[Strategies for the diagnosis and treatment of prenatal toxoplasmosis - a survey]. / Strategien zur Diagnostik und Behandlung der pränatalen.

Today, a decreasing number of infants with prenatal toxoplasmosis present with clinical signs of severe, generalised infection and cerebral involvement. The favourable clinical outcome - mild or subclinical infection - is considered to be an effect of early maternofetal treatment with spiramycin and pyrimethamine/sulfadiazine (PS). However, a Cochrane Review and a recently published European multicentre study on congenital toxoplasmosis did not only question this positive effect but also the efficiency of a postnatal long-term therapy. Both studies caused much confusion among neonatologists and paediatricians. The new setting requires an update of the diagnostic possibilities and different therapeutic strategies for prenatal toxoplasmosis. Only few prospective studies are available to compare the efficiency of different drug regimens in infected infants. However, clinical data demonstrate that the available therapeutics are not curative and cannot prevent late sequelae. Follow-up studies in pregnant women and their offspring show that prenatal parasite detection does not predict an unfavourable clinical outcome when treatment is initiated early after diagnosis. In Germany, prenatal screening is not obligatory. In case of primary maternal infection, materno-fetal therapy is recommended. A combination therapy consisting of PS is considered more effective than a spiramycin monotherapy. Treatment is recommended for all infected newborns with different strategies for infants with or without clinical symptoms. The treatment strategies of different European countries are discussed. This paper provides recommendations for the diagnosis and treatment of newborn toxoplasmosis and materno-fetal infection as well as recommendations for the clinical management of infected neonates and their follow-up, including drug monitoring.

Targeting enzymes involved in spermidine metabolism of parasitic protozoa--a possible new strategy for anti-parasitic treatment.

Sequencing data obtained from the Plasmodium, Anopheles gambiae and human genome projects provide a new basis for drug and vaccine development. One of the most characteristic features in the process of drug development against parasitic protozoa is target identification in a biological pathway. The next step must be a structure-based rational drug design if the target is not only present in the parasite. In mouse models of malaria, such drugs should be tested for efficacy of the new therapies. Here, we present data that pinpoint the existence of two enzymes of the polyamine pathway involved in spermidine metabolism in P. falciparum, i.e. deoxyhypusine synthase (DHS; EC 1.1.1.249) and homospermidine synthase (HSS; EC 2.5.1.45). Recent data obtained from the malaria genome databases showed that at least a putative gene encoding DHS is present in the parasite. Sequencing data from the P. falciparum genome project prove that the eukaryotic initiation factor eIF5A (the substrate for DHS) exists in P. falciparum. Here, we present the amino acid sequence of eIF5A from P. vivax, which causes tertiary malaria. EIF5A from P. vivax shows 82% nucleic acid and 97% amino acid identity to its homologue from P. falciparum. GC/MS data and inhibitor studies with agmatine prove that the triamine homospermidine occurs in the parasite. These data suggest a separate locus encoding HSS in P. falciparum. The hss gene recruits from the dhs gene in eukaryotes. Here, we present genomic DNA fragments obtained by amplification with primers of a conserved region (amino acid positions 550-1,043) between the putative P. falciparum DHS gene ( dhs) and the HSS gene ( hss) from the plant Senecio vulgaris (Asteraceae). The amplification product from different P. falciparum strains reveals differences in sequence identity, compared with the putative dhs gene from P. falciparum strain 3D7. Expression of the full-length clone and determination of HSS-specific activity will finally prove whether a separate region encoding HSS exists.

A case of imported paracoccidioidomycosis in a German legionnaire.

We report on a case of the chronic form of paracoccidioidomycosis with swelling and ulcerations of the mouth in a German legionnaire who also suffered from a chronic bronchitis. The patient had worked for many years in Brazil, an area endemic for the disease. Infection due to Paracoccidioides brasiliensis was diagnosed in Germany, more than 10 years after the patient's return. Diagnosis was established by the presence of yeast cells with multipolar budding in the tissue of the oral lesion. Furthermore, the fungus was grown in a liquid Leishmania culture medium. Identification of the fungus was based on morphology and genetic sequencing. Furthermore, IgG antibodies against a 43-kDa antigen of P. brasiliensis were detected in a western blot. After itraconazole therapy (400 mg day(-1)) for 4 weeks, the lesions had disappeared almost completely, but the therapy was continued for further 5 months to avoid relapse of the infection.

The necessity to develop drugs against parasitic diseases.

This review focuses on the most significant trends in the development of drugs for the treatment of malaria, African sleeping sickness and toxoplasmosis. In the case of malaria, those include new fixed-dose artemisinin combinations, antifolates and new targets in the apicoplast of Plasmodium falciparum. Targets in the treatment of trypanosomiasis are the biosynthesis of glycosylphosphatidylinositol and enzymes involved in the biosynthesis of trypanothione. Efforts to develop a vaccine against toxoplasmosis are discussed as well.

Effect of drugs inhibiting spermidine biosynthesis and metabolism on the in vitro development of Plasmodium falciparum.

Treatment of Plasmodium falciparum with the potent inhibitor dicyclohexylamine completely arrests in vitro cell proliferation of the chloroquine-susceptible P. falciparum strain NF54 and the R strain, which shows less sensivity to chloroquine. The average inhibitory concentration (IC50) values determined for both strains revealed different inhibition profiles. The IC50 value for the chloroquine-sensitive NF54 strain was 97 microM and 501 microM for the R strain. Monitoring polyamine pools after treatment with dicyclohexylamine leads to a significant decrease in the intracellular spermidine content, which was nearly reversed by supplementation with spermidine. Since spermidine is an important precursor for the biosynthesis of hypusine and homospermidine in eukaryotes, we studied the developmental effect on both P. falciparum strains of 1,7-diaminoheptane as an inhibitor of deoxyhypusine synthase (EC 1.1.1.249) in mammalian cells, and agmatine as a moderate inhibitor of homospermidine synthase (EC 2.5.1.44). Inhibition profiles with 1,7-diaminoheptane resulted in an IC50 value of 466 microM for the NF54 strain and 319 microM for the R strain. Spermidine pools changed significantly. Inhibition with agmatine caused a strong decrease in parasitemia for the chloroquine-susceptible NF54 strain, with a determined IC50 value of 431 microM and an IC50 value of 340 microM for the less chloroquine-susceptible R strain. Spermidine was not detectable after inhibition. The uncommon triamine homospermidine occurred in both P. falciparum strains. To our knowledge this is the first evidence of homospermidine in P. falciparum. The use of specific inhibitors of spermidine metabolism might be a novel strategy for the design of new antimalarials, and suggests the occurrence of both enzymes in the parasite.

[Painless acanthamoeba keratitis]. / Akanthamöbenkeratitis ohne Schmerzen12.

BACKGROUND: Acanthamoeba keratitis is a severe, painful corneal infection found in contact lens wearers. The entity can easily be confused with herpetic or fungal keratitis, especially if no ocular pain is reported. HISTORY AND SIGNS: A 32-year old myopic female presented a unilateral keratitis of unknown etiology since 3 weeks. Administration of topical antiviral substances and corticosteroids led only to temporary improvement of the condition. The patient complained of photophobia but not of ocular pain. The affected eye showed corneal edema, central stromal thickening, descemet's striae as well as fibrin deposits on the corneal endothelium and in the anterior chamber. DIAGNOSIS: An aqueous specimen was negative for a viral infection. A culture for bacteria was negative. Staphylococci were cultured from corneal scrapings and Enterococci from the contact lens solution. Another corneal scraping revealed Acanthamoeba class II (6 weeks after the onset of symptoms). CLINICAL COURSE: Under treatment with propamidine, polymyxin b, neomycin, gramicidin and polyhexidine (topical) as well as fluconazole/ketoconazole (systemic) the diameter of the annular infiltrate, which had developed decreased, but the infiltrate persisted. In the further course, the infiltrate persisted while the amount of fibrin in the anterior chamber increased. Penetrating keratoplasty was performed. Histologic examination of the host corneal tissue revealed massive infiltration with Acanthamoeba. CONCLUSIONS: Severe pain and history of wearing contact lenses are features suggestive of Acanthamoeba keratitis. The patient presented here had a history of contact lens wear, but no ocular pain was reported. The characteristic annular infiltrate had a late onset. Bacterial superinfection could not be ruled out. Therapeutic penetrating keratoplasty had to be performed as the condition deteriorated inspite of intensive chemotherapy. With penetrating keratoplasty a good visual acuity could be regained.

Localized lymphadenopathy due to leishmanial infection.

A 25-year-old female patient presented with an isolated cervical lymph node enlargement several months after having returned from Spain and Latin America. She had no other signs or symptoms of disease. Leishmania infantum/chagasi was identified as the causative agent. With extended travel activities localized lymph node enlargement due to leishmanial infection should be included in the differential diagnosis of lymphadenopathy of unknown origin.

Vannella sp. harboring Microsporidia-like organisms isolated from the contact lens and inflamed eye of a female keratitis patient.

Viable Hartmannella sp. and two strains of Vannella sp.--but no Acanthamoebae--multiplied on NN-agar inoculated with pieces of the contact lens from a female keratitis patient. Within the cytoplasm of one Vannella isolate, intracellular parasites could be observed whose earliest stages were developing within the nucleus, resembling those Microsporidia-like parasites seen within Vannella isolated recently from a warm tapwater system. This assumption was also confirmed by electron microscopy. In swabs taken directly from the cornea, Pseudomonas aeruginosa were identified, but they did not yield any growth of amebas in culture. However, cocultivation of parasite-free Vannella strains with the above-mentioned swab matter resulted in infected amebas harboring the same intracellular parasites seen before. This infection could be established only if the corresponding spores were present as infective agents in the swab matter. The successful treatment of the patient with antibiotics supports the assumption that P. aeruginosa was the main cause of the corneal ulceration. The extent to which the Microsporidia-like organisms may have been involved in the development of keratitis remains a matter of discussion.

Extrahepatic alveolar echinococcosis without liver involvement: a rare manifestation.

BACKGROUND: Alveolar echinococcosis (AE) primarily affects the liver and extrahepatic disease is considered the consequence of a secondary infection via metastatic spread from the hepatic focus. PATIENTS: Two patients with extrahepatic AE without liver involvement are presented. The first case is a patient with AE of the spleen and a small pulmonary calcification. In the second case exclusive affection of the spine was observed. DISCUSSION: Various pathogenetic explanations for hepatic omission appear plausible: a passage of oncospheres through hepatic sinuses without causing disease, a passage via lymphatic vessels or via portocaval anastomoses and the vascular passage in a retrograde fashion. Extrahepatic manifestation of AE without apparent liver involvement is rare. However, AE should be taken into account among other differential diagnoses even in cases of extrahepatic lesions without liver involvement.

Is stage conversion the initiating event for reactivation of Toxoplasma gondii in brain tissue of AIDS patients?

Reactivation of chronic toxoplasmosis resulting in Toxoplasma encephalitis (TE) is a common event in acquired immune deficiency syndrome (AIDS) patients. Conversion from Toxoplasma gondii bradyzoites to tachyzoites is a prerequisite for reactivation. Until recently, the study of stage conversion in human tissue was not possible due to the lack of antibodies that recognize stage-specific epitopes after long-term formaldehyde fixation. Using the combination of a polyclonal anti-T. gondii antibody, the cyst-stage-specific monoclonal antibody CC2, and a tachyzoite-specific polyclonal antibody (anti-SAG1, recombinant), we tried to demonstrate parasite differentiation in the brain tissue of 10 AIDS patients with clinically suspected TE. Double labeling of the stage-specific antibodies enabled us to demonstrate interconversion between tachyzoites and bradyzoites for the first time in human tissue. The study confirmed that the transformation process is nonsynchronous and that the manifestation of TE depends on the degree and site of tissue destruction caused by invading tachyzoites. The original source of tachyzoites could never be located, but a few samples suggested that tachyzoites may invade by dissemination across the blood-brain barrier. Cyst rupture as the first event in the process of reactivation was not seen. We conclude that the initial site(s) of reactivation will be destroyed by tissue-destructive tachyzoites long before clinical symptoms occur.

Ribosomal RNA of Nosema algerae and phylogenetic relationship to other microsporidia.

Microsporidia are intracellular parasites that are common in invertebrates. Taxonomic classification is mostly restricted to morphologic and physiologic data. Limited data are available about taxonomic classification using DNA-sequence data for analysis. We examined the small-subunit (SSU) rDNA, the intergenic spacer (ITS) region, and a part of the large-subunit (LSU) rDNA of Nosema algerae, a parasite of mosquitoes, taken from a laboratory colony of Anopheles stephensi. Target gene amplifications were done by polymerase chain reaction (PCR) and, after cloning, DNA fragments were sequenced. The SSU-rDNA sequence obtained was aligned with several other microsporidian SSU-rDNA sequences available from the GenBank or EMBL data bases and was analyzed by different methods. On the basis of the results of our phylogenetic analysis, we suggest that our N. algerae isolate is not closely related to other microsporidia belonging to the genus Nosema.

The past and present role of the Sabin-Feldman dye test in the serodiagnosis of toxoplasmosis.

The dye test for the detection of Toxoplasma-specific antibodies was first described by Sabin and Feldman 50 years ago. The test is highly specific and sensitive and considerable information is available on the development and persistence of dye test antibodies after primary Toxoplasma infection. However, the test uses live Toxoplasma gondii and is now only employed in a few laboratories. It is still the reference method for the serodiagnosis of toxoplasmosis, and a multicentre study comparing dye test results between different laboratories was much needed. We report in this article the results of a multicentre evaluation of the test involving nineteen laboratories in eight countries. The study revealed overall satisfactory standardization between the laboratories, but there were differences in the test protocols, the use of reference/standard preparations and the interpretation of results. There is still no agreement on the level of dye test values which reflect infection with the parasite, and conversion from titres to international units (IUs) did not improve standardization. However, the results indicated that a value of > 4 IU or a titre of 1:16 met the definition of positivity of most participants. We recommend that the dye test be retained as a reference method and that interlaboratory standardization be improved by the use of a common protocol and the expression of results in titres.

In vitro replication of Nosema algerae (Microsporidia), a parasite of anopheline mosquitoes, in human cells above 36 degrees C.

Microsporidia form a large and ubiquitous group of obligately intracellular parasitic eukaryotes, increasingly recognized as pathogens in humans. Transmission of invertebrate microsporidia to mammals has been considered impossible because temperature seemed to be a limiting factor for development. Nosema algerae, a microsporidian of anopheline mosquitoes, was cultured in human muscle fibroblasts at temperatures of 31 degrees C and 38 degrees C. This is the first record of an invertebrate microsporidian developing in human cells at a temperature above 36 degrees C. The ultrastructure of N. algerae growing in human muscle fibroblasts is similar to that of Brachiola vesicularum, a microsporidian species previously described in the muscle of an AIDS patient.

50 años de Sabin-Feldman test. Comentarios referents a la especificidad y la sensibilidad del "Golden standard" / Fifty years since the Sabin-Feldman test: specificity and sensibility of the \"golden standard\"

Con motivo de cumplirse los 50 años de la descripción del Dye test por Sabin y Feldman, se comentan los trabajos en los que se evalúa la especificidad del método. Además, se enumeran las propiedades de esta reacción serológica aplicada al estudio de la toxoplasmosis, y que se considera como el gold standard" para el diagnóstico de la parasitosis

50 años de Sabin-Feldman test. Comentarios referents a la especificidad y la sensibilidad del "Golden standard" / Fifty years since the Sabin-Feldman test: specificity and sensibility of the "golden standard"

Con motivo de cumplirse los 50 años de la descripción del Dye test por Sabin y Feldman, se comentan los trabajos en los que se evalúa la especificidad del método. Además, se enumeran las propiedades de esta reacción serológica aplicada al estudio de la toxoplasmosis, y que se considera como el gold standard" para el diagnóstico de la parasitosis

Growth-stimulating influence of human chorionic gonadotropin (hCG) on Plasmodium falciparum in vitro.

In this study, it is reported that human Chorionic Gonadotropin (hCG), being one of the most important hormones of pregnancy, has a growth-stimulating effect on the asexual stages of Plasmodium falciparum in vitro. On the one hand, it is shown that the effect of the hormone is dose-related: The highest growth-rates of Plasmodium falciparum in vitro are achieved, when doses of 8.32 i.u./ml (= 50 i.u. hCG/6 ml) and 16.67 I.U./ml (= 100 i.u. hCG/6 ml) are added to the culture medium. These doses correspond to the physiological peak amounts of hCG between the 9th and 16th week of pregnancy, when parasitaemia also reaches its highest rate. On the other hand, it is shown, that any growth-stimulating effect disappears after inactivation of the hormone by heating at 120 degrees C for 20 minutes. These data support the hypothesis, that hCG does not only possess immunosuppressive properties acting on the response of T-lymphocytes, but also increases the growth of Plasmodium falciparum in vitro. The combination of both effects may explain why malaria still remains one of the most serious complications of pregnancy.

Seasonal density, sporozoite rates and entomological inoculation rates of Anopheles gambiae and Anopheles funestus in a high-altitude sugarcane growing zone in Western Kenya.

An entomological study was conducted on vectors of malaria and their relative contribution to Plasmodium falciparum transmission in Mumias, a high-altitude site and large-scale sugarcane growing zone in Kakamega district, western Kenya. Anopheles gambiae s.l., the predominant vector species, represented 84% (n=2667) of the total Anopheles mosquitoes collected with An. funestus comprising only 16%. Polymerase chain reaction (PCR) identified all 600 specimens of the An. gambiae complex tested as An. gambiae sensu stricto, an indication that it is the only sibling species represented in the high-altitude sites in western Kenya. Plasmodium falciparum sporozoite rates of 6.3% (133/2118) for An. gambiae s.l. and 9.5% (38/402) for An. funestus by ELISA were obtained in Mumias. None of 1600 mosquitoes tested for P. malariae sporozoites was positive. ELISA tests of mosquito blood meals indicated a high tendency of anthropophagy, a behaviour contributing significantly to malaria transmission by the vector species, with 95.9%, 4.86% and 0.2% having taken at least one blood meal on human, bovine and avian hosts, respectively Malaria transmission intensity was low as revealed by the low entomological inoculation rates (EIR) recorded. The EIR values for An. gambiae s.l. were 29.2 infective bites per person per year (ib/p/year) and 17.5 ib/p/year for An. funestus in Mumias. The highest inoculation rate for both vector species was 7.0 ib/p/month in July. Plasmodium falciparum parasite rate among asymptomatic children was 55.4% and 44% in the wet (July-September) and dry (December-February) seasons, respectively. These results indicate that malaria transmission intensity in the high-altitude site is low but perennial, with transmission being maintained by An. gambiae s.s. and An. funestus.