Alice J. Norton

Management of Evans syndrome

Evans syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anaemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known underlying aetiology. This condition generally runs a chronic course and is characterised by frequent exacerbations and remissions. First‐line therapy is usually corticosteroids and/or intravenous immunoglobulin, to which most patients respond; however, relapse is frequent. Options for second‐line therapy include immunosuppressive drugs, especially ciclosporin or mycophenolate mofetil; vincristine; danazol or a combination of these agents. More recently a small number of patients have been treated with rituximab, which induces remission in the majority although such responses are often sustained for <12 months and the long‐term effects in children are unclear. Splenectomy may also be considered although long‐term remissions are less frequent than in uncomplicated ITP. For very severe and refractory cases stem cell transplantation (SCT) offers the only chance of long‐term cure. The limited data available suggest that allogeneic SCT may be superior to autologous SCT but both carry risks of severe morbidity and of transplant‐related mortality. Cure following reduced‐intensity conditioning has now been reported and should be considered for younger patients in the context of controlled clinical trials.

Genetic consequences of mass human chemotherapy for Schistosoma mansoni: population structure pre- and post-praziquantel treatment in Tanzania.

Recent shifts in global health policy have led to the implementation of mass drug administration (MDA) for neglected tropical diseases. Here we show how population genetic analyses can provide vital insights into the impact of such MDA on endemic parasite populations. We show that even a single round of MDA produced a genetic bottleneck with reductions in a range of measures of genetic diversity of Schistosoma mansoni. Phylogenetic analyses and indices of population differentiation indicated that schistosomes collected in the same schools in different years were more dissimilar than those from different schools collected within either of the studys 2 years, in addition to distinguishing re-infection from non-clearance (that might indicate putatively resistant parasites) from within those children infected at both baseline and follow-up. Such unique results illustrate the importance of genetic monitoring and examination of long lived multi-cellular parasites such as these under novel or increased chemotherapeutic selective pressures.

Evolutionary concepts in predicting and evaluating the impact of mass chemotherapy schistosomiasis control programmes on parasites and their hosts

Schistosomiasis is a parasitic disease of significant medical and veterinary importance in many regions of the world. Recent shifts in global health policy have led towards the implementation of mass chemotherapeutic control programmes at the national scale in previously ‘neglected’ countries such as those within sub‐Saharan Africa. Evolutionary theory has an important role to play in the design, application and interpretation of such programmes. Whilst celebrating the rapid success achieved to date by such programmes, in terms of reduced infection prevalence, intensity and associated human morbidity, evolutionary change in response to drug selection pressure may be predicted under certain circumstances, particularly in terms of the development of potential drug resistance, evolutionary changes in parasite virulence, transmission and host use, and/or competitive interactions with co‐infecting pathogens. Theoretical and empirical data gained to date serve to highlight the importance of careful monitoring and evaluation of parasites and their hosts whenever and wherever chemotherapy is applied and where parasite transmission remains.

Population genetic structure of Schistosoma mansoni and Schistosoma haematobium from across six sub-Saharan African countries: Implications for epidemiology, evolution and control

We conducted the first meta-analysis of ten Schistosoma haematobium (one published and nine unpublished) and eight Schistosoma mansoni (two published and six unpublished) microsatellite datasets collected from individual schistosome-infected school-children across six sub-Saharan Africa countries. High levels of genetic diversity were documented in both S. haematobium and S. mansoni. In S. haematobium populations, allelic richness did not differ significantly between the ten schools, despite widely varying prevalences and intensities of infection, but higher levels of heterozygote deficiency were seen in East than in West Africa. In contrast, S. mansoni populations were more diverse in East than West African schools, but heterozygosity levels did not vary significantly with geography. Genetic structure in both S. haematobium and S. mansoni populations was documented, at both a regional and continental scale. Such structuring might be expected to slow the spread to new areas of anti-schistosomal drug resistance should it develop. There was, however, limited evidence of genetic structure at the individual host level, which might be predicted to promote the development or establishment of drug resistance, particularly if it were a recessive trait. Our results are discussed in terms of their potential implications for the epidemiology and evolution of schistosomes as well as their subsequent control across sub-Saharan Africa.

The impact of single versus mixed Schistosoma haematobium and S. mansoni infections on morbidity profiles amongst school-children in Taveta, Kenya.

Two schistosome species--Schistosoma haematobium and S. mansoni--with two very different pathological profiles (urogenital versus intestinal), are responsible for the majority of human schistosomiasis infections across sub-Saharan Africa. The aim of this study was to determine whether coinfections have an impact on species-specific morbidity measures when compared to single species infections. Children from two neighbouring schools in Taveta, Kenya were grouped by infection status, i.e. uninfected, single species infections or coinfected. Clinical examination of the liver and spleen by palpation was performed and urinary albumin levels were recorded at baseline and at 12 months after praziquantel administration. Additional ultrasonographic profiles of the childrens liver, spleen and bladder were incorporated at follow-up. It was found that S. haematobium-associated urogenital morbidity was lower in the coinfected group relative to single S. haematobium infections, even when infection intensities were taken into account. We also observed an association between S. haematobium infection and liver (intestinal-associated) morbidity regardless of coinfections. The findings reported here suggest that further research should be performed on the impact of S. haematobium infections on liver morbidity as well as to determine the impact of mixed schistosome species infections on human morbidity outcomes across different endemic settings.

Inter-specific parasite competition: mixed infections of Schistosoma mansoni and S. rodhaini in the definitive host

Competition between parasite species has been predicted to be an important force shaping parasite and host ecology and evolution, although empirical data are often lacking. Using the Mus musculus-Schistosoma mansoni and Schistosoma rodhaini host-parasite systems we characterized mate choice and inter-specific competition between these two schistosome species. Simultaneous infections revealed species-specific mate preferences for both species as well as suggesting mating competition, with male S. rodhaini appearing dominant over male S. mansoni. S. rodhaini homologous pairs were also shown to have increased reproduction per paired female in the presence of a competitor in simultaneous infections. Overall total reproductive success was, however, similar between the two species under conditions of direct competition due to the greater initial infectivity of S. mansoni in comparison to S. rodhaini. Inter-specific competition was also implicated as increased parasite virulence to the host. The potential effects of such interactions on parasite and host ecology and evolution in nature are discussed.

Simultaneous infection of Schistosoma mansoni and S. rodhaini in Biomphalaria glabrata: impact on chronobiology and cercarial behaviour

BackgroundThe chances of a schistosome cercaria encountering a suitable definitive host may be enhanced by emergence from the molluscan intermediate host with maximal glycogen stores and by an appropriate chronobiological rhythm. This study aimed to identify and characterize the effects of potential competitive interactions in the snail host Biomphalaria glabrata, between the closely-related Schistosoma mansoni and S. rodhaini, on phenotypic behavioural traits. It was predicted that inter-specific competition would affect chronobiological emergence rhythms and reduce the activity of schistosome swimming behavioural traits. Biomphalaria glabrata snails (120) were exposed to either S. mansoni or S. rodhaini single infections, or a mixed infection of both species simultaneously and the resulting cercarial phenotypic traits were characterised. Cercariae were identified from co-exposed snails by amplification and sequencing of the mitochondrial cytochrome oxidase subunit 1 (CO1).ResultsS. mansoni and S. rodhaini largely maintained their distinct chronobiological rhythms after mixed exposures and infections. However, inter-specific competition appeared to result in a restriction of the shedding pattern of S. rodhaini and slight shift in the shedding pattern of S. mansoni. Inter-specific competition also significantly lowered hourly cercarial production for both parasite species in comparison to single exposures and infections and reduced cercarial swimming activity.ConclusionInter-specific competition was shown to influence cercarial production, chronobiology and activity and should therefore be investigated further in field situations to determine the effects of these changes on parasite fitness (incorporating both host finding and infectivity) where these two species overlap. Importantly this competition did not result in a large change in chronobiological emergence of cercariae for either species indicating that it would not have a large influence on the species of hosts available for infection at time of emergence. This study has furthermore demonstrated the potential for phenotypic measures to provide markers for species-specific identification even in conditions of co-infection.

Propagule Behavior and Parasite Transmission

Many parasites with complex, indirect, life-cycles involve one or more free-living propagule stages, such as eggs and larvae, which serve in dissemination and transmission between host species. The larvae are often non-feeding and obtain their energy through stored glycogen. These limited energy supplies provide strong constraints and selective pressures to rapidly disperse, and locate, and penetrate a suitable host to complete the life-cycle. Host location can either be achieved by direct attraction to the host, or to a habitat and/or temporal space which is likely to contain the host. Mechanisms for these attractions include kinesis or taxis and are often innate behaviors in response to environmental and/or biological cues. Parasite larval behaviors often involve complex interactions between different stimuli and trade-offs occur between host-seeking and energy-saving traits. These result in a vast array of techniques which aid dispersion and successful transmission. The type of hosts that larvae are required to infect can vary greatly even with a single life-cycle, and parasites have thus evolved complex species- and stage-specific behavioral traits to aid transmission. These are discussed here, with examples focusing on trematode species, where the majority of research has been carried out to date, predominantly due to their medical and veterinary importance.