W. Conrad Liles

Combinations of host biomarkers predict mortality among Ugandan children with severe malaria: A retrospective case-control study

Background Severe malaria is a leading cause of childhood mortality in Africa. However, at presentation, it is difficult to predict which children with severe malaria are at greatest risk of death. Dysregulated host inflammatory responses and endothelial activation play central roles in severe malaria pathogenesis. We hypothesized that biomarkers of these processes would accurately predict outcome among children with severe malaria. Methodology/Findings Plasma was obtained from children with uncomplicated malaria (n = 53), cerebral malaria (n = 44) and severe malarial anemia (n = 59) at time of presentation to hospital in Kampala, Uganda. Levels of angiopoietin-2, von Willebrand Factor (vWF), vWF propeptide, soluble P-selectin, soluble intercellular adhesion molecule-1 (ICAM-1), soluble endoglin, soluble FMS-like tyrosine kinase-1 (Flt-1), soluble Tie-2, C-reactive protein, procalcitonin, 10 kDa interferon gamma-induced protein (IP-10), and soluble triggering receptor expressed on myeloid cells-1 (TREM-1) were determined by ELISA. Receiver operating characteristic (ROC) curve analysis was used to assess predictive accuracy of individual biomarkers. Six biomarkers (angiopoietin-2, soluble ICAM-1, soluble Flt-1, procalcitonin, IP-10, soluble TREM-1) discriminated well between children who survived severe malaria infection and those who subsequently died (area under ROC curve>0.7). Combinational approaches were applied in an attempt to improve accuracy. A biomarker score was developed based on dichotomization and summation of the six biomarkers, resulting in 95.7% (95% CI: 78.1–99.9) sensitivity and 88.8% (79.7–94.7) specificity for predicting death. Similar predictive accuracy was achieved with models comprised of 3 biomarkers. Classification tree analysis generated a 3-marker model with 100% sensitivity and 92.5% specificity (cross-validated misclassification rate: 15.4%, standard error 4.9%). Conclusions We identified novel host biomarkers of pediatric severe and fatal malaria (soluble TREM-1 and soluble Flt-1) and generated simple biomarker combinations that accurately predicted death in an African pediatric population. While requiring validation in further studies, these results suggest the utility of combinatorial biomarker strategies as prognostic tests for severe malaria.

C5a Enhances Dysregulated Inflammatory and Angiogenic Responses to Malaria In Vitro: Potential Implications for Placental Malaria

Background Placental malaria (PM) is a leading cause of maternal and infant mortality. Although the accumulation of parasitized erythrocytes (PEs) and monocytes within the placenta is thought to contribute to the pathophysiology of PM, the molecular mechanisms underlying PM remain unclear. Based on the hypothesis that excessive complement activation may contribute to PM, in particular generation of the potent inflammatory peptide C5a, we investigated the role of C5a in the pathogenesis of PM in vitro and in vivo. Methodology and Principal Findings Using primary human monocytes, the interaction between C5a and malaria in vitro was assessed. CSA- and CD36-binding PEs induced activation of C5 in the presence of human serum. Plasmodium falciparum GPI (pfGPI) enhanced C5a receptor expression (CD88) on monocytes, and the co-incubation of monocytes with C5a and pfGPI resulted in the synergistic induction of cytokines (IL-6, TNF, IL-1β, and IL-10), chemokines (IL-8, MCP-1, MIP1α, MIP1β) and the anti-angiogenic factor sFlt-1 in a time and dose-dependent manner. This dysregulated response was abrogated by C5a receptor blockade. To assess the potential role of C5a in PM, C5a plasma levels were measured in malaria-exposed primigravid women in western Kenya. Compared to pregnant women without malaria, C5a levels were significantly elevated in women with PM. Conclusions and Significance These results suggest that C5a may contribute to the pathogenesis of PM by inducing dysregulated inflammatory and angiogenic responses that impair placental function.

Immunopathogenesis of falciparum malaria: implications for adjunctive therapy in the management of severe and cerebral malaria

Despite optimal antimalarial treatment and advances in malaria eradication, the mortality rate associated with severe malaria due to Plasmodium falciparum infection, including cerebral malaria (CM), remains unacceptably high. This suggests that strategies directed solely at parasite eradication may be insufficient to prevent neurological complications and death in all cases of CM. Therefore, there is an urgent need to develop innovative adjunctive therapeutic strategies to effectively reduce CM-associated mortality. CM pathogenesis is believed to be due, in part, to an aberrant host immune response to P. falciparum, resulting in deleterious consequences, including vascular activation and dysfunction. Development of effective and affordable therapeutic strategies that act to modulate the underlying host-mediated immunopathology should be explored to improve outcome. In this article, we summarize immunomodulatory therapies that have been assessed in clinical trials to date, and highlight novel and promising treatment strategies currently being investigated to address this major global health challenge.

Inhaled Nitric Oxide Reduces Endothelial Activation and Parasite Accumulation in the Brain, and Enhances Survival in Experimental Cerebral Malaria

The host immune response contributes to the onset and progression of severe malaria syndromes, such as cerebral malaria. Adjunctive immunomodulatory strategies for severe malaria may improve clinical outcome beyond that achievable with artemisinin-based therapy alone. Here, we report that prophylaxis with inhaled nitric oxide significantly reduced systemic inflammation (lower TNF, IFNγ and MCP-1 in peripheral blood) and endothelial activation (decreased sICAM-1 and vWF, and increased angiopoeitin-1 levels in peripheral blood) in an experimental cerebral malaria model. Mice that received inhaled nitric oxide starting prior to infection had reduced parasitized erythrocyte accumulation in the brain, decreased brain expression of ICAM-1, and preserved vascular integrity compared to control mice. Inhaled nitric oxide administered in combination with artesunate, starting as late as 5.5 days post-infection, improved survival over treatment with artesunate alone (70% survival in the artesunate only vs. 100% survival in the artesunate plus iNO group, p = 0.03). These data support the clinical investigation of inhaled nitric oxide as a novel adjunctive therapy in patients with severe malaria.

Fas (CD95) induces rapid, TLR4/IRAK4-dependent release of pro-inflammatory HMGB1 from macrophages

Although Fas (CD95) is recognized as a death receptor that induces apoptosis, recent studies indicate that the Fas/FasL system can induce pro-inflammatory cytokine production by macrophages independent of conventional caspase-mediated apoptotic signaling. The precise mechanism(s) by which Fas activates macrophage inflammation is unknown. We hypothesized that Fas stimulates rapid release of high mobility group box 1 (HMGB1) that acts in an autocrine and/or paracrine manner to stimulate pro-inflammatory cytokine production via a Toll-like receptor-4 (TLR4)/Interleukin-1 receptor associated kinase-4 (IRAK4)-dependent mechanism. Following Fas activation, HMGB1 was released within 1 hr from viable RAW267.4 cells and primary murine peritoneal macrophages. HMGB1 release was more rapid following Fas activation compared to LPS stimulation. Neutralization of HMGB1 with an inhibitory anti-HMGB1 monoclonal antibody strongly inhibited Fas-induced production of tumor necrosis factor (TNF) and macrophage inflammatory protein-2 (MIP-2). Both Fas-induced HMGB1 release and associated pro-inflammatory cytokine production were significantly decreased from Tlr4-/-and Irak4-/-macrophages, but not Tlr2-/-macrophages. These findings reveal a novel mechanism underlying Fas-mediated pro-inflammatory physiological responses in macrophages. We conclude that Fas activation induces rapid, TLR4/IRAK4-dependent release of HMGB1 that contributes to Fas-mediated pro-inflammatory cytokine production by viable macrophages.

Colony-Stimulating Factors in the Prevention and Management of Infectious Diseases

Colony-stimulating factors (CSFs) are attractive adjunctive anti-infective therapies. Used to enhance innate host defenses against microbial pathogens, the myeloid CSFs increase absolute numbers of circulating innate immune effector cells by accelerating bone marrow production and maturation, or augment the function of those cells through diverse effects on chemotaxis, phagocytosis, and microbicidal functions. This article summarizes the evidence supporting the accepted clinical uses of the myeloid CSFs in patients with congenital or chemotherapy-induced neutropenia, and presents an overview of proposed and emerging uses of the CSFs for the prevention and treatment of infectious diseases in other immunosuppressed and immunocompetent patient populations.

Systemic Dysregulation of Angiopoietin-1 and -2 in Streptococcal Toxic Shock Syndrome

Streptococcal toxic shock syndrome (STSS) is characterized by diffuse vascular leak resulting from widespread endothelial activation. Angiopoietin-1 and -2 (Ang-1 and Ang-2), which are important regulators of endothelial quiescence and activation, respectively, are dysregulated in certain diseases that are associated with endothelial dysfunction, but they have not been previously investigated in STSS. Plasma Ang-1 and Ang-2 concentrations were measured in 37 patients with invasive streptococcal infection with and without concurrent STSS. Greater angiopoietin dysregulation (decreased Ang-1 and increased Ang-2) occurred in STSS than in invasive infection without shock; dysregulation decreased with convalescence. These results suggest that systemic Ang-1 and Ang-2 dysregulation is associated with disease severity in invasive streptococcal infection and that plasma levels of Ang-1 and Ang-2 may serve as clinically informative biomarkers in STSS.

A Novel Tissue-Engineered Approach to Problems of the Postpneumonectomy Space

BACKGROUND Transfer of viable tissue flaps and thoracoplasty are effective against pleural space complications after pneumonectomy but highly disfiguring. The aim of this study was to explore the possibility of engineered tissue to treat space complications after pneumonectomy. METHODS A left pneumonectomy was performed in mice, and the cavity immediately filled with the cellularized collagen matrices. First, bone marrow derived-mesenchymal stroma cells with luciferase expression were used as donor cells to evaluate cell viability and angiogenesis using bioluminescence imaging. Second, using bone marrow cells from GFP mice, histologic evaluation, immunohistochemistry for von Willebrand Factor, and flow cytometric analysis was performed compared with acellular matrix implants. The effect on bacterial clearance was examined using an empyema model with Staphylococcus aureus expressing luciferase. RESULTS Embedded cells proliferated within the denatured collagen matrices ex vivo. In vivo, bioluminescent imaging activity could be detected till day 8, and the slope (suggesting rate of perfusion with luciferin) increased with time up to day 6 but decreased after day 7. Although GFP-positive donor cells decreased with time, total cellularity increased. Furthermore, vessels stained by von Willebrand factor were significantly increased. Both cellularized and acellularized matrices showed bacterial clearance in vivo. CONCLUSIONS Cells within collagen matrices survive in the thoracic cavity at early time points. Cellularized matrices quickly lead to neovascularization and recipient cell infiltration. Both cellularized and acellularized matrices show bacterial clearance in vivo. This study indicates the potential feasibility of a novel tissue engineering approach to problems of the postpneumonectomy space.

Early Studies of AMD3100/Plerixafor in Healthy Volunteers

Approval of CXCR4 antagonist AMD3100 or plerixafor for hematopoietic stem cell mobilization followed a series of basic and clinical studies on the retention and release of hematopoietic cells from the bone marrow. The first observation was the importance of the ligand pair SDF1-CXCR4 in the trafficking of hematopoietic progenitor cells [1]. About the same time, it was learned that CXCR4 and CCR5 are coreceptors for the entry of HIV into human cells [2]. Soon after AMD3100/plerixafor was identified as a promising CXCR4 antagonist that appeared to inhibit HIV entry into host target cells, its effects were examined in preclinical models [3, 4] and then in ten men with HIV infection [5]. These studies showed that administration of AMD3100/plerixafor was well tolerated and caused significant leukocytosis, with increases in neutrophils, lymphocytes and monocytes. The only concern was premature ventricular contractions in 2 of 40 subjects during the study [5]. These results prompted investigations addressing specific details of the leukocytosis induced by AMD3100/plerixafor in healthy subjects.

Clinical Applications of G-CSF and GM-CSF in the Treatment of Infectious Diseases

Infectious diseases remain a major cause of morbidity and mortality throughout the world, including the United States. The immune system represents the primary host defense against pathogenic bacteria, fungi, and parasites. The first line of defense is comprised primarily of polymorphnuclear granulocytes (PMNs), macrophages, natural killer (NK) cells, and cytotoxic lymphocytes. Upon activation, these cells can destroy and eliminate pathogenic microorganisms. The possibility of augmenting host defense has increased dramatically during the past two decades with the discovery and development of cytokines. The immunomodulatory effects of colony-stimulating factors (CSFs) on selected leukocyte populations have received increasing attention recently.