Documentos de Académico
Documentos de Profesional
Documentos de Cultura
D. ROLLINSON S. I. HAY
Department of Zoology, Spatial Epidemiology and Ecology Group
The Natural History Museum, Tinbergen Building, Department of Zoology
London, UK University of Oxford, South Parks Road
d.rollinson@nhm.ac.uk Oxford, UK,
simon.hay@zoo.ox.ac.uk
EDITORIAL BOARD
M. G. BASÁÑEZ R. E. SINDEN
Reader in Parasite Epidemiology, Immunology and Infection Section,
Department of Infectious Disease Department of Biological Sciences,
Epidemiology, Faculty of Medicine Sir Alexander Fleming Building, Imperial
(St Mary’s campus), Imperial College College of Science, Technology and
London, London, UK Medicine, London, UK
S. BROOKER D. L. SMITH
Wellcome Trust Research Fellow and Johns Hopkins Malaria Research Insti-
Reader, London School of Hygiene and tute & Department of Epidemiology,
Tropical Medicine, Faculty of Infectious Johns Hopkins Bloomberg School of
and Tropical, Diseases, London , UK Public Health, Baltimore, MD,USA
R. B. GASSER R. C. A. THOMPSON
Department of Veterinary Science, Head, WHO Collaborating Centre for
The University of Melbourne, Parkville, the Molecular Epidemiology of Parasitic
Victoria, Australia Infections, Principal Investigator, Envi-
ronmental Biotechnology CRC (EBCRC),
N. HALL School of Veterinary and Biomedical
School of Biological Sciences, Bios- Sciences, Murdoch University, Murdoch,
ciences Building, University of Liverpool, WA, Australia
Liverpool, UK
R. C. OLIVEIRA X. N. ZHOU
Centro de Pesquisas Rene Rachou/ Professor, Director, National Institute
CPqRR - A FIOCRUZ em Minas Gerais, of Parasitic Diseases, Chinese Center
Rene Rachou Research Center/CPqRR for Disease Control and Prevention,
- The Oswaldo Cruz Foundation in the Shanghai , People’s Republic of China
State of Minas Gerais-Brazil, Brazil
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Radarweg 29, PO Box 211, 1000 AE Amsterdam, The Netherlands
Daniel Adesse
Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de
Janeiro; and Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de
Janeiro, Brazil
Daniele Andrade
Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de
Janeiro, CCS, Laboratório de Imunologia Molecular, Cidade Universitária
Rio de Janeiro, Rio de Janeiro, Brazil
Anthony W. Ashton
Department of Pathology, Albert Einstein College of Medicine, Bronx,
New York, USA; and Division of Perinatal Research, Kolling Institute for
Medical Research, University of Sydney, Sydney, New South Wales,
Australia
Barbara A. Burleigh
Department of Immunology and Infectious Diseases, Harvard School of
Public Health, Boston, Massachusetts, USA
Kacey L. Caradonna
Department of Immunology and Infectious Diseases, Harvard School of
Public Health, Boston, Massachusetts, USA
Streamson C. Chua
Departments of Medicine, and Neuroscience; and The Diabetes Research
Center, Albert Einstein College of Medicine, Bronx, New York, USA
Marina V. Chuenkova
Department of Pathology and Sackler School of Graduate Students, Tufts
University School of Medicine, Boston, Massachusetts, USA
xv
xvi Contributors of Volume 76
Edecio Cunha-Neto
Laboratório de Imunologia, Instituto do Coração, Hospital das Clı́nicas;
Disciplina de Imunologia Clı́nica e Alergia, Faculdade de Medicina,
Universidade de São Paulo; and Instituto de Investigação em Imunolo-
gia—INCT, São Paulo, SP, Brazil
Mahalia S. Desruisseaux
Departments of Pathology and Medicine, Albert Einstein College of
Medicine, Bronx, New York, USA
Monisha Dhiman
Department of Microbiology and Immunology, University of Texas
Medical Branch, Galveston, Texas, USA
Lisia Esper
Department of Biochemistry and Immunology, Institute of Biological
Science, Federal University of Minas Gerais, Belo Horizonte, Brazil
Stephen M. Factor
Departments of Pathology and Medicine, Albert Einstein College of
Medicine, Bronx, New York, USA
Fabio S. Fortes
Colegiado de Ciencias Biologicas e da Saude (CCBS), Centro Universitario
Stadual da Zona Oeste (UEZO), Rio de Janeiro, Brazil
Shivali Gupta
Department of Microbiology and Immunology, University of Texas
Medical Branch, Galveston, Texas, USA
Huan Huang
Department of Pathology, Albert Einstein College of Medicine, Bronx,
New York, USA
Dumitru A. Iacobas
Dominick P. Purpura Department of Neuroscience, Albert Einstein
College of Medicine, Bronx, New York, USA
Sanda Iacobas
Dominick P. Purpura Department of Neuroscience, Albert Einstein
College of Medicine, Bronx, New York, USA
Jasmin
Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de
Janeiro, Brazil; and Dominick P. Purpura Department of Neuroscience,
Albert Einstein College of Medicine, Bronx, New York, USA
Linda A. Jelicks
Department of Physiology & Biophysics, Albert Einstein College of
Medicine, Bronx, New York, USA
Jorge Kalil
Laboratório de Imunologia, Instituto do Coração, Hospital das Clı́nicas;
Disciplina de Imunologia Clı́nica e Alergia, Faculdade de Medicina,
Universidade de São Paulo; and Instituto de Investigação em
Imunologia—INCT, São Paulo, SP, Brazil
Fabiana S. Machado
Department of Biochemistry and Immunology, Institute of Biological
Science, Federal University of Minas Gerais, Belo Horizonte, Brazil
Shankar Mukherjee
Department of Pathology, Albert Einstein College of Medicine, Bronx,
New York, USA
Fnu Nagajyothi
Department of Pathology, Albert Einstein College of Medicine, Bronx,
New York, USA
xviii Contributors of Volume 76
Mercio PereiraPerrin
Department of Pathology and Sackler School of Graduate Students, Tufts
University School of Medicine, Boston, Massachusetts, USA
Cibele M. Prado
Department of Pathology, Laboratory of Cellular and Molecular Cardiology,
Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
Xiaohua Qi
Department of Microbiology and Immunology, Albert Einstein College of
Medicine, Bronx, New York, USA
Marcos A. Rossi
Department of Pathology, Laboratory of Cellular and Molecular Cardiology,
Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão
Preto, São Paulo, Brazil
Julio Scharfstein
Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de
Janeiro, CCS, Laboratório de Imunologia Molecular, Cidade Universitária
Rio de Janeiro, Rio de Janeiro, Brazil
Philipp E. Scherer
Touchstone Diabetes Center, Departments of Internal Medicine and Cell
Biology, University of Texas Southwestern Medical Center, Dallas, Texas,
USA
Milena B. Soares
Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
David C. Spray
Dominick P. Purpura Department of Neuroscience, Albert Einstein
College of Medicine, Bronx, New York, USA
André Talvani
Laboratório de doença de Chagas, Departamento de Ciências Biológicas
& NUPEB, Universidade Federal de Ouro Preto, Ouro Preto, Minas
Gerais, Brazil
Contributors of Volume 76 xix
Herbert B. Tanowitz
Departments of Pathology and Medicine; and The Diabetes Research
Center, Albert Einstein College of Medicine, Bronx, New York, USA
Mauro M. Teixeira
Laboratório de Imunofarmacologia, Departamento de Bioquı́mica e
Imunologia/ICB; and Faculdade de Medicina, Universidade Federal de
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
Louis M. Weiss
Departments of Pathology and Medicine, Albert Einstein College of
Medicine, Bronx, New York, USA
Jian-jun Wen
Department of Microbiology and Immunology, University of Texas
Medical Branch, Galveston, Texas, USA
PREFACE
xxi
xxii Preface
FIGURE 1 (A) Carlos Chagas on the 10,000 Cruzados Banknote from Brazil.
(B) A photograph of Carlos Chagas (white arrow) and Albert Einstein (black arrow)
taken during Einstein’s visit to the Oswaldo Cruz Institute in 1925 (Lewinsohn, 2003).
With permission of Casa de Oswaldo Cruz-Fiocruz, Arquivo e Documentação, Rio de
Janeiro, Brazil.
that, despite over 100 years of research, still is the most important para-
sitic disease in the Americas.
Chagas disease is present in the countries of Latin America with the
exception of the Caribbean. Vector-borne transmission of the T. cruzi
parasite usually occurs in individuals living in primitive houses in areas
where the sylvatic cycle is active. The parasite has a complex life cycle
which is detailed in the epidemiology chapter. One of the important
recent changes in the epidemiology of Chagas diseases has been the
increased immigration of infected, usually asymptomatic, individuals
from endemic areas to non-endemic areas such as North America, Eur-
ope, Japan and Australia. Thus, Chagas disease is being recognized with
increasing frequency worldwide. This immigration into non-endemic
areas of potentially chronically infected individuals has led to screening
of blood donors to identify people who are asymptomatic but have the
potential to transmit the infection via blood transfusion and organ trans-
plantation. Interestingly, as a result of the immigration of populations into
non-endemic areas, congenital Chagas disease has now been diagnosed in
Europe among immigrants from Latin America. The exacerbation of
xxiv Preface
LOUIS M. WEISS
HERBERT B. TANOWITZ
April 2011
REFERENCES
Apt, W., 2010. Current and developing therapeutic agents in the treatment of Chagas disease.
Drug Des. Devel. Ther. 4, 243–253.
Aufderheide, A.C., Salo, W., Madden, M., Streitz, J., Buikstra, J., Guhl, F., et al., 2004. A 9,000-
year record of Chagas’ disease. Proc. Natl. Acad. Sci. USA. 101, 2034–2039.
Biolo, A., Ribeiro, A.L., Clausell, N., 2010. Chagas cardiomyopathy—where do we stand after
a hundred years? Prog. Cardiovasc. Dis. 52, 300–316.
Britto, C.C., 2009. Usefulness of PCR-based assays to assess drug efficacy in Chagas disease
chemotherapy: value and limitations. Mem Inst Oswaldo Cruz 104 (Suppl. 1), 122–135.
xxvi Preface
Buckner, F.S., Navabi, N., 2010. Advances in Chagas disease drug development: 2009–2010.
Curr. Opin. Infect. Dis. 23, 609–616.
Carod-Artal, F.J., Vargas, A.P., Falcao, T., 2011. Stroke in asymptomatic Trypanosoma
cruzi-infected patients. Cerebrovasc. Dis. 31, 24–28.
Casadei, D., 2010. Chagas’ disease and solid organ transplantation. Transplant. Proc. 42,
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Chagas, C., 1909. Nova tripanozomiase humana: Estudos sobre a morfolojia e o ciclo evolu-
tivo do schizotrypanum cruzi n. Gen., n. Sp., ajente etiolojico de nova entidade morbida
do homem. (New human trypanosomiasis. Studies about the morphology and life-cycle
of Schizotripanum cruzi, etiological agent of a new morbid entity of man). Mem Inst
Oswaldo Cruz 1, 159–218.
Epting, C.L., Coates, B.M., Engman, D.M., 2010. Molecular mechanisms of host cell invasion
by Trypanosoma cruzi. Exp. Parasitol. 126, 283–291.
Junqueira, C., Caetano, B., Bartholomeu, D.C., Melo, M.B., Ropert, C., Rodrigues, M.M., et al.,
2010. The endless race between Trypanosoma cruzi and host immunity: lessons for and
beyond Chagas disease. Expert Rev. Mol. Med. 12, e29.
Lewinsohn, R., 2003. Prophet in his own country: Carlos Chagas and the Nobel Prize.
Perspect. Biol. Med. 46, 532–549.
Lima-Costa, M.F., Matos, D.L., Ribeiro, A.L., 2010. Chagas disease predicts 10-year stroke
mortality in community-dwelling elderly: the Bambui cohort study of aging. Stroke 41,
2477–2482.
Otani, M.M., Vinelli, E., Kirchhoff, L.V., del Pozo, A., Sands, A., Vercauteren, G., et al., 2009.
WHO comparative evaluation of serologic assays for Chagas disease. Transfusion 49,
1076–1082.
Rassi, A., Jr., Rassi, A., Marin-Neto, J.A., 2010. Chagas disease. Lancet 375, 1388–1402.
Shah, D.O., Chang, C.D., Cheng, K.Y., Salbilla, V.A., Adya, N., Marchlewicz, B.A., et al., 2010.
Comparison of the analytic sensitivities of a recombinant immunoblot assay and the
radioimmune precipitation assay for the detection of antibodies to Trypanosoma cruzi in
patients with Chagas disease. Diagn. Microbiol. Infect. Dis. 67, 402–405.
Tanowitz, H.B., Machado, F.S., Jelicks, L.A., Shirani, J., de Carvalho, A.C., Spray, D.C., et al.,
2009. Perspectives on Trypanosoma cruzi-induced heart disease (Chagas disease).
Prog. Cardiovasc. Dis. 51, 524–539.
Villalta, F., Scharfstein, J., Ashton, A.W., Tyler, K.M., Guan, F., Mukherjee, S., et al., 2009.
Perspectives on the Trypanosoma cruzi-host cell receptor interactions. Parasitol. Res. 104,
1251–1260.
CHAPTER 1
Bioactive Lipids in Trypanosoma
cruzi Infection
Fabiana S. Machado,* Shankar Mukherjee,†
Louis M. Weiss,†,‡ Herbert B. Tanowitz,†,‡ and
Anthony W. Ashton†,§
* Department of Biochemistry and Immunology, Institute of Biological Science, Federal University of Minas
Gerais, Belo Horizonte, Brazil
{
Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, USA
{
Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
}
Division of Perinatal Research, Kolling Institute for Medical Research, University of Sydney, Sydney,
New South Wales, Australia
1
2 Fabiana S. Machado et al.
ABBREVIATIONS
AA arachidonic acid
AhR aryl hydrocarbon receptor
ALX lipoxin receptor
ARNT aryl hydrocarbon receptor nuclear translocator
ASA aspirin
Bioactive Lipids in Trypanosoma cruzi Infection 3
1.1. INTRODUCTION
In Latin America, millions of people are at risk for infection with the
parasite Trypanosoma cruzi the causative agent of Chagas disease. Clini-
cally, T. cruzi (Tc) infection causes acute myocarditis followed by chronic
cardiomyopathy and vasculopathy in humans and experimental models.
4 Fabiana S. Machado et al.
There are three stages of infection: acute, intermediate and chronic. Acute
myocarditis is characterized by an intense inflammatory response typified
by upregulation of inflammatory mediators such as cytokines, chemokines,
nitric oxide (NO) and endothelin-1 (Huang et al., 1999a, b; Machado et al.,
2008; Machado and Aliberti, 2009; Petkova et al., 2000, 2001; Tanowitz et al.,
2005). As the acute infection wanes, individuals may remain asymptomatic,
but 10–30% of infected individuals may ultimately develop chronic
cardiomyopathy (Tanowitz et al., 2009). The manifestations of the chronic
disease include dilated cardiomyopathy with congestive heart failure, con-
duction abnormalities and thromboembolic events (Tanowitz et al., 1992,
2009). Parasite persistence is central to the aetiology of the cardiomyopathy
and is aggravated by microvascular spasm with focal ischaemia and
autoimmune mechanisms (Factor et al., 1985; Petkova et al., 2000, 2001;
Tanowitz et al., 1996). As early as the 1990s, it was suggested that eicosa-
noids may play a significant role in the vasospasm and platelet aggregation
that characterize Chagas disease (Tanowitz et al., 1990).
1.2.1. AA metabolism
AA is a 20-carbon polyunsaturated fatty acid derived from linoleic acid.
Once synthesized, AA is stored as a part of glycerophospholipids that
compose the lipid bilayer of the plasma membrane and can be released
via the action of phospholipases A2, C and D (PLA2, PLC and PLD,
respectively; Fig. 1.1). AA can be reincorporated into cellular lipids via
reacylation and recombination with lysophospholipid. AA is metabolized
predominantly by the following three independent metabolic pathways:
1. The cyclooxygenase (COX) pathway: producing prostaglandins (PGs) and
thromboxane A2 (TXA2).
2. The lipoxygenase (LO) pathway: producing leukotrienes (LTs), lipoxins
(LXs), hydroxyeicosatetraenoic acids (HETE) and hydroperoxyeicosa-
tetraenoic acids (HPETE).
3. Cytochrome P-450 monooxygenase pathway: producing epoxides and
hydroxyeicosatetraenoic acids.
Bioactive Lipids in Trypanosoma cruzi Infection 5
Phosphatidic
acid (PA) PLC
Lyso PL
DG kinase
Lyso PA Diglyceride
(DG)
PLA2
DG lipase
COOH
Free arachidonic
acid
Cytochrome P-450
Cyclooxygenase Lipoxygenase
Monooxygenase
FIGURE 1.1 Production and use of free arachidonic acid from various intracellular
sources.
life stages of T. cruzi (Ashton et al., 2007; Kabututu et al., 2003). While it is
clear that in the trypomastigote and amastigote forms of the parasite,
multiple functions exist for bioactive lipids, almost nothing is known
about the role of these mediators in the epimastigote stage. Insects fed
on blood treated with inhibitors to COX, LO and PLA2 enhance parasi-
taemia and mortality due to parasite challenge with T. rangeli (Garcia
et al., 2004), leading to a hypothesis that parasite-derived PGs suppress
immunity and permit the chronic habitation of the vector (Azambuja and
Garcia, 2005; Azambuja et al., 2005). Eicosanoids such as TXA2 may aid in
the colonization of the gut by producing mucosal injury (Walt et al., 1987)
and increase the potential spread of the parasite through increasing gut
motility (Schultheiss and Diener, 1999). The survival of T. cruzi in the gut
of its insect vector is largely dependent upon nutritional status (Azambuja
and Garcia, 2005; Azambuja et al., 2005). Thus, the same scavenging
mechanism that operates to provide lipid precursors in the mammalian
host (see next section for a discussion of these mechanisms) may also
apply to the insect vector.
with the use of such general inhibitors and highlight the need for specific
receptor blockers and terminal synthase antagonists to be applied to identi-
fying the PGs most relevant to the pathogenesis of Chagas disease.
The dichotomy of the effects seen with NSAIDs in acute disease might
result from the different combination of agents, mice and parasite strains
previously employed. The expression of both COX isoforms remains
unchanged during infection, and there is no increase in COX-2 levels in
COX-1 null mice by immunoblotting (S. Mukherjee, unpublished data).
While the role of COX-2 in T. cruzi infection is largely undefined, both
COX-1 and COX-2 appear to play different roles during acute infection.
Inhibition of COX-2 (celecoxib), but not COX-1 (ASA), prevented the
thrombocytopenia and leukopenia associated with acute infection and
increased reticulocyte counts in response to infection (Hideko
Tatakihara et al., 2008). Inhibition of COX-1 and -2 reciprocally regulates
NO release from M1 and M2 macrophages which may correlate with
resistance to infection. Consistent with this observation, COX-2-derived
PGs mediate most of the immunosuppressive effects during the initial
phase of T. cruzi infection (Michelin et al., 2005). This may result from the
observations that PGI2 and PGE2 are more closely linked to COX-2 metab-
olism, while COX-1 is responsible for TXA2 synthesis (Parente and
Perretti, 2003; Smith et al., 1997). In addition, timing of onset of treatment
is important; that is, administration of ASA early in disease, 5 days
post-infection increased parasitaemia and mortality (Mukherjee et al.,
2011). This observation suggests that caution should be exercised when
employing COX inhibitors for controlling fever and pain in the setting of
acute Chagas disease. Conversely, use of ASA during chronic disease had
no effect on mortality or parasitaemia but improved cardiac function,
suggesting the same COX-1 products that mediate host survival during
the acute disease are likely to contribute to the progression of cardiac
damage and heart failure in the chronic stage.
The selectivity of the NSAIDs used may also determine whether
parasite or host production of PGs is the primary target of the treatment
regimen used. Many of the biosynthetic enzymes in trypanosomes appear
to be unaffected by inhibitors of their mammalian counterparts (Kabututu
et al., 2003). Conversely, indomethacin-amides were recently shown to
have anti-T. cruzi activity (Konkle et al., 2009). Although these com-
pounds were tested for inhibition of steroid biosynthesis in T. cruzi, they
are uniquely specific to COX-2 inhibition in mammals. Thus, a logical
hypothesis is that free fatty acid, eicosanoid and sterol biosynthesis may
be linked in T. cruzi through the use of enzymes whose biosynthetic
capabilities allow them to participate in more than one pathway.
LTs are necessary for control of parasitaemia and survival in the acute
T. cruzi infection (Borges et al., 2009) due to modulation of NO and
cytokine release. The treatment of T. cruzi-infected mice with a BLT1
Bioactive Lipids in Trypanosoma cruzi Infection 19
studies by several groups have shown that ATL regulates cytokine pro-
duction and release (Maderna and Godson, 2009; Ryan and Godson,
2010), induces SOCS-2 and suppresses TNF receptor-associated factor-6
(TRAF-6) to silence cytokine signalling (Machado et al., 2006). Impor-
tantly, Machado et al. (2006) demonstrated that ASA-treated SOCS-2
null mice given LPS by the intra-peritoneal route could not inhibit neu-
trophil migration and TNF-a. It is therefore possible that mortality may
have more to do with modulation of the impending cytokine storm
during acute disease than actual PG production. Thus, the effects of
ASA in T. cruzi infection may be via dual mechanisms that operate during
different phases of disease.
Pharmacological inhibition may not distinguish between the potential
for the host and parasite to function as the source of eicosanoid synthesis
during disease. Importantly, the differences between pharmacological inhi-
bition of COX-1 and the COX-1 null mice indicated that there was an
unrecognized and essential host–parasite interdependence that dictates
the biosynthetic activity of the parasite. The basis for this relationship
appears to be the requirement for host-derived PGH2 for PG synthesis
throughout infection. A reduction in PGF2a release in COX-1 null, but not
TXA2 synthase null, mice was observed. As TXA2 synthase null mice have
normal COX activity, the data indicate that COX activity in the host likely
provides precursor molecules required for the biosynthetic pathways of this
parasite. This ‘‘scavenging’’ hypothesis is confirmed by the inability of the
parasite (the primary source of TXA2 during infection) to sustain TXA2
release in the COX-1 null mice. Moreover, the fatty acid synthesis pathways
in trypanosomes are defective regarding synthesis of polyunsaturated lipids
(Livore et al., 2007) which makes scavenging precursors from the host not
just energetically favourable but a requirement. Secretion of PLA-like activ-
ity into the host cell from intracellular amastigotes (Belaunzaran et al., 2007)
would liberate AA from the inner layer of the host cytoplasmic membrane.
This variation on transcellular synthesis would ensure a constant supply of
precursors for parasite biosynthetic pathways.
If the parasite were scavenging precursors from the host, then they
would only need the terminal synthases to produce bioactive lipids. The
fatty acid biosynthetic pathways in trypanosomes are poorly defined, and
little homology is reported between the mammalian biosynthetic enzymes
and their trypanosomal homologues (Kubata et al., 2000). The PGF2a
synthase identified in the parasite is more similar to yeast old yellow
enzyme than to mammalian enzyme (Kubata et al., 2002), however, the
recent report of anti-parasitic activity of indomethacin-amide derivatives
indicates that the active site of some parasite enzymes, if not their primary
sequences, is sufficiently homologous to their mammalian counterparts
(Konkle et al., 2009). Interestingly, no enzyme other than COX has been
identified as being sensitive to indomethacin. However, it remains to be
22 Fabiana S. Machado et al.
ACKNOWLEDGEMENTS
This work was supported by grants from the United States National Institutes of Health
(H. B. T. [AI-76248]), the National Health and Medical Research Council of Australia
(A. W. A. [512154]) and a Scientist Development Grant from the American Heart Association
(S. M. [0735252N]). This work was also supported by Career Development Awards from the
24 Fabiana S. Machado et al.
National Health and Medical Research Council of Australia (A. W. A. [402847]), Conselho
Nacional de Desenvolvimento Cientı́fico e Tecnológico (CNPq) (F. S. M. [576200/2008-5;
473670/2008-9]) and Fundação de Amparo à Pesquisa do Estado de Minas Gerais
(FAPEMIG) (F. S. M. [14916]).
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CHAPTER 2
Mechanisms of Host Cell
Invasion by Trypanosoma cruzi
Kacey L. Caradonna and Barbara A. Burleigh
Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston,
Massachusetts, USA
33
34 Kacey L. Caradonna and Barbara A. Burleigh
2.1. INTRODUCTION
Trypanosoma cruzi, the protozoan parasite that causes human Chagas
disease, has a digenetic life cycle involving both vertebrate and invertebrate
hosts within which, distinct developmental stages of the parasite arise
(Fig. 2.1). As an obligate intracellular parasite in the vertebrate host, intracel-
lular localization is critical for establishment and maintenance of T. cruzi
infection. Host cell invasion is accomplished by trypomastigotes, both meta-
cyclic and bloodstream forms, which are highly specialized, non-dividing
forms of T. cruzi that can penetrate a wide variety of mammalian cell types.
Once inside the host cell, trypomastigotes undergo a developmental process
that culminates in the formation of replicative amastigotes that proliferate in
the host cell cytoplasm for 5–6 days until they occupy most of the cell
volume. At this stage, amastigote division ceases and differentiation to
trypomastigotes occurs followed by rupture of the host cell plasma
membrane (Costales and Rowland, 2007) releasing trypomastigotes that
disseminate infection (De Souza, 2002; Fig. 2.1).
Mechanisms of Host Cell Invasion by Trypanosoma cruzi 35
Metacyclic
Epimastigote
trypomastigote
Reduviid host
Mammalian host
Metacyclic/
bloodstream
trypomastigote
Intracellular
amastigote
FIGURE 2.1 Trypanosoma cruzi life cycle. Metacyclic trypomastigotes arising from
epimastigotes in the reduviid host are transmitted to mammalian host in the faeces of
the insect vector. Inside the host, trypomastigotes invade cells and are rapidly targeted
to a lysosome-derived vacuole. Within the vacuole, trypomastigotes begin the trans-
formation to amastigotes (2–8 h) after which the vacuole is gradually disrupted and
parasites localize to the host cell cytoplasm (8–16 h). Cytosolic amastigotes begin to
divide at 24 h post-invasion and continue to divide every 12 h for 5–6 days, then
differentiate back into trypomastigotes, rupture the host cell, enter the host circulation
and disseminate infection.
Cardiomyocytes are clearly one of the most important target cell types
for T. cruzi infection in vivo, where early establishment of infection and
parasite persistence in the heart correlate with disease progression in
chagasic cardiomyopathy (Benvenuti et al., 2008; Jones et al., 1993;
Monteon-Padilla et al., 2001; Mortara et al., 1999; Zhang and Tarleton,
1999). Tissues harvested from rare autopsies performed on acute Chagas
patients reveal the presence of intracellular T. cruzi amastigotes not only
in cardiomyocytes but also in smooth muscle of the oesophagus, larynx
and bladder with concomitant inflammatory infiltrate (e.g. Bittencourt
et al., 1984; Montalvo-Hicks et al., 1980). In cases of reactivation of acute
Chagas disease in immunocompromised individuals, parasites have also
been noted in the central nervous system (Marchiori et al., 2007; Mortara
et al., 1999; Sartori et al., 1995). Much of our knowledge of the T. cruzi
infection process has been generated from experimental animal models,
from which it is clear that T. cruzi is able to infect a variety of tissues
during the acute stage of infection (Barbabosa-Pliego et al., 2009; Barr
36 Kacey L. Caradonna and Barbara A. Burleigh
fundamental mechanistic insights into the host recognition and cell attach-
ment process, as mediated by members of the gp85/TS superfamily, have
recently been achieved (Alves and Colli, 2008; de Melo-Jorge and
PereiraPerrin, 2007; Scharfstein and Lima, 2008; Yoshida and Cortez,
2008) as outlined briefly below.
this compartment once the parasite enters results in poor T. cruzi infectiv-
ity (Andrade and Andrews, 2005; Andrews et al., 1990; Woolsey and
Burleigh, 2004). Studies over the past decade or so suggest that T. cruzi
trypomastigotes can access the host cell lysosomal compartment by
several different routes. In the following sections, we outline the
studies that have led to this hypothesis as well as current knowledge of
the molecular basis for vacuole egress and cytosolic localization of
the parasites.
1. Exocytosis 2. Endocytosis
Ca2+-dependent
exocytosis
Kinesin-based
movement on
Rab5
microtubules
Early
endosomes
EEA1
?
Autophagosome Lysosome
targeting Late
endosomes
Lysosome
3. Autophagy
Trans golgi network
vesicles
Golgi
Endoplasmic
N
reticulum
FIGURE 2.2 Pathways for host cell invasion by T. cruzi. En route to the host cell
lysosomal compartment in non-professional phagocytic cells, T. cruzi trypomastigotes
can engage three major cellular pathways. Pathway 1 involves recruitment and targeted
exocytosis of host cell lysosomes with the host plasma membrane at the parasite
attachment site. Kinesin motors propel lysosomes along microtubules to the host
plasma membrane where Ca2þ-dependent fusion takes place. Exploiting this pathway,
trypomastigotes bypass other cellular pathways to directly target lysosomes. Pathway 2
involves formation of a plasma membrane-derived vacuole around T. cruzi that fuses
with early endosomes prior to fusion with lysosomes. Pathway 3 involves both direct
targeting of autophagosomes, which are derived from lysosome fusion with early
autophagic compartments, to the nascent parasite vacuole and/or fusion with T. cruzi
vacuoles formed following entry via the other routes. The contribution of the autop-
hagic route is enhanced following nutrient starvation of cells.
It was recently reported that the T. cruzi can utilize the low-density
lipoprotein receptor (LDLr) in its invasion and for the subsequent fusion
of the parasitophorous vacuole with host lysosomes (Nagajyothi et al.,
2011). Endocytosis of LDLr in association with calcium mobilization, its
subsequent trafficking to lysosomes and the release of ligands at low pH
are processes reminiscent of those involved in T. cruzi invasion.
Nagajyothi et al. (2011) demonstrated that T. cruzi directly binds to
LDLr, and inhibition or disruption of LDLr significantly decreases para-
site entry. Additionally, immunofluorescence analysis demonstrated an
association of phosphotidylinositol phosphates to LDLr cross-linked
parasites in clathrin-coated pits, which may initiate a signalling cascade
that results in the recruitment of lysosomes, possibly via the sorting motif
in the cytoplasmic tail of LDLr, to the site of adhesion/invasion. The
results were supported by the earlier reports that demonstrated that
parasite invasion was perturbed in dynasore-treated cells (Barrias et al.,
2010) and that there was increased rate of invasion in the presence of
lipoproteins (Prioli et al., 1990). Studies of infected CD1 mice demon-
strated that LDLr expression is upregulated in infected mice hearts and
that both LDL and LDLr were associated with amastigotes (pseudocysts)
in the heart tissue of infected mice. The accumulation of LDL and LDLr in
the heart is likely a contributing factor in the pathogenesis of chagasic
heart disease (Nagajyothi et al., 2011).
2.3.2.3. Autophagy
Autophagy is a conserved catabolic process that operates in the cytoplasm
of eukaryotic cells to degrade excess or damaged cellular organelles and
proteins via the formation of autophagosomes that fuse with lysosomes
(Yang and Klionsky, 2010). The hallmarks of early autophagosome
48 Kacey L. Caradonna and Barbara A. Burleigh
2.5.1. Actin
Early studies addressing the mechanism of T. cruzi trypomastigote
invasion into non-professional phagocytic cells quickly revealed that
the entry process was distinct from the actin-dependent macropinocy-
totic or phagocytic processes that are engaged by a number of bacterial
or protozoan pathogens in order to induce uptake into host cells
(Schenkman et al., 1991). Rather than inhibiting T. cruzi uptake,
actin-depolymerizing drugs enhanced trypomastigote entry into
non-professional phagocytic cells, whereas similar treatments block
phagocytic uptake of latex beads or bacteria. When cells were exposed
to live trypomastigotes or lysate that trigger IP3-dependent increases in
intracellular Ca2þ levels (Burleigh and Andrews, 1995; Rodriguez et al.,
1995; Tardieux et al., 1994), rapid and transient reorganization of the
host cell actin cytoskeleton occurs. Because the [Ca2þ]i-transients that
were triggered in cells by parasites or other agonists produced a tran-
sient decrease in cortical F-actin content, these data were interpreted
within the context of the existing T. cruzi invasion model: the lysosome
recruitment model. It was postulated that the cortical actin cytoskeleton
acts as a barrier to prevent docking and fusion of lysosomes with the
plasma membrane, and that transient depolymerization of the cytoskel-
eton with each [Ca2þ]i-transient would provide greater access of lyso-
somes to the plasma membrane for fusion (Rodriguez et al., 1995;
Tardieux et al., 1992, 1994). This assumption turned out to be incorrect
as cytochalasin D pretreatment of cells completely abolished early lyso-
some association with nascent T. cruzi vacuoles while enhancing entry
via the alternate, plasma membrane invagination pathway (Woolsey
and Burleigh, 2004). The ability to uncouple trypomastigote entry of
cells from early lysosome association with the vacuole with cytochalasin
D provided a convenient way to probe the kinetics of organelle marker
accumulation by the T. cruzi vacuole during and shortly after parasite
entry. In drug treatment and washout experiments, it was noted that as
host cells recovered from cytochalasin D pretreatment, the parasite
vacuole accumulated the early endosome marker, EEA1, before the
lysosomal marker, LAMP1 (Woolsey and Burleigh, 2004). This observa-
tion provides strong experimental support for the existence of a viable
T. cruzi invasion pathway that does not immediately rely on lysosome–
plasma membrane fusion. Secondly, these experiments revealed that
actin dynamics are required for lysosome fusion with the plasma
membrane/parasite vacuole (Woolsey and Burleigh, 2004).
52 Kacey L. Caradonna and Barbara A. Burleigh
Given that the Rho family of GTPases are important regulators of actin
polymerization that can be targeted by bacterial effector proteins in order
to modulate the uptake of bacterial pathogens (Bulgin et al., 2010), the
activation state of the main Rho GTPases, Rac, RhoA and Cdc42, in host
cells was investigated in the context of T. cruzi infection. Exposure of
fibroblasts to T. cruzi trypomastigotes resulted in a rapid and transient
reduction in the level of GTP-bound RhoA, with no change in the
activation state of Rac1 or Cdc42, suggesting that RhoA may play a role
in parasite entry and association with the endosomal/lysosomal compart-
ment. In support of this hypothesis, it was shown that while T. cruzi
trypomastigote entry was initially greatly enhanced in CHO cells expres-
sing a dominant negative (DN)-RhoA most of the internalized parasites
failed to traffic to lysosomes and were not retained in the cells. These
experiments, therefore, were the first to introduce the concept of cellular
retention of T. cruzi following internalization (see Section 2.6).
2.5.2. Microtubules
Experimental evidence suggests that host cell microtubules play a signifi-
cant role in the T. cruzi invasion process (Rodriguez et al., 1996; Tyler
et al., 2005). First, disruption of microtubule dynamics within mammalian
host cells using a variety of microtubule/tubulin-binding drugs reduces
the overall efficiency of T. cruzi invasion of fibroblast and myoblast cell
lines (Rodriguez et al., 1996). The localized accumulation of tubulin at the
point of parasite contact with the host cell in cells stably expressing
GFP-a-tubulin, as well as the recruitment of tubulins to nascent T. cruzi
vacuoles, supports the idea that host microtubules participate in the
parasite entry process (Tyler et al., 2005). While colchicine treatment of
recently invaded cells does not prevent the recruitment of GFP-a-tubulin
to the parasite vacuole, subsequent removal of drug permits the forma-
tion of microtubules, which can be seen radiating out from the parasito-
phorous vacuole membrane (Tyler et al., 2005). Given the clear role for
endosomal/lysosomal fusion with membrane surrounding invading and
recently internalized parasites, a likely function of microtubules is the
transport of endosomes, lysosomes or autophagosomes which contribute
to vacuole biogenesis, as discussed above. Lysosomes are transported
along microtubules, moving in both anterograde and retrograde
directions guided by the action of kinesins and cytoplasmic dyneins,
respectively (Harada et al., 1998; Nakata and Hirokawa, 1995). As the
motor-based movements of lysosomes are susceptible to changes in cyto-
solic pH (Heuser, 1989), this property was exploited to demonstrate
that cells with an increase in the number of peripherally localized
lysosomes are more readily infected by T. cruzi than control cells and,
conversely, cells exhibiting perinuclear aggregation of lysosomes were
Mechanisms of Host Cell Invasion by Trypanosoma cruzi 53
Host cell lysosomes have clearly emerged as the interim target of at least
three cellular pathways/processes that T. cruzi trypomastigotes exploit to
infect non-professional phagocytic cells. The parasite can enter lysosomes
directly by inducing Ca2þ-dependent lysosome exocytosis at the site of
trypomastigote attachment at the plasma membrane or can target this
compartment indirectly by intersecting with the endocytic or autophagic
pathways. The ability of T. cruzi to engage different organellar/vesicular
trafficking pathways within mammalian cells to attain their goal of
transient lysosome residence may increase options for host cell selection
aiding in the overall success of the pathogen in establishment of infection.
Although it is clear that the activation of cellular signalling pathways via
parasite–host cell interactions at the cell surface, our ability to integrate
particular T. cruzi-triggered signalling events with the different routes of
parasite entry is currently limited and further study is warranted. Further,
there is still much to learn regarding the role of surface-expressed glyco-
protein families and in mediating early host cell interactions. Looking
ahead, increasing access to new genome-scale technologies will permit
the application of functional genomics approaches for more rapid discov-
ery of important regulators of the T. cruzi infection process that have the
potential to be exploited as targets for drug or vaccine development.
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CHAPTER 3
Gap Junctions and Chagas
Disease
Daniel Adesse,*,† Regina Coeli Goldenberg,*
Fabio S. Fortes,‡ Jasmin,*,§ Dumitru A. Iacobas,§
Sanda Iacobas,§ Antonio Carlos Campos de
Carvalho,*,§ Maria de Narareth Meirelles,† Huan
Huang,} Milena B. Soares,k Herbert B. Tanowitz,}
Luciana Ribeiro Garzoni,† and David C. Spray§
* Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Brazil
{
Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
{
Colegiado de Ciencias Biologicas e da Saude (CCBS), Centro Universitario Stadual da Zona Oeste (UEZO),
Rio de Janeiro, Brazil
}
Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx,
New York, USA
}
Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, USA
k
Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Salvador, Bahia, Brazil
63
64 Daniel Adesse et al.
3.1. INTRODUCTION
Cell 1
Membrane
Gap
Membrane
Cell 2
Amino
Terminus
Carboxyl
Terminus
FIGURE 3.1 Schematic representation of gap junction and connexin structures. Two cells
are coupled through connexon hemichannels, each composed of six subunits of con-
nexin (Cx). Gap junction channels connect two cells’ cytoplasms, allowing free exchange
of small metabolites such as Ca2þ, IP3 and cAMP, which in heart tissue are important for
maintaining synchronous contraction. Gating properties of gap junctions can be regu-
lated by Cx structure, which consists of four primarily a-helical transmembrane domains,
cytoplasmic amino and carboxyl termini and a cytoplasmic loop, all of which contain
some regions of a-helix, and extracellular loops that are primarily b-structure. A number
of proteins that bind to cardiac connexins are known, and more are certain to be
discovered, linking the connexin into an intercellular signalling complex, the Nexus.
Binding sites may either correspond to structured regions within the connexin molecules
or be unstructured, leading to presumably low-affinity and dynamic interactions.
Gap junction function and distribution within and between cells are
affected by phosphorylation state of the connexins that form them and by
other factors including intracellular pH and protein–protein interactions
(see Hervé et al., 2004; Spray et al., 2001 for reviews). In diverse cardiac
disease states, such as myocardial infarction and ischaemia, significant
remodelling of the distribution of Cx43 occurs in ventricles, resulting in
disorganization of normal microconduction pathways and arrhythmias
(Severs, 2001); similarly, altered Cx40 distribution has been associated
with atrial fibrillation (see Chaldoupi et al., 2009 for review).
Studies of alterations in cardiac myocytes during in vitro infection with
Trypanosoma cruzi indicate that the parasite is capable of impairing host
cell functioning through alterations in cell–cell communication (de
Carvalho et al., 1992). Such an effect is expected to be of particular
importance in the heart, where maintenance of synchronous contractions
requires functional gap junctions (see Duffy et al., 2006; Severs et al., 2006
66 Daniel Adesse et al.
A C
B D
Tc
20 µm
FIGURE 3.2 Trypanosoma cruzi infection impairs cell–cell coupling. The micrographs
depict the pioneer experiment that tried to understand the basis of arrhythmogenesis in
T. cruzi infection. Cultured cardiac myocytes were injected with the dye lucifer yellow
(LY) that spreads to adjacent cells through gap junctions. Non-infected cells (A,B) were
capable of transmitting LY to up to six cells, whereas when the injection was done in a
highly infected cell (C,D), dye spread was abolished. Asterisks indicate the cells that were
injected. Bars ¼ 20 mm. From de Carvalho et al. (1992).
A B
F
ER
SR
MF
C D
50 mm 50 mm
E F
E A T E A T
75 kDa 75 kDa
Cx43 Cx43
Sigma (363–382) 181A (346–360)
FIGURE 3.3 Does Trypanosoma cruzi express connexin43? The use of specific antibo-
dies directed to different residues of connexin43 C-terminal tail demonstrated that Cx43
shares a homologous residue with a T. cruzi surface protein. (A and B) Immunogold
analysis using the 181A antibody (residues 346–360) displayed typical localization at
cell–cell contacts in non-infected cardiac myocytes (A, arrows). However, in T. cruzi
infected cells, membrane Cx43 immunolocalization was absent and there was a consis-
tent staining of the amastigotes (B, arrowheads). Confocal microscopy using a com-
mercially available anti-Cx43 antibody (Sigma), recognizing residues 363–382 of the
C-tail, reveals no staining of the intracellular parasites (C). Highly infected cardiac cells
lost Cx43 immunoreactivity for both Sigma and 181A antibodies (C and D, stars), but
non-parasitized cells displayed normal Cx43 plaques (C and D, arrows). Staining of
T. cruzi by 181A antiserum is likely due to the recognition of a homologous protein,
70 Daniel Adesse et al.
A 1 hpi 72 hpi
B 1 hpi 72 hpi
FIGURE 3.4 Connexin43 protein and mRNA expression during in vitro infection with
T. cruzi. Mouse cardiac myocytes were cultivated and infected with the Y strain of
T. cruzi. Protein analysis showed that infection induces a bidirectional effect on Cx43,
starting with a significant increase at 1 hour post-infection (hpi), followed by a normal-
ization in protein levels until 72 hpi, when there is a drop of 61% in protein levels. Semi-
quantitative RT-PCR showed no alteration on Cx43 mRNA at 1 hpi, but a significant
decrease in Cx43 transcripts at 72 h.
present in all three evolutive forms of the parasite (F), showing a different molecular
weight from Cx43 as compared to mouse heart lysates used as positive controls. Staining
of a 120-kDa band was observed in immunoblots using the 181A antibody (F) but not with
the Sigma antibody (E). (E, epimastigote; A, amastigote; T, trypomastigote; SR, sarco-
plasmic reticulum; ER, endoplasmic reticulum; F, fibroblast; P, parasite; MF, myofibril.)
Gap Junctions and Chagas Disease 71
conduction block and changes in heart rate (Costa et al., 2000). This
observation seems to contradict the results described above, in which
we observed substantial impairment in the coupling and Cx43 expression
of infected cells but not in non-parasitized cells in infected dishes (Adesse
et al., 2008, de Carvalho et al., 1992). The difference between these data
could be in part explained by the high concentrations of serum proin-
flammatory cytokines and chemokines found during chronic infection in
which parasite load is much reduced. It has been shown that growth
factors, such as transforming growth factor-b (TGF-b), can regulate gap
junction intercellular communication (Chandross et al., 1995; see Chanson
et al., 2005 for review). TGF-b is required for the invasion of host cells and
is produced early upon infection, and constantly throughout the acute
and chronic phases (see Araújo-Jorge et al., 2008 for review). Recently, it
was demonstrated that the addition of 2 ng/mL TGF-b in cardiomyocytes
in vitro downregulated Cx43 protein expression in non-infected myocytes,
resulting in reduced organization of gap junctions similar to the pattern
observed in infected cultures. These results were further reinforced when
the TGF-b receptor type 1 (ALK-5) was inhibited by SB-431542, which
completely reversed the effect of TGF-b and T. cruzi infection on Cx43
expression. The authors suggested that TGF-b produced in infected cul-
ture could affect both infected and non-infected cells and affect the pat-
tern of Cx43. In addition, because TGF-b regulates a diverse array of
cellular processes, including tissue development and repair (see Ramos-
Mondragón et al., 2008, Yarnold and Brotons, 2010 for reviews), the high
levels of TGF-b and consequent disorganized expression of Cx43 could
both act in synergy to promote dysrhythmias in chagasic patients
(Waghabi et al., 2009).
Confocal microscopy experiments revealed that acute infection
(30 days post-infection with the Brazil strain) induces connexin remodel-
ling with lateralization of Cx43 plaques, that is, delocalization from the
intercalated discs (Fig. 3.5A–B). Such remodelling is commonly observed
in cardiac diseases such as hypertrophic cardiomyopathy (Seidel et al.,
2010), myocardial infarction (Wang et al., 2010) and heart failure (Akar
et al., 2004) and contributes to impairment of impulse propagation.
In a murine model of chronic T. cruzi infection (Y strain), we observed
structural damage to the myofibrils, mitochondria and sarcoplasmic
reticulum with intercalated disc discontinuity, as shown in the electron
micrographs in Fig. 3.5C and D. Interestingly, using oligonucleotide
microarrays, we have previously described that both in in vitro and in
in vivo models of infection, there are marked changes in the expression of
genes related to contractile proteins as well as to the intercalated
disc (Adesse et al., 2010; Goldenberg et al., 2009; Mukherjee et al., 2008).
An important recent report indicated that in human chagasic cardiomyo-
pathic hearts, Cx43 distribution is altered in areas of fibrosis and this
Gap Junctions and Chagas Disease 73
FIGURE 3.5 Cardiac Chagas disease affects connexins and intercalated discs morphol-
ogy. Hearts from acutely infected mice (30 days post-infection with the Brazil strain)
were harvested and processed for immunohistochemistry for Cx43 (red) and F-actin
(green) (A–B). Non-infected animals (A) displayed abundant Cx43 staining (red) in
cell–cell contacts, mainly in the intercalated discs (arrows). Acutely infected myocar-
dium (B) presented amastigotes pseudo-cysts (*), as revealed by DAPI staining in blue and
lateralization of Cx43 in neighbour cells (arrowheads). Transmission electron microscopy
revealed that during chronic Chagas disease (180 days post-infection with the Y strain),
there are foci of severe damage to myocytes (D) in which cells are hypertrophied and
display mitochondria swelling and disarray of contractile elements as compared to
age-matched uninfected mouse hearts (C). The arrows point to a region where myofibrils
anchor to intercalated discs, indicating substantial cellular disorganization. Original
magnification: 8000 (C) and 10,000 (D). M, mitochondria; MF, myofibril; T, T-tubule.
FIGURE 3.6 Trypanosoma cruzi infection affects Cx43 but not other junctional proteins.
MDCK2 cells were cultured and infected with T. cruzi (Brazil strain) for 72 h. Immuno-
fluorescence for Cx43 (A, in red) and Zona Occludens-1 (B, in green) showed that despite
the drastic decrease in Cx43 immunoreactivity in most of the highly infected cells (*),
ZO-1 distribution was maintained intact (arrows mark regions where Cx43 was lost but
ZO-1 was still present, arrowhead where Cx43 was still present in nonparasitized cells).
With nucleic acid staining with TOPRO3, is possible to visualize host cell nuclei and also
kinetoplastid DNA from intracellular amastigotes (small spots in (C)). In (D) the merged
image is displayed. Bars ¼ 20 mm.
3.5. CONCLUSIONS
This suggests that there are signals sent out from infected cell to
non-infected cells that may alter the physiological responses of cells
within the whole culture dish. This is likely similar to what occurs in
the heart with alterations in gap junctions as a result of infection. Chronic
chagasic heart disease is associated with profound conduction distur-
bances associated with fibrosis, lipid accumulation and cellular and tissue
level hypertrophy. We now appreciate that even during the chronic phase
of the disease, there is a persistence of the parasite with a low-level
continuous infection that is associated with fibrosis and vasculopathy.
In part, this manifestation of dysfunction as a consequence of only a small
number of cells being affected may reflect the anatomy of the tissue that is
targeted. The heart is composed of specialized conduction and contrac-
tion myocytes, and optimized output depends upon the progressive
synchronized activation of the contractile myocardium. Thus, reducing
gap junction expression in only a small number of cells could provide
focal slowing of conduction or focal compromise of chamber contraction.
Infection of cardiac myocytes and more globally, infection of the
animal, leads to functional uncoupling of cardiac myocytes, as a conse-
quence of reduced expression of Cx43 and its gene. A variety of methods
have been used to evaluate the changes in gap junction expression in the
chagasic heart. These methods include functional studies in which dye
coupling, junctional conductance or conduction synchrony were evalu-
ated, by immunostaining and Western blotting and measurements of
gene expression, either through Northern blots or, more recently, from
microarray analysis. The findings from these studies include the observa-
tion that the cardiac gap junction protein and the channels that it forms
are a target of infection. In a population of acutely infected cardiac
myocytes, gap junction abundance and immunoreactivity with certain
antibodies are severely compromised, as are functional coupling and
synchronous contraction. In adjacent non-infected cells, gap junction
expression and function are less affected so that there is a mosaic of
cells that are either connected or disconnected to their neighbours
depending on presence and extent of parasitaemia. In chronic chagasic
cardiomyopathy, the number of parasitized cells is low, but circulating
factors such as IL-1b and TGF-b are elevated in the chronically inflamed
myocardium, resulting in not only reduced expression of Cx43 but also
structural remodelling due to fibrosis.
In summary, the available data suggest that the effect on gap junctions
of small numbers of infected cells in both acute and chronic disease has a
critical role in the underlying pathophysiological processes which result
in clinical chagasic cardiomyopathy.
Gap Junctions and Chagas Disease 79
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CHAPTER 4
The Vasculature in Chagas
Disease
Cibele M. Prado,* Linda A. Jelicks,§
Louis M. Weiss,†,‡ Stephen M. Factor,†,‡ Herbert B.
Tanowitz,†,‡ and Marcos A. Rossi*
* Department of Pathology, Laboratory of Cellular and Molecular Cardiology, Faculty of Medicine of Ribeirão
Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
{
Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, USA
{
Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
}
Department of Physiology & Biophysics, Albert Einstein College of Medicine, Bronx, New York, USA
83
84 Cibele M. Prado et al.
A/J mice infected with the Brazil strain and perfused with silicone rubber
(Microfil) 15–17 days post-infection revealed numerous areas of focal
vascular constriction, microaneurysm formation, vascular dilatation and
proliferation of microvessel (Factor et al., 1985) which is similar to the
observations in the Syrian cardiomyopathic hamster and in human
cardiomyopathies of other aetiologies (Sonnenblick et al., 1985). In that
model, the administration of verapamil ameliorated the microvascular
alterations and the myocardial pathology. Similarly, in the Brazil strain-
infected CD-1 mouse, verapamil ameliorated the myocardial pathology
when verapamil was administered early but not late infection (Chandra
et al., 2002; De Souza et al., 2004; Morris et al., 1989). Verapamil increases
coronary blood flow, inhibits platelet aggregation and contributes to the
amelioration of the pathology. These observations were corroborated by
direct in vivo visualization utilizing a surrogate murine model, that is, the
cremaster microvascular bed (Tanowitz et al., 1996). Direct observation of
the effects of T. cruzi infection on microcirculatory flow in vivo and quantita-
tive measurement of parameters such as the velocity of red blood cell flow
(Vrbc) and vessel diameter were provided. When the cremaster model was
examined 20–25 days post-infection in male CD-1 mice infected with the
Brazil strain, a significant decrease in Vrbc, reversed by verapamil treatment,
was observed in the first- and third-order arterioles and venules accompa-
nied by an attenuation of the inflammation. The arterioles of the infected
mice exhibited segmental areas of vasospasm and dilatation, possibly the
initiating event in microaneurysm formation (Tanowitz et al., 1996; Fig. 4.1).
A B
C D
FIGURE 4.1 (A) Images obtained from T. cruzi-infected mouse. Perivascular inflamma-
tion. (B) Vasculitis of the pulmonary vasculature. (C) Endothelialitis of the subendocar-
dium. (D) Vasculitis of a blood vessel in the liver (images from Petkova et al., 2001).
88 Cibele M. Prado et al.
Dogs have been used in investigations of Chagas disease because they are
a larger animal than the standard mouse model and may better recapitu-
late the human disease. Hearts obtained from dogs sacrificed 18–26 days
after intraperitoneal inoculation with the 12SF strain of T. cruzi demon-
strated myocarditis characterized by small focal areas of lesion and
myocytic necrosis associated with interstitial mononuclear infiltration.
Electron microscopic studies revealed degenerative changes in the ECs
in contact with T lymphocytes, as well as platelet aggregates and fibrin
thrombi in the intramyocardial capillaries. These alterations suggested
that a possible interaction between ECs and effector immune cells might
The Vasculature in Chagas Disease 89
A B
C D
It may suggest that caution should be used in the treatment of fever and
pain with ASA during acute infection.
TXA2 and ET-1 share several important properties important in the
pathogenesis of Chagas disease. They both cause vasoconstriction and
platelet aggregation. Additionally, they are both pro-inflammatory. Mice
infected with T. cruzi display an increased expression of ET-1 protein and
mRNA in the myocardium and an increase in plasma ET-1 levels (Petkova
et al., 2000). Treatment of infected mice with phosphoramidon, an
inhibitor of ECE, reduced T. cruzi-infection-induced right ventricular
dilation (Tanowitz et al., 2005). T. cruzi infection of mice in which the
gene for ET-1 is deleted either in cardiac myocytes or in ECs ameliorated
cardiac remodelling as demonstrated by histopathology, echocardiogra-
phy and cardiac MRI (Tanowitz et al., 2005). Elevated plasma levels of
ET-1 have been demonstrated in patients with chronic chagasic cardio-
myopathy (Salomone et al., 2001). However, it is unclear if this is a result
of congestive heart failure in general or chagasic cardiomyopathy in
particular. It is important to note that Hassan et al. (2006) found increased
expression of ET-1 in the carotid arteries of infected mice. This observa-
tion clearly demonstrated the importance of ET-1 in the vasculature of
infected mice and by implication in infected humans. The release of
platelet-activating factor by macrophages in this infection causes transient
ischaemia and myocytolytic necrosis (Talvani et al., 2003; see Chapter 1
for a discussion of eicosanoids and Chapter 5 for a discussion of the role of
bradykinin and bradykinin receptors).
4.7. CONCLUSIONS
ACKNOWLEDGEMENTS
This work was supported by grants from the Fundação de Amparo à Pesquisa do Estado de
São Paulo (M. A. R.; FAPESP 09/17787-8; 10/19216-5) and National Institutes of Health
(NIH) Grants AI-076248 (H. B. T.) and CA-123334 (L. A. J.). C. M. P. was supported in part by
a grant from the Fogarty International Center–NIH (D43-TW007129). M. A. R. is senior
investigator of the Conselho Nacional de Desenvolvimento Cientı́fico e Tecnológico (CNPq).
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CHAPTER 5
Infection-Associated
Vasculopathy in Experimental
Chagas Disease: Pathogenic
Roles of Endothelin and
Kinin Pathways
Julio Scharfstein and Daniele Andrade
Instituto de Biofı́sica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, CCS, Laboratório de
Imunologia Molecular, Cidade Universitária Rio de Janeiro, Rio de Janeiro, Brazil
101
102 Julio Scharfstein and Daniele Andrade
ABBREVIATIONS
5.1. INTRODUCTION
et al. (2007) reported that mice deficient in the thromboxane receptor (TP)
bear a highly susceptible phenotype, characterized by increased mortal-
ity, cardiac pathology and higher tissue parasitism. After showing that
TXA2 is the predominant eicosanoid lipid produced in the blood of
chagasic mice, the authors demonstrated that up to 90% of the circulating
levels of TXA2 were of parasite origin, rather than from the host. Interest-
ingly, the levels of TXA2 produced by amastigotes are significantly higher
than those of trypomastigotes or epimastigotes. Clues to understand the
potential significance of these findings emerged from analysis of the
outcome of infection in cultures of endothelial cells derived from
wild-type versus TP-deficient mice; the authors noted that the infection
index was markedly increased in the mutant mice. Based on these obser-
vations, the authors proposed that TP, most likely triggered by amasti-
gote-derived TXA2, may fine-tune the rate of intracellular parasite
growth, preventing dysregulated expansion of the intracellular load of
parasites within endothelial cells. Extending these studies to the in vivo
settings, Ashton et al. (2007) observed that T. cruzi-TP-null mice displayed
an increased mortality, parasite tissue load and cardiac pathology.
Infections employing bone marrow chimeric mice argued against the
possibility that TP deficiency in immune cells might account for the
susceptible phenotype of TP-null mice. These results, combined with
the culture studies performed with endothelial cells, suggest that the
TXA2/TP axis may limit parasite infectivity in somatic cells, through
mechanisms that remain unclear.
Another area of research linking T. cruzi activity to endothelium injury
emerged from studies on the pathogenic role of TS. Progress in this field
started with the observation that endothelial cells and cardiomyocytes
suffered de-sialylation upon treatment with T. cruzi neuraminidase
(Libby et al., 1986), the latter being described as a TS (Previato et al.,
1985; Zingales et al., 1987). More recently, Dias et al. (2008) used catalyti-
cally inactive recombinant TS to characterize in further details the
molecular basis of TS binding to endothelial cells. Their data showed
that TS binds to endothelial cell surface a2,3-linked sialic acid residues
through a lectin-binding site. Functional analysis of the outcome of the
lectin site of TS with the endothelium revealed that the interaction (i) led
to the activation of NF-kB, (ii) increased expression of adhesion molecules
and (iii) reduced apoptosis upon endothelial cell exposure to growth
factor deprivation (Dias et al., 2008). Focusing a novel aspect of TS
research, that is, the molecular mechanism involved in endothelium
transmigration and tissue tropism, Tonelli et al. (2010) postulated that
trypomastigotes might interact with microvascular beds through the
binding of a conserved peptide motif of TS shared by several members
of the polymorphic T. cruzi family. The presence of circulating antibodies
to TS (Duthie et al., 2005) may also account for the infection-associated
108 Julio Scharfstein and Daniele Andrade
(Doyle et al., 2007). These results strongly suggested that the level of
bioactive kinins generated in peripheral sites of T. cruzi infection
(‘‘steady-state’’ conditions) depends on the balance between cruzipain
and ACE.
In a crucial observation, Monteiro et al. (2006) observed that Dm28c
epimastigotes did not elicit significant FITC-dextran leakage in captopril-
treated HCP, despite the fact that these avirulent parasite stages express
high levels of cruzipain. These results suggested that expression of cru-
zipain was necessary but insufficient for trypomastigotes to induce
plasma leakage via the BK2R pathway. Consistent with this hypothesis,
purified cruzipain (enzymatically active) failed to induce plasma leakage
in the captopril-treated HCP superfusate. However, the combination of
cruzipain and purified HK to captopril-HCP led to a full-blown plasma
leakage via the BK2R pathway. Based on these findings, Monteiro and
co-workers proposed that the rate-limiting step governing extent of kinin
release by cruzipain is the level of plasma-borne kininogens available
in peripheral sites of infection. As a corollary, the authors predicted that
(i) in ‘‘steady-state’’ tissues (i.e. in the absence of a pre-established inflam-
mation), the levels of kininogens in interstitial spaces are not sufficiently
high to propitiate appreciable proteolytic release of vasoactive kinins,
either in tissues exposed to avirulent epimastigotes or to purified
cruzipain, and (ii) trypomastigotes might be empowered with proinflam-
matory molecules (absent in epimastigotes) which rapidly induce the
diffusion of plasma-borne proteins (including kininogens) into the inter-
stitial spaces. Efforts to identify this putative molecule converged to the
glycophosphatidyl-linked mucin anchor of trypomastigotes (tGPI),
originally characterized as a potent TLR2 ligand by Almeida and
Gazzinelli (2001). According to these workers, tGPI possesses an unsatu-
rated fatty acid at the sn-2 position (TLR2 agonist) of the alkylacylglycerol
moiety, which is absent in the counterpart GPI anchors of epimastigotes.
Consistent with a role for tGPI, Monteiro and co-workers demonstrated
that Dm28 trypomastigotes failed to elicit appreciable oedema both in
TLR2/ and in neutrophil-depleted mice, irrespective of treatment with
ACE inhibitors. Moreover, assays performed in captopril-treated mice
(wild-type, BK2R/, TLR2/ and neutrophil-depleted) injected with
the combination of purified tGPI (TLR2 ligand) and cruzipain (enzymati-
cally active) demonstrated that tGPI and cruzipain synergistically
induced footpad oedema via the TLR2/neutrophil/BK2R-dependent
pathway, while ACE/kininase II has an anti-inflammatory role, since it
interferes with the transcellular ‘‘crosstalk’’ between TLR2 and BK2R.
It is well established that activated neutrophils are capable of inducing
endothelial barrier disruption through a variety of mechanisms (DiStasi
and Ley, 2009). Intravital microscopy observations in HCP suggested that
neutrophils play a role in the dynamics of oedematogenic inflammation
114 Julio Scharfstein and Daniele Andrade
FIGURE 5.1 Mechanistic model depicting how the proinflammatory activities of kinins
and endothelins may converge to aggravate myocardial pathology in Chagas heart
disease. Lower side of panel, sparsely distributed the heart of chronically infected
patients, the heart cells containing pseudocysts sooner or later disrupt, releasing
numerous trypomastigotes to the interstitial spaces. Acting as typical microbial PAMPS,
tGPI-mucin (TLR2 ligands) shed by the TCTs are sensed by TLR2 constitutively expressed
by resident macrophages (left side of panel). Next, the activated macrophages secrete
neutrophil-attracting CXC chemokines (KC/MIP-2), which in turn bind to CXCR2
expressed by neutrophils/endothelium (upper left). Neutrophils activated by CXC
chemokines secrete vascular permeability factors which then disrupt the integrity of the
endothelium barrier. This allows for incipient leakage of plasma proteins, including
kininogens and ET-1 (present at high levels in the blood of patients with cardiac disease)
into peripheral sites of infection (upper side of panel). T. cruzi trypomastigotes process
kininogens associated to GAGs, liberating kinins via cruzipain (CZP). The biological
activity of the short-lived kinins (BK2R agonist) is mitigated by the kinin-degrading
activity of ACE/kininase II. The vigour of the inflammation steered by the TLR2/CXCR2/
neutrophil pathway may eventually overcome the regulatory constraints imparted by
ACE/kininase II. The build-up in the extravascular levels of vasoactive kinins leads to
overt activation of the kinin system, due to feedback loops of activation of endothelium
BK2R/BK1R. Further downstream, T. cruzi may then take advantage of the odedemato-
genic inflammation to invade cardiovascular cells through the cooperative activation of
116 Julio Scharfstein and Daniele Andrade
BKRs and ETRs (Andrade et al., 2011). The interstitial oedema driven by kinins is further
intensified (top, right), increasing the levels of ET-1 in the interstitial spaces. Sustained
inflammation may also lead to upregulated expression of B1KR in the myocardium,
offering a window of opportunity for parasite invasion of cardiovascular cells. The
increase in intracellular parasite load translates as upregulated expression of endothe-
lins, which may then aggravate infection-associated vasculopathy and myocardial
fibrosis via ETRs. In addition, the upregulated expression of BK1R in the endothelium
lining may favour the recruitment of circulating anti-parasite IFN-g/TNF-a-producing
CD4þ T effector and CD8þ T effectors to the heart parenchyma. For the sake of
simplicity, the panel does not illustrate the impact of TLR2/B2R activation on DC
maturation and on TH1 development, at early stages of T. cruzi infection (Monteiro et al.,
2006, 2007).
Role of Kinins and Endothelins in Chagasic Vasculopathy 117
wild-type BK2Rþ/þ DCs (i.v.) into the susceptible BK2R/ mice before
injecting the pathogen. Remarkably, this DC transfer manoeuvre rendered
the recipient BK2R/ mice resistant to acute T. cruzi challenge and
restored their capability to generate protective IFN-g-producing CD4þ
CD44þ and CD8þ CD44þ effector T cells, while conversely suppressing
the potentially detrimental TH17 (CD4þ subset) anti-parasite responses.
Using expression of IL-12 and co-stimulatory molecules (CD86, CD80,
CD40) as readout for DC maturation in vitro, Monteiro et al. (2007) further
demonstrated that Dm28c trypomastigotes potently activate BK2Rþ/þ
CD11cþ DCs (splenic origin) but not BK2R/ DCs. Moreover, the authors
showed that trypomastigotes pretreated with the irreversible cruzipain
inhibitor (Z11777) failed to robustly activate wild-type DCs, thus suggest-
ing that the BK2R agonist (DC maturation signal) is indeed released by
cruzipain. Dm28c trypomastigotes induced the maturation of splenic
CD11cþ DCs derived from TLR2/ and TLR4 mutant (C3H/HeJ) via
BK2R, thus precluding cooperative signalling between this GPCRs and
either PRRs. While not excluding the contribution of TLR9 (Bafica et al.,
2006) or NOD2 (Silva et al., 2010) as potential sensors of T. cruzi, these
results were consistent with the concept that kinin ‘‘danger’’ signals pro-
teolytically released by trypomastigotes activate BK2Rþ/þ DCs, converting
these APCs into inducers of type-1 immunity (Monteiro et al., 2007;
Scharfstein et al., 2007). Since the spleen is continuously exposed to plasma
proteins, it is conceivable that Dm28 trypomastigotes might be faced with
abundant levels of blood-borne kininogens bound to their docking sites (e.
g., sulfate proteoglycans) present on cell surfaces and/or extracellular
matrixes. As a corollary, we may predict that the levels of kinin ‘‘danger’’
signals proteolytically generated in the parasitized/inflamed splenic
stroma may suffice to convert conventional CD11cþ DCs into TH1 indu-
cers. As part of an initial effort to determine if some of these mechanistic
principles are extended to the settings of human infection, Coelho dos
Santos et al. (2010) have recently reported that ACE inhibitors convert
human monocytes into drivers of TH17-type responses against T. cruzi.
ACKNOWLEDGEMENTS
This research was supported by funds from the Instituto Nacional de Biologia Estrutural
e Bio-Imagem do CNPq; PRONEX (26/110.562/2010), FAPERJ; CNPq; financed in part by
NIH Grant AI-076248 (HBT). D. A. was supported in part by a Fogarty International Center–
NIH Training Grant (D43-TW007129). The authors acknowledge the help of Rafaela Serra in
the preparation of the illustration (Fig. 5.1).
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CHAPTER 6
Autoimmunity
Edecio Cunha-Neto,*,†,‡ Priscila Camillo Teixeira,*,‡
Luciana Gabriel Nogueira,*,‡ and Jorge Kalil*,†,‡
129
130 Edecio Cunha-Neto et al.
6.1. INTRODUCTION
Molecular
Host component T. cruzi antigen Host definition Reference
Molecular
Host component T. cruzi antigen Host definition Reference
47 kDa neuron protein FL 160 H rDNA, AS Van Voorhis and Eisen (1989) and
Van Voorhis et al. (1991, 1993)
23 kDa ribosomal protein 23 kDa ribosomal H Ab Bonfa et al. (1993)
protein
Ribosomal P protein Ribosomal P protein H rDNA, Ab, SP Levitus et al. (1991)
b1 adrenoreceptor M2 Ribosomal P0 and P2b H rDNA, Ab, SP Ferrari et al. (1995), Kaplan et al. (1997),
cholinergic receptor proteins Lopez Bergami et al. (1997, 2001),
Masuda et al. (1998) and Mahler et al.
(2001)
b1-adrenoreceptor M2 150 kDa protein H, M Mab Cremaschi et al. (1995)
cholinergic receptor
M2 cholinergic receptor unknown H Ab Motran et al. (1998)
38-kDa heart antigen R13 peptide from M IgG1, IgG2 Hernandez et al. (2003)
ribosomal protein
P1, P2
Cha antigen SAPA, 36 kDa M Ab, T cell Girones et al. (2001b)
TENU2845
Calreticulin Calreticulin H,M Ab Ribeiro et al. (2009)
M, mouse; H, human; Rb, rabbit; R, rat; AS, antiserum; Ab, patient antibody; Mab, monoclonal antibody; rDNA, recombinant DNA; SP, synthetic peptides.
TABLE 6.2 Evidence for pathological autoimmunity in Chagas disease
The high parasite load typical of the acute infection ensues a strong
innate and adaptative immune response against T. cruzi, leading to the
control—but not the complete elimination—of tissue and blood parasit-
ism, establishing a low-grade persistent infection regardless of the clinical
progression of the disease (Martin et al., 1987).
Chagas disease cardiomyopathy, the most clinically significant conse-
quence of T. cruzi infection, is an inflammatory cardiomyopathy that
occurs in 25–30% of patients, 5–30 years after infection. About a third of
patients developing CCC present a particularly lethal form of dilated
cardiomyopathy, with shorter survival than idiopathic dilated cardiomy-
opathy, often presenting with severe arrhythmia and heart block (Bocchi
and Fiorelli, 2001; Mady et al., 1994). Five to 10 percentage of infected
patients develop denervation of parietal smooth muscle in the oesopha-
gus and colon, with clinical obstructive disease (Koberle, 1968). Cardiac or
digestive ‘syndromes’ of chronic Chagas disease may also present in
isolated or overlapping forms. Sixty to 70 percentage chronically
T. cruzi-infected individuals remain devoid of both cardiac and digestive
manifestations and are otherwise asymptomatic (also called ‘indetermi-
nate’ patients). Functional damage of the autonomic nervous system is
also observed, affecting a subgroup of patients presenting the cardiac,
digestive or asymptomatic forms of chronic Chagas disease (Amorim and
Marin Neto, 1995).
The observation that most tissue pathology occurs many years after acute
infection, when parasites were very scarce in tissue, led investigators as
early as 80 years ago (Torres, 1929) to suggest that the mononuclear cell
infiltrate should directly damage the heart, perhaps in an autoimmune
fashion. Early studies were characterized by the lack of molecular defini-
tion of the antigen systems employed; most used tissue or T. cruzi homo-
genates. Peripheral T cells from experimentally infected mice and CCC
patients displayed responses against cardiac tissue homogenate (de la
Vega et al., 1976; Gattass et al., 1988). Non-infected cardiomyocytes
were targets of cytotoxicity by PBMC from chronically infected rabbits
(Santos-Buch and Teixeira, 1974) and CCC patients (Teixeira et al., 1978).
Repeated injection of T. cruzi subcellular fractions induced myocardial
inflammatory lesions in mice and rabbits (Acosta and Santos-Buch, 1985;
Teixeira and Santos-Buch, 1975).
Cossio et al. (1974) described antibodies binding to vascular endothe-
lium and interstitium in mice in the serum of CCC patients, that could be
absorbed with T. cruzi epimastigotes (Table 6.1), but these were found to
be antibodies against a-galactosyl moieties, structures present in rodent,
but not in human tissue (Khoury et al., 1983). Experimentally infected
mice frequently developed T. cruzi-heart muscle cross-reactive antibodies
(Laucella et al., 1996b; McCormick and Rowland, 1989). Conversely,
138 Edecio Cunha-Neto et al.
6.5.1. Autoantibodies
During T. cruzi infection, mice can display antibodies specific for various
autoantigens contained in target tissues. Chronically T. cruzi-infected
mice display anti-tubulin IgG antibodies (Ternynck et al., 1990). Sera
from acutely or chronically infected mice recognized cardiac myosin,
desmin and actin (Leon et al., 2001; Tibbetts et al., 1994). In human Chagas
disease, there is a net loss of neurons from the autonomic system along the
hollow viscerae and the heart (Koberle, 1968), and sera from over 80% of
Chagas disease patients contained anti-neuron autoantibodies (Ribeiro
dos Santos et al., 1979). Antibodies against sciatic nerve homogenate
have been found in sera from Chagas disease patients (Gea et al., 1993).
Antibodies against ribonucleoproteins (Bach-Elias et al., 1998) have been
detected during T. cruzi infection. Autoantibodies against galectin-1 are
correlated with the severity of cardiac damage in CCC (Giordanengo
et al., 2001). The Cha human autoantigen and its major B cell epitope
Cha are recognized by sera from Chagas disease patients (Girones et al.,
2001a,b).
Autoimmunity 139
6.7. CONCLUSION
T. cruzi
Acute infection
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CHAPTER 7
ROS Signalling of Inflammatory
Cytokines During Trypanosoma
cruzi Infection
Shivali Gupta,* Monisha Dhiman,* Jian-jun Wen,*
and Nisha Jain Garg*,†,‡
* Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, Texas, USA
{
Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
{
Faculty of the Center for Tropical Diseases, Sealy Center for Vaccine Development, and the Institute for
Human Infections and Immunity, University of Texas Medical Branch, Galveston, Texas, USA
153
154 Shivali Gupta et al.
Broadly defined, reactive oxygen species (ROS; e.g. O2, OH, and H2O2)
are derivatives of molecular oxygen. The site and extent of ROS produc-
tion has important consequences and determines the ultimate cell/tissue
fate. ROS can be formed in the heart, vascular tissue, splenocytes, and
blood leukocytes through the action of specific oxidases and oxygenases
(e.g. xanthine oxidase, NADPH oxidase—NOX), peroxidases (e.g. myelo-
peroxidase), the Fenton reaction, and as by-products of the electron trans-
port chain of mitochondria (Turrens, 2003). Further, cyclooxygenase,
lipooxygenase, and cytochrome P-450 enzymes produce ROS as a by-
product during arachidonic acid metabolism (Cohen, 1994). Nitric oxide
(NO) is produced by the enzymatic activity of nitric oxide synthases
(NOS), which oxidize L-arginine, transferring electrons from NADPH.
Different NOS isoforms have been identified for example, inducible
NOS (iNOS) in phagocytic cells, mtNOS in mitochondria, (eNOS) in
endothelial cells, and neuronal nNOS (Andrew and Mayer, 1999). Read-
ers are referred to recently published review articles for further details on
ROS biochemistry (D’Autreaux and Toledano, 2007) and the role of iNOS
and NO in Chagas disease (Gupta et al., 2009b).
We focus on two major ROS producers relevant in Chagas disease
here. The prototypic NOX (gp91phox), renamed as NOX2, was first identi-
fied in phagocytes (neutrophils, macrophages). When activated, NOX
catalyses a rapid ROS production by the one-electron reduction of O2,
referred as respiratory burst that serves as the first line of host defence
against microbes. Presently, seven mammalian NOX homologs have been
identified, namely NOX1–NOX5, dual oxidase 1 and 2 (DUOX1 and
DUOX2). In cardiovascular system, NOX1, NOX2, NOX4, and NOX5
have been identified. NOX1 is expressed mainly in vascular smooth
muscle cells (VSMCs). NOX2 and NOX4 are expressed in endothelial
cells, cardiomyocytes, fibroblasts, and VSMCs (Weintraub, 2002). NOX5
has been reported in human endothelial cells and smooth muscle cells but
is not found in rodents (Belaiba et al., 2007).
The earliest studies have reported cytochemical detection of NOX at
plasma membrane of peritoneal mouse macrophages during interaction
with Trypanosoma cruzi (Cardoni et al., 1997). Others have used in vitro
assay systems or animal models and demonstrated that T. cruzi-mediated
macrophage activation results in increased levels of O2 formation, likely
by NOX-dependent oxidative burst (Alvarez et al., 2004; Melo et al., 2003;
Munoz-Fernandez et al., 1992). We have extended these observations and
shown that splenocytes of infected mice and in vitro cultured macro-
phages respond to T. cruzi infection by activation of NOX2 and a substan-
tial increase in ROS production (Dhiman and Garg, 2011). A robust
ROS Signalling of Inflammatory Cytokines During Trypanosoma cruzi Infection 155
(e.g. TNF-a, IFN-g, IL-1b; Ba et al., 2010). Two, ROS caused 8-hydroxygua-
nine (8-oxoG) lesions and DNA fragmentation that signalled polyadenosine
ribose polymerase 1 (PARP-1) activation, evidenced by poly-ADP-ribose
(PAR) modification of PARP-1, and other proteins in infected cardiomyo-
cytes. PARP-1 signals DNA repair via PARylation of histones; however, its
hyperactivation may have pathophysiological effects ranging from catalytic
activation of inflammatory and hypertrophic gene expression, depletion of
NADþ pool, and cell death (Balakumar and Singh, 2006; Pacher and Szabo,
2008). Inhibition of PARP-1 using RNAi or chemical inhibitor (PJ34), or by
removal of ROS using an antioxidant, was beneficial in blocking the mtROS
formation and DNA damage (Ba et al., 2010). Importantly, we found that
PARP-1 inhibition also regulated cytokine gene expression, albeit via a
different mechanism. PARP-1 did not directly interact with p65, and it did
not signal RelA (p65) translocation to nuclei in infected cardiomyocytes.
Instead, PARP-1 contributed to PAR-modification of RelA (p65)-interacting
nuclear proteins and assembly of NF-kB transcription complex. These stud-
ies suggested that ROS-PARP-1-RelA signalling pathway contribute to
inflammatory cytokine production in cardiomyocytes infected by T. cruzi.
It remains to be seen whether mitochondria serve as activator of an innate
defence response by cardiomyocytes upon T. cruzi exposure, or these events
are bystander effects of T. cruzi infection of the host cells.
ACKNOWLEDGEMENTS
The work in NJG’s laboratory has been supported in part by grants from the American Heart
Association, John Sealy Memorial Endowment Fund for Biomedical Research, American
Health Assistance Foundation, and National Institutes of Health. S. G. is an awardee of a
Postdoctoral Fellowship from the Sealy Center of Vaccine Development.
164 Shivali Gupta et al.
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CHAPTER 8
Inflammation and Chagas
Disease: Some Mechanisms
and Relevance
André Talvani* and Mauro M. Teixeira†,‡
* Laboratório de doença de Chagas, Departamento de Ciências Biológicas & NUPEB, Universidade Federal de
Ouro Preto, Ouro Preto, Minas Gerais, Brazil
{
Laboratório de Imunofarmacologia, Departamento de Bioquı́mica e Imunologia/ICB, Universidade Federal
de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
{
Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
171
172 André Talvani and Mauro M. Teixeira
Dogs
Human
Acute phase
Chronic phase
FIGURE 8.1 Timeline of Trypanosoma cruzi infection in human and experimental models.
Timeline demonstrated above is the temporal course followed by different hosts after
T. cruzi infection and takes in consideration the approximate time in months, years and
decades described for these models (mice, rats, dogs) in the literature.
Inflammation and Chagas Disease: Some Mechanisms and Relevance 175
prevent use of any particular animal species and parasite strain to model
Chagas disease. Any animal model has limitations. The appropriate use of
these tools must be guided by the question to be answered and kinetic
issues related to the course of infection need to be fully taken into account.
Platelet activator factor (PAF) " Production of CCL5 in vivo and " production of Aliberti et al. (1999),
CCL2 þ LTB4 in vitro; " NO and mice survival Rodrigues et al. (1999),
# trypanocidal activity and parasitaemia peak in vivo; Talvani et al. (2003)
" of parasite ecto-phosphatase activities
Leukotriene B4 (LTB4) " NO and TNF-a synthesis in vitro; " trypomastigotes Talvani et al. (2002), Wirth
killing in vitro and Kierszenbaum
(1985)
5-Lipoxygenase (5-LO) # Heart tissue parasitism in vivo; " erythrocyte oxidative Borges et al. (2009),
stress; " IFN-g, TNF-a, IL-6 and NO in vivo Pavanelli et al. (2010)
Prostaglandin E2 (PGE2) " Inflammatory infiltration, parasite nests and cardiac Abdalla et al. (2008),
fibrosis and its " production is due by activation of Sterin-Borda et al. (1996)
muscarinic receptors in CD8T cells
Nitric oxide (NO) " Killing of parasites by murine macrophages; " apoptosis Chandra et al. (2002a),
of T cells; modulates chemokine production by T. cruzi- Durand et al. (2009),
infected myocytes; " ventricular dilation and systolic Machado et al. (2008),
dysfunction in acute murine chagasic myocarditis Silva et al. (2003)
Brain (BNP) and atrial (ANP) In human: correlated with # LV ejection fraction, Moreira Mda et al. (2008),
natriuretic peptides " LV end-diastolic diameter, " LV premature Ribeiro et al. (2002),
complexes, " NYHA class; good predictors of death or Talvani et al. (2004c)
necessity for heart transplant (p < 0.0001)
Endothelin (ET-1) Triggered by T. cruzi-derived molecules, " NO, Camargos et al. (2004),
inflammation and fibrosis in heart tissues; " levels of Petkova et al. (2000),
ET-1 in patients with CC; " right ventricular internal Rachid et al. (2006),
diameter, " left ventricular end-diastolic, " diameter/ Salomone et al. (2001),
fractional shortening and " wall thickness in mice; Tanowitz et al. (2005)
blockade of ET-1 receptor # parasitaemia, tissue
parasitism and inflammation
Chemokines # Parasite growth and triggers the chemotaxis and Guedes et al. (2010),
(MCP-1/CCL2, RANTES/ morphogenesis of trypomastigote forms; " activation Marino et al. (2005),
CCL5 and MIP-1a/CCL3) and recruitment of heart inflammatory infiltrate; Paiva et al. (2009),
" uptake and killing of intracellular parasites by Talvani et al. (2004a),
inducing NO synthesis and production by Yamauchi et al. (2007)
macrophages and cardiomyocytes; in humans, " in
serum levels and variant in CCL2 -2518AA genotypes
suggest severe CC; " expression and seric levels are
associated with severe CC in patients and dog models
Chemokine receptors (CCR4, Participate in the control of parasite growth and in the Guedes et al. (2010),
CCR5, CCR2, CXCR4) development of a protective immune response during Hardison et al. (2006),
acute infection; " CXCR3 and CCR5 (heart) and # CCR5 Machado et al. (2005),
(PBMC) associated with severe CC; # expression levels Marino et al. (2005),
of CXCR4 in severe patients Talvani et al. (2004b)
Tumour necrosis factor " Leukocytes activation with " production of Bilate et al. (2007), Lula
(TNF-a) and interferon- inflammatory cytokines and chemokines; # parasite et al. (2009), Talvani
gamma (IFN-g) replication in murine macrophages, " (TNF-a) and et al. (2000), Talvani
# (IFN-g) associated with fibrosis; " serum levels in et al. (2004b)
patients with severe CC
Interleukin-10 " Percentage of CD4 and CD8 co-expressing CCR3 and Costa et al. (2009), Gomes
(IL-10) IL-10 in asymptomatic patients, # expression associated et al. (2005), Silva et al.
with worse cardiac function; controls (1992)
Th-1-like immune response and prevents excessive
damage in host inflamed tissue
Transforming growth factor " Invasion of cardiac fibroblasts and myocytes and Araújo-Jorge et al. (2008),
(TGF-b) modulates pro-inflammatory cytokines; " intracellular Silva et al. (1991),
parasite cycle; " fibrosis, disorganize GAP connexin-43 Waghabi et al. (2009a,b)
junctions and " heart remodelling
(continued)
TABLE 8.1 (continued)
Toll-like receptors (TLR—2, 4, TLR-2 þ NF-kB in response to T. cruzi " cardiomyocyte Bafica et al. (2006), Campos
7, 9) and nucleotide-binding hypertrophy; macrophages activation on innate and Gazzinelli (2004),
oligomerization domain immunity is TLR-dependent; natural host resistance Koga et al. (2006),
(NOD) (# parasitaemia and " surviving) is TLR-4 and NOD- Oliveira et al. (2004),
dependent; TLR# chemokine production; TLR9 has a Petersen et al. (2005),
primary role in the MyD88-dependent induction of Silva et al. (2010)
IL-12/IFN-g, products from NF-kB stimulation in vivo
are NOD-dependent in T. cruzi infection
" CD8 T cells apoptosis; " cardiac infiltration and Fas Guillermo et al. (2007), de
ligand/CD95L associated with myocarditis; # activated Oliveira et al. (2007),
T cells, # NO production and # parasites load Rodrigues et al. (2008)
Matrix metalloproteinases " TNF-a, IFN-g, nitrite and nitrate; " heart inflammation Gutierrez et al. (2008),
(MMPs) and # survival rate in T. cruzi-infected mice Nogueira de Melo et al.
(2010)
Adiponectins # Levels are associated with # inflammation and Nagajyothi et al. (2008,
" cardiovascular disease 2009)
C-reactive protein (CRP) " parasite invasion to cardiac cells through a CRP-like López et al. (2006),
molecule on T. cruzi surface; " levels associated with Aparecida da Silva et al.
worsening human heart function (with or without (2010), Melo Coutinho
T. cruzi infection) et al. (1998)
CC, Chagas cardiomyopathy; PBMC, peripheral blood mononuclear cells; LV, left ventricle; NYHA, New York Heart Association; RANTES, regulated upon activation, normal T
cell expressed and secreted; MIP-1a, macrophage inflammatory protein-alpha; MCP-1, monocyte chemoattractant protein; ", increase; #, decrease.
Inflammation and Chagas Disease: Some Mechanisms and Relevance 181
GPI-mucin
Cardiac form
↑ of TNF-a, CCL2, CCL5, TGF-b, ET-1,
NK s MMPs with leukocyte recruitment, necrosis,
p tor
cells ece apoptosis, fibrosis, cardiomyocyte hypertrophy
Dr
s /NO
LR
IF
T
N-
g
(↑ of regulatory cells,
Par
rs
a
vatio
mm
site ctors
fa
Infla
inte
Acti
rac
tive
PMN TNF-a
IFN-g
Mac IL-12 Mediators Control of parasite Tissue parasite
PAF replication and persistence
acting on
T cells LTB4 ↑ of inflammation
CCL2
EC
CCL3
CCL5
Cardiomyocytes NO
Chronic phase
(PMN, polymorphic mononuclear cells; Mac, macrophages; EC, endothelial cells; NO, nitric
oxide; NK, natural killer; GPI, glycophosphatidilinositol; TLR, toll like-receptors; NOD, nucleotide-
binding oligomerization domain; MMPs, matrix metalloproteinases; ET-1, endothelin-1; , increase)
8.4.1. Chemokines
Chemokines are small (8–14 kDa) inducible cytokines that recognize a
large group of seven transmembrane-spanning G-protein-coupled ser-
pentine receptors displayed on the leukocyte surface and are involved
182 André Talvani and Mauro M. Teixeira
to attain total control of infection and parasites persist. In the long term,
however, chemokines/IFN-g interaction may contribute to the heart dam-
age observed in patients (Cunha-Neto et al., 2009). Indeed, experiments
using Met-RANTES, an N-terminally modified human RANTES/CCL5
capable of inhibiting CCR1 and CCR5, showed that treatment with the
drug decreased the infiltration of CD4þ and CD8þ T cells and deposition
of fibronectin in the heart of infected animals, without decreasing or
interfering with parasitism (Marino et al., 2004).
Few studies have attempted to understand the possible role of chemo-
kines in the context of human Chagas cardiomyopathy (Dutra et al., 2005).
Studies have been carried out in patients with established disease in
comparison with those who were infected but without disease and non-
infected subjects. The idea of the studies was to evaluate whether levels of
chemokines or chemokine receptors would increase in Chagas disease
and correlate with disease severity. It was found that high plasma levels
of CCL2 increased in patients with Chagas disease, especially in those
with heart dysfunction, correlated with the degree of heart dysfunction
(Talvani et al., 2004b). When spontaneous production of CCL2 by periph-
eral blood mononuclear cells (PBMC; in vitro assay) was examined, it was
noticed that levels of CCL2 were enhanced in patients with Chagas
disease, irrespective of their clinical condition (Talvani et al., 2004b).
These studies would suggest that CCL2 marks the severity of the disease
and may be important for Chagas disease progression. In support of a
possible role of CCL2 in Chagas disease, it has been shown that patients
presenting a ccl2 promoter polymorphism at position -2518A/G, which is
recognized to increase serum level of the protein by influencing its tran-
scriptional activity, had a fourfold greater risk of developing CC than
those without this genotype (Ramasawmy et al., 2006). However, elevated
levels of chemokines, such as CCL2, and chemokine receptors on leuko-
cytes may alter in patients with cardiomyopathy irrespective of the cause
(Sigusch et al., 2006; Stumpf et al., 2008). Therefore, it is not possible to
conclude for a direct role of CCL2 in the context of Chagas disease and the
elevated levels of the chemokines may simply mark, and not be the cause
of, the alterations observed in chronic heart failure. However, these stud-
ies do suggest that CCL2 may be a marker of heart dysfunction measure
in blood akin to the role of TNF-a and BNP (Lula et al., 2009; Ribeiro et al.,
2002, 2006; Talvani et al., 2004b,c).
Another member of the chemokine family that has received some
interest in the past few years is the chemokine receptor CCR5—a receptor
for CCL3, CCL5, CCL8 and CCL14. Studies in patients demonstrated that
circulating CD3þCD8þ T cells expressing high levels of CCR5 associated
with mild cardiomyopathy form when compared with uninfected indivi-
duals or those patients presenting severe form of the disease (Talvani
et al., 2004a). These data supported two previous studies showing that
184 André Talvani and Mauro M. Teixeira
light of results discussed above showing that different species may pres-
ent different outcomes when faced with the same infectious challenge.
Moreover, as discussed above, studies in human are not simple as one
usually compares patients with disease with those without disease. There
is not a long-term follow-up but cross-sectional studies performed in
individuals who have developed disease. As discussed, levels of chemo-
kines (and of other mediators of inflammation) may reflect the present
condition of the patient (e.g. heart failure) and not the cause that led to
that condition.
8.4.3. Endothelin
Endothelin 1 (ET-1), a potent vasoconstrictor, is another important exam-
ple of mediator released by endothelial cell and myocardium whose
involvement in chronic events of T. cruzi infection was proposed since
the beginning of the 1990s. Experimental studies involving rodents
186 André Talvani and Mauro M. Teixeira
8.5. CONCLUSION
ACKNOWLEDGEMENTS
We recognize the financial support of Conselho Nacional de Desenvolvimento Cientı́fico
e Tecnológico (CNPq), Coordenação de Aperfeiçoamento Pessoal de Ensino Superior
(CAPES), Fundação de Amparo a Pesquisas do Estado de Minas Gerais (FAPEMIG), Inter-
national Society for Infectious Disease (ISID/EUA) and Drugs for Neglected Disease initia-
tive (DNDi). M. M. T. and A. T. are recipients of productivity awards from CNPq.
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CHAPTER 9
Neurodegeneration and
Neuroregeneration in
Chagas Disease
Marina V. Chuenkova and Mercio PereiraPerrin
Department of Pathology and Sackler School of Graduate Students, Tufts University School of Medicine,
Boston, Massachusetts, USA
195
196 Marina V. Chuenkova and Mercio PereiraPerrin
9.1. INTRODUCTION
Chronic Chagas disease (CD) is the most lethal endemic infection in the
Western hemisphere and regardless of the recent progress on vector
control remains a significant public health issue in Latin America
(Coura, 2007; Rassi et al., 2000). Despite nearly one century of research,
the pathogenesis of CD is not completely understood and many questions
regarding disease progression and treatment are still unsolved, mainly
due to extremely complex nature of the parasite interaction with the
vertebrate host.
During the acute phase of Trypanosoma cruzi infection, the parasite has
the ability to infect a wide variety of cells in most tissues; however, the
clinical picture of CD is dominated by cardiologic and gastrointestinal
(GI) manifestations. Chagasic cardiomyopathy is the most important
clinical presentation of CD and comprises a wide range of symptoms,
including congestive heart failure, arrhythmias, heart blocks, sudden
death, thromboembolism, and stroke.
Neurodegeneration and Neuroregeneration in Chagas Disease 197
Marin-Neto et al., 2007) and have a clinical course worse than that
of patients with non-chagasic dilated cardiomyopathy (Bestetti and
Muccillo, 1997).
The noradrenergic innervation of atrial blood vessels was usually
more resistant to the infection than the myocardial one, and in experimen-
tal T. cruzi infection, animals with moderate to severe myocardial dener-
vation demonstrated well-preserved vascular sympathetic innervation
(Camargos et al., 2000).
Although it is likely that the origin of chagasic heart disease is more
complex, and other factors such as inflammation and autoimmune reac-
tions contribute to the damage of the myocardium, the striking neuro-
genic disturbances in the hearts of many T. cruzi-infected patients should
have a major pathophysiological impact in the severity of chagasic
cardiomyopathy.
9.2.2. GI neurodegeneration
Approximately 10% of chronic chagasic patients (one-third in certain
regions) can develop GI motor disorders, mostly of oesophagus and
colon, such as aperistalsis, achalasia of the cardia and disturbances of
gastric emptying, which lead to organ obstruction and stagnated food
passage followed by megasyndromes, malnutrition and severe weight
loss (Herbella et al., 2008; Matsuda et al., 2009; Meneghelli, 2004).
Whereas the pathogenic impact of autonomic dysfunction in the
development of cardiac CD is still a matter of debate, it is universally
accepted that denervation in GI is the primary, pathogenic mechanism
in the chronic GI form of CD (Adad et al., 2001; da Silveira et al., 2007a;
de Oliveira et al., 1995; Meneghelli, 2004). In his fundamental study of
200 autopsied cases, Köberle initially showed that the dilatation
and hypertrophy of the oesophagus and colon in CD patients corre-
sponded to 50–90% reduction in ganglion cells in enteric plexuses
(Koeberle, 1963).
Later clinical studies invariably confirmed dramatic (up to 95%) neu-
ronal depopulation in patients with megaesophagus and megacolon and
in T. cruzi-infected animals, and demonstrated that the primary target of
injury by infection in GI are the neuronal ganglia in both extrinsic (para-
sympathetic) and intrinsic (myenteric and submucous plexuses) nervous
systems (Caetano et al., 2006; da Silveira et al., 2008; Iantorno et al., 2007;
Machado et al., 2001; Matsuda et al., 2009; Meneghelli, 2004; Nascimento
et al., 2010).
Basic functions of the gut, such as peristalsis, secretion and blood flow,
are primarily regulated by the intrinsic network of GI ganglia, the enteric
nervous system (ENS), which interacts with the sympathetic and para-
sympathetic neurons but constitutes an independent part of the ANS.
Neurodegeneration and Neuroregeneration in Chagas Disease 201
9.3.1. Parasitism
The peripheral neurons are predominantly damaged during the acute
phase, when parasitemia and tissue parasitism are high (da Silveira et al.,
2009; Rodrigues et al., 2002; Soares and Santos, 1999). At that time, trypo-
mastigotes are often found in myenteric and submucosal plexuses and in
the interstitium of sympathetic and parasympathetic ganglia, where they
target glial and other supporting cells for intracellular parasite proliferation
(Lenzi et al., 1996; Meyer et al., 1982; Tanowitz et al., 1982). Infected cells are
ruptured at the end of the parasite intracellular cycle to release newly
produced trypomastigotes and parasite-derived products. It is possible
that certain T. cruzi molecules may damage neuronal cells, similar to
LYT1, a parasite factor with hemolytic activity (Manning-Cela et al., 2001),
although to-date, no parasite-produced neurotoxins have been described.
T. cruzi
Inflammation
IL-12
TNFα Auto-immunity
Intracellular IFNγ
parasitism
Macrophages
iNOS
Auto-antibody
Apoptosis
NO•
?
Peripheral neurons
Glial cells
9.3.3. Autoimmunity
Sera from CD patients contain auto-antibodies specific for various host
molecules in cardiac, nervous and other tissues (Marin-Neto et al., 2007).
Autoimmune reactions develop as a result of molecular mimicry between
206 Marina V. Chuenkova and Mercio PereiraPerrin
9.4. NEUROREGENERATION
period of 20–30 years separates initial acute infection and the onset of
chronic disease. The parasite/host factors generally speculated to define
the rate of CD progression and different clinical outcomes are the hetero-
geneity in virulence and tissue tropism among the parasite population,
and the efficiency of host defensive and regenerative responses to
infection (Adesse et al., 2010; Camargos et al., 2000; da Silveira et al.,
2007b; Dutra and Gollob, 2008; Haolla et al., 2009). One of such responses
is the capacity of peripheral neurons to regenerate and compensate
for functional deficits caused by nerve injuries with reinnervation
of target organs. Neuronal plasticity in the peripheral nervous system
(PNS) would allow regrowth and reconnection of the damaged axons,
and sprouting by the intact adjacent axons of new branches into dener-
vated areas (Navarro et al., 2007), thus restoring the PNS functional
integrity lost as the result of neuronal lesions.
That neuronal regeneration is taking place in CD and can be important
for the clinical status of infected patients is indicated by the comparative
physiological and pathological studies which revealed substantial differ-
ences in the extent of organ innervations between asymptomatic and
chronic CD patients. While neuronal deficiency in the symptomatic
group correlated with poor functional characteristics, asymptomatic
patients with better neuronal counts showed normal electrocardiogram
and X-rays of the heart, oesophagus and colon, and were not much
different to seronegative controls (Correia et al., 2007; da Silveira et al.,
2005, 2009; Junqueira and Soares, 2002; Koberle, 1970; Marin-Neto, 1998;
Nascimento et al., 2010; Villar et al., 2004).
The direct demonstration of autonomic recovery after the acute phase
of T. cruzi infection was further provided by experimental CD models.
Functional improvement in the heart and colon of infected animals was
associated with reinnervation of muscle fibres, collateral sproutings of the
damaged nerves and axonal regrowth, remyelination of vagus nerve
fibres and axons of intramuscular nerves (Fazan and Lachat, 1997;
Losavio et al., 1989; Machado et al., 1998; Machado and Ribeiro, 1989;
Maifrino et al., 1999b; Molina et al., 1987; Rodrigues et al., 2002). At 5–6-
month post-infection, that roughly corresponds to chronic stage in
humans, infected animals that survived the acute phase generally demon-
strated normal pattern of both vagal and sympathetic innervation in
myocardium and vasculature (Alves and Machado, 1984; Camargos
et al., 2000; Fazan and Lachat, 1997).
Another indication of active neuronal regenerative processes in
later stages of T. cruzi infection is an increase in the number and func-
tional activity of glial population in the heart and GI tract in both humans
and experimental animals (da Silveira et al., 2008; Fazan and Lachat, 1997;
Nascimento et al., 2010). Schwann and EGCs provide local environment
supportive for regrowth of damaged nerve fibres by secreting the
208 Marina V. Chuenkova and Mercio PereiraPerrin
Heart
Normal
6000
Number of neurons
Chagas
4000
2000
0
0 25 50 75
Years
Esophagus
1500
Normal
Number of neurons
Chagas
1000
500
0
25 50 75
Years
Indeterminate/Megaesophagus
Number of neurons, log 10
Indeterminate
Megaesophagus
100
10
1
30 45 60
Years
FIGURE 9.2 Age-related degeneration of ganglion cells in the heart and oesophagus of
normal and Chagasic individuals. Adapted from Koberle (1968) and Burkauskiene et al.
(2006).
9.5. TRANS-SIALIDASE/PARASITE-DERIVED
NEUROTROPHIC FACTOR
9.5.1. Trans-Sialidase
Trans-Sialidase (TS), also known as PDNF, belongs to one of the largest
T. cruzi protein families (Atwood et al., 2005). It was originally discovered
as a neuraminidase that cleaved monosaccharide sialic (N-acetyl-
210 Marina V. Chuenkova and Mercio PereiraPerrin
neuraminic) acid from glycoconjugates (Pereira, 1983), and later was also
described as TS that can simultaneously catalyze covalent binding of
sialic acid to b-galactosyl residues on the parasite surface or on the host
cells (Parodi et al., 1992; Schenkman et al., 1992).
Expression of TS enzymatic activity is developmentally regulated and
restricted to infective bloodstream trypomastigotes (Cavallesco and
Pereira, 1988), each of them literally covered with more than 10 million
molecules of TS/PDNF, attached to the parasite surface by a GPI anchor.
Upon GPI cleavage, trypomastigotes copiously release TS into the extra-
cellular space and bloodstream at the rate of about 106 mol/min (Agusti
et al., 1997; Rubin-de-Celis et al., 2006; Scudder et al., 1993). Thus during
the acute infection TS/PDNF is present in blood and tissues not only
surface-linked to circulating trypomastigotes, but also as a soluble factor,
mediating a variety of the host–parasite interactions.
By sialylating mucins on the parasite surface, TS/PDNF protects
bloodstream trypomastigotes from complement lysis (Beucher and
Norris, 2008; Buscaglia et al., 2006), while by binding to the host sialil
and b-Gal residues, it promotes parasite attachment to and invasion of,
the host cells (Ming et al., 1993; Todeschini et al., 2004). As a soluble factor,
TS/PDNF was shown to remodel surface of immune cells and augment
T. cruzi immunosuppression in the acute phase of CD by inhibiting
CD8þ lymphocytes cytotoxicity and promoting apoptosis of T cells
(Freire-de-Lima et al., 2010; Mucci et al., 2006).
Typical structure of enzymatically active TS/PDNF represents a
70-kDa globular core that accommodates the catalytic site (Buschiazzo
et al., 2002), followed with a variable number of 12 amino acid repeats in
tandem (long tandem repeat—LTR), also called SAPA (shed acute phase
antigen; Frasch, 2000). LTR/SAPA is not required for sialic acid transfer
but is highly immunogenic (Alvarez et al., 2001) and contributes to para-
site immune evasion by inducing abnormal polyclonal B cell activation
and production of non-specific Igs, characteristic for the acute phase of
CD (Gao and Pereira, 2001; Gao et al., 2002). LTR/SAPA was also shown
to up-regulate secretion of IL-6 (Saavedra et al., 1999), which mediates
anti-parasite protective immune responses (Gao and Pereira, 2002).
The TS catalytic activity, however, is expressed by a relatively small
subset of TS/PDNF molecules. Recent data on sequencing of the parasite
genome and characterization of the proteome demonstrate that T. cruzi
encodes many more species of TS and TS-like molecules as was initially
thought (Atwood et al., 2005; El-Sayed et al., 2005). TS gene family com-
prises 1400 members, of which 220 are expressed as proteins, ranging in
size from 60 to more than 200 kDa. Only 15 of them, produced exclusively
by the invasive trypomastigotes, can function as TSs (Atwood et al., 2005).
Trypomastigotes also express TS/PDNF molecules without catalytic
activity, due to a single mutation of Tyr342 to His, and several other
Neurodegeneration and Neuroregeneration in Chagas Disease 211
Trk receptor
Ig 1
Ig 2
Ras
P Y490 Shc
Raf
P
PI3K P
P MEK
P
GSK3 Akt
P
Erk
Bcl2
P
CREB
Transcription
ROS
Survival Differentiation
– PDNF – PDNF
Neurotransmission
1 632 1200
425 445
FIGURE 9.4 TS/PDNF molecule with a TrkA receptor interactive motif (blue) and
substrate sites for Akt kinase (red). Above: primary structure of TS/PDNF with the
N-terminus (grey, residues 1–632) and C-terminal tandem repeats (black ovals, residues
633–1200); below: 3D visualization of the N-terminal surface residues created using
Polyview-3D (based on Amaya et al., 2004).
T. cruzi activation of Trk receptors prior to using them as a vehicle for cell
entry is an essential mechanism for efficient cell invasion.
The importance of Trk receptors in T. cruzi invasion is further under-
lined by the discovery that anti-Trk auto-antibodies, isolated from chagasic
patients, block T. cruzi cell entry, and reduce parasitemia and inflammation
in the heart of infected mice (Lu et al., 2008a,b). Given that these anti-Trk
antibody entry also demonstrated therapeutic agonist-like activity and
improve pathology in various animal models of neurodegeneration
(Sahenk et al., 2010), induction of such autoimmune response might func-
tion as a defence mechanism to control T. cruzi invasion of the PNS.
been shown to inhibit the apoptotic response of their host cell by regulat-
ing host pro-survival signalling (Carmen and Sinai, 2007). However,
though such parasite strategies are extensively described, the molecular
basis underlying parasites crosstalk with the host intracellular signalling
molecules remains largely unexplored.
Although T. cruzi, via PDNF, interaction with Trks induces cell resis-
tance to death stimuli, such receptor-mediated effects are time-limited
and cannot solely account for the protection against cell damaging events
resulting from the long-lasting intracellular parasitism.
It was shown that PDNF has a role in the parasite intracellular devel-
opment, because trypomastigotes with elevated expression of PDNF were
released to cell cytosol earlier and proliferate faster (Rubin-de-Celis et al.,
2006). Both trypomastigotes and intracellular amastigotes express GPI-
anchored proteins of TS/PDNF family (Garg et al., 1997; Silveira et al.,
2008) which, surface-bound or shed into the cell cytoplasm (Frevert et al.,
1992), are able to directly interact with the cell signalling effector mole-
cules responsible for regulation of cell fate.
This hypothesis got an experimental support when it was demon-
strated that in infected Schwann cells PDNF, expressed by the intracellu-
lar parasites, integrated into the host PI3K/Akt signalling cascade as a
substrate-activator of Akt (Chuenkova and PereiraPerrin, 2009).
PDNF contains several motifs that correspond to the consensus R/K-
x-R/K-x-x-pS/T required for an Akt substrate (Fig. 9.4; Manning and
Cantley, 2007), and was recognized as such by the host Akt in the
T. cruzi-infected cells (Chuenkova and PereiraPerrin, 2009). Moreover,
accumulation of phosphorylated PDNF in the cytoplasm of infected
cells corresponded to an increase in Akt activation and cell resistance to
apoptosis (Chuenkova and PereiraPerrin, 2009; Chuenkova et al., 2001).
Ectopically expressed in Schwann cells, PDNF reproduced anti-apoptotic
effects of the parasite residence and induced Akt activation and transcrip-
tion of Akt and PI3 kinases, while down-regulating expression of the pro-
apoptotic genes: caspase-9 and caspase recruitment domains (CARD),
transcription factor FOXO, the mitochondrial Bax and NF-B inhibitor
IkB (Chuenkova and PereiraPerrin, 2009). In addition, PDNF induced
expression of glial fibrillary acidic protein (GFAP; MVC, unpublished
observations), implicated in survival and regenerative capacities of glial
cells in enteric CD (Nascimento et al., 2010).
Combination of PI3K/Akt activation and down-regulation of the pro-
apoptotic effectors protected PDNF-expressing cells against apoptotic
death induced by oxidative stress and cytokines TNF-a and TGF-b
(Chuenkova and PereiraPerrin, 2009). In addition to stimulation of NO
production by activated macrophages, TNF-a promotes apoptosis via
‘‘death’’ domain-containing TNFR1 (Shen and Pervaiz, 2006), and is pres-
ent, together with TGF-b, in the inflammatory lesions in the PNS, where
220 Marina V. Chuenkova and Mercio PereiraPerrin
both are shown to cause degeneration of Schwann cells (Skoff et al., 1998).
Anti-apoptotic activity of the intracellular PDNF in conditions similar to
immune response during T. cruzi infection (Gutierrez et al., 2009a; Silva
et al., 2003; Wen et al., 2006) characterizes PDNF as a T. cruzi factor that
defines, at least in part, the mechanism of infected cells resistance to
cytotoxic environment.
How the intracellular PDNF can activate host Akt is not clear. Phos-
phorylation of Ser- and Thr-containing PDNF motifs by Akt can create
sites for interaction with phospho-Ser/Thr-binding intracellular signal-
ling molecules (Seeburg et al., 2005; Yaffe and Elia, 2001) and thus recruit
PDNF into protein–protein signalling complexes. One such example is
presented by 14-3-3 proteins, implicated in multiple signalling pathways,
including that of PI3K/Akt (Barry et al., 2009), and up-regulated by
intracellular T. cruzi (MVC and MPP, unpublished observation). Some
of Akt-phosphorylated PDNF sites overlap with the sequences recog-
nized by 14-3-3 proteins, and in the cytoplasm of the T. cruzi-infected
Schwann cells, PDNF was shown to associate with 14-3-3 (Chuenkova
and PereiraPerrin, unpublished observation). Such interactions can
underlie PDNF integration, as a scaffolding adaptor, in the assembly of
PI3K/Akt signalosome, Akt activation and pro-survival transcriptional
remodelling.
9.6. CONCLUSIONS
As one of the most successful parasitic protozoans, T. cruzi has evolved
active strategies to maintain persistent infection in the vertebrate host. A
spontaneous cure is uncommon, suggesting a balanced interaction between
the parasite and the host, which is clearly beneficial to T. cruzi, while
excessive tissue pathology and host lethality would interrupt the infectious
cycle and undermine the parasite chances for successful transmission. To
prevent such an outcome T. cruzi developed potent adaptive mechanisms
which underlie the remarkable symbiosis inherent in the course of the
chronic asymptomatic CD when the majority of infected population, while
still retaining the pathogen, is clinically normal. The data discussed above
illustrate the natural complexity of T. cruzi residence in the mammalianPNS.
Parasite modulation of the host pro-survival responses ranges from its
complete inhibition to promotion and became an important component of
the T. cruzi pathogenic profile. Destruction of the nervous tissue in the acute
phase is counterbalanced by regeneration in the indeterminate stage of the
infection which leads to preservation of the host as the parasite habitat and
allows maintaining infection at a stable level.
While pathogenic effects of the T. cruzi infection have been extensively
studied, the parasite role in the host regeneration has just began to
Neurodegeneration and Neuroregeneration in Chagas Disease 221
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CHAPTER 10
Adipose Tissue, Diabetes and
Chagas Disease
Herbert B. Tanowitz,*,†,k Linda A. Jelicks,‡
Fabiana S. Machado,# Lisia Esper,#
Xiaohua Qi,} Mahalia S. Desruisseaux,*,†
Streamson C. Chua,†,§,k Philipp E. Scherer,**,††,‡‡ and
Fnu Nagajyothi*
* Department of Pathology, Albert Einstein College of Medicine, Bronx, New York, USA
{
Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
{
Department of Physiology & Biophysics, Albert Einstein College of Medicine, Bronx, New York, USA
}
Department of Neuroscience, Albert Einstein College of Medicine, Bronx, New York, USA
}
Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York, USA
k
The Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York, USA
#
Department of Biochemistry and Immunology, Institute of Biological Science, Federal University of Minas
Gerais, Belo Horizonte, Brazil
** Touchstone Diabetes Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
{{
Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
{{
Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
235
236 Herbert B. Tanowitz et al.
Abstract Adipose tissue is the largest endocrine organ in the body and is
composed primarily of adipocytes (fat cells) but also contains fibro-
blasts, endothelial cells, smooth muscle cells, macrophages and
lymphocytes. Adipose tissue and the adipocyte are important in
the regulation of energy metabolism and of the immune response.
Adipocytes also synthesize adipokines such as adiponectin which is
important in the regulation of insulin sensitivity and inflammation.
Infection of mice with Trypanosoma cruzi results in an upregulation
of inflammation in adipose tissue that begins during the acute phase
of infection and persists into the chronic phase. The adipocyte is
both a target of infection and a reservoir for the parasite during the
chronic phase from which recrudescence of the infection may occur
during periods of immunosuppression.
10.1. INTRODUCTION
10.2. ADIPONECTIN
The potential contribution of adipose tissue and the obese state to the
infectious process in general had been recently reviewed (Desruisseaux
et al., 2007). It has been appreciated that obese humans and animals have
difficulties responding to many types of infections including frank sepsis.
The first well-designed study to examine the possible relationship of
infection and adipose tissue was published by the Scherer laboratory
(Pajvani et al., 2005). In this study, it was demonstrated that injection of
LPS into mice that were rendered fatless, using the regulated fat apoptosis
murine model, did not result in the immediate death of mice as seen in
control mice with a normal component of adipose tissue (Pajvani et al.,
2005). This observation suggested that adipose tissue makes a significant
contribution during the acute phase response to infection. Interestingly,
during the recent H1N1 influenza epidemic, it was reported that in
individuals with increased BMI the morbidity rate was increased
(Tsatsanis et al., 2010), and this has been confirmed by studies in obese
mice (Karlsson et al., 2010). Responses to Staphylococcus aureus infection
have recently been studied by injection of S. aureus into the footpad of
the leptin receptor null mouse model of diabetes and obesity. Whereas
Adipose Tissue, Diabetes and Chagas Disease 241
non-diabetic lean mice resolved this infection within 10 days, in the obese
mice the infection was prolonged and was associated with a significant
increase in the associated inflammatory response (Park et al., 2009). One
of the most intensively investigated areas in the interface between infec-
tion and adipose tissue has been in HIV/AIDS where receptors for the
virus have been reported on adipocytes and HIV-associated lipodystro-
phy has been described (Anuurad et al., 2010; Garrabou et al., 2011; Hazan
et al., 2002; Jan et al., 2004; Maurin et al., 2005; Mynarcik et al., 2002).
A C
LD
LD
LD
into the circulation (at a level below detection by routine blood smear)
resulting in chronic infection. During the chronic phase of infection,
examination of adipose tissue reveals persistence of both macrophages
and parasites. Thus, adipose tissue is both an early sensor and target of
T. cruzi infection and a chronic reservoir from which infection can recru-
desce during periods of immunosuppression and/or lipoatrophic states.
Recently, Kosteli et al. (2010) have demonstrated that local lipolysis-
induced increases in fatty acids in adipose tissue lead to an increased
infiltration of immune cells, particularly macrophages. This offers a
potential explanation for the long-term effects we observe on some fat
pads after acute T. cruzi infection. The presence of parasites within chron-
ically infected fat pads leads to insulin resistance, associated with
increased lipolysis with chronically elevated local free fatty acid levels
that in turn will be triggering the observed increased infiltration of
macrophages.
Since adipose tissue is composed of many cell types, it was important
to determine if infection of adipocytes in the absence of other compound-
ing variables found in the tissue also resulted in an inflammatory pheno-
type. Indeed, T. cruzi infection of cultured adipocytes resulted in an
increased expression of chemokines, such as CCL2, CCL3, CCL5 and
CXCL10, as well as the cytokines TNF-a, IL-10 and interferon-g
(Nagajyothi et al., 2008). The expression of STAT3, an important down-
stream mediator of cytokine signalling, was also increased. TLR expres-
sion was increased (TLR-2 and -9), and there was evidence of activation of
components of the mitogen-activated protein kinase (MAPK) pathway,
such as ERK. Cyclin D1 expression was increased, and it is usually
upregulated by ERK and inversely regulated by caveolin-1 (Hulit et al.,
2000). Indeed, we demonstrated that infection resulted in a reduction in
the expression of caveolin-1 and the activation of ERK. Both of these
events increase the expression of cyclin D1. A reduction in caveolin-1
expression has also been demonstrated to be associated with an increased
proinflammatory cytokine response (Cohen et al., 2003, 2004). Interest-
ingly, T. cruzi infection activates the Notch pathway, which also regulates,
in part, the expression of cyclin D1 (Stahl et al., 2006).
T. cruzi infection of cultured adipocytes results in increased expression
of PI3 kinase and the activation of AKT, strongly suggesting that T. cruzi
infection induces the insulin/IGF-1 receptor pathway. This is an unex-
pected observation since the upregulation of proinflammatory pathways
is usually associated with a down-regulation of the insulin signal trans-
duction pathway (Ferrante, 2007; Hotamisligil, 2006). Whether other path-
ways influenced by insulin are affected is not known. Thus, T. cruzi
infection of cultured adipocytes as well as adipose tissue results in altera-
tions of several important pathways early in infection that persist well
into the chronic phase.
Adipose Tissue, Diabetes and Chagas Disease 245
sufficient to correct the metabolic defects (de Luca et al., 2005). They are
lean and normoglycaemic. In order to determine the consequences of the
lack of leptin signalling on infection in the absence of metabolic dysregu-
lation, we infected these mice with the Brazil strain and found a minimal
transient peripheral parasitaemia and tissue parasitism and no mortality.
The myocardium was virtually devoid of parasites. The observation in the
NSE-Rb db/db mice was similar to that observed in the wild-type FVB
mice (Nagajyothi et al., 2010). Thus, the restoration of the metabolic
dysfunction was sufficient to control the Brazil strain infection. More
recently, we observed that when we infected the NSE-Rb db/db mice
with the virulent Tulahuen strain the mortality was 100% (unpublished
observations). This is an example demonstrating that both the strain of
mouse and parasite are important in the final outcome of infection. These
findings suggest that leptin resistance in individuals with obesity and
diabetes mellitus may have adverse consequences in T. cruzi infection.
10.6. CONCLUSIONS
ACKNOWLEDGEMENTS
This study was supported by grants from the United States National Institutes of Health
National Institutes of Health (Grants R01-AI-076248, R01-HL-73732 and R21-AI-06538 to
H. B. T.; Grants R01-DK55758, R01-CA112023, RC1 DK086629 and P01-DK088761 to P. E.
S.; Grants P60-DK020541 and PO1-DK-26687 to S. C. C.); Einstein Diabetes Center (pilot grant
to H. B. T.); Conselho Nacional de Desenvolvimento Cientı́fico e Tecnologico (grant to F. S.
M.) and Fundação de Amparo à Pesquisa do Estado de Minas Gerais (grant to F. S. M.).
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INDEX
251
252 Index
257
258 Contents of Volumes in This Series
Volume 49 Volume 52
Antigenic Variation in Trypanosomes: The Ecology of Fish Parasites with
Enhanced Phenotypic Variation in a Particular Reference to
Eukaryotic Parasite Helminth Parasites and their
H.D. Barry and R. McCulloch Salmonid Fish Hosts in Welsh
Rivers: A Review of Some of the
The Epidemiology and Control of Human
Central Questions
African Trypanosomiasis
J.D. Thomas
J. Pépin and H.A. Méda
Biology of the Schistosome Genus
Apoptosis and Parasitism: from the
Trichobilharzia
Parasite to the Host Immune
P. Horák, L. Kolárová, and C.M. Adema
Response
G.A. DosReis and M.A. Barcinski The Consequences of Reducing
Transmission of Plasmodium
Biology of Echinostomes Except
falciparum in Africa
Echinostoma
R.W. Snow and K. Marsh
B. Fried
Cytokine-Mediated Host Responses
during Schistosome Infections:
Volume 50 Walking the Fine Line Between
The Malaria-Infected Red Blood Cell: Immunological Control and
Structural and Functional Changes Immunopathology
B.M. Cooke, N. Mohandas, and R.L. K.F. Hoffmann, T.A. Wynn, and D.W.
Coppel Dunne