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Persistent Infections by Leishmania (Viannia) Braziliensis José Luis Ramírez+, Palmira Guevara

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Persistent Infections by Leishmania (Viannia) Braziliensis José Luis Ramírez+, Palmira Guevara Mem Inst Oswaldo Cruz, Rio de Janeiro, Vol. 92(3): 333-338, May/Jun. 1997 333 Persistent Infections by Leishmania (Viannia) braziliensis José Luis Ramírez+, Palmira Guevara Instituto de Biología Experimental, Facultad de Ciencias, Universidad Central de Venezuela. Apdo. 47525, Caracas 1041-A, Venezuela Here we review the phenomenon of persistency in Leishmania (Viannia) braziliensis infections. In other Leishmania species where appropriate animal models exist, considerable advances in the under- standing of basic immunologic mechanisms of persistency have been made; for a review see Aebisher (1994). On the contrary, the evidences of persistence in infections with L. braziliensis rest on studies of human clinical cases many of which we summarized and discussed in this work. Key words: Leishmania (V.) braziliensis - persistent infections - American tegumentary leishmaniasis American tegumentary leishmaniasis (ATL) is slow evolution, difficult to cure and with frequent a widely spread disease accounting for thousands relapses. This picture portrays very well the vi- of new cases per year. Most cases are produced cious nature of the infections by L. braziliensis. by organisms included in the sub-genus Viannia Different terms have been coined for atypical (Lainson & Shaw 1987), with three major species: infections: inapparent or cryptic is accounted for Leishmania panamensis causing single lesions by the presence of any infectious agent with no easily cured, with nodules along the lymphatics associated pathology. Persistent infection refers and few nasopharyngeal lesions; L. guyanensis to the permanence of these agents after clinical producing disseminate infections compromising cure; the infection can stay asymptomatical or the lymphatic system but no nasopharyngeal in- show relapses at different times. A persistent in- volvement; and L. braziliensis causing primary lo- fection is also referred to as chronic, but this term calized skin ulcers (localized cutaneus leishma- is more often applied to a different stage of the niasis - LCL) with frequent relapses involving the disease. For example in hepatitis, ictericia and gen- nasopharyngeal mucosa (mucocutaneous leishma- eral weakness remains, and in Chagas’ disease, al- niasis MCL or espundia) a few years later. The though the parasite is at low numbers, damage to cases of leishmaniasis associated with L. the cardiac muscle is occurring. Chronicity is also braziliensis are predominant in many countries related to transmission of a disease by asymptom- leading indefinite follow-ups, extended treat- atic subjects. In the case of Leishmania, except for ments and hospital bed space occupation for long L. donovani sensus latus, the transmission between periods (Marsden 1994). humans appears to be restricted to blood transfu- PERSISTENCY sion (André et al. 1957) or organ transplantation (Greemblatt 1980). As the dogma goes in Tropi- A characteristic of all Leishmania species is cal Medicine, the Phlebotomus or Lutzomyia need their tendency to establish inapparent infections, to take a high concentration of parasites which is or to persist after clinical resolution of the disease. only attainable at the skin of the animal reservoirs. This tendency, well documented and fashionable Despite this, there are reported cases of in the AIDS era (Coura et al. 1987, Bastuji-Garin intradomiciliary transmission that have been attrib- et al. 1991) was known by the earlier workers in L. uted to infected Phlebotomus, when they bite the braziliensis endemic areas. In fact, Lindenberg parasite-rich wound crest (Rojas & Scorza 1989). (1909) reported among workers laying the tracks In patients living in endemic areas, it is diffi- for the railroad from the State of São Paulo to cult (if not impossible) to discriminate reactiva- Mato Grosso, a high incidence of skin ulcers with tion (relapse) of a latent infection from a reinfec- tion. There are no appropriate biochemical or mo- lecular markers to distinguish a resident parasite from a newcomer, unless the latter clearly belongs This research was supported by grants from CONICIT to a different group or population. Karyotype analy- S1-2323 and Fondo Pro-Salud from CAVEFACE. + ses lacks of sensitivity and do not seem to corre- Corresponding author. Fax: +58-2-753.5897. e-mail: late with the zymodeme analysis (Saravia et al. [email protected] 1990); isoenzymes are useful in discriminating Received 12 June 1996 Accepted 19 February 1997 species but lack the sensitivity to distinguish or- 334 Persistent Infections by L. (V.) braziliensis • JL Ramírez, P Guevara ganisms of the same population (Saravia et al. WHY PERSISTENT INFECTIONS? 1990), restriction fragment length polymorphism In Tropical Medicine courses, tegumentary analysis (RFLP) involving unique nuclear genes leishmaniasis is thought of as a zoonosis (Manson are in general insensitive, and kinetoplast minicircle 1982) where the vertebrate animal host harbors the restriction analysis analysis (Morel et al. 1980) parasite without apparent harm. According to this provide unstable markers, as Pacheco et al. view, the human host is an accidental player who (1995) have shown, variable sequence polymor- suffers the disease as an intruder in the parasite’s phisms can emerge during experimental infec- life cycle. The strong dermal reaction has allergic tions with cloned L. guyanensis cells. It remain characteristics, and the cure can occur spontane- to be tested whether RAPDs analysis targeted in ously. The picture is more complex because not other Leishmania sequences can provide the right all humans react with the same intensity or never tool (Macedo et al. 1992). react. To explain these differences, nutritional fac- In a given endemic area it is very difficult to tors (Badaró et al. 1986) and genetic susceptibility estimate the number of inhabitants with persistent have been advanced (Lara et al. 1991, Cabrera et infections. When serological (immunofluores- al. 1996). Badaró et al. (1986) have implicated cent antibodies test, IFA, enzyme-linked malnutrition as an important risk factor for suffer- immunosorbent assay, ELISA) and delayed-type ing visceral leishmaniasis in children in Brazil. Al- hypersensitivity (DTH) tests are applied in Ven- though this association was found for a viscero- ezuelan endemic areas, it is frequent to observe a tropic parasite, it appears logical that good nutri- positive response in approximately 12% of the tion is essential to an effective immune system, and healthy individuals (with no lesions or scars) (Dr the possibility of fighting any kind of infection. Néstor Añez, pers. comm.). Thus, not every per- In the mouse, resistance to the infection by L. son contacting the parasite develops the disease, mexicana was shown to be inherited as a domi- but unless more sensitive and direct techniques nant character (Pérez et al. 1979) and polymorphic are used, we can not assess whether they have genetic markers have been linked to the suscepti- eliminated the parasite. bility to leishmaniasis (Blackwell 1988). Some The existence of cryptic or inapparent infec- of these markers are also related to the susceptibil- tion by Leishmania is revealed in patients affected ity to other infections (Roberts et al. 1990). An by AIDS when cutaneous or mucocutaneous le- interesting aspect of these studies is the differen- sions appear without a previous history of leish- tial correlation of the genetic markers with differ- maniasis (Coura et al. 1987, Machado et al. 1992). ent Leishmania species (Pérez et al. 1979, Akuffo Recently, using a L. braziliensis specific poly- et al. 1987) a fact that emphasizes the importance merase chain reaction assay (PCR) (Guevara et of the parasite’s genetic makeup in the course of al. 1992) based on ribosomal nontranscribed spacer the infection. Because there is no appropriate ani- sequences, we detected parasite DNA on blood mal model to study L. braziliensis infections, simi- samples of a patient who suffered from multiple lar studies with this parasite are lacking. The mouse cutaneous lesions 30 years ago, and was cured genetic markers are being used as heterologous spontaneously (Guevara et al. 1993). Since the probes to try to identify «risk» genes in humans. If patient has lived in a non endemic area ever since, these polymorphisms are also encountered in hu- reinfection appears unlikely. An alternative and man populations, they will open the way for risk important source of information about persistent assessment and more rational therapy (Alexander Leishmania can be found in individuals who & Russell 1992). sufferred the disease and latter migrated to non In two independent studies searching for ge- endemic areas or countries where the disease does netic markers confering susceptibility to suffer not exist (Guevara et al. 1994). LCL and MCL in Venezuelan families, Lara et al. A characteristic of L. (V.) braziliensis infection (1991) working in an endemic area for L. (V.) is its tendency to metastasis through different parts braziliensis and L. (V.) guyanensis, have linked the of the body, with particular preference for the presence of antigens HLA II Bw22 and DQw3, nasopharygeal mucosa. Secondary mucosal infec- respectively, as genetic risk factors for LCL at the tions can occur months or even years after the cure population level. These genetic markers are likely of a LCL. However the parasite can be found in related to the ability of the patients to trigger the the nasal mucosa without evidences of a primary TH1 or TH2 arms of the immune
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