Week 4 - Leishmaniasis Flashcards
1
Q
How many countries is Leish distributed over?
A
88
2
Q
how many new cases each year?
A
2 million
3
Q
how many people are infected each year?
A
12 million
4
Q
how many deaths are there per year?
A
52,000
5
Q
how many people are at risk each year? what may cause this to rise
A
350 million
global woarming
6
Q
what is the parasite transmitted by?
A
Sand flies
7
Q
how big are sand flies?
A
2mm in length
8
Q
what are adult sand flies characterised by?
A
hairy body and wings
9
Q
Generally Phlebotomus sp are found in which ecosystems?
A
desert / semi arid
10
Q
Lutzomyia sp are found in which ecosystem?
A
forest
11
Q
why is the term sand fly misleading?
A
they do not fly, rather hop as short bursts of flight only
12
Q
which gender spread the disease?
A
only females
13
Q
when do sandflies most actively feed?
A
nocturnal and dusk
14
Q
what sort of feeders are sand flies?
A
saw feeders. their saw like mouth parts create a wound which allows blood to well up in to a pool
suck the blood and lymph from that pool
15
Q
where is the parastie located inthe sand fly?
A
anterior portion of gut and pharynx
16
Q
how does the sand fly transmit the parasite?
A
regurgitates it up
17
Q
transmission of leish can be both ___ and ___
A
zoonotic
anthroponotic
18
Q
Zoonotic transmission is common in which 2 places? and which animals are reservoirs?
A
mediterranean
latin america
canines and rodents
19
Q
generally whether the transmission cycle is zoonotic or antrhoponotic depends on which factor?
A
the human density in that area
20
Q
What are 4 other mechanisms of transmission of leish?
A
blood transfusion
organ / bone marrow transplant
congenital - mother to foetus
drug usage - needle sharing
21
Q
how many different species of Leishmania are there and how many can infect humans?
A
30
21 can infect humans
22
Q
What has molecular typing demonstrated about some o fthe Leishmania species?
A
that in the old and new world the species are synonymous
23
Q
How can you distinguish Leishmania species?
A
morphologcically indistinguishable
can only distinguish by molecular level
24
Q
What are the 2 forms of the parasite?
A
promastigote
amastigote
25
where do you find the promastigote?
insect vector
26
key features of the promastigote?
flagellum sticks straight out of the body
| kinetoplast in front of nucleus
27
what are the 2 types of promastigote?
non infectious promastigote
| infectious metacyclic promastigote
28
The non - infectious promastigote is found where? can it divide?
insect gut
| binary fission
29
the infectious metacyclic promastigote is found where? can it divide?
human macrophages and neutrophils
non - dividing
also found in the insect gut - transformed from non-infectious promastigote
30
what does the term metacyclic generally mean?
go from the insect to human
31
Key features of the amastigote?
intracellular
infectious
invade macrophages and neutrophils - binary fission
non motile
32
when the amastigote is inside the macrophage what are they like?
inside a vesicular compartment - essentially have a membrane around them which is derived from the host
33
which form of the parasite is transmitted back from humans into the insect?
amastigote
34
Life cycle :
| the sand fly takes a meal and starts to regurgitate ___ _____ form parasites into the host
infectious metacyclic promastigote
35
What causes the regurgitation mechansim in the sand fly?
the parasite
dysfunctional stomedeal valve at foregut/midgut junction
when the insect feeds the blood goes down into the gut and because the valve doesnt close properly it washes back up into the host bringing up metacyclic promastigote
36
The whole process of regurgitating the parasite is exacerbated by what?
parasite secretes promastigote secretory gel that acts like a bung and promotes the insect to feed for longer
increases the chance of the parasite being transferred into the pool of blood if the feeding time is longer
37
why do the insect saliva and promastigote secretory gel contain elements that our immune system will respond to?
Our immune system responds to the damage done by the insect feeding and also responds to the secretory gel and insect saliva so this magnifies the attraction of neutrophils to that site.
Want more neutrophils for the metacyclic promastigote to infect
38
How does the metacyclic promastigote form invade neutrophil cells?
phagocytosed
39
What does the parasite do to the neutrophil cells?
alters their gene expresssion to promote itself
40
why doesnt the parasite want to stay in the neutrophil cells?
because they are short lived
41
what are the 2 hypotheses as to how the parasite gets form the neutrophils into macrophages?
trojan horse
| simple one
42
explain the trojan horse hypothesis
Infects neutrophil
causes the neutrophil to undergo apoptosis
apoptotic marjers are then exposed on the cell surface of the neutrophil
the macrophages recognise the apoptotic markers and consume the dying cell
phagocytose the neutrophil along with the metacyclic promastigote inside the neutrophil
43
what happens to the metacyclic promastigote once it is inside the macrophage?
undergoes differentiation into an amastigote and then starts dividing
44
in the trojan horse hypothesis what is the trojan horse?
neutrophil
45
what is the simple hypothesis as to how the metacyclic promastigotes get into macrophages?
Whilst the metacyclic is inside the neutrophil undergoes differentiation into amastigote
amastigotes start to divide and rupture the neutrophil
the amastigotes are released into the blood stream and then taken up by the macrophages
46
What is key about the 2 hypothesis as to how the metacyclic promastigotes get out of the neutrophils?
they both lead to amastigotes form in the macrophage where they can divide and rupture the macrophage and then reinfect other cells
47
how long can leishmania infection last?
6 months
48
why is it likely we have these 2 different hypotheses?
because we are dealing with 21 different leish species
49
how does the parasite get back into the insect vector?
sand fly takes a blood meal from an infected person and may take up a macrophage with amastigotes in it. once inside the sand fly the macrophage is digested and amastigotes are released
50
what happens to the amastigotes when they are inside the insect vector after the macrophage has ruptured?
once in the digestive tract of the insect vector the amastigotes decrease in temperature and increase in pH causes the amastigotes to transform into non-infectious promastigotes
51
what do the non infectious promastigotes do in the insect vector?
covered in a mucous layer that is derived from the insect itself, which contains a protein mesh
oarasite is trapped inside this peritrophic matrix
with time various enzymes produced byt the insect and parastie witll degrade away this matrix and the non infectious promastigote is released into the lumen
52
when the non infectious promastigote is in the insect vector and has been released from the matrix into the lumen what occurs?
using a LPG molecule will stick to the epithelial layer of the gut wall which prevents the parasite from being excreted
non infectious promastigotes divide by binary fission and colonises insect gut wall
release the promastigote sseceretory gel to damage the valve
transformation into metacyclic promastigotes
53
what happens to the metacyclic promastigotes in the insect?
they detach from the wall
and congregate around where the valve is found
life cycle complete
54
Leish species are obligate ____ parasites in the mammalian host
intracellular
55
which cells do leish species inffect?
microbicidal capability - macrophages and neutrophils
56
which mechanism does the parasite exploit to get into the macrophages and neutrophils?
complementary cascade
57
what is the complement mediated lysis (alternative activation pathway)?
binding of early complement components to organism is followed by assembly of membrane attack complex
58
when the parasite is inside the neutrophil cell it has to overcome the mechanisms this cell uses to destroy foregin cells, what is it facing? (3)
lysosomal pH
lysosomal enzymes
oxidative stress
59
Explain the lysosmal pH the parasite has to overcome?
phagosomal compartment is acidified upon fusion with lysosomes to pH 5
most infectious agents this is sufficient to damage the membrane
leishmania parasite utilises this change in pH to recognise it is inside a mammalian host cell and transforms into an amastigote
60
explain the lysosomal enzymes the parasite has to overcome?
lysosomes contain an array of digestive enzymes including proteases, nucleases, and lipases.
parasite appears to be resistant to all of these
61
explain the oxidative stress the parasite has to overcome?
NADPH oxidase (Phox) complex on phagosomal membrane generates superoxide leading to the production of hydrogen peroxide and hypochloride
reaction with transitionmetals lead to formation of hydroxyl radicals
nitric oxide synthase generates nitric oxide which combines with superoxide to form peroxynitrite
62
The player is Leishmania infection:
```
Infective - ???
Host target cells - ??
Mode of entry - ??
Host receptors - ??
Parasite molecules implicated in the uptake - ??
Site of replication - ??
```
```
metacyclic promastigotes
neutrophils then macrophages
passive, opsonised phagocytosis
CR1, CR3
gp63 protease, lipophosphoglycan (LPG)
phagolysosome vacuole
```
63
the parasite cells surface changes during differntiation from non-infectious promastigote (replicative) to the infectious metacyclic promastigote, explain (2)
Replicative promastigote has short LPG and low levels of GP63
Infective metacyclic promastigote has long LPG and high levels of GP63
64
what is the LPG similar to?
the variant surface glycoprotein of t.brucei but have to remember this is not a protein it is a sugar, a fat phosphor sugar mix
65
So the LPG plays a part in attaching the promastigote to the insect gut wall, explain the structure of LPG further
LPG consists of several domains.
It has a phosphoglycan region that contains repeated elements.
The galactosyl side chain binds to gelactin and this binds parasite to the wall of the insect gut
the side chains of the metacyclic promastigote are capped with a galactose residue which prevents it from binding to gelactin and this facilitates detachment form the wall of the mid gut
66
the whole LPG molecule is linked by a ____ anchor which is way of doing what?
GPI anchor
| packing many molecules closely together on the cell surface
67
why should the parasite bother to make the change of its cell when it changes the promastigote form? (2)
it causes a detachment from the lumen so the parasite can be transmitted
the longer LPG coat prevents the membrane complex from getting access to the parasite cell membrane so it cant puncture holes through it
68
so what happens to C3 on the parasite?
during the complement cascade C3 is broken down into C3a and C3b
the parasite binds C3b component in the LPG layer and this C3b is partially degraded by zinc protease to be inactivated so it cannot be involved in the complement cascade any more
complement cascade is now modified
69
what happens to the iC3b on the parasite?
essentially coats itself with the inactivated C3b componenet which then attracts neutrophils and macrophages.
This iC3b is still attracted to complement receptors 1 and 3 (CR1, CR3) and the complement receptors on the macrophage bind to iC3b and promote the entry of the parasite into the macrophage via phagocytosis
70
Cell invasion the parasite uses complement and phagocytosis occurs, how do we know this process is phagocytotic?
pseudopodia form to start the engulfment process.
we know this is phagocytotic because you can block this process using an appropriate drug which will prevent this process from occurring.
also use cell biology marker and see the marker forming around the parasite
71
what makes the parasite more susceptible to phagocytosis?
iC3b
72
once the metacyclic promastigote is inside the phagosome what occurs?
lysosome vesicles fuse with the phagosome and some of these vesicles will result in a drop in the pH of the lumen to pH 5
the promastigote responds to the drop in pH and differentiates into the amastigote form which then undergoes binary fission and colonises that cell
73
How does the parasite modulate host cell signalling and essentially overcome the oxidative stress?
Leish sp inhibits protein kinase C activity and the NADPH oxidase (Phox) complex is no longer formed. This reduces respiratory burst (ie oxidative stress)
74
How else does the parasite modulate host cell signalling so the inflammatory responses are reduced?
Leish activates SHP1 a tyrosine phosphatase
SHP1 causes dephosphoylation of Jak (Janus kinase)
The transcription factors STAT is not phosphorylated and remains in cytosol
change in gene expression as STAT can no longer access nucelus
Inflammatory responses are supressed
75
not all macrophages in our body are the same how does Leish respond to this?
dermal macrophages lack the respiratory burst machinery and promastigotes have enhance ability to differentiate as amastigotes in these cells compared to other populations and so some of the parasites have a preference for invading dermal layer macrophages.
76
Which is the most common pathology of Leish?
cutaneous leishmaniasis
77
out of the 12 million reported leish cases how many are cutaneous?
10 million
78
cutaneous lesih starts out how?
raised, generally painless red lesion at site of the bit and can ulcerate.
79
what are the 2 most common species that are associated with cutaneous leish pathology?
l. tropica - cities
| l. major - rural
80
Generally all the other pathologies of leish start off as which pathology?
cutaneous leish
81
In cutaneous leish ulcers that form can be classified as 2 types, what are they and which species are they commonly associated with?
L.major - wet ulcer
| L.tropica - dry ulcer
82
Is there puss formation in cutaneous leish?
no only get pus if there is a secondary infection
83
Do you need medication for cutaneous leish?
they will eventuallly self heal and once heled you have immunity against that leish species for life
84
When in cutaneous leish would you be provided medication?
if the ulcer is on your face for cosmetic reasons and also to speed up healing / reduce scarring
85
In __% of cases the lesion can disappear and you get ___ leish
5
| diffuse
86
what are the 2 types of diffuse leishmania?
```
diffuse cutaneous (DCL)
mucocutaneous (MCL)
```
87
Describe the pathology of diffuse leishmaniasis (4)
- -metastasizes over whole body
- -non-ulcerated, scaly lesions
- -generally associated with anergy (lack of immune response)
- -amastigotes abundant lesions
88
Describe the pathology of mucocutaneous leishmaniasis (5)
- --metastasizes mucocutaneous junctions (open or scaly)
- -can occur weeks/years after primary infection
- -tissue destroyed and severe disfiguremnet
- -secondary bacterial infection common
- -most prevalent in latin america
- -3-5% cutaneous will progress to this type
89
what is the most serious pathology of leish?
visceral leishmaniasis --- kala azar --- dum dum fever
90
what is a characteristic symptom of visceral leish?
darkening of the skin
91
which is the pathology of leishmaniasis that kills people?
visceral. 50,000 per year
the other forms of the disease are not lethal, they are highly disfiguring but may cause death due to secondary infections
92
In visceral leish the parasite invades which organs?
reticuloendothelial system
| liver spleen bone marrow lymph nodes
93
what symptoms are visceral leishmaniasis commonly characterised by? (4)
```
fever
spenomegaly
heptomegaly
enlarged lymph nodes
wasting symptoms
```
94
In leishmaniasis disease severity depends on the immune status of the individual, what are the 2 immune responses that can occur?
TH1
| TH2
95
what is a TH1 type response?
cellular immune response triggered
no/low antibody formation
recover from infection and are immune CL
96
what is a TH2 type response?
humoral immune response triggered antibody formation occurs
| succumb to infection (VL)
97
what is the problem we have with our immune system and strong l.donovani strains?
force host to switch from TH1 (that would clear parasitemia) to Th2 (does not clear parasitemia favours the parasite) response by an unknown mechanism
98
if you have a suspected case of leishmaniasis what 2 things do you look to diagnose?
for visceral and dermal - geographical presence of parasite
| history of sand fly bite
99
what are the symptoms for the 3 types of dermal leish?
```
chronic painless leision (CL)
mucocutaneous lesion (MCL)
scaly lesions (DCL)
```
100
what are the symptoms for visceral leish?
prolonged fever
spenomegaly
aneamia
leucopenia
101
definitive diagnosis - detection of parasites
| what are the four ways to detect the parasites in dermal leish?
amastigotes in scraping
amastigotes in aspirates
invitro culturing of promastigotes from aspirates
innoculation of aspirates in model organism - hamster
102
definitive diagnosis - detection of parasites
| what are the 2 ways to detect the parasite in visceral leish?
amastigotes in bone marrow or biopsy
| invitro culturing of promastigotes from aspirates
103
seriology diagnosis
| immunodiagnostics - method for dermal leish?
leishmanian skin test
- ---intradermal injection of killed promastigotes
- ---monitor for local delayed hypersensitivity
- ---development of erythema if leish +ve
104
seriology diagnostics
| immunodiagnostics - visceral (2)
- ---serological test direct agglutination
| - ----K39 dipstick
105
what is the frontline drug treatment against leish?
pentavalent antimonial
106
Pentavalent antimonial is a ___ ___ that is administered in its inactive state. It can only be activated by ____ form.
prodrug
| amastigote
107
Which species are more susceptible to pentavalent antimonial?
Luckily the species that cause the more severe form of the disease appear to be slightly more susceptible than the species which cause CL
108
How is pentavalent antimonial administered to the patient?
intramuscular or intravenous
109
what are the problems associated with pentavalent antimonial?
heavy metal drug
toxicity - fatigue, nausea, joint pain
may fail to clear parasiteimia - resistance in the field
110
how does pentavalent antimonial work?
activation can occur inside/outside the cell we dont know where as both forms of the drug can enter the cell
has to be converted to its trivalent form by amastigote
111
what does the trivalent antimonial do?
binds and conjugate with various targets, the trivalent form can inhibit trypanothione which has major implications for how these parasites can synthesise DNA and respond to oxidative stress
112
where do the most resistant cases to antimonial occur?
Bihar 50-65%
113
why are the parasites resistant (3)?
unrestricted availability - no public health system
incorrect dosages - dont have standards / monitoring
inconsistent quality
114
the mechansim of resistance in the field is unknown but how do leish parasites become resistant to antimonials in the lab?
growing cells on sub lethal levels of drug
| ABC transporter
115
see slides for antimonial resistance specifics
see slides for antimonial resistance specifics
116
what are 3 alternative drugs for leishmaniasis?
amphotericin B
Miltefosine
paromomycin
117
Amphotericin B
Was initially developed as an _____ ____, however it was discovered to be toxic. Played around with the formulation and placed the drugs in ____, these are ___ globules which you insert the drug into. This drastically ___ toxicity.
How does this drug function?
antifungal agent
mycells
lipid
reduced
Binds to 24-substituted sterols in the parasite membrane and essentially punches holes in the membrane, disrupting osmotic integrity of the membrane
118
Miltefosine
Developed as an __ ___, but was abandoned due to toxicity problems. It is the only drug which can be administered _____. Significant drawback of this drug is that it is ____ and therefore cannot be used by women of childbearing age.
The mode of action is uncertain
anti cancer drug
orally
tetratigenic (causes malformations in embryos)
119
Paromomycin
developed as an _____ to treat infections.
still undergoing clinical trials and so not clinically used unless all other drugs have failed.
Administered ___
antibacterial
| orally
120
Prevention and control of reservoir species? (2)
canine vaccinations
| culling in brazil of canines
121
What are 3 types of vector control?
insecticides
repellents
bed screens / nets
122
Why is vector control brilliant in theory but practice more difficult?
because it requires money and political will
