Helminth parasites alter protection against Plasmodium infection

Abstract

More than one-third of the world's population is infected with one or more helminthic parasites. Helminth infections are prevalent throughout tropical and subtropical regions where malaria pathogens are transmitted. Malaria is the most widespread and deadliest parasitic disease. The severity of the disease is strongly related to parasite density and the host's immune responses. Furthermore, coinfections between both parasites occur frequently. However, little is known regarding how concomitant infection with helminths and Plasmodium affects the host's immune response. Helminthic infections are frequently massive, chronic, and strong inductors of a Th2-type response. This implies that infection by such parasites could alter the host's susceptibility to subsequent infections by Plasmodium. There are a number of reports on the interactions between helminths and Plasmodium; in some, the burden of Plasmodium parasites increased, but others reported a reduction in the parasite. This review focuses on explaining many of these discrepancies regarding helminth-Plasmodium coinfections in terms of the effects that helminths have on the immune system. In particular, it focuses on helminth-induced immunosuppression and the effects of cytokines controlling polarization toward the Th1 or Th2 arms of the immune response.

Figure 1

Representation of the course of Plasmodium chabaudi infection. Early infection with the erythrocytic stage is characterized by the production of proinflammatory cytokines, such as IL-12 and TNF-α, and a pronounced IFN-γ response. In addition, NO produced by Mφ helped control parasitemia (1). IFN-γ activates Mφ-mediated responses, in particular phagocytosis and elimination of pRBC (2). CD4⁺ T cells, together with B cells, are crucial for developing efficient protection (3). Th1 production is downregulated later by an increased Th2-type immune response following primary infection (4). In a later stage of infection, after the peak parasitemia has been reached, CD4 T cells switch from a Th1 to a Th2 cytokine profile (5). This switch helps B cells produce antibodies (6). The antibodies inhibit the invasion of RBCs by the parasites, opsonize parasitized RBCs, or block pRBC adhesion to the vascular endothelium (7, 8). The slow late switch from noncytophilic (IgM and IgG2a) (7) to cytophilic subclasses (i.e., IgG1 and IgG3) (8) is involved in parasite elimination (9). However, IgE correlates with protection against severe malaria. Figure modified from Langhorne et al. 2004 [75] and Stevenson and Urban 2006 [67].

Figure 2

Helminth infections are strong inducers of a Th2-type immune response. These infections are characterized by the expansion and activation of eosinophils, basophils, and mast cells (1). Their upregulation due to high levels of immunoglobulin E (IgE) and the proliferation of T cells that secrete IL-4, IL-5, IL-9, and IL-13 are part of the host immune response against the parasite (2). However, helminth infections tend to be long-lived and largely asymptomatic because helminth infections are sustained through a parasite-induced immunomodulatory network, in particular through activation of regulatory T cells (3) and systemically elevated levels of IL-10 produced by B regulatory cells (4). They are additionally affected by the expression of the regulatory cytokines IL-10 and TGF-β, produced by regulatory dendritic cells (5) and alternatively activated Mφ (AAMφ) (6).

Figure 3

Concomitant helminth infection modified the immune response and susceptibility to Plasmodium infection. Helminth parasites have developed complicated strategies to infect and successfully colonize their host. (1) In an acute helminth infection, an initial Th1-like immune response (i.e., IFN-γ, IL-12, and classical activation macrophage (CAMφ)) is associated with low parasite growth. (2) However, as the parasite colonizes the host, the immune response rapidly shifts toward a Th2-dominant response (IL-4, IL-5, IL-10, IL-13, and AAMφ) in parallel with increased helminth parasitemia. (3) This “immune environment” determined by helminth infection modifies the immune response and the susceptibility to Plasmodium. That is, acutely helminth-infected mice exhibited (2) decreased transmission of Plasmodium (2.1), decreased parasitemia and increased survival (2.2) due to high levels of IFN-γ and TNF-α in the early stage. However, this immune response increased mortality during the chronic stage of malaria (2.3) and increased severe pathology, such as ECM and severe malaria anemia (SMA) (2.4). In contrast, chronically helminth-infected mice (3) increased the transmission of Plasmodium (3.1), parasitemia and mortality (3.2) due to high levels of IL-4, IL-10, and TGF-β and low levels of IFN-γ and TNF-α. However, during the course of the coinfection, the Th1 response against Plasmodium was increased. In fact, a mixed Th1/Th2 response during the chronic stage induced low levels of parasitemia and was asymptomatic (3.3). Interestingly, chronic helminth infections inhibited severe pathologies caused by Plasmodium, such as ECM and SMA (3.4), and increased the survival due to a decreased inflammatory response. Abbreviations: Schistosoma mansoni (Sm), Heligmosomoides polygyrus (Hp), Echinostoma caproni (Ec), Strongyloides ratti (Sr), Nippostrongylus brasiliensis (Nb), Litomosoides sigmodontis (Ls), Brugia pahangi (Bp), and Trichinella spiralis (Ts).