Introduction
Pathophysiology of cerebral malaria
Mechanical hypothesis
Permeability hypothesis
Humoral hypothesis
Blood–brain barrier impairment in cerebral malaria
Phenotype of brain and non-brain endothelial cells co-cultured with Plasmodium iRBCs in vitro
Endothelial cell type | Plasmodium strain | Evaluated parameters | Endothelial phenotype | Ref. |
---|---|---|---|---|
Porcine brain capillary endothelial cells (PBCEC) |
P. falciparum
| - ICAM-1, E-selectin expression; | - increased ICAM-1 and E-selectin | [99] |
- TEER; | - decreased BBB function; | |||
- tight junction expression | - tight junction disruption | |||
Human umbilical vascular endothelial cells (HUVEC) co-cultured with iRBC-fed peripheral blood mononuclear cells |
P. falciparum from patients with uncomplicated malaria, severe malaria, or CM
| mRNA expression of: | - increased adhesion molecule mRNA (not CM-specific); | [100] |
- adhesion molecules (ICAM-1, VCAM-1, E-selectin); | ||||
- reduced tight junction mRNA (CM-specific) | ||||
- tight junctions (occludin, vinculin, ZO-1) | ||||
TNF-α- or LT-α-activated human brain endothelial cell line (HBEC-5i) (with/without platelet co-culture) |
P. falciparum
| - permeability to 70-kDa dextran; | - increased BBB permeability; | [101] |
- TEER; | - decreased BBB function; | |||
- endothelial microparticle release; | - increased microparticle release; | |||
- endothelial apoptosis | - increased endothelial apoptosis (all effects potentiated by platelets) | |||
Human brain microvascular endothelial cells (HBMEC); HUVEC |
P. falciparum
| - ICAM-1 expression | increased ICAM-1 expression in HBMEC but not in HUVEC | [93] |
HBMEC |
P. falciparum
| - electrical cell substrate sensing; | - reduced BBB function; | [102] |
- TEER | - increased BBB permeability | |||
Human dermal microvascular endothelial cells (HDMEC); human lung microvascular endothelial cells (HLMEC) (with parasite sonicates or iRBCs) |
P. falciparum
| - immunofluorescence staining of ZO-1, claudin-5, VE-cadherin; | - loss in total protein content of claudin-5; | [103] |
- observation of inter-endothelial gaps in monolayers; | - redistribution of ZO-1 from cytoskeleton to membrane and cytosolic/nuclear fractions; | |||
- evaluation of pro-inflammatory response, direct cellular cytotoxicity or cell death. | ||||
- minimal inflammation and death (all effects only with sonicates) | ||||
HBMEC |
P. falciparum
| - expression of transcriptome (including ICAM-1 and pro-inflammatory molecules) | - increased expression of ICAM-1 and pro-inflammatory molecules | [104] |
HBEC-5i; immortalized human cerebral microvascular cell line hCMEC/D3 |
P. falciparum
| - immunofluorescent microscopy to evaluate malaria antigen presentation by endothelial cells; | - malaria antigen presentation by endothelial cells; | [56] |
- tight junction opening; | ||||
- TEER | - increased BBB permeability | |||
hCMEC/D3 |
P. falciparum
| - fluorescent permeability assay; | - increased BBB permeability; | [105] |
- expression of cell adhesion molecules and tight junctions | - increased ICAM-1 expression; | |||
- cytoadherence; | ||||
- altered ZO-1 distribution | ||||
TNF-α-activated subcutaneous fat tissue-derived EC from patients with uncomplicated malaria or CM |
P. falciparum
| - adhesion molecule expression (ICAM-1, VCAM-1, CD61, CD62-E) | - higher ICAM-1, VCAM-1, CD61; | [106] |
- enhanced microparticle release; | ||||
- microparticle production; | ||||
- induced MCP-1 and IL-6 release; | ||||
- MCP-1, RANTES, IL-6 release ; | - higher caspase-3 activation (all effects CM-specific) | |||
- caspase-3 activation | ||||
HBEC-5i | P. falciparum (various strains) | parasite strain selection assay based on cytoadherence | CM-associated cytoadherence | [107] |
Murine brain vascular endothelial cells (MBVEC) murine lung vascular endothelial cells (MLVEC) | P. berghei ANKA (CM model); P. berghei K173 (non-CM model) | - study of cytoadherence mechanisms; | higher VCAM-1-mediated cytoadherence in CM model compared to non-CM model | [108] |
Blood–brain barrier and in vivo animal models of cerebral malaria
Animal source | Plasmodium strain | Method to evaluate BBB integrity | Degree of impairment | Reference |
---|---|---|---|---|
Rhesus monkey (Macaca mulatta) |
P. knowlesi
| Examination of movement of proteins across the BBB by radiometric and fluorimetric methods | Increase of BBB permeability | |
Rhesus monkey (Macaca mulatta) |
P. fragile
| Electron microscopy, immunohistochemical analysis (CD36, thrombospondin, ICAM-1), formation of rosettes | Parasitized red blood cells sequestration and adherence to endothelial cells in the cerebral microvessels, neurological symptoms similar to humans | [112] |
Rhesus monkey (Macaca mulatta) |
P. coatneyi
| Clinical observation | Anemia, coagulopathy, and renal and metabolic dysfunction | [113] |
Rhesus monkey (Macaca mulatta) |
P. coatneyi
| Tissue samples from the brain (cortex and white matter of the cerebrum, cerebellum, and midbrain) collected for quantitation of mRNA expression of cytokines, adhesion molecules, and iNOS | Expression of pro-inflammatory and T helper-1 cytokines, adhesion molecules, and iNOS appears to predominate in the cerebellum of infected rhesus monkeys | [114] |
A/J and CBA/H mice | P. berghei (ANKA) | Detection of the movement of the dye Evans blue, radioisotope labelled albumin and erythrocytes | Breakdown of BBB | [115] |
mouse | P. berghei (K173) | Histochemical and histological evaluation of cerebral lesions and their distribution | Progressive deterioration of BBB integrity | |
CBA/T6, Balb/c and DBA/2 J mice | P. berghei (ANKA and K173) | Evaluation of neurological signs (ataxia, hemiplegia and coma) | Increased permeability of BBB | [119] |
Mouse | P. berghei (ANKA) | Multimodal magnetic resonance techniques (imaging, diffusion, perfusion, angiography, spectroscopy). | BBB breakdown | [120] |
CM- resistant BALB/c mice | P. berghei (ANKA) | Evaluation of pro-inflammatory cytokines produced | BBB breakdown | [121] |
C57BL/6 and BALB/c mice | P. berghei (NK65) | Histopathological analysis of cerebral tissue | Increased permeability of BBB | [122] |
TNF-α-and LT-α-deficient mice | P. berghei (ANKA) | Histochemical and histological evaluation | Neurological signs of CM, associated with perivascular brain haemorrhage in TNF-α -/- mice; completely resistant to CM in LT-α -/- mice | [47] |
Mouse | P. berghei (ANKA) | Examination of the outcome of TGF-β and TNF-α production in the context of splenocyte apoptosis | Critical balance between TGF-β and TNF-α might have a key role in BBB breakdown | [123] |
Different murine models: CBA/CaJ and Swiss Webster mice (CM sensitive), Balb/c and A/J mice (CM resistant) | P. berghei (ANKA) P. yoelii (17XL) P. berghei (NK65) and P. yoelii (YM) | Examination of histopathological alterations, BBB dysfunction, or neurological signs | CM related to the opening of paracellular-junctional and transcellular-vesicular fluid transport pathways at the neuroimmunological BBB | [124] |
Blood–brain barrier and human studies on cerebral malaria
Group type | Plasmodium strain | Number of patients per cohort | Method to evaluate BBB integrity | Degree of impairment | Reference |
---|---|---|---|---|---|
Thai patients |
P. falciparum
| 157 | Albumin CSF/serum ratio | BBB intact | [126] |
Vietnamese patients |
P. falciparum
| 20 | Albumin and Immunoglobulins G plasma/CSF ratios | Minimal BBB breakdown in a few cases of CM | [127] |
Zairean children |
P. falciparum
| 21 | Albumin CSF/serum ratio | BBB not impaired | [128] |
Malawian children |
P. falciparum
| 72 | Immunohistochemistry on autopsy brain tissues | Disruption of endothelial intercellular junctions and impaired BBB function | [129] |
Kenyan children |
P. falciparum
| 100 | Protein and immunoglobulin CSF/serum ratio | Mild BBB impairment in some cases | [130] |
Malawian children |
P. falciparum
| 50 | Immunohistochemistry on autopsy brain tissues | BBB breakdown | [131] |
Nigerian children |
P. falciparum
| 61 | Examination of the possible risk factors for poor prognosis and studies on post mortem samples | Cerebral edema and raised intracranial pressure in 50% | [132] |
Thai and Vietnamese children |
P. falciparum
| 65 | Studies on post mortem samples | Cerebral sequestration of P. falciparum-infected erythrocytes | [133] |
Vietnamese patients |
P. falciparum
| 20 | Studies on post mortem samples | Heterogeneous cerebral edema and plasma protein leakage | [134] |
Vietnamese adults and Malawian children |
P. falciparum
| 14 | Immunohistochemistry | Alteration of cell junction proteins occludin, vinculin and ZO-1 | [135] |
Kenyan children |
P. falciparum
| 14 | Computed tomography | Cerebral edema and ischemia | [136] |
French adults back from Cameroon, Niger, and Thailand |
P. falciparum
| 3 | Magnetic resonance | Hemorrhagic cortical lesions | [137] |
Malian children |
P. falciparum
| 8 | Computed tomography | Diffuse atrophy with asymmetrical ventricle dilation, suggesting limited CSF circulation | [138] |
French adult back from Equatorial Guinea |
P. falciparum
| 1 | Magnetic resonance | BBB breakdown | [140] |
Malawian children |
P. falciparum
| 14 | Computed tomography | Fatal CM: cerebral edema, large vessel infarcts; Non fatal CM with neurological sequelae: focal/multifocal atrophy | [141] |
Indian adults |
P. falciparum
| 4 | Magnetic resonance | Bithalamic infarctions with or without haemorrages | [142] |
Malawian children |
P. falciparum
| 120 | Magnetic resonance | increased brain volume; abnormalities in cortical, deep gray, and white matter structures | [143] |
Malawian children |
P. falciparum
| 38 | Magnetic resonance | periventricular and subcorical T2 signal changes, atrophy, and focal cortical defects |
Blood–brain barrier impairment in cerebral malaria: some reflections upon the available studies
Involvement of matrix metalloproteinases in cerebral malaria
Matrix metalloproteinases and animal models
Matrix metalloproteinases and human studies
Possible role of matrix metalloproteinases in pathophysiology and therapy of cerebral malaria
MMP | MMP substrate: junctions | Junction type |
---|---|---|
MMP-1 | Collagen I/II/III/VII/VIII/X; Aggrecan; Entactin; Tenascin | Cell-matrix adhesion |
MMP-3 | Collagen II/IV/IX/X; Claudin-5; E-cadherin; Elastin; Fibronectin; Laminin; Occludin; Selectin; ZO-1 | Cell-matrix adhesion; Adherens junctions; Tight junctions |
MMP-8 | Collagen I/II/III/V/VII/VIII/X; Claudin-5; Laminin; Occludin; ZO-1 | Cell-matrix adhesion; Tight junctions |
MMP-9 | Collagen IV/V/VII/X/XIV; Aggrecan; Claudin-5; E-cadherin; Elastin; Fibronectin; Laminin; Occludin; Vitronectin; ZO-1 | Cell-matrix adhesion; Adherens junctions; Tight junctions |
MMP-12 | Elastin; Fibronectin; Laminin; Proteoglycans | Cell-matrix adhesion |
MMP-13 | Collagen I/II/III/IV/V/IX; Aggrecan; Elastin; Fibronectin; Laminin; Tenascin | Cell-matrix adhesion |
MMP-14 | Collagen I/II/III; E-cadherin; αvβ4 integrin; Aggrecan; Fibronectin; Laminin; Vitronectin | Cell-matrix adhesion; Adherens junctions |
MMP | MMP substrate: cytokine | MMP substrate: chemokine |
---|---|---|
MMP-1 | IL-1β | CCL-2/MCP-1/JE |
TNF-α | CCL-25/TECK | |
MMP-2 | IL-1β | CCL-2/MCP-1/JE |
TGF-β | CCL-11/Eotaxin | |
TNF-α | CCL-25/TECK | |
CXCL-1/GRO-α/KC | ||
CXCL-2/GRO-β/MIP-2 | ||
CXCL-12/SDF- 1 | ||
MMP-3 | proIL-1β | CCL-2/MCP-1/JE |
proTNF-α | ||
MMP-7 | proTNF-α | |
MMP-8 | CCL-2/MCP-1/JE | |
CXCL-5/ENA-78/LIX | ||
MMP-9 | IL-1β | CXCL-1/GRO-α/KC |
IL2-R | CXCL-2/GRO-β/MIP-2 | |
TGF-β | CXCL-4/PF-4 | |
proTNF-α | CXCL-5/ENA-78/LIX | |
CXCL-10/IP-10 | ||
CXCL-12/SDF- 1 | ||
CCL-5/RANTES | ||
CCL-7/MCP-3/MARC | ||
CCL-17/TARC | ||
CCL-25/TECK | ||
MMP-10 | CCL-25/TECK | |
MMP-11 | CCL-25/TECK | |
MMP-12 | CXCL-3/GRO-γ | |
CXCL-9/MIG | ||
CXCL-10/IP-10 | ||
CXCL-11/I-TAC | ||
MMP-14 | proTNF-α | CXCL-8/IL-8 |
CXCL-12/SDF- 1 |