysfunction of the endothelial barrier through disturbing gene expression in the Wnt/ß-catenin signaling pathway. We demonstrate that IE exposure induces a substantial increase in BECs glucose uptake while glycolysis blockade abrogates INFb secretion impairing immunoproteasome activation, antigen presentation and Wnt/ß-catenin signaling.DiscussionMetabolome analysis show that energy demand and production are markedly increased in BECs exposed to IE as revealed by enriched content in glucose and amino acid catabolites. In accordance, glycolysis blockade in vivo delayed the clinical onset of CM in mice. Together the results show that increase in glucose uptake upon IE exposure licenses Type 1 IFN signaling and subsequent immunoproteasome activation contributing to enhanced antigen presentation and impairment of endothelial barrier function. This work raises the hypothesis that Type 1 IFN signaling-immunoproteasome induction in BECs contributes to CM pathology and fatality (1) by increasing antigen presentation to cytotoxic CD8+ T cells and (2) by promoting endothelial barrier dysfunction, that likely favor brain vasogenic edema.
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Affiliation(s)
| | - Ákos Végvári
- Proteomics Biomedicum, Division of Physiological Chemistry I, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
- Division of Physiological Chemistry I, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Roman A. Zubarev
- Division of Physiological Chemistry I, Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Carlos Penha-Gonçalves
- Disease Genetics, Instituto Gulbenkian de Ciência, Oeiras, Portugal
- *Correspondence: Carlos Penha-Gonçalves,
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Pais TF, Penha-Gonçalves C. In vitro model of brain endothelial cell barrier reveals alterations induced by Plasmodium blood stage factors. Parasitol Res 2023; 122:729-737. [PMID: 36694092 PMCID: PMC9988999 DOI: 10.1007/s00436-023-07782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/25/2022] [Indexed: 01/26/2023]
Abstract
Cerebral malaria (CM) is a severe neurological condition caused by Plasmodium falciparum. Disruption of the brain-blood barrier (BBB) is a key pathological event leading to brain edema and vascular leakage in both humans and in the mouse model of CM. Interactions of brain endothelial cells with infected red blood cells (iRBCs) and with circulating inflammatory mediators and immune cells contribute to BBB dysfunction in CM. Adjunctive therapies for CM aim at preserving the BBB to prevent neurologic deficits. Experimental animal and cellular models are essential to develop new therapeutic strategies. However, in mice, the disease develops rapidly, which offers a very narrow time window for testing the therapeutic potential of drugs acting in the BBB. Here, we establish a brain endothelial cell barrier whose disturbance can be monitored by several parameters. Using this system, we found that incubation with iRBCs and with extracellular particles (EPs) released by iRBCs changes endothelial cell morphology, decreases the tight junction protein zonula occludens-1 (ZO-1), increases the gene expression of the intercellular adhesion molecule 1 (ICAM-1), and induces a significant reduction in transendothelial electrical resistance (TEER) with increased permeability. We propose this in vitro experimental setup as a straightforward tool to investigate molecular interactions and pathways causing endothelial barrier dysfunction and to test compounds that may target BBB and be effective against CM. A pre-selection of the effective compounds that strengthen the resistance of the brain endothelial cell barrier to Plasmodium-induced blood factors in vitro may increase the likelihood of their efficacy in preclinical disease mouse models of CM and in subsequent clinical trials with patients.
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Affiliation(s)
- Teresa F Pais
- Instituto Gulbenkian de Ciência, Rua da Quinta Grande, 6, 2780-156, Oeiras, Portugal.
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45
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Cell-Membrane-Coated Nanoparticles for Targeted Drug Delivery to the Brain for the Treatment of Neurological Diseases. Pharmaceutics 2023; 15:pharmaceutics15020621. [PMID: 36839943 PMCID: PMC9960717 DOI: 10.3390/pharmaceutics15020621] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/21/2023] [Accepted: 02/01/2023] [Indexed: 02/16/2023] Open
Abstract
Neurological diseases (NDs) are a significant cause of disability and death in the global population. However, effective treatments still need to be improved for most NDs. In recent years, cell-membrane-coated nanoparticles (CMCNPs) as drug-targeting delivery systems have become a research hotspot. Such a membrane-derived, nano drug-delivery system not only contributes to avoiding immune clearance but also endows nanoparticles (NPs) with various cellular and functional mimicries. This review article first provides an overview of the function and mechanism of single/hybrid cell-membrane-derived NPs. Then, we highlight the application and safety of CMCNPs in NDs. Finally, we discuss the challenges and opportunities in the field.
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46
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Muppidi P, Wright E, Wassmer SC, Gupta H. Diagnosis of cerebral malaria: Tools to reduce Plasmodium falciparum associated mortality. Front Cell Infect Microbiol 2023; 13:1090013. [PMID: 36844403 PMCID: PMC9947298 DOI: 10.3389/fcimb.2023.1090013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Cerebral malaria (CM) is a major cause of mortality in Plasmodium falciparum (Pf) infection and is associated with the sequestration of parasitised erythrocytes in the microvasculature of the host's vital organs. Prompt diagnosis and treatment are key to a positive outcome in CM. However, current diagnostic tools remain inadequate to assess the degree of brain dysfunction associated with CM before the window for effective treatment closes. Several host and parasite factor-based biomarkers have been suggested as rapid diagnostic tools with potential for early CM diagnosis, however, no specific biomarker signature has been validated. Here, we provide an updated review on promising CM biomarker candidates and evaluate their applicability as point-of-care tools in malaria-endemic areas.
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Affiliation(s)
- Pranavi Muppidi
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily Wright
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel C. Wassmer
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Himanshu Gupta
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, Mathura, UP, India
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47
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Andrews A, Zelleke T, Harrar D, Izem R, Gai J, Postels D. Theta-Alpha Variability on Admission EEG Is Associated With Outcome in Pediatric Cerebral Malaria. J Clin Neurophysiol 2023; 40:136-143. [PMID: 34669356 PMCID: PMC8626528 DOI: 10.1097/wnp.0000000000000865] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Pediatric cerebral malaria has high rates of mortality and neurologic morbidity. Although several biomarkers, including EEG, are associated with survival or morbidity, many are resource intensive or require skilled interpretation for clinical use. Automation of quantitative interpretation of EEG may be preferable in resource-limited settings, where trained interpreters are rare. As currently used quantitative EEG factors do not adequately describe the spectrum of variability seen in studies from children with cerebral malaria, the authors developed and validated a new quantitative EEG variable, theta-alpha variability (TAV). METHODS The authors developed TAV, a new quantitative variable, as a composite of multiple automated EEG outputs. EEG records from 194 children (6 months to 14 years old) with cerebral malaria were analyzed. Independent EEG interpreters performed standard quantitative and qualitative analyses, with the addition of the newly created variable. The associations of TAV with other quantitative EEG factors, a qualitative assessment of variability, and outcomes were assessed. RESULTS Theta-alpha variability was not highly correlated with alpha, theta, or delta power and was not associated with qualitative measures of variability. Children whose EEGs had higher values of TAV had a lower risk of death (odds ratio = 0.934, 95% confidence interval = 0.902-0.966) or neurologic sequelae (odds ratio = 0.960, 95% confidence interval = 0.932-0.990) compared with those with lower values. Receiver operating characteristic analysis in predicting death at a TAV threshold of 0.244 yielded a sensitivity of 74% and specificity of 70% for an area under the receiver operating characteristic curve of 0.755. CONCLUSIONS Theta-alpha variability is independently associated with outcome in pediatric cerebral malaria and can predict death with high sensitivity and specificity. Automated determination of this newly created EEG factor holds promise as a potential method to increase the clinical utility of EEG in resource-limited settings by allowing interventions to be targeted to those at higher risk of death or disability.
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Affiliation(s)
- Alexander Andrews
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, District of Columbia, U.S.A
| | - Tesfaye Zelleke
- Department of Neurology, The George Washington University School of Medicine, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Dana Harrar
- Department of Neurology, The George Washington University School of Medicine, Children's National Hospital, Washington, District of Columbia, U.S.A
| | - Rima Izem
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Washington, District of Columbia, U.S.A
- Division of Epidemiology, The George Washington University School of Public Health, Washington, District of Columbia, U.S.A
- Department of Pediatrics, The George Washington University School of Medicine, Washington, District of Columbia, U.S.A.; and
| | - Jiaxiang Gai
- Division of Biostatistics and Study Methodology, Children's National Research Institute, Washington, District of Columbia, U.S.A
| | - Douglas Postels
- Department of Neurology, The George Washington University School of Medicine, Children's National Hospital, Washington, District of Columbia, U.S.A
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
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48
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Lin Y, Tebulo A, Small D, Seydel K, Taylor T, Zhang B. Using Malarial Retinopathy to Improve the Diagnosis of Pediatric Cerebral Malaria. Am J Trop Med Hyg 2023; 108:69-75. [PMID: 36509055 PMCID: PMC9833082 DOI: 10.4269/ajtmh.22-0547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022] Open
Abstract
In malaria endemic areas, a high proportion of children have detectable parasitemia but show no clinical symptoms. When comatose from a cause other than malaria, this group confounds the cerebral malaria (CM) definition, making accurate diagnosis challenging. One important biomarker of CM is malarial retinopathy, a set of specific features visible in the ocular fundus. In this study, we quantified the contribution of malarial retinopathy in discriminating malaria-caused coma from non-malaria-caused coma. We estimated that 10% of our study cohort of N = 1,192 patients who met the WHO clinical definition of CM in Malawi had non-malarial coma based on a Gaussian mixture model using the parasite protein Plasmodium falciparum histidine-rich protein-2. A classification based on platelets, white blood cells, and retinopathy significantly improved the discriminative power of a previously established model including only platelets plus white blood cells (area under the receiver operating characteristic curve: 0.89 versus 0.75, P value < 0.001). We conclude that malarial retinopathy is highly predictive of malaria-caused versus non-malaria-caused coma and recommend that an ocular funduscopic examination to determine malarial retinopathy status be included in the assessment of parasitemic comatose African children.
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Affiliation(s)
- Yuzhou Lin
- Department of Statistics, Harvard University, Cambridge, Massachusetts
| | - Andrew Tebulo
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Dylan Small
- Department of Statistics and Data Science, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl Seydel
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan
| | - Terrie Taylor
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
- Department of Osteopathic Medical Specialties, Michigan State University, East Lansing, Michigan
| | - Bo Zhang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington
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49
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Malaria Vaccines. Infect Dis (Lond) 2023. [DOI: 10.1007/978-1-0716-2463-0_536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
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50
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Kurup AR, Wigdahl J, Benson J, Martínez-Ramón M, Solíz P, Joshi V. Automated malarial retinopathy detection using transfer learning and multi-camera retinal images. Biocybern Biomed Eng 2023; 43:109-123. [PMID: 36685736 PMCID: PMC9851283 DOI: 10.1016/j.bbe.2022.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cerebral malaria (CM) is a fatal syndrome found commonly in children less than 5 years old in Sub-saharan Africa and Asia. The retinal signs associated with CM are known as malarial retinopathy (MR), and they include highly specific retinal lesions such as whitening and hemorrhages. Detecting these lesions allows the detection of CM with high specificity. Up to 23% of CM, patients are over-diagnosed due to the presence of clinical symptoms also related to pneumonia, meningitis, or others. Therefore, patients go untreated for these pathologies, resulting in death or neurological disability. It is essential to have a low-cost and high-specificity diagnostic technique for CM detection, for which We developed a method based on transfer learning (TL). Models pre-trained with TL select the good quality retinal images, which are fed into another TL model to detect CM. This approach shows a 96% specificity with low-cost retinal cameras.
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Affiliation(s)
| | - Jeff Wigdahl
- VisionQuest Biomedical Inc., Albuquerque, NM, USA
| | | | | | - Peter Solíz
- VisionQuest Biomedical Inc., Albuquerque, NM, USA
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