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1.  Immunological and Viral Features in Patients with Overactive Bladder Associated with Human T-Cell Lymphotropic Virus Type 1 Infection 
Journal of medical virology  2012;84(11):1809-1817.
The majority of patients infected with human T-cell lymphotropic virus-type 1 (HTLV-1) are considered carriers, but a high frequency of urinary symptoms of overactive bladder, common in HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP) have been documented in these patients. The aim of this study was to determine if immunological and viral factors that are seen in HAM/TSP are also observed in these patients. Participants were classified as HTLV-1 carriers (n=45), HTLV-1 patients suffering from overactive bladder (n=45) and HAM/TSP (n=45). Cells from HTLV-1 overactive bladder patients produced spontaneously more proinflammatory cytokines than carriers. TNF-α and IL-17 levels were similar in HAM/TSP and HTLV-1 overactive bladder patients. High proviral load was found in patients with overactive bladder and HAM/TSP and correlated with proinflammatory cytokines. In contrast with findings in patients with HAM/TSP, serum levels of Th1 chemokines were similar in HTLV-1 overactive bladder and carriers. Exogenous addition of regulatory cytokines decreased spontaneous IFN-γ production in cell cultures from HTLV-1 overactive bladder patients. The results show that HTLV-1 overactive bladder and HAM/TSP patients have in common some immunological features as well as similar proviral load profile. The data show that HTLV-1 overactive bladder patients are still able to down regulate their inflammatory immune response. In addition, these patients express levels of chemokines similar to carriers, which may explain why they have yet to develop the same degree of spinal cord damage as seen in patients with HAM/TSP. These patients present symptoms of overactive bladder, which may be an early sign of HAM/TSP.
PMCID: PMC3457650  PMID: 22997085
HTLV-1; immune response; cytokines; chemokines; proviral load
2.  Epidemiological and Clinical Changes in American Tegumentary Leishmaniasis in an Area of Leishmania (Viannia) braziliensis Transmission Over a 20-Year Period 
The Health Post of Corte de Pedra is located in a region endemic for American tegumentary leishmaniasis (ATL) in the Brazilian state of Bahia, and it treats 500–1,300 patients annually. To describe temporal changes in the epidemiology of ATL, we reviewed a random sample of 10% of patient charts (N = 1,209) from 1988 to 2008. There was a twofold increase in the number of cases over the 20-year period, with fluctuations in 10-year cycles. Patients were most frequently male, between the ages of 10 and 30 years, and engaged in agricultural labor; 4.3% of patients had mucosal disease, and 2.4% of patients had disseminated disease. Over the study period, the number of disseminated cases increased threefold, the proportion of cases in younger patients and agricultural workers decreased, and the proportion of patients residing in coastal areas increased. ATL is on the rise in Bahia, with a 10-year periodicity and evolving changes in epidemiology and manifestations of disease.
PMCID: PMC3284357  PMID: 22403312
3.  Association of Treatment of American Cutaneous Leishmaniasis Prior to Ulcer Development with High Rate of Failure in Northeastern Brazil 
Cure rates for American cutaneous leishmaniasis (ACL) range between 60% and 90%. Early evidence suggests lower cure rates for early ACL before the development of the ulceration. We evaluated risk factors for treatment failure in patients with early and classic ulcerative ACL. Patients (n = 136) were 13–60 years of age and had lesions with a duration of 15–90-days. Patients were treated with antimony (20 mg/kg/day for 20 days). The primary outcome was lesion cure by 90 days without recurrence. Patients with early ACL (n = 16) had papules, nodules, plaques, or superficial ulcerations with less than 30 days of illness. Patients with classic ulcerative ACL (n = 120) had ulcerated classic lesions, longer duration, larger lesions, and higher levels of interferon-γ and tumor necrosis factor-α (P ≤ 0.01 for all comparisons). Ulcerated lesions were associated with a lower treatment failure rate compared with early ACL (25.8% versus 75.0%; P < 0.001). Early treatment of ACL does not prevent lesion ulceration and is associated with higher rates of treatment failure.
PMCID: PMC3557504  PMID: 19346378
4.  Functional Activity of Monocytes and Macrophages in HTLV-1 Infected Subjects 
The Human T lymphotropic virus type-1 (HTLV-1) infects predominantly T cells, inducing proliferation and lymphocyte activation. Additionally, HTLV-1 infected subjects are more susceptible to other infections caused by other intracellular agents. Monocytes/macrophages are important cells in the defense against intracellular pathogens. Our aims were to determine the frequency of monocytes subsets, expression of co-stimulatory molecules in these cells and to evaluate microbicidal ability and cytokine and chemokine production by macrophages from HTLV-1 infected subjects. Participants were 23 HTLV-1 carriers (HC), 22 HAM/TSP patients and 22 healthy subjects (HS) not infected with HTLV-1. The frequencies of monocyte subsets and expression of co-stimulatory molecules were determined by flow cytometry. Macrophages were infected with L. braziliensis or stimulated with LPS. Microbicidal activity of macrophages was determined by optic microscopy. Cytokines/chemokines from macrophage supernatants were measured by ELISA. HAM/TSP patients showed an increase frequency of intermediate monocytes, but expression of co-stimulatory molecules was similar between the groups. Macrophages from HTLV-1 infected individuals were infected with L. braziliensis at the same ratio than macrophages from HS, and all the groups had the same ability to kill Leishmania parasites. However, macrophages from HTLV-1 infected subjects produced more CXCL9 and CCL5, and less IL-10 than cells from HS. While there was no correlation between IFN-γ and cytokine/chemokine production by macrophages, there was a correlation between proviral load and TNF and CXCL10. These data showed a dissociation between the inflammatory response and microbicidal ability of macrophages from HTLV-1 infected subjects. While macrophages ability to kill an intracellular pathogen did not differ among HTLV-1 infected subjects, these cells secreted high amount of chemokines even in unstimulated cultures. Moreover the increasing inflammatory activity of macrophages was similar in HAM/TSP patients and HC and it was related to HTLV-1 proviral load rather than the high IFN-γ production observed in these subjects.
Author Summary
HTLV-1 predominantly infects T cells, inducing cell proliferation and activation. While there is a larger amount of studies regarding T cells functions in HTLV-1 infected subjects, little is known about innate immunity. We evaluated monocyte and macrophage functions in HTLV-1 infected subjects. We observed that HAM/TSP patients have an increased frequency of intermediate monocytes, but expression of co-stimulatory molecules in these cells was similar between HTLV-1 infected subjects and healthy subjects (HS). Additionally, the microbicidal ability of macrophages from HTLV-1 infected subjects to kill Leishmania braziliensis is preserved, and these cells showed inflammatory profile, producing more CXCL9 and CCL5, and less IL-10 than macrophages from HS. It was important to determine if the exacerbated ability of macrophages to secrete cytokine was due to IFN-γ production. While there was no correlation between IFN-γ levels by PBMCs and cytokine/chemokine production by macrophages, there was a direct correlation between proviral load and TNF and CXCL10 levels. Our data indicate that despite the high production of proinflammatory mediators, macrophages from HTLV-1 infected subjects kill an intracellular pathogen in similar levels than cells from HS and pointed out for the role of viral factors inducing the inflammatory response in these cells.
PMCID: PMC4270688  PMID: 25521499
5.  Characterization of regulatory T cell (Treg) function in patients infected with Leishmania braziliensis 
Human immunology  2013;74(12):10.1016/j.humimm.2013.08.269.
Th1 immune responses are crucial for eliminating Leishmania parasites. However, despite strong Th1 responses, cutaneous leishmaniasis (CL) patients infected with L. braziliensis develop the disease, while milder Th1 responses are found in sub-clinical (SC) infections. Therefore, CL patients may experience impaired regulatory T cell (Treg) function, causing excessive Th1 responses and tissue damage. To address this hypothesis, we characterized the function of circulating Tregs in L. braziliensis infected CL patients and compared them to Tregs from uninfected controls (UC) and SC subjects. The frequency of circulating Tregs was similar in CL patients, UC and SC subjects. Moreover, CL patients Tregs suppressed lymphocyte proliferation and PBMC pro-inflammatory cytokine production more efficiently than UC Tregs, and also produced higher levels of IL-10 than UC and SC Tregs. Furthermore, PBMC and mononuclear cells from lesions of CL patients responded normally to Treg-induced suppression. Therefore, the lesion development in CL patients infected with L. braziliensis is not associated with impairment in Treg function or failure of cells to respond to immunomodulation. Rather, the increased Treg activation in CL patients may impair parasite elimination, resulting in establishment of chronic infection. Thus, immunological strategies that interfere with this response may improve leishmaniasis treatment.
PMCID: PMC3846617  PMID: 23993989
Regulatory T cells; Leishmania braziliensis; cutaneous leishmaniasis
6.  Matrix Metalloproteinase 9 Production by Monocytes is Enhanced by TNF and Participates in the Pathology of Human Cutaneous Leishmaniasis 
Cutaneous leishmaniasis (CL) due to L.braziliensis infection is characterized by a strong inflammatory response with high levels of TNF and ulcer development. Less attention has been given to the role of mononuclear phagocytes to this process. Monocytes constitute a heterogeneous population subdivided into classical, intermediate and non-classical, and are known to migrate to inflammatory sites and secrete inflammatory mediators. TNF participates in the induction of matrix metalloproteinases (MMPs). MMP-9 is an enzyme that degrades basal membrane and its activity is controlled by the tissue inhibitor of metalloproteinase.
Mononuclear cells were obtained from ex-vivo labeling sub-populations of monocytes and MMP-9, and the frequency was determined by flow cytometry. Culture was performed during 72 hours, stimulating the cells with SLA, levels of MMP-9 and TIMP-1 in the supernatants were determined by ELISA.
We observed that cells from CL lesions secrete high amounts of MMP-9 when compared to healthy subjects. Although MMP-9 was produced by monocytes, non-classical ones were the main source of this enzyme. We also observed that TNF produced in high level during CL contributes to MMP-9 production.
These observations emphasize the role of monocytes, TNF and MMP-9 in the pathogenesis of L. braziliensis infection.
Author Summary
To examine the participation of MMP-9 in the pathogenesis of L. braziliensis infection, we realized a cross-sectional study with CL patients in an early phase of the disease or with a classical ulcer, and healthy controls. We evaluated the frequency of MMP-9 in monocyte subsets and its mechanism of production. Our results showed that monocytes were the major cells producing MMP-9. The MMP-9 production by CL patients was presented in higher levels when compared with healthy subjects and early cutaneous leishmaniasis (ECL) patients, and the levels of MMP-9 inhibitor, TIMP-1, were lower in CL patients when compared to healthy subjects. The production of MMP-9 was enhanced by TNF, a cytokine associated with tissue damage in CL patients. Thus, therapeutic modulation of MMP-9 may be a useful approach for improving disease outcome in L. braziliensis patients.
PMCID: PMC4230914  PMID: 25393535
7.  IL-17 and Regulatory Cytokines (IL-10 and IL-27) in L. braziliensis Infection 
Parasite immunology  2011;33(2):132-136.
Cutaneous leishmaniasis (CL) is characterized by high production of pro-inflammatory cytokines and development of pathology. Individuals with subclinical L. braziliensis infection (SC) have a positive skin test to leishmania but do not develop disease. We evaluated if the downregulation of inflammatory response in SC is mediated by IL-10 and IL-27 and if IL-17 is associated with control of infection. Participants include SC individuals, CL patients and healthy subjects. Cytokines protein and mRNA were detected by ELISA and real-time PCR. IFN-γ and TNF-α levels were higher in CL than in SC group. The IL-10 levels and mRNA for IL-10 were similar in both SC and CL. mRNA for IL-27 was increased in cells from SC after stimulation with L. braziliensis antigen. There was a tendency for increased levels of IL-17 in SC compared to CL. The weak type 1 immune response observed in SC L. braziliensis infection is not due to the regulatory effects of IL-10 and IL-27. The control of Leishmania infection may be mediated by innate immune response with participation of IL-17. The results from this pilot study warrant further larger studies to investigate the potential contributions of IL-17 and IL-27 to the control of L. braziliensis infection.
PMCID: PMC3077537  PMID: 21226726
Leishmania braziliensis; subclinical infection; cutaneous leishmaniasis; IL-17; regulatory cytokines
8.  Forecasting Temporal Dynamics of Cutaneous Leishmaniasis in Northeast Brazil 
Cutaneous leishmaniasis (CL) is a vector-borne disease of increasing importance in northeastern Brazil. It is known that sandflies, which spread the causative parasites, have weather-dependent population dynamics. Routinely-gathered weather data may be useful for anticipating disease risk and planning interventions.
Methodology/Principal Findings
We fit time series models using meteorological covariates to predict CL cases in a rural region of Bahía, Brazil from 1994 to 2004. We used the models to forecast CL cases for the period 2005 to 2008. Models accounting for meteorological predictors reduced mean squared error in one, two, and three month-ahead forecasts by up to 16% relative to forecasts from a null model accounting only for temporal autocorrelation.
These outcomes suggest CL risk in northeastern Brazil might be partially dependent on weather. Responses to forecasted CL epidemics may include bolstering clinical capacity and disease surveillance in at-risk areas. Ecological mechanisms by which weather influences CL risk merit future research attention as public health intervention targets.
Author Summary
Cutaneous leishmaniasis (CL) is a disease resulting from infection by the Leishmania parasites, which humans may acquire when bitten by an infected sandfly. From a public health standpoint, it is important to identify cases early and monitor patients' clinical outcomes because unsuccessfully-treated patients are at risk for severe complications. Since weather conditions affect survival and reproduction of sandflies that transmit Leishmania, routinely-gathered weather and climate data may be useful for anticipating CL outbreaks, bolstering clinical capacity for high-risk periods, and initiating interventions such as active case-finding during these periods to limit disease burden. Here we assessed whether the number of CL cases occurring per month in a rural region of Bahía, Brazil was associated temperature, humidity, precipitation, and El Niño sea surface temperature oscillation patterns observed during preceding seasons. We formulated models that improved accuracy of one, two, and three month-ahead CL predictions by accounting for weather. Forecasts of this nature can contribute to reducing CL burden by informing resource allocation and intervention planning in preparation for epidemics.
PMCID: PMC4214672  PMID: 25356734
9.  Protective and pathologic immune responses in human tegumentary leishmaniasis 
Studies in the recent years have advanced the knowledge of how host and parasite factors contribute to the pathogenesis of human tegumentary leishmaniasis. Polymorphism within populations of Leishmania from the same species has been documented; indicating that infection with different strains may lead to distinct clinical pictures and can also interfere in the response to treatment. Moreover, detection of parasite genetic tags for the precise identification of strains will improve diagnostics and therapy against leishmaniasis. On the host side, while a predominant Th1 type immune response is important to control parasite growth, it does not eradicate Leishmania and, in some cases, does not prevent parasite dissemination. Evidence has accumulated showing the participation of CD4+ and CD8+ T cells, as well as macrophages, in the pathology associated with L. braziliensis, L. guayanensis, and L. major infection. The discovery that a large percentage of individuals that are infected with Leishmania do not develop disease will help to understand how the host controls Leishmania infection. As these individuals have a weaker type 1 immune response than patients with cutaneous leishmaniasis, it is possible that control of parasite replication in these individuals is dependent, predominantly, on innate immunity, and studies addressing the ability of neutrophils, macrophages, and NK cells to kill Leishmania should be emphasized.
PMCID: PMC3463898  PMID: 23060880
Leishmaniasis; immune response; Leishmania braziliensis
10.  Prevalence of Erectile Dysfunction in HTLV-1 Infected Patients and its Association with Overactive Bladder 
Urology  2010;75(5):1100-1103.
To determine the prevalence of erectile dysfunction (ED) in HTLV-I infected patients, and its association with overactive bladder (OB).
In a cross-sectional study 111, male patients with positive serology for HTLV-I (by ELISA and Western blot) were examined between October, 2003 and December, 2006. Exclusion criteria were age <18 and >80 years, other neurological diseases, penile prosthesis, neoplasm, and psychological and mental disease. Patients were evaluated by a urologist and neurologist. ED was determined by application of the abridged form of International Index of Erectile Dysfunction (IIEF-5). ED was defined as IIEF-5 ≤ 21. OB was determined by International Continence Society (ICS) criteria. Using the Expanded Disability Status Scale (EDSS) to determine disautonomy status, a neurologist classified all patients as either asymptomatic carriers (EDSS=0), “oligosymptomatic myelopathy” (EDSS>0 e ≤2), or HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP); (EDSS>2). Diagnosis of HAM/TSP was performed according to WHO recommendations.
After six patients were excluded, 105 were analyzed. The mean age was 48±10.7 years. ED was observed in 55.2%. ED was documented in all patients who had HAM/TSP, in 79% of the group with EDSS>0 and ≤2, and in 35.9% of HTLV-1 infected individuals with EDSS = 0. OB was detected in 93.75%, 33.3% and 4.6% respectively. Moreover there was an association observed between ED and OB.
ED is a frequent disease in HTLV-I-infected individuals, and the prevalence is directly correlated to the neurological disability degree measured by EDSS. ED was strongly associated with OB symptoms.
PMCID: PMC2866747  PMID: 20189229
Erectile dysfunction; HTLV-1; HTLV-1 associated myelopathy; overactive bladder
11.  Dendritic Cell Profile Induced by Schistosoma mansoni Antigen in Cutaneous Leishmaniasis Patients 
BioMed Research International  2014;2014:743069.
The inflammatory response in cutaneous leishmaniasis (CL), although responsible for controlling the infection, is associated with the pathogenesis of disease. Conversely, the immune response induced by S. mansoni antigens is able to prevent immune-mediated diseases. The aim of this study was to evaluate the potential of the S. mansoni Sm29 antigen to change the profile of monocyte-derived dendritic cells (MoDCs) from subjects with cutaneous leishmaniasis (CL) in vitro. Monocytes derived from the peripheral blood mononuclear cells of twelve patients were cultured with GM-CSF and IL-4 for differentiation into dendritic cells and then stimulated with soluble Leishmania antigen (SLA) in the presence or absence of Sm29 antigen. The expression of surface molecules associated with maturation and activation (HLA-DR, CD40, CD83, CD80, and CD86), inflammation (IL-12, TNF), and downregulation (IL-10, IL-10R) was evaluated using flow cytometry. We observed that the frequencies of HLA-DR, CD83, CD80, and CD86 as well as of IL-10 and IL-10R on MoDCs were higher in cultures stimulated with Sm29, compared to the unstimulated cell cultures. Our results indicate that the Sm29 antigen is able to activate regulatory MoDCs in patients with cutaneous leishmaniasis. It might be useful to control the inflammatory process associated with this disease.
PMCID: PMC4182898  PMID: 25309922
A few reports have suggested that HTLV-1 may influence immunological response and therefore, clinical course of tuberculosis in co-infected individuals. We wished to determine the prevalence of HTLV-1 infection among hospitalized patients in Salvador, Brazil, a region endemic for both HTLV-1 infection and latent tuberculosis infection.
A cross-sectional study was conducted at a pulmonary disease hospital between September 1st of 2006 to August 31st of 2007. Study participants were interviewed and tested for HTLV-1 infection and current or past episode of tuberculosis.
Of 607 participants recruited into the study, 360 (59.3%) had current or past history of tuberculosis and 50 (8.2%) had HTLV-1 infection; 39 (6.4%) had both. After controlling for confounding variables, we found that the odds of patients with a positive HTLV-1 test having tuberculosis were 2.57 times the odds (95%, CI: 1,23, 5:35) in those who tested negative for HTLV-1 infection.
In a region endemic for both tuberculosis and HTLV-1 infection, HTLV-1 infection increases the risk of Mycobacterium tuberculosis infection. Such a risk may influence tuberculosis transmission and therefore epidemiology of the disease in this community.
PMCID: PMC2963180  PMID: 19919770
HTLV-1; Tuberculosis; Mycobacterium tuberculosis
13.  IL-17 Production in Patients with American Cutaneous Leishmaniasis 
Interleukin 17 (IL-17) plays a critical role in inflammation and autoimmunity. Very little is known about IL-17 in protozoa infection. Here we show that lymphocytes from mucosal leishmaniasis (ML) and cutaneous leishmaniasis (CL) produce higher levels of IL-17 than uninfected controls (UC) (p<0.01). There was a tendency for higher number of cells in tissue expressing IL-17 in ML than in CL and a direct correlation between number of cells expressing IL-17 and cellular inflammation at the lesion site (r2 = 0.86, p = 0.0001). This data gives support for the role of IL-17 in the pathogenesis of the inflammatory reaction in leishmaniasis.
PMCID: PMC2732405  PMID: 19476435
Interleukin 17; leishmaniasis; cytokines; cutaneous leishmaniasis; mucosal leishmaniasis
14.  Recent developments leading toward a paradigm switch in the diagnostic and therapeutic approach to human leishmaniasis 
Purpose of review
To identify recent papers showing how human and parasite genetics influence leishmaniasis, and how understanding of the immunopathology may be utilized in immunotherapy for these diseases.
Recent findings
Progress has been made in recent years showing the complexity within populations of Leishmania spp. and indicating that different strains lead to diverse clinical pictures and responses to treatment. Thus detection of parasite genetic tags for the precise identification of infecting strains, and for predictive diagnosis of clinical and therapeutic fates seems now possible. Host genetic loci involved in disease outcome have been detected, which may also be explored for better case management. These developments in diagnosis will demand expanding the therapeutic arsenal to take their expected effect. This is starting to be fulfilled by immunotherapies successfully employed to treat cases refractory to standard first line drugs, as the result of a more profound comprehension of the immunopathology of the leishmaniases.
The knowledge mounting has already helped explain why different patients present different forms of leishmaniasis and respond differently to treatment, and may be on the verge of catalyzing a major change in the already over a century old paradigm of diagnosing and managing these patients.
PMCID: PMC2593452  PMID: 18725797
immune response; leishmania; leishmaniasis; polymorphism; treatment
15.  Monocyte Subsets in Schistosomiasis Patients with Periportal Fibrosis 
Mediators of Inflammation  2014;2014:703653.
A major issue with Schistosoma mansoni infection is the development of periportal fibrosis, which is predominantly caused by the host immune response to egg antigens. Experimental studies have pointed to the participation of monocytes in the pathogenesis of liver fibrosis. The aim of this study was to characterize the subsets of monocytes in individuals with different degrees of periportal fibrosis secondary to schistosomiasis. Monocytes were classified into classical (CD14++CD16−), intermediate (CD14++CD16+), and nonclassical (CD14+CD16++). The expressions of monocyte markers and cytokines were assessed using flow cytometry. The frequency of classical monocytes was higher than the other subsets. The expression of HLA-DR, IL-6, TNF-α, and TGF-β was higher in monocytes from individuals with moderate to severe fibrosis as compared to other groups. Although no differences were observed in receptors expression (IL-4R and IL-10R) between groups of patients, the expression of IL-12 was lower in monocytes from individuals with moderate to severe fibrosis, suggesting a protective role of this cytokine in the development of fibrosis. Our data support the hypothesis that the three different monocyte populations participate in the immunopathogenesis of periportal fibrosis, since they express high levels of proinflammatory and profibrotic cytokines and low levels of regulatory markers.
PMCID: PMC3976880  PMID: 24757288
16.  Immunoregulatory Profile of Monocytes from Cutaneous Leishmaniasis Patients and Association with Lesion Size 
Parasite immunology  2013;35(2):65-72.
Leishmaniasis is an important tropical disease composed of several clinical forms that adversely affect millions of people globally. Critical cells involved in the host-Leishmania interaction are monocytes and macrophages, which act to protect against infections due to their ability to both control intracellular infections and regulate the subsequent adaptive immune response. Both soluble factors and cell surface receptors are key in directing the immune response following interaction with pathogens such as Leishmania. Toll like receptors (TLRs) have an essential role in immune responses against infections, but little is known about their role in human infection with Leishmania braziliensis. In this work, we evaluated peripheral blood CD14+ monocytes for expression of immunoregulatory cytokines, co-stimulatory molecules and TLR9 from cutaneous leishmaniasis patients infected with L. braziliensis and non-infected individuals. Our results showed that patients present decreased expression of co-stimulatory molecules, such as CD80 and CD86 following culture with media alone or after stimulus with soluble Leishmania antigen. Interestingly, TLR9 expression was higher after culture with SLA suggesting a role for this molecule in immunoregulation of active disease. Lastly, higher frequencies of TLR9+ monocytes were correlated with greater lesion size. These findings demonstrate a peripheral monocytes profile compatible with important immunoregulatory potential.
PMCID: PMC3575026  PMID: 23050581
Leishmania; cutaneous leishmaniasis; human; immunoregulation; monocytes; TLR9; cytokines; co-stimulatory molecules
22.  Impaired Lymphocyte Profile in Schistosomiasis Patients with Periportal Fibrosis 
The Th2 immune response in chronic schistosomiasis is associated with the development of periportal fibrosis. However, little is known about the phenotype and activation status of T cells in the process. Objective. To evaluate the profile of T cells in schistosomiasis patients with periportal fibrosis. Methods. It was a cross-sectional study, conducted in the village of Agua Preta, Bahia, Brazil, which included 37 subjects with periportal fibrosis determined by ultrasound. Peripheral blood mononuclear cells were obtained by the Ficcol-hypaque gradient and the frequency of T cells expressing the surface markers CD28, CD69, CD25, and CTLA-4 was determined by flow cytometry. Results. The frequency of CD4+CD28+ T lymphocytes was higher in individuals with moderate to severe fibrosis compared to patients with incipient fibrosis. We did not observe any significant difference in the frequency of CD4+ T cells expressing CD69 among groups of individuals. There was also no significant difference in the frequency of CD8+ T cells expressing CD28 or CD69 among the studied groups. Individuals with moderate to severe fibrosis presented a lower frequency of CD8+ T cells, CD4+CD25high T cells, and CD4+CTLA-4+ T cells when compared to patients without fibrosis or incipient fibrosis. The frequency of CD4+CD25low cells did not differ between groups. Conclusion. The high frequency of activated T cells coinciding with a low frequency of putative Treg cells may account for the development of periportal fibrosis in human schistosomiasis.
PMCID: PMC3855942  PMID: 24348679
23.  Immunologic response and memory T cells in subjects cured of tegumentary leishmaniasis 
BMC Infectious Diseases  2013;13:529.
The main clinical forms of tegumentary leishmaniasis are cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML). L.braziliensis infection is characterized by an exaggerated production of IFN-gamma and TNF-alpha, cytokines involved in parasite destruction, but also in the pathology. Maintenance of an antigen-specific immune response may be important for resistance to re-infection and will contribute for vaccine development. In the present work we investigated the immune response in CL and ML cured individuals.
Participants in the present study included 20 CL and 20 ML patients, who were evaluated prior to, as well as 2 to 15 years after therapy. IFN-gamma, IL-2 and TNF-alpha production were determined by ELISA in supernatants of mononuclear cells stimulated with soluble L.braziliensis antigen (SLA). The frequency of memory CD4+ T cell populations was determined by FACS.
Here we show that the majority of CL and ML patients did not produce in vitro IFN-gamma in response to SLA after cure. In the cured individuals who responded to SLA, effector memory (CD45RA-CCR7-) CD4+ T cells were the ones producing IFN-gamma. Because a large percent of CL and ML cured patients lost SLA-induced IFN-gamma production in peripheral blood, we performed Leishmania skin test (LST). A positive LST was found in 87.5% and 100% of CL and ML cured individuals, respectively, who did not produce IFN-gamma or IL-2 in vitro.
This study shows that in spite of losing in vitro antigen-specific response to Leishmania, cured CL and ML subjects retain the ability to respond to SLA in vivo. These findings indicate that LST, rather than IFN-gamma production, may be a better assessment of lasting immunity to leishmaniasis in human studies, and thus a better tool for assessing immunization after vaccine. Furthermore, in cured individuals which maintains Leishmania-specific IFN-gamma production, effector memory CD4+ T cells were the main source of this cytokine.
PMCID: PMC3870979  PMID: 24206576
Cured leishmaniasis; IFN-gamma; Effector memory CD4+ T cells
24.  Wound healing genes and susceptibility to cutaneous leishmaniasis in Brazil 
Infection, Genetics and Evolution  2012;12(5):1102-1110.
Leishmania braziliensis causes cutaneous (CL) and mucosal (ML) leishmaniasis. In the mouse, Fli1 was identified as a gene influencing enhanced wound healing and resistance to CL caused by L. major. Polymorphism at FLI1 is associated with CL caused by L. braziliensis in humans, with an inverse association observed for ML disease. Here we extend the analysis to look at other wound healing genes, including CTGF, TGFB1, TGFBR1/2, SMADS 2/3/4/7 and FLII, all functionally linked along with FLI1 in the TGF beta pathway. Haplotype tagging single nucleotide polymorphisms (tag-SNPs) were genotyped using Taqman technology in 325 nuclear families (652 CL cases; 126 ML cases) from Brazil. Robust case-pseudocontrol (CPC) conditional logistic regression analysis showed associations between CL and SNPs at CTGF (SNP rs6918698; CC genotype; OR 1.67; 95%CI 1.10–2.54; P=0.016), TGFBR2 (rs1962859; OR 1.50; 95%CI 1.12–1.99; P=0.005), SMAD2 (rs1792658; OR 1.57; 95%CI 1.04–2.38; P=0.03), SMAD7 (rs4464148; AA genotype; OR 2.80; 95%CI 1.00–7.87; P=0.05) and FLII (rs2071242; OR 1.60; 95%CI 1.14–2.24; P=0.005), and between ML and SNPs at SMAD3 (rs1465841; OR 2.15; 95%CI 1.13–4.07; P=0.018) and SMAD7 (rs2337107; TT genotype; OR 3.70; 95%CI 1.27–10.7; P=0.016). Stepwise logistic regression analysis showed that all SNPs associated with CL at FLI1, CTGF, TGFBR2, and FLII showed independent effects from each other, but SNPs at SMAD2 and SMAD7 did not add independent effects to SNPs from other genes. These results suggest that TGFβ signalling via SMAD2 is important in directing events that contribute to CL, whereas signalling via SMAD3 is important in ML. Both are modulated by the inhibitory SMAD7 that acts upstream of SMAD2 and SMAD3 in this signalling pathway. Along with the published FLI1 association, these data further contribute to the hypothesis that wound healing processes are important determinants of pathology associated with cutaneous forms of leishmaniasis.
PMCID: PMC3372530  PMID: 22554650
leishmaniasis; wound healing; TGFB pathway; CTGF; SMADs; FLII; FLI1
25.  A proposed new clinical staging system for patients with mucosal leishmaniasis 
Mucosal leishmaniasis occurs mainly in areas where Leishmania braziliensis is transmitted. It affects predominantly the nasal mucosa and, in more severe forms, can lead to significant tissue destruction. There is no standard method for grading the severity of disease. We categorised 50 patients with mucosal leishmaniasis according to a proposed clinical staging system. Their age ranged from 10 to 86 y (mean ± SD: 36 ± 16 y) and 43 (86%) patients were male. The different degrees of evolution of mucosal disease, from the initial stage to the more severe long-term cases, enabled mucosal leishmaniasis to be graded into five stages. Stage I is characterised by nodular lesions of the mucosa without ulcerations. Stage II is represented by superficial mucosal ulcerations with concomitant fine granular lesions. Stage III is characterised by deep mucosal ulcerations with granular tissue formation. In stage IV there are irreversible lesions leading to perforation of the cartilaginous nasal septum with necrosis. In stage V the nasal pyramid is compromised with alterations of facial features as a consequence of severe tissue destruction. These stages may be useful in characterising the severity of the lesion and optimising the therapeutic outcome.
PMCID: PMC3360834  PMID: 22578516
Leishmaniasis; Mucosal leishmaniasis; Disease stage; Nasal mucosa; Nose diseases; Brazil

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