Favourable prognostic value of antibodies anti-HSP20 in patients with cystic echinococcosis: a differential immunoproteomic approach

Proteomics Analysis of Hydatigera taeniaeformis Metacestode Stage

Hydatigera taeniaeformis (H. taeniaeformis) is one of the most robust of tapeworm parasites that is widely distributed around the world. Information of proteins of H. taeniaeformis has not previously been reported. Using liquid chromatography tandem-mass spectrometry (LC-MS/MS) analysis, the proteome of H. taeniaeformis metacestode was profiled and a total of 408 proteins were identified. Of these, 26.5% (108/408) were annotated to be associated with metabolic pathways. Consistently, Gene Ontology analysis showed that those identified proteins were mainly classified into metabolic process of the biological processes. A set of metabolic enzymes, including Fructose-1,6-bisphosphate aldolase, enolase, Glucan phosphorylase, and phosphoenolpyruvate carboxykinase, were abundant in H. taeniaeformis metacestodes. In addition, some rare but interesting proteins like antigens (such as tegument protein and Antigen B) were identified. The two recombinant proteins of tegument protein and Antigen B were well-recognized by the sera from the H. taeniaeformis-infected mice. The H. taeniaeformis metacestode proteome might help to find new candidates for the immunodiagnosis and vaccine development and provide valuable information on H. taeniaeformis biology.

Targeted Sequencing of Genomic Repeat Regions Detects Circulating Cell-free Echinococcus DNA

Background

Echinococcosis is a chronic zoonosis caused by tapeworms of the genus Echinococcus. Treatment of the disease is often expensive and complicated, sometimes requiring extensive surgery. Ultrasonographic imaging is currently the main technique for diagnosis, while immunological analysis provides additional information. Confirmation still needs pathological analysis. However, these diagnostic techniques generally detect infection in late stages of the disease. An accurate, early and non-invasive molecular diagnostic method is still unavailable.

Methodology/Principal findings

We sequenced the cell-free DNA (cfDNA) from plasma of echinococcosis patients and confirmed the presence of Echinococcus DNA. To improve detection sensitivity, we developed a method based on targeted next-generation sequencing of repeat regions. Simulation experiments demonstrate that the targeted sequencing is sensitive enough to detect as little as 0.1% of an Echinococcus genome in 1 mL of plasma. Results obtained using patient plasma shows that the Area Under the Curve (AUC) of the method is 0.862, with a detection sensitivity of 62.50% and specificity of 100%, corresponding to a Youden-index of 0.625.

Conclusions/Significance

This study provides evidence that hydatid cysts release cfDNA fragments into patient plasma. Using the repeat region targeted sequencing method, highly specific detection of Echinococcus infection was achieved. This study paves a new avenue for potential non-invasive screening and diagnosis of echinococcosis.

Echinococcosis is a severe chronic parasitic disease caused by tapeworms of the genus Echinococcus. According to the World Health Organization, there are more than 1 million people living with echinococcosis worldwide. For decades, little progress has been made to develop a molecular diagnosis and specific treatment for the disease. Although imaging and immunological detection are used for diagnosis, these technologies are either only effective for late stages of the disease or hardly conclusive. The detection of cell-free DNA has been a powerful tool for precise diagnosis. In this study, we showed the presence of Echinococcus-derived cell-free DNA in plasma of echinococcosis patients. We further established an assay to detect parasite DNA in blood samples based on amplification of Echinococcus specific repeat regions followed by targeted next-generation sequencing. This technique provides a new method for potential extensive screening and precision diagnosis of echinococcosis with high specificity.

Evaluation of the recombinant antigens B2t and 2B2t, compared with hydatid fluid, in IgG-ELISA and immunostrips for the diagnosis and follow up of CE patients

Cystic echinococcosis (CE) is one of the most widespread helminthic zoonoses and is caused by the tapeworm Echinococcus granulosus complex. CE diagnosis and monitoring primarily rely on imaging techniques, complemented by serology. This is usually approached by the detection of IgG antibodies against hydatid fluid (HF), but the use of this heterogeneous antigenic mixture results in a variable percentage of false positive and negative results, and has shown to be useless for follow-up due to the long persistence of anti-HF antibodies in cured patients. To improve test performances and standardization, a number of recombinant antigens mainly derived from HF have been described, among them the B2t and 2B2t antigens. The performance of these antigens in the diagnosis and follow up of patients with CE has been so far evaluated on a limited number of samples. Here, we evaluated the performances of tests based on B2t and 2B2t recombinant antigens compared to HF in IgG-ELISA and immunochromatography (IC) for the diagnosis and follow-up of patients with CE in a retrospective cohort study. A total of 721 serum samples were collected: 587 from 253 patients with CE diagnosed by ultrasonography (US), 42 from patients with alveolar echinococcosis and 92 from healthy donors from Salamanca (Spain). The highest overall sensitivity was obtained with HF in ELISA (85.5%), followed by IC containing HF and 2B2t-HF (83.0% and 78.2%, respectively). The lowest sensitivity was obtained with B2t and 2B2t in ELISA (51.8%). The highest specificity was obtained with IC containing 2B2t-HF (100%), and the lowest with HF-ELISA (78.0%). The lowest cross-reactivity with sera from patients with alveolar echinococcosis was detected with the recombinant antigens in ELISA (9.5% - 16.7%) and the highest with the HF-IC (64.3%). The results of B2t and 2B2t-ELISA were influenced by cyst stage, as classified by US according to the WHO-Informal Working Group on Echinococcosis (WHO-IWGE), with low sensitivity for inactive (CE4 and CE5) cysts, and by the drug treatment, with higher sensitivity in patients after drug treatment compared with patients not subjected to drug treatment. The two recombinant antigens in ELISA provided promising results for monitoring patients in follow-up, although their use is limited to patients with positive serology against them at the beginning of the follow-up. Potential biological reasons behind the low sensitivity of the recombinant antigens and possible strategies to enhance the performance of CE serology are discussed.

Cystic echinococcosis (CE) is a helminthic zoonosis caused by Echinococcus granulosus sensu lato. CE diagnosis and monitoring is of paramount importance for the clinical management of patients and primarily rely on imaging techniques, complemented by serology. CE serology is usually based on the detection of antibodies against hydatid fluid (HF), but the use of this heterogeneous antigenic mixture shows several drawbacks, including false positive and negative results, unsatisfied predictive values, and long persistence of detectable antibody levels in cured patients. As an alternative, to improve test performances and standardization, several recombinant antigens have been described, but these have been so far evaluated only on a limited number of samples. Here, two recombinant antigens derived from one of the immunodominant HF antigens (antigen B2) have been tested in enzyme-linked immunosorbent assay (ELISA) and in immunochromatographic strips (IC) against 721 serum samples. Although more specific than the HF, the recombinant antigens in ELISA showed low sensitivity for patients with inactive (CE4 and CE5) cysts and for patients not subjected to drug treatment. This limited their use for follow-up, although promising, to those patients with positive serology at the beginning of the follow-up period. These results will aid in the future development of a serological test with enhanced performance in the diagnosis and follow-up of patients with CE.

Follow-up of surgically treated patients with cystic echinococcosis: can novel recombinant antigens compete with imaging? Analysis of a patient cohort

OBJECTIVE

To compare the performance of two novel recombinant antigens (EgP29, 2B2t) with imaging in a well-defined cohort of surgically treated cystic echinococcosis (CE) patients to determine whether serology reflects surgical cure as defined by imaging.

METHODS

From a cohort of 223 CE-confirmed patients of a national clinical center for echinococcosis, 36 surgically treated patients were eligible for analysis. Sera were tested by enzyme-linked immunosorbent assay (ELISA) for specific IgG and IgG4 antibodies against the EgP29 and 2B2t antigens. We used a hierarchical linear regression model to examine the course of antibody levels over time for each patient. A meta-analysis of the patient-specific estimates of the time to negativity was performed using the metan command in Stata.

RESULTS

The range of positive serological results at the beginning of post-surgical monitoring was 34-60%: 2B2t 51%, 2B2t-IgG4 34%, EgP29 60% and EgP29-IgG4 40%. The pooled estimates of time to seronegativity were as follows: 2B2t-ELISA 3.92 (3.24, 4.61) years; 2B2t-IgG4-ELISA 4.60 (3.91, 5.29) years; EgP29-ELISA 3.94 (3.50, 4.39) years; EgP29-IgG4-ELISA 2.55 (1.93, 3.18) years.

CONCLUSION

After surgical treatment, antibodies to the recombinant antigens 2B2t and EgP29 become negative in the majority of CE-confirmed, surgically cured patients. The major drawback is the fact that only around half of the CE-confirmed, surgically treated patients were at all responsive to the test antigens, so they are of limited benefit for documenting primary cure. Equally, these antigens do not appear to be sensitive to recurrences.

Laboratory Diagnosis of Echinococcus spp. in Human Patients and Infected Animals

Among the species composing the genus Echinococcus, four species are of human clinical interest. The most prevalent species are Echinococcus granulosus and Echinococcus multilocularis, followed by Echinococcus vogeli and Echinococcus oligarthrus. The first two species cause cystic echinococcosis (CE) and alveolar echinococcosis (AE) respectively. Both diseases have a complex clinical management, in which laboratory diagnosis could be an adjunctive to the imaging techniques. To date, several approaches have been described for the laboratory diagnosis and followup of CE and AE, including antibody, antigen and cytokine detection. All of these approaches are far from being optimal as adjunctive diagnosis particularly for CE, since they do not reach enough sensitivity and/or specificity. A combination of several methods (e.g., antibody and antigen detection) or of several (recombinant) antigens could improve the performance of the adjunctive laboratory methods, although the complexity of echinococcosis and heterogeneity of clinical cases make necessary a deep understanding of the host-parasite relationships and the parasite phenotype at different developmental stages to reach the best diagnostic tool and to make it accepted in clinical practice. Standardization approaches and a deep understanding of the performance of each of the available antigens in the diagnosis of echinococcosis for the different clinical pictures are also needed. The detection of the parasite in definitive hosts is also reviewed in this chapter. Finally, the different methods for the detection of parasite DNA in different analytes and matrices are also reviewed.

Parasite molecules and host responses in cystic echinococcosis

Cystic echinococcosis is the infection by the larvae of cestode parasites belonging to the Echinococcus granulosus sensu lato species complex. Local host responses are strikingly subdued in relation to the size and persistence of these larvae, which develop within mammalian organs as 'hydatid cysts' measuring up to tens of cm in diameter. In a context in which helminth-derived immune-suppressive, as well as Th2-inducing, molecules garner much interest, knowledge on the interactions between E. granulosus molecules and the immune system lags behind. Here, we discuss what is known and what are the open questions on E. granulosus molecules and structures interacting with the innate and adaptive immune systems, potentially or in demonstrated form. We attempt a global biological approach on molecules that have been given consideration primarily as protective (Eg95) or diagnostic antigens (antigen B, antigen 5). We integrate glycobiological information, which traverses the discussions on antigen 5, the mucin-based protective laminated layer and immunologically active preparations from protoscoleces. We also highlight some less well-known molecules that appear as promising candidates to possess immune-regulatory activities. Finally, we point out gaps in the molecular-level knowledge of this infectious agent that hinder our understanding of its immunology.

Serological Diagnosis and Follow-Up of Human Cystic Echinococcosis: A New Hope for the Future?

Cystic echinococcosis (CE) is an important helminthic zoonotic disease caused by the Echinococcus granulosus complex. In humans, CE is a chronic disease driven by the growth of echinococcal cysts in different organs. Prognosis of this disease depends on multiple factors, including location, number, size, and stage of the cysts, making CE a disease of complex management. CE is usually asymptomatic for years and attracts limited attention from funding organizations and health authorities. For this reason, only experts' recommendations are available but no evidence-based conclusions have been drawn for CE clinical management. One of those pitfalls refers to the lack of evidence to support the use of serological tools for the diagnosis and follow-up of CE patients. In this respect, crude antigens are used to detect specific antibodies in patients, giving rise to false positive results. The advent of molecular techniques allowing the production of recombinant proteins has provided a number of candidate antigens that could overcome the problems associated with the use of crude parasite extracts in the serological assays. In this review, we present the last advances in this field, proposing the use of serology to support cyst stage-specific diagnosis and follow-up.

The helminth parasite proteome at the host-parasite interface - Informing diagnosis and control

Helminth parasites are a significant health burden for humans in the developing world and also cause substantial economic losses in livestock production across the world. The combined lack of vaccines for the major human and veterinary helminth parasites in addition to the development of drug resistance to anthelmintics in sheep and cattle mean that controlling helminth infection and pathology remains a challenge. However, recent high throughput technological advances mean that screening for potential drug and vaccine candidates is now easier than in previous decades. A better understanding of the host-parasite interactions occurring during infection and pathology and identifying pathways that can be therapeutically targeted for more effective and 'evolution proof' interventions is now required. This review highlights some of the advances that have been made in understanding the host-parasite interface in helminth infections using studies of the temporal expression of parasite proteins, i.e. the parasite proteome, and discuss areas for potential future research and translation.

Proteomic characterization of larval and adult developmental stages in Echinococcus granulosus reveals novel insight into host-parasite interactions

Cystic hydatid disease is an important zoonosis caused by Echinococcus granulosus infection. The expression profiles of its parasitic life stages and host-Echinococcus interactions remain to be elucidated. Here, we identified 157 adult and 1588 protoscolex proteins (1610 in all), including 1290 novel identifications. Paramyosins and an antigen B (AgB) were the dominant adult proteins. Dog proteins (30) identified in adults indicated diminished local inflammation caused by adult infection. The protoscolex expresses proteins that have been reported to be antigens in other parasites, such as 6-phosphofructokinase and calcineurin B. Pathway analyses suggested that E. granulosus uses both aerobic and anaerobic carbohydrate metabolisms to generate ATP. E. granulosus expresses proteins involved in synthesis and metabolism of lipids or steroids. At least 339 of 390 sheep proteins identified in protoscolex were novel identifications not seen in previous analyses. IgGs and lambda light chains were the most abundant antibody species. Sheep proteins were enriched for detoxification pathways, implying that host detoxification effects play a central role during host-parasite interactions. Our study provides valuable data on E. granulosus expression characteristics, allowing novel insights into the molecular mechanisms involved in host-parasite interactions.

BIOLOGICAL SIGNIFICANCE

In this study, the Echinococcus granulosus adult worm proteome was analyzed for the first time. The protein identification of E. granulosus protoscoleces was extended dramatically. We also identified the most abundant host proteins co-purified with Echinococcus. The results provide useful information pertaining to the molecular mechanisms behind host-Echinococcus interaction and Echinococcus biology. This data also increases the potential for identifying vaccine candidates and new therapeutic targets, and may aid in the development of protein probes for selective and sensitive diagnosis of echinococcosis infection. In addition, the data collected here represents a valuable proteomic resource for subsequent genome annotation.

Immunology and immunodiagnosis of cystic echinococcosis: an update

Cystic echinococcosis (CE) is a cosmopolitan zoonosis caused by the larval cystic stage of the dog tapeworm Echinococcus granulosus. This complex multicellular pathogen produces various antigens which modulate the host immune response and promote parasite survival and development. The recent application of modern molecular and immunological approaches has revealed novel insights on the nature of the immune responses generated during the course of a hydatid infection, although many aspects of the Echinococcus-host interplay remain unexplored. This paper summarizes recent developments in our understanding of the immunology and diagnosis of echinococcosis, indicates areas where information is lacking, and suggests possible new strategies to improve serodiagnosis for practical application.

Host-parasite relationship in cystic echinococcosis: an evolving story

The larval stage of Echinococcus granulosus causes cystic echinococcosis, a neglected infectious disease that constitutes a major public health problem in developing countries. Despite being under constant barrage by the immune system, E. granulosus modulates antiparasite immune responses and persists in the human hosts with detectable humoral and cellular responses against the parasite. In vitro and in vivo immunological approaches, together with molecular biology and immunoproteomic technologies, provided us exciting insights into the mechanisms involved in the initiation of E. granulosus infection and the consequent induction and regulation of the immune response. Although the last decade has clarified many aspects of host-parasite relationship in human cystic echinococcosis, establishing the full mechanisms that cause the disease requires more studies. Here, we review some of the recent developments and discuss new avenues in this evolving story of E. granulosus infection in man.