Progress in vaccine research and possible effector mechanisms in visceral leishmaniasis

Visceral leishmaniasis represents a serious public health concern in endemic regions and is rapidly emerging as an opportunistic infection in HIV patients. The disease is difficult to diagnose and prevent, and available treatment is associated with toxicity and drug resistance. Even though significant headway has been made in the development of vaccines against cutaneous leishmaniasis, visceral leishmaniasis has received limited attention. The fact that a large proportion of the people living in endemic areas have self-resolving subclinical infection and individuals once recovered are immune to reinfection provides a rationale for designing immunoprophylactic strategies against visceral leishmaniasis. The primary aim of this paper is to review advances in vaccination strategies against visceral leishmaniasis, suggesting possible effector mechanism leading to resistance. It also covers the role of immunostimulators and gives an account of the adjuvants used against visceral leishmaniasis. Vaccine strategies in different established experimental models have also been dealt with which can provide potential leads for their application in humans. In light of the available observations made during the course of studies performed on experimental models of visceral leishmaniasis there is increasing evidence that a successful approach towards a vaccine involves the requirement of Th1 subset of CD4+ cells along with Th2, CD8+, and B cells. In this review we present the possible mechanism of interaction of these cells and their effector molecules in providing resistance against visceral leishmaniasis for the future design of effective vaccine against this disease.     

Leishmania mexicana mexicana: genetic heterogeneity of mexican isolates revealed by restriction length polymorphism analysis of kinetoplast DNA

Leishmania mexicana mexicana isolates from 23 patients with localized, diffuse, and an atypical "pseudodiffuse" form of cutaneous leishmaniasis were obtained in various endemic regions of Mexico. Restriction fragment length polymorphism analysis of kinetoplast DNA was done with nine different endonucleases in addition to an in vitro growth pattern analysis. We found that the 23 L. mexicana mexicana isolates could be consistently classified into six groups, according to the endonuclease digestion patterns obtained with HaeIII, HpaII, and MseI. Whereas localized cutaneous leishmaniasis isolates could have any of five patterns, diffuse cutaneous leishmaniasis showed only two patterns and pseudodiffuse cutaneous leishmaniasis consistently showed only one pattern. Thus, a clear correlation among digestion pattern, clinical disease, and geographical localization was obtained for the pseudodiffuse cutaneous leishmaniasis group. Additionally, the L. mexicana mexicana isolates could be differentiated into fast- and slow-growing groups. Diffuse cutaneous leishmaniasis isolates were found to be fast growing, whereas localized cutaneous leishmaniasis isolates fell into both categories. In contrast, all pseudo diffuse cutaneous leishmaniasis isolates were slow growing. Here we report the first study in which distinct and persistent genotypic characteristics of kinetoplast DNA heterogeneity within the L. mexicana mexicana species could be directly correlated with clinical disease and its growth behavior, suggesting that a distinctive restriction pattern could have important biological implications. Additionally, this study sheds new light on the biological significance of parasite kinetoplast DNA, since the heterogeneity seems not to be random but to form a distinct pattern.     

Human leishmaniasis vaccines: Use cases,target population and potential global demand

The development of vaccines against one or all forms of human leishmaniasis remains hampered by a paucity of investment, at least in part resulting from the lack of well-evidenced and agreed estimates of vaccine demand. Starting from the definition of 4 main use cases (prevention of visceral leishmaniasis, prevention of cutaneous leishmaniasis, prevention of post-kala-azar dermal leishmaniasis and treatment of post-kala-azar dermal leishmaniasis), we have estimated the size of each target population, focusing on those endemic countries where incidence levels are sufficiently high to justify decisions to adopt a vaccine. We assumed a dual vaccine delivery strategy, including a wide age-range catch-up campaign before the start of routine immunisation. Vaccine characteristics and delivery parameters reflective of a target product profile and the likely duration of the clinical development effort were considered in forecasting the demand for each of the four indications. Over a period of 10 years, this demand is forecasted to range from 300–830 million doses for a vaccine preventing visceral leishmaniasis and 557–1400 million doses for a vaccine preventing cutaneous leishmaniasis under the different scenarios we simulated. In a scenario with an effective prophylactic visceral leishmaniasis vaccine, demand for use to prevent or treat post-kala-azar dermal leishmaniasis would be more limited (over the 10 years ~160,000 doses for prevention and ~7,000 doses for treatment). Demand would rise to exceed 330,000 doses, however, in the absence of an effective vaccine for visceral leishmaniasis. Because of the sizeable demand and potential for public health impact, a single-indication prophylactic vaccine for visceral or cutaneous leishmaniasis, and even more so a cross-protective prophylactic vaccine could attract the interest of commercial developers. Continuous refinement of these first-of-their kind estimates and confirmation of country willingness and ability to pay will be paramount to inform the decisions of policy makers and developers in relation to a leishmaniasis vaccine. Positive decisions can provide a much-needed contribution towards the achievement of global leishmaniasis control.     

Miltefosine for disseminated cutaneous leishmaniasis

Disseminated cutaneous leishmaniasis is a rare presentation characterized by hematogenous dissemination of the parasite that causes the appearance of multiple nodules and plaques in the skin of the whole body and even including the nasal mucous membrane. It differs from diffuse cutaneous leishmaniasis because the alteration in cellular immunity is lower and the lesions may have epidermal desquamation. On the other hand, diffuse cutaneous leishmaniasis presents nodular lesions and a specific anergy in the immune response directed against the parasite. This article describes the case of a Colombian patient with disseminated cutaneous leishmaniasis caused by L. (V) panamensis. The initial treatments with Glucantime and Amphotericin B failed, but his lesions healed after treatment with miltefosine.     

Practical progress and new drugs for changing patterns of leishmaniasis

The problems surrounding leishmaniasis are changing. An increase in travel, the Indian and Sudanese epidemics of visceral leishmaniasis, parasite resistance to antimony and the emergence of AIDS-related leishmaniasis have all increased the urgency for new drugs, and led to reappraisals of the old ones, as discussed here by Piero Olliaro and Anthony Bryceson.     

Present status of antileishmanial vaccines

The term leishmaniasis refers collectively to various clinical syndromes that are caused by obligate intracellular protozoa of the genus Leishmania. Approximately 350 million people in 8 countries are estimated to be threatened by the disease [1]. The World Health Organization estimated that there are 12 million cases of all forms of leishmaniasis worldwide, with over 500,000 new cases of visceral disease occurring each year [1]. Most of the drugs commonly used to treat different forms of leishmaniasis are toxic and have unacceptable side effects. Moreover, cases of drug resistant leishmaniasis are on the rise. Due to non-existence of effective vaccine to date, improved immunoprophylactic approaches still remain desirable to combat leishmaniasis. Antileishmanial vaccines developed around the globe are discussed.     

Second-generation vaccines against leishmaniasis

Several species of Leishmania cause human diseases that range from self-healing cutaneous lesions to fatal visceral leishmaniasis, mucosal leishmaniasis and diffuse cutaneous leishmaniasis. Drug resistance and toxicities associated with chemotherapy emphasize the need for a safe, effective vaccine. Studies of the immunopathogenesis and mechanisms of protective immunity define several features that should be met by an effective vaccine. The leishmaniases are unique among parasitic diseases because a single vaccine has the potential to protect against more than one species (disease) and be successful at both treating and preventing disease. In addition, several antigens have been identified and characterized that might be potential vaccine candidates. In this article, we focus on advances made with second-generation vaccines against leishmaniasis.     

Survey of dogs from Vietnam for antibodies to visceralizing Leishmania spp

Cases of visceral leishmaniasis, one of the most neglected tropical diseases, are increasing globally. Dogs are considered an important reservoir host for visceral leishmaniasis in people. The first cases of human visceral leishmaniasis in Vietnam have recently been reported. Blood samples were collected from 41 dogs in rural Vietnam. Sera were examined for antibodies to visceralizing Leishmania spp. by canine immunochromatographic strip assays based on recombinant K39 antigen. Antibodies to Leishmania spp. were not detected in any of the dogs tested. Results from this study suggest that rural dogs are not likely to be involved in the emergence of human visceral leishmaniasis in Vietnam.     

Arginase Activity in the Blood of Patients with Visceral Leishmaniasis and HIV Infection

Background

Visceral leishmaniasis is a parasitic disease associated with high mortality. The most important foci of visceral leishmaniasis in Ethiopia are in the Northwest and are predominantly associated with high rates of HIV co-infection. Co-infection of visceral leishmaniasis patients with HIV results in higher mortality, treatment failure and relapse. We have previously shown that arginase, an enzyme associated with immunosuppression, was increased in patients with visceral leishmaniasis and in HIV seropositive patients; further our results showed that high arginase activity is a marker of disease severity. Here, we tested the hypothesis that increased arginase activities associated with visceral leishmaniasis and HIV infections synergize in patients co-infected with both pathogens.

Methodology/Principal Findings

We recruited a cohort of patients with visceral leishmaniasis and a cohort of patients with visceral leishmaniasis and HIV infection from Gondar, Northwest Ethiopia, and recorded and compared their clinical data. Further, we measured the levels of arginase activity in the blood of these patients and identified the phenotype of arginase-expressing cells. Our results show that CD4⁺ T cell counts were significantly lower and the parasite load in the spleen was significantly higher in co-infected patients. Moreover, our results demonstrate that arginase activity was significantly higher in peripheral blood mononuclear cells and plasma of co-infected patients. Finally, we identified the cells-expressing arginase in the PBMCs as low-density granulocytes.

Conclusion

Our results suggest that increased arginase might contribute to the poor disease outcome characteristic of patients with visceral leishmaniasis and HIV co-infection.     

Improving Serodiagnosis of Human and Canine Leishmaniasis with Recombinant Leishmania braziliensis Cathepsin L-like Protein and a Synthetic Peptide Containing Its Linear B-cell Epitope

Background

The early and correct diagnosis of human leishmaniasis is essential for disease treatment. Another important step in the control of visceral leishmaniasis is the identification of infected dogs, which are the main domestic reservoir of L. infantum. Recombinant proteins and synthetic peptides based on Leishmania genes have emerged as valuable targets for serodiagnosis due to their increased sensitivity, specificity and potential for standardization. Cathepsin L-like genes are surface antigens that are secreted by amastigotes and have little similarity to host proteins, factors that enable this protein as a good target for serodiagnosis of the leishmaniasis.

Methodology/Principal Findings

We mapped a linear B-cell epitope within the Cathepsin L-like protein from L. braziliensis. A synthetic peptide containing the epitope and the recombinant protein was evaluated for serodiagnosis of human tegumentary and visceral leishmaniasis, as well as canine visceral leishmaniasis.

Conclusions/Significance

The recombinant protein performed best for human tegumentary and canine visceral leishmaniasis, with 96.30% and 89.33% accuracy, respectively. The synthetic peptide was the best to discriminate human visceral leishmaniasis, with 97.14% specificity, 94.55% sensitivity and 96.00% accuracy. Comparison with T. cruzi-infected humans and dogs suggests that the identified epitope is specific to Leishmania parasites, which minimizes the likelihood of cross-reactions.     

The infection risk of visceral leishmaniasis among household members of active patients

Human visceral leishmaniasis (HVL), caused by Leishmania infantum is mainly observed as sporadic cases in Turkey and dogs are considered as the main reservoir of the disease. The incidence of visceral leishmaniasis among members of households where a HVL infection has already been diagnosed was studied in clusters around the diagnosed cases in different regions in Turkey. A total of 47 serum samples collected from the households of 11 proven visceral leishmaniasis patients were screened for anti-Leishmania antibodies by indirect immunofluorescent antibody test (IFAT). Three and one such household members belonging to the different families were found to be seropositive and borderline, respectively. Diagnosis was confirmed with the presence of amastigotes in bone marrow aspiration samples in all seropositives while the borderline case with slight and indefinitive symptoms of VL was followed only serologically at 3-month intervals and improved spontaneously in 1 year. Household members of individuals with previously confirmed visceral leishmaniasis were found to have higher frequency of the disease suggesting the household members should be included in the risk group for visceral leishmaniasis and serological screening should be performed for the detection of possible infection.     

Leishmaniasis vectors (Diptera, Psychodidae) in 3 different environments of western Sicily and 2 of the Aeolian Islands

Some cases of visceral leishmaniasis in children and in adults have been diagnosed in the last fifteen years in Western Sicily and an increasing number of cases of canine leishmaniasis has been recorded, mainly in the province of Palermo. Such a human leishmaniasis recrudescence, after the antimalaria campaign had reduced the transmission, and the increase of canine leishmaniasis in the city of Palermo and its suburbs suggest that transmission in urban areas may be possible. Using the oiled paper method, a survey of phlebotomine sandflies was carried out during June and July 1988 both in the centre and suburbs of Palermo, and during July and August '88 in the Madonie mountains (at 800 to 1200 meters above sea level) and in two Eolian Islands: Lipari and Filicudi. Details of collected species are given. In both surveys, the oiled paper method did not turn out to be selective towards any given species of sandflies.     

Leishmaniasis in non-human primates: Clinical and pathological manifestations and potential as reservoirs

Although the domestic dog is the most important reservoir of visceral leishmaniasis in urban areas, there have been an increasing number of reports of naturally occurring leishmaniasis in non-human primates. Reported cases affecting neotropical and Old World non-human primates as well as their potential role as reservoirs were reviewed.     

Viscerotropic growth pattern of Leishmania tropica in BALB/c mice is suggestive of a murine model for human viscerotropic leishmaniasis

Leishmania (L.) tropica is a causative agent of cutaneous leishmaniasis, and occasionally of visceral or viscerotropic leishmaniasis in humans. Murine models of Leishmania infection have been proven to be useful for elucidation of mechanisms for pathogenesis and immunity in leishmaniasis. The aim of this study was to establish a murine model for human viscerotropic leishmaniasis, and the growth pattern of L. tropica was studied in different tissues of BALB/c mice in order to find out whether the parasite visceralizes in this murine model. L. major was used as a control as this species is known to cause a progressive infection in BALB/c mice. L. tropica or L. major was injected into the footpad of mice, and thickness of footpad, parasite loads in different tissues, and the weight of the spleen and lymph node were determined at different intervals. Results showed that L. tropica visceralizes to the spleen and grows there while its growth is controlled in footpad tissues. Dissemination of L. tropica to visceral organs in BALB/c mice was similar to the growth patterns of this parasite in human viscerotropic leishmaniasis. The BALB/c model of L. tropica infection may be considered as a good experimental model for human diseases.     

Characterization of the immune response to Leishmania infantum recombinant antigens

Leishmaniases have a high prevalence in tropical countries. In order to improve existing diagnostic systems based on total Leishmania proteins, and to identify antigen candidates for vaccine development, an intensive search for the identification of antigens was performed using molecular biology techniques. In this study, the immune response to three L. infantum recombinant antigens was evaluated. Upon stimulation with KMP11, mononuclear cells from leishmaniasis patients produced high levels of IL-10, while a predominant IFN-gamma production could be observed in cultures stimulated with H2A and soluble Leishmania antigen. All the recombinant antigens induced very little IL-5. KMP11 decreased IFN-gamma production by 48% in cultures of peripheral blood mononuclear cells from cutaneous leishmaniasis patients who had been stimulated with soluble Leishmania antigen. Furthermore, antibodies to KMP11 were detected in the sera from all patients with visceral leishmaniasis and in the majority of the sera from patients with cutaneous leishmaniasis or individuals with asymptomatic L. chagasi infection. Thus, KMP11 is recognized by cells and sera of patients with different clinical forms of leishmaniasis, and KMP11, through IL-10 production, proved to be a potent antigen in modulating type 1 immune response.     

Leishmania, Trypanosoma and monoxenous trypanosomatids as emerging opportunistic agents

Immunosuppression is associated with the occurrence of a large variety of infections, several of them due to opportunistic protozoa. The parasitic protozoa of the family Trypanosomatidae vary greatly in their importance as potential opportunistic pathogens. African trypanosomiasis is no more common nor severe during AIDS. The situation with Chagas' disease, however, is much different. Although the process is not clearly understood, there appears to be a reactivation of Trypanosoma cruzi infection, which can lead to severe meningoencephalitis. In persons with AIDS, leishmaniasis is often exacerbated, particularly Leishmania infantum, which causes visceral leishmaniasis in southern Europe. Since 1990, 1,616 cases of visceral leishmaniasis/HIV co-infection have been reported, mainly from southern Europe, and particularly from Spain, southern France, and Italy. The co-infected patients are primarily young adults and belong to the risk group of intravenous drug users. Isoenzymatic identification of 272 isolates showed 18 different L. infantum zymodemes, of which 10 represent new zymodemes hitherto found only during HIV co-infection. New foci of co-infection are emerging in various parts of the world, including Brazil and East Africa. Moreover, since 1995, non-human monoxenous trypanosomatids have been found in AIDS patients, causing both diffuse cutaneous lesions and visceral infections. In countries where visceral leishmaniasis is endemic, particularly in southern Europe, immunosuppressive treatments for organ transplants or malignant diseases often result either in reactivation of asymptomatic visceral leishmaniasis or in facilitation of new infections.     

Characterization of a membrane antigen of Leishmania amazonensis that stimulates human immune responses.

To investigate human immune responses to defined leishmania Ag we have begun to characterize biochemically and immunologically, an abundant 42-kDa surface Ag of Leishmania amazonensis, a causative agent of human leishmaniasis. We have shown that this Ag, La gp42, is expressed on the surface of L. amazonensis promastigotes, being anchored to the membrane by a glycosyl-phosphatidylinositol moiety. As demonstrated by lectin blotting studies, La gp42 is glycosylated, binding both Con A and wheat germ agglutinin. Immunologically, La gp42 is strongly recognized by sera from patients with different forms of leishmaniasis as well as by patients with Chagas' disease. In addition, we show that purified La gp42 stimulates the proliferation of human T lymphocytes obtained from several leishmaniasis patients. Finally, the N-terminal sequence of La gp42 was obtained and a serologically cross-reactive 42-kDa protein with a homologous sequence was identified in Leishmania major.     

Lutzomyia longipalpis in Clorinda, Formosa province, an area of potential visceral leishmaniasis transmission in Argentina

Phlebotomine captures were performed during 2004 in Clorinda, Argentina. Clorinda is located across the branches of the Paraguay river in front of Asunción city, Paraguay. Reports of canine and human visceral leishmaniasis in Asunción have been increasing since 1997, however neither leishmaniasis cases nor sand flies were ever recorded from Clorinda. Light traps were located in migration paths (bridges, port), and peridomestic environments of Clorinda and surrounding localities. Lutzomyia longipalpis was found in Clorinda and Puerto Pilcomayo, first report in a potential visceral leishmaniasis transmission area for Argentina. Active surveillance is required immediately in the localities involved and the surrounding area.     

PCR detection and identification of Leishmania parasites in clinical specimens in Ecuador: a comparison with classical diagnostic methods

A simplified polymerase chain reaction (PCR)-based assay was used for detection and typing of Leishmania parasites in clinical specimens from patients suspected of cutaneous leishmaniasis. Using cultures as the reference standard, our PCR detection method was more sensitive (92%) than classical diagnostic techniques, including microscopy (42% sensitivity), histologic staining (33%), and IgG enzyme-linked immunosorbent (20%). The PCR assay was also 100% specific. Parasites in both lesion biopsies and isolates cultured from lesion aspirates were identified as Leishmania braziliensis by PCR. In this study, we have demonstrated the suitability of simplified PCR assays for the simultaneous diagnosis and typing of parasites causing cutaneous leishmaniasis in a developing country where leishmaniasis is endemic.     

Serum neopterin concentrations during treatment of leishmaniasis: useful as test of cure?

Neopterin, a product of gamma-interferon-activated macrophages, was measured in sera from 28 patients (12 patients with cutaneous leishmaniasis and 16 patients with visceral leishmaniasis) to determine the utility as a marker of disease activity and therapeutic efficacy. Patients originated from Kenya (n=5) and from the Academic Medical Center, Amsterdam, The Netherlands (n=23). In seven patients follow-up sera after treatment were available. Two patients at the time of diagnosis of visceral leishmaniasis were co-infected with HIV. The 12 patients with cutaneous leishmaniasis had serum neopterin levels below the upper limit of the normal range. All 16 patients with visceral leishmaniasis had elevated levels of serum neopterin before treatment. In six out of seven patients with visceral leishmaniasis followed during treatment neopterin levels decreased to values below the upper limit of the normal range (10 nmol l(-1)). Sequential measurements of serum neopterin levels may be useful for monitoring therapeutic efficacy in patients with visceral leishmaniasis.