The American Journal of Tropical Medicine and Hygiene - Volume 46, Issue 2, 1992

Immunology. The first four papers in this issue are concerned with aspects of the immune response associated with a variety of infectious disease agents. Dumler and co-workers (see page 105) worked with human volunteers to demonstrate the development of a cell-mediated response with Rickettsia rickettsii after vaccination, challenge with virulent organisms or a combination of the two. Belgian investigators, using an experimental mouse model have been able to show that maternal influences can be detrimental to the offspring of mothers with chronic Trypanosoma cruzi infections. This impact reaches a maximum when offspring are exposed to both placental and lactating influences. Active visceral leishmaniasis is associated with antigen-specific immunosuppression, but there is a cell-mediated response in patients who have been cured of the disease. Investigators from Venezuela (page 123) report a delayed-type hypersensitivity in patients cured of the disease as well as in some of their relatives and neighbors.

It is with sadness and a great sense of loss that we announce the death on 19 January 1992 of Dr. William E. Tigertt. The American Society of Tropical Medicine and Hygiene will miss his counsel and expertise. Through a long career Bill made a lasting contribution to the Society and its goals. Clearly his value was most specifically expressed during his tenure as Editor of the American Journal of Tropical Medicine and Hygiene. Under his tutelage many positive changes were made. A monthly format was instituted and computer programs were developed and implemented which made it possible to manage and eventually publish an ever increasing number of manuscripts. His honesty and integrity were well-known and he provided the readership with a first-class publication which had international respect. He remained as Editor Emeritus and a very active member of the Editorial Board and was a ready source of advice and support which was found to be most valuable.

As a part of a study to evaluate a formalin-killed Rickettsia rickettsii vaccine, lymphoproliferative (LT) and delayed-type hypersensitivity (DTH) skin test responses to killed R. rickettsii were measured as correlates of cell-mediated immunity in volunteers who were vaccinated, challenged with R. rickettsii, or both. We detected LT responses in 26 (51%) of 51 volunteers after vaccination. After challenge, six of six unvaccinated volunteers and 12 of 16 vaccinated volunteers developed Rocky Mountain spotted fever (RMSF); all 22 mounted LT responses. The vaccinated individuals developed LT responses of greater magnitude and 1–2 weeks earlier than unimmunized controls (41,049 versus 15,084 mean net counts per minute [cpm]), suggesting that vaccination primed the cellular immune system. Moreover, development of LT responses postvaccination was associated with the amelioration of RMSF, as indicated by a slightly longer mean incubation period (328 hr versus 302 hr) and a shorter illness (19 hr versus 26 hr) in LT responders than in LT nonresponders. However, the postvaccination LT response did not discriminate between vaccinated individuals who resisted challenge and those who did not. Skin tests using killed R. rickettsii as antigen, performed in volunteers 14–17 months postvaccination or 12–15 months after challenge, revealed a weak but significant reaction in 50% of those who had received vaccine only, and a moderately strong reaction in all vaccinated and unvaccinated volunteers who had been challenged with R. rickettsii. The relationships between induction of protective immunity against intracellular bacteria by killed and replicating organisms and LT and DTH responses are discussed.

The course of Trypanosoma cruzi infection was studied in an experimental model, using the offspring of mice that were chronically infected with T. cruzi. When infected two months after birth, a higher mortality rate in heavily parasitized mice occurred in these offspring than in controls born to uninfected mothers. The harmful maternal influence reached a maximum when offspring were exposed both to prenatal (placental) and postnatal (lactating) influences. It was a reversible phenomenon that led to a T. cruzi-specific failure of the offspring to control the acute phase of the infection. Such features are suggestive of a maternally-induced impairment of the immune response of the offspring.

Active visceral leishmaniasis is associated with antigen-specific immunosuppression. However, cured patients develop a cellular immune response associated with resistance to reinfection. Recent studies have identified patients with asymptomatic or subclinical infections, which are also accompanied by an immune response. In order to identify subjects immune to Leishmania chagasi, we performed a skin-test survey in an endemic area in eastern Venezuela. The delayed-type hypersensitivity (DTH) response was assessed in patients cured of visceral leishmaniasis, as well as in their relatives and neighbors. Of the latter, 36 (34.2%) of 105 were positive and 26 (24.7%) of 105 gave intermediate responses. The DTH reaction correlated with age. The antigens recognized by a subgroup of cured patients, those with positive skin-test results, and controls (skin-test negative) were assessed by Western blotting with sera, and T cell immunoblotting with peripheral blood mononuclear cells. No consistent differences between the groups were noted in Western blots with L. chagasi antigens. T cell blots were performed on five patients from each group. For the cured patients and skin-test positive contacts, a significant proliferative response to fraction 12 (< 20.5 kDa) was noted in four of five patients in each group. Cells from three of five cured patients and two of five skin-test-positive patients proliferated in response to fraction 4 (73–115 kDa). The response to other fractions was variable, with only a minority of patients responding to any one fraction. These data suggest that the antigens recognized by patients with evidence of immunity to L. chagasi are quite variable. However, response to antigens in fraction 12 (≤ 20.5 kDa) was noted in most patients, and could be of significance in protective immunity.

Patients infected with schistosomes may develop a clinical picture of chronic salmonellosis. We have investigated the altered function of macrophages capable of playing a role in the development of chronic salmonellosis associated with Schistosoma mansoni in an experimental model. The capacity of mouse peritoneal macrophages to ingest and kill Salmonella was assessed in mice infected with S. mansoni with or without concurrent Salmonella typhimurium infection. Schistosomiasis was associated with a significant decrease in the phagocytic index of macrophages, due to the reduced number of cells engaged in phagocytosis. However, the number of bacteria ingested by these cells was comparable to that of the control group. The bactericidal capacity of macrophages from S. mansoni-infected mice was also significantly lower than that of cells from normal mice. Macrophages from animals infected only with Salmonella typhimurium showed an increased phagocytic capacity. It was concluded that S. mansoni infection alters phagocytosis and intracellular destruction of salmonellae. This demonstration of a novel mechanism of survival of salmonellae represents a step forward in understanding the pathogenesis and management of chronic septicemic salmonellosis.

Hydrogen breath tests were performed in Gabon (Central Africa) after a loading dose of lactose in 67 well-nourished African children (50 with intestinal parasites and 17 unparasitized) and in 18 unparasitized young adults. All had normal nutritional status, and none had diarrhea or digestive symptoms. Parasites that were found included Ascaris lumbricoides in 76% of the parasitized children, Trichuris trichiura in 58%, Giardia in 24%, Entamoeba histolytica in 20%, Schistosoma intercalatum in 16%, and Necator Americanus in 14%. A similar proportion of parasitized (64%) or unparasitized (62.8%) subjects were lactose malabsorbers. Giardia infection was associated with a higher, but not significantly different, proportion of lactose intolerance (10 of 12, 83.3%). The presence of infection with A. lumbricoides or T. trichiura did not increase the percentage of lactose malabsorption. These data indicate that a decrease of lactase activity in well-nourished African children is not related to the presence or the importance of Ascaris or other intestinal parasites if the nutritional status is normal.

The incidence and prevalence of histoplasmosis in Southeast Asia has not been extensively described. The first microbiologically documented case of disseminated histoplasmosis with cutaneous papulonodules in a 56-year-old woman from the Philippines is reported. She presented with fever and generalized papulonodular lesions in various stages, which evolved into vesicles with central necrosis that resembled molluscum contagiosum with an indurated erythematous halo. Biopsies revealed a granulomatous mass of lymphohistiocytic and epithelioid cells with intracellular budding yeast cells and dark nuclei. Cultures were positive for Histoplasma capsulatum. The patient was treated with amphotericin B (3 g) and 5-fluorocytosine (50 mg/kg/day), followed by ketoconazole (400 mg/day). Her clinical course was complicated by intractable hemolytic anemia that was initially treated with corticosteroids. A splenectomy was subsequently performed. Pneumonia and a brain abscess caused by Nocardia asteroides were secondary complications. Nine months after her admission, repeat testing was diagnostic for systemic lupus erythematosus.

This patient serves to re-emphasize that cutaneous lesions in an immunocompromised patient must be evaluated by biopsy and culture analysis. Disseminated histoplasmosis in the immunocompromised host may present with unusual cutaneous lesions, and must be considered even in a nonendemic area.

A case of fulminant disseminated pulmonary adiaspiromycosis is reported. The patient, a 35-year-old black male farm worker, presented with a four-week history of generalized weakness, unproductive cough, evening fever, and a weight loss of 8 kg. He died 12 days after hospitalization of respiratory failure due to granulomatous lung disease. The clinical and radiographic findings were indistinguishable from those of military tuberculosis. Microscopic examination of material obtained at autopsy revealed the large fungus characteristic of adiasporomycosis in the center of suppurative granulomas throughout the lungs. This is believed to be the first fatal case of pulmonary adiaspiromycosis reported in humans, and it may have been occupationally acquired.

Of 46 patients with clinical melioidosis, 35 (22 culture-positive and 13 culture-negative) had relatively uneventful disease courses, with elevated serum C-reactive protein (CRP) concentrations (> 5 mg/dl) that decreased with the commencement of appropriate antibiotic therapy, and continued to show an uninterrupted decrease (mean 29.4 days, range 12–52 days) to the normal range (< 1 mg/dl), with resolution of their infections. In five culture-positive patients with complicated disease courses, CRP concentrations remained elevated (> 5 mg/dl) until the underlying disorders were successfully managed, or until the antibiotic regimen was changed, and CRP values then decreased to the normal range. During surveillance, elevated CRP concentrations (> 10 mg/dl) led to the diagnosis of reactivation of infection in three afebrile patients, while the serum CRP values in other patients remained within the normal range in the absence of intercurrent complications. The CRP estimations may be helpful in ascertaining active infection in patients with low serum levels of specific IgM antibody, and serial measurements of serum CRP in patients with clinical melioidosis may be useful in determining the optimal duration of treatment and for detecting occult or unresolved infection with Pseudomonas pseudomallei.

Pap smears occasionally reveal protozoa of the genus Entamoeba in the uterus of intrauterine device (IUD) users, but definitive identification of the species involved has not been possible. Using riboprinting, a technique that compares ribosomal RNA gene sequences, we present evidence that the organism is Entamoeba gingivalis, an inhabitant of the mouth. Colonization most likely occurs via orogenital contact and requires the presence of an IUD and a concomitant bacterial infection.

We report on the clinical, epidemiologic, and laboratory characteristics of the first case of human ehrlichiosis acquired outside the United States caused by an Ehrlichia sp. other than E. sennetsu. The patient, a 24-year-old woman, presumably acquired the infection in Mali in northern Africa; the diagnosis was made when she returned to North America. The patient reported a fever and diarrhea a week before she left Mali; the diarrhea resolved, but the fever and chills continued. She also reported intermittent tingling in both hands and feet and muscle discomfort. Her temperature was 37.8°C and her pulse rate was 100 per minute. She had two erythematous maculopapules (0.5 × 0.7 mm) on her thigh and ankle that resembled infected insect bites. Her hemoglobin level was 148 g/l with normal indices, and her white blood cell count was 10, 500/mm3 with many atypical lymphocytes and platelets. This report is intended to increase physicians' awareness of ehrlichiosis in foreign travelers and other patients, and suggests the need for further research to determine the prevalence and distribution of this disease.

The effect of prophylactic doses of chloroquine on the phagocytic function of human monocytes was studied in young healthy male volunteers. They received placebo, 300, or 600 mg of chloroquine base/week for six weeks. In each subject, the phagocytic function was tested before and at the end of the chloroquine intake period. In the 600-mg chloroquine group, it was also tested six weeks after receiving the last dose. Chloroquine at both doses inhibited the phagocytosis of IgG-coated sheep red blood cells and of zymosan particles. The effect was more pronounced with the 600 mg dose of chloroquine. The phagocytic activity returned to normal values six weeks after the end of treatment.

The gametocytocidal and sporontocidal activity of three 8-aminoquinolines (primaquine, WR-238605, and WR-242511), three dihydroacridine-diones (floxacrine, WR-250547, and WR-250548), a 1, 4-naphthoquinone (menoctone), a synthetic aminoalcohol (halofantrine), and a guanide (WR-182393) was determined against a cloned line of Plasmodium berghei ANKA. Gametocytocidal activity was assessed by treating mice with a single intraperitoneal inoculation of a given compound (25 mg base drug/kg mouse body weight) four days after the mice were infected with P. berghei. Thin blood smears were made every other day, and the percent parasitemia and macrogametocyte and microgametocyte rates were determined. Floxacrine, menoctone, WR-242511, WR-250547, and WR-250548 effectively cleared sexual and asexual parasites from the peripheral circulation within six days of drug administration. Halofantrine, primaquine, WR-182393, and WR-238605 were ineffective at clearing P. berghei ANKA from circulating erythrocytes at the doses tested; however, mice survival time increased markedly with these compounds when compared with the controls. Significant numbers of macrogametocytes and microgametocytes were present throughout the duration of the infection in mice treated with halofantrine, primaquine, WR-182393, and WR-238605. Sporontocidal activity was evaluated by allowing Anopheles stephensi mosquitoes to feed on P. berghei-infected mice 90 min after treatment with a particular drug. Halofantrine and WR-182393 exhibited no sporontocidal activity, while floxacrine, menoctone, primaquine, WR-238605, WR-242511, WR-250547, and WR-250548 exhibited significant activity. Minimum effective doses (mg base drug/kg of mouse body weight) that prevented mosquitoes from developing sporozoite-infected salivary glands were 0.1563 mg/kg for WR-250547, 0.625 mg/kg for menoctone, 1.25 mg/kg for primaquine, 10 mg/kg for floxacrine, 10 mg/kg for WR-242511, 10 mg/kg for WR-250548, and 25 mg/kg for WR-238605.

Brugia malayi-infected microfilaremic jirds (Meriones unguiculatus) were treated with ivermectin at a single dose of 200 µg/kg of body weight injected subcutaneously. Susceptible Aedes aegypti mosquitoes were fed on treated jirds 24 hours later. Mosquitoes fed on untreated jirds served as controls. Infected mosquitoes were dissected at 1, 3, 24, 48, 72, and 96 hr after the blood meal, and differential counts of sheathed microfilariae, exsheathed microfilariae, and cast sheaths were performed using fluoresceinated wheat germ agglutinin. Microfilariae failed to exsheath in mosquitoes fed on ivermectin-treated jirds. Microfilariae from ivermectin-treated jirds also did not exsheath in vitro in the presence of 10 mM CaCl2, whereas 85–90% of sheathed microfilariae from untreated jirds exsheathed in vitro. In addition, sheathed microfilariae from untreated jirds, when pretreated in vitro with ivermectin at 0.25, 0.5, or 1 µg/ml, lost their ability to exsheath in vitro in the presence of 10 mM CaCl2. However, ivermectin treatment had no effect on exsheathing of microfilariae when incubated with papaya protease. Thus, ivermectin appears to inhibit the intrinsic exsheathing process of microfilariae in the mosquito host, thereby blocking their development and further transmission of infection.

Onchocerca volvulus worms in nodules from Guatemalan patients treated with four, eight, or 11 single doses of ivermectin (150 µg/kg of body weight) that were given once every three months were examined by routine histologic techniques and compared with worms in control nodules from untreated persons living in the same location over the same time periods. All treated nodules were removed four months after the last dose of ivermectin, i.e., 13, 25, or 34 months after the start of the trial. At the 25th and 34th months, i.e., after the eighth or eleventh doses of ivermectin, there were excess mortalities in female worms of 25.5% and 32.6%, respectively, over and above the levels in controls. Furthermore, the proportions of live females still producing scanty embryos up to the gastrula stage were only 7.7% and 18.2%, and no females were producing microfilariae. Ivermectin given at 3-month intervals also reduced significantly the mean numbers of live male worms in nodules, as well as the proportions of inseminated females. This regimen was effective in preventing embryogenesis to the microfilarial stage while, at the same time, it caused a slow but steady attrition of the adult worms.

A shuttle plasmid was developed that is capable of replicating both in Escherichia coli and in Rhodococcus rhodnii, a bacterial symbiont of the Chagas' disease vector Rhodnius prolixus. We have been able to transform R. rhodnii with this plasmid, infect aposymbiotic R. prolixus with the transformed symbiont, select with the antibiotic thiostrepton, and re-isolate genetically altered symbionts from the insects following successive molts. Symbiotic bacteria are potentially valuable as vehicles for the stable introduction of foreign genes into insects with the goal of eventually altering the ability of the insect to transmit a pathogenic agent.

Transmission electron microscopy was used to examine replication of the New Jersey serotype of vesicular stomatitis virus (VSNJ) (Rhabdoviridae: Vesiculovirus) in Lutzomyia shannoni (Diptera: Psychodidae), a recently implicated sand fly vector. Following ingestion of an infectious blood meal, female sand flies were fixed and examined at approximately 12-hr intervals for six days. The New Jersey serotype of vesicular stomatitis virus was first detected in the abdominal midgut after 34 hr of incubation. Virus next appeared in fat body and the thoracic midgut at 48 hr, while salivary glands first contained visible virus in apical cavities 5–6 days after infection. Flight muscles and nervous tissue occasionally contained small numbers of VSNJ virions, while virus was never detected in the ovaries or malphigian tubules.

The midgut and fat body appeared to be major sites of VSNJ virus replication. In all tissues examined, virus matured primarily by budding from the plasma membrane. Virions were occasionally observed within vacuoles, along with nucleocapsids. In the midgut, budding occurred exclusively from the basolateral plasma membrane, while maturation in salivary gland cells involved apical budding. Accumulation of virions adjacent to basal laminae surrounding several tissues suggested that this structure physically impedes virus dissemination within the sandfly. The paucity of virus budding 120–144 hr after infection suggested that the VSNJ virus infection was modulated in Lu. shannoni.

The life cycle of Leishmania panamensis in Phlebotomus papatasi was studied to characterize barriers limiting parasite colonization, differentiation, migration, and attachment in an unnatural sand fly host. The insects were fed a suspension of L. panamensis-infected macrophages and human erythrocytes, and were examined up to 16 days post-infection by light and electron microscopy. Histologic examination of 401 flies showed the peritrophic membrane to be the first important barrier to parasite establishment in the gut lumen. In most flies, parasites were unable to escape from the closed peritrophic sac, which was either excreted or retained intact in the midgut. After five days, only 31% of the flies were infected; attached parasites colonized the pylorus-ileum and/or colon regions of the hindgut. Anterior migration into the cardia region of the midgut occurred in < 1% of infected flies; no parasites colonized the foregut. In the bloodmeal and residual bloodmeal, five morphologic forms developed from ingested amastigotes: stumpy, spatulate, elongate, short nectomonad promastigotes, and paramastigotes. Abnormal retention of amastigotes in macrophages and delayed development of promastigote stages was observed. The primary form attached in the hindgut was a pear-shaped haptomonad promastigote. Differentiation of L. panamensis in Ph. papatasi appeared to be similar to that described in natural hosts, except that metacyclic infective forms were not observed, and some forms developed in unusual locations. Phlebotomus papatasi was a partly refractory biological host for L. panamensis. The peritrophic membrane adversely affected the infection rate; rare anterior migration and a lack of metacyclic promastigotes may preclude transmission by bite.

The paracentric inversion polymorphisms of Anopheles gambiae and An. arabiensis populations in the Kisumu area of western Kenya were studied in relation to parameters of Plasmodium falciparum transmission. Anopheles gambiae (n = 1, 387) was polymorphic for inversions b on chromosomal arm 2R and a on arm 2L, with frequencies of the inverted arrangements of 17% and 43%, respectively. Anopheles arabiensis (n = 484) was polymorphic for inversion b on chromosomal arm 2R and a on 3R, with frequencies of the inverted arrangements of 58% and 5%, respectively. Observed karyotypic frequencies did not deviate from Hardy-Weinberg equilibrium, indicating a condition of panmixia (i.e., random mating) for both species. The overall degree of intraspecific polymorphism was low, confirming findings from other zones of East Africa. No significant differences in inversion frequencies of either An. gambiae or An. arabiensis were observed, either between collecting sites or between similar sampling periods of consecutive years. At the same time, a stable, significant two-fold difference in Plasmodium infection rates was detected among An. gambiae carriers of different inversion karyotypes on chromosome 2. A significant non-uniform distribution of human- and bovid-fed specimens was also detected among the carriers of different 2Rb inversion karyotypes in indoor resting An. arabiensis. Relationships among inversion karyotypes of the two major malaria vectors in the An. gambiae complex and key factors affecting malaria transmission intensity emphasize that intraspecific variation could contribute significantly to the diversity and stability of malaria vectorial systems in Africa.