For personal use. Only reproduce with permission from The Lancet Publishing Group.

THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 472

Malaria is still a major cause of severe disease which is
responsible for millions of deaths, mostly in children under 5
years old, in tropical countries, especially sub-Saharan
Africa. Complications of severe anaemia and cerebral
malaria are thought to be the major cause of morbidity and
mortality but recent evidence suggests that the hosts
immunological response could also contribute to the
pathophysiology of the disease in human beings. Intensive
studies of the immune response to malaria parasites in
human beings have provided a wealth of information about
the cells and cytokines implicated in the pathophysiology of
survival and fatal outcome in severe infections. This review
focuses on the pivotal role of macrophages and other
important cellular effectors, molecules, and cytokines
involved in the activation of the immune response at the
different stages of human falciparum malaria. Our
understanding of the putative mechanisms by which
cytokines may mediate beneficial and harmful effects,
through activation of phagocytic cells, could help to develop
new treatment strategies, regardless of the emergence of
parasite multidrug resistance.
Lancet Infect Dis 2002; 2: 47278
Malaria is a disease caused by an intracellular parasitic
protozoa of the genus Plasmodium and is transmitted via
the bite of an infected female Anopheles sp mosquito. The
Plasmodium falciparum life cycle includes a non-pathogenic,
symptomless extraerythrocytic stage, which is followed
by the invasion of mature erythrocytes by infective
forms (merozoites) and the initiation of pathogenic
intraerythrocytic stages (figure 1). During the
extraerythrocytic stage sporozoites invade hepatocytes, in
which they replicate asexually for a period of 5 to 10 days for
the human malaria species. Each sporozoite produces tens of
thousands of merozoites per infected hepatocyte, that will
initiate the intraerythrocytic stages of the infection. The
erythrocytes contain mature schizonts, and at the time of
rupture (48 h after erythrocyte invasion), each erythrocyte
releases 15 to 30 merozoite progeny; these may bind to, and
enter, uninfected erythrocytes to begin a new cycle. Some of
these merozoites can be ingested by a mosquito during a
blood meal. The sexual stages occur in the mosquito midgut
lumen where a small number of gametocytes develop into
mature ookinetes, some of which develop into oocysts after
traversing the midgut epithelium. At the later stages of
infection, when the oocyst ruptures, only a fraction of the
released sporozoites end up in the salivary glands.
1
The sporozoite/liver stage represents the first encounter of
the host with the parasite, while during the erythrocytic stage,
the cyclic rupture of infected erythrocytes produces the
clinical symptoms of malaria. Immunity against the malaria
parasite is also complex and stage-specific.
2
The parasite
induces a specific immune response, stimulating the release of
cytokines from human peripheral blood mononuclear cells
(PBMC),
3
which might play an important function in
activating the hosts monocytes,
4
neutrophils,
5
T cells,
6
and
natural killer (NK) cells
7
to react to the subsequent liver and
blood stage parasite.
Several antigens, specific to the liver stage, have been
identified, and it has been suggested that these antigens, along
with those brought in with the invading sporozoite, are
rapidly processed by the host cell and present on the surface of
infected hepatocytes in combination with MHC class I.
8
This
presentation leads to recognition by cytotoxic T lymphocytes
(CTLs) and killing of the infected cell, or stimulation of NK
and CD4+ T cells to produce interferon , which can trigger a
cascade of immune reactions and can lead, ultimately, to the
death of intracellular parasite.
8,9
Hence, the plasmodium
parasite developing within the host hepatocyte is the major
target of protective immunity at the extraerythrocytic stage.
10
The CTLs may be directly cytolytic against malaria-infected
hepatocytes by releasing perforin and granzyme or by binding
to apoptosis-inducing receptors on the infected cells.
10
The merozoite enters the red blood cell by receptor-
mediated endocytosis. At the time of erythrocyte rupture,
parasite antigens are released into the bloodstream,
stimulating the release of tumour necrosis factor (TNF)
and other factors.
11
Often, merozoites escape the immune
reaction and infect other red blood cells, continuing the cycle
of the infection and stimulation of the immune system.
12
Merozoites that survive to the pre-erythocytic stage are
responsible for the modification of infected red blood cells in
terms of parasite proteins expressed on the cell surface and the
concomitant immune response to the plasmodium parasite,
resulting in the clinical manifestations of malaria.
12,13
An
antibody binding to the surface of the merozoite, and to
proteins that are externalised from the apical complex of
organelles involved in erythrocyte recognition and invasion,
seems to have an important role in immunity to asexual blood
stages. This antibody could neutralise parasites, or lead to Fc-
dependent mechanisms of parasite killing by macrophages.
14
The pathogenic manifestations during a malaria crisis are due
Review
Immune response to malaria
LM is at the Department of Biomedical Sciences, University of
Catania, Italy; and SM is at the Department of Paediatrics, University
of Sassari, and at the Institute of Population Genetics, Italian
National Research Council, Alghero, Italy.
Correspondence: Dr Lucia Malaguarnera, Department of
Biomedical Sciences, Via Androne 83, Catania, Italy.
Tel/ fax +39 95 320267; email lucmal@mbox.unict.it
The immune response to Plasmodium falciparum
malaria
Lucia Malaguarnera and Salvatore Musumeci
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 473
to proinflammatory cytokines released by T cells and
macrophages in response to malaria parasites and their
products, including glycosylphosphatidylinositol (GPI)
moieties,
15
malaria pigment,
16
and plasmodium-derived nitric
oxide synthase (NOS)-inducing factor.
17
Macrophages
A large proportion of resident macrophages and circulating
monocytes and neutrophils of malaria-infected patients
contain granules of malaria pigment known as haemozoin.
The haemozoin pigments are aggregates of insoluble polymers
resulting from the ingestion of intraerythrocytic malaria
parasites, which are unable to catabolise haem that precipitates
in the erythrocytes. Unpurified haemozoin, as is present
within the food vacuole, contains ferriprotoporphyrin IX, a
globin related to host haemoglobin, and several lipids and
proteins of host and parasitic origin.
18
The destruction of
parasites containing erythrocytes represents an enormous
stimulus for the macrophage system.
19
Macrophages participate in the
control of the infection through both
antibody-dependent and independent
phagocytosis, and secretion of soluble
factors directly or indirectly toxic to
the parasite, such as interleukin 1,
TNF,
16
granulocytes-macrophage
colony stimulating factor (GM-CSF),
20
reactive nitrogen (NOI), and oxygen
radicals (ROI).
21
Haemozoin is a key
factor in malaria-associated immuno-
suppression, affecting both the antigen
processing and immunomodulatory
functions of macrophages.
19
However, accumulation of pigment
inside macrophages has also been
shown to impair macrophage activation
and function. The percentages of
heavily haemozoin-laden leucocytes
and macrophages seem to roughly
correlate with severity of disease.
19
They become unable to digest
haemozoin, repeat phagocytosis,
22
generate oxidative burst upon
appropriate stimulation, or produce
nitric oxide (NO).
23
Moreover, it has
been shown that in haemozoin-laden
monocytes the induction of MHC
class II in response to interferon
stimulation was defective, suggesting
a link between the haemozoin loading
of phagocytes, the suppression of
interferon responsiveness, the failure
of MCH class II upregulation,
disturbances in antigen presentation,
and immunodepression in malaria.
24
Disease severity, susceptibility to
severe anaemia, cerebral malaria,
and other aspects of malarial
pathophysiology could each derive
from the response of host macrophages to the various
parasite-specific products. NO has a two-fold role in the
protection of the pathology of malaria. As a host defender,
nitric oxide mediates the intrahepatic killing of parasites in
response to TNF, and interleukin-1 secretion.
25
It is
noteworthy that if nitric oxide production is inhibited by the
administration of a competitive inhibitor of inducible NO
(iNOS), intrahepatic parasite killing is prevented and
protection is impaired.
26
On the other hand, a negative effect is
revealed: when produced in excess NO is cytotoxic not only to
the invading parasites but also to the hosts own cells. During
cerebral malaria, parasitised erythrocytes become sequestered
in the brain vasculature where they cause microvascular
obstructions and proinflammatory cytokine secretion
that induce the local production of iNOS-generated NO
by leucocytes and endothelial cells.
17,27
Recent
immunohistological studies suggest widespread iNOS
induction in cerebral endothelium and the resultant
Review
Immune response to malaria
Sporozoites are injected when infected
mosquito takes second blood meal
Gametocytes are ingested
when mosquito takes
first blood meal
Sporozoites
Infected liver
cell ruptures,
release
merozoites
Trophozoite
Anaemia Splenomegaly
Hypnozoite (latent stage)
remains in liver
Merozoites enter
bloodstream
Erythrocytic cycle
Ring
Schizont
Ruptured
red cell
Pathology
Sporozoites enter
bloodstream
Exoerythrocytic cycle
Figure 1. Plasmodium falciparum cycle in man and mosquito.
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 474
production of NO, suggesting that NO may act as a local
neuroactive mediator contributing to the coma of cerebral
malaria. Acute induction of iNOS expression seems to
correlate with disease severity. As nitric oxide may activate
several secondary neuropathological mechanisms in the brain,
including modulators of synaptic function, induction of iNOS
expression in cerebral malaria may contribute to coma,
seizures, and death.
28
Some studies have reported that high
concentrations of plasma NO correlate with depth of coma in
cerebral malaria,
28,29
while others reported that high plasma
concentrations are protective against severe disease.
30
However, it is difficult to verify these hypotheses because
plasma concentrations of NO do not indicate local NO
production in the brain.
Macrophages are also involved in the pathogenesis of
malaria via their expression and interaction of cytokines or
chemokines. The outcome of such an interaction can have
important consequences for disease progression, morbidity,
and mortality, in addition to presenting possible avenues for
therapeutic intervention.
Proinflammatory cytokines and malaria
In human malaria altered immune reactivity appears late in
the acute phase of the disease and can last a long time after the
clearance of parasites from the circulation.
31
An explanation
for the poor acquisition of malaria immunity in naturally
exposed populations is that the parasite actively modulates the
immune system of the host, preventing the development of
specific immune responses.
32
The inflammatory response that
is needed to remove parasites leads to considerable tissue
damage, and activation of phagocytes to kill intracellular
or extracellular parasites requires the production of
inflammatory cytokines, which can cause systemic effects such
as severe anaemia and cerebral malaria.
33,34
The outcome of
infection depends on a delicate balance between appropriate
and inappropriate induction of these mediators.
TNF
The first characterised parasite-induced cytokine was TNF,
induced in macrophages by erythrocytes infected by
plasmodium, malarial pigment,
16
and certain glycolipids
such as GPI moiety.
15
It has been shown that GPI moiety
induces NOS in macrophages
27
and activates endothelial
cells by tyrosine-kinase-mediated signal transduction.
35
Antibodies directed against GPI blocked the stimulatory
function of lysates from different strains of plasmodia-
infected erythrocytes to induce TNF from mononuclear
cells.
36
Review
Immune response to malaria
Infected
hepatocyte
Ag+
MHC 1
T cell
IFN
IFN
+
TGF
inhibits
IFN
TNF
IFN
TH1
CD4
TH2
B cells
B cells,
Th2
IL10
NK, T cells, M
CTL
M
NK, T cells,
B cells
IL18
IL4
IL10
IL12
TGF
TNF
IFN
IL10
inhibitors
CD8
cell death
receptor
Perforine
Granzyme
M
NOI
ROI

+
Figure 2. Sporozoites are rapidly processed by the host cell and presented on the surface of infected hepatocytes in combination with MHC I. This
presentation leads to recognition by CTLs and killing of the infected cell, or stimulation of NK and CD4+ T cells to produce interferon (IFN), which
can trigger a cascade of immune reactions and can lead to the death of intracellular parasites. Cytokines are the major inducers of Th1 and Th2 subset
development. Naive CD4+ T cells can develop into Th1, which are important for the eradication of the parasite. The hallmark cytokine of Th1 cells is
IFN, which promotes the microbicidal activity of macrophage and cytokine production such as TNF, interleukin (IL) 12, and IL-18. Development of
Th1 response can be antagonised directly by IL-4 and TGF, and indirectly by IL-10, which inhibit the production of proinflammatory cytokines. IL-10
induces B-cell proliferation, which is essential for the development of malarial antibodies. M=macrophages.
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 475
The amount of TNF produced by malaria parasites seems
to vary between people in the same endemic area, exposed to
similar parasites and inoculation rates.
37
In this regard, it has
been proposed that the most important area of control of
TNF production is at gene level. In fact, a high correlation
between people homozygous for the TNF2 allele of the TNF-
gene-promoter region and death, or severe neurological sequel
due to cerebral malaria, has been shown.
33
It has also been
shown that the variation of concentrations and appearance of
TNF in people with severe malaria and subclinical malaria
could be modulated by other factors such as NOI, ROI,
25
leukotrienes, and cytokines such as interferon , interleukin 4,
and interleukin 10 (figure 2).
38,39
Moreover, different strains of
P falciparum obtained from children with mild or cerebral
malaria show marked variation in their ability to induce TNF
from monocytes/macrophages.
40
TNF can increase the
phagocytic capacity due to an increased expression of Fc
receptors on monocytes, or to the modulation of Fc-receptor
signalling pathways by signals originating from the binding
of TNF to its receptors. TNF also acts on lymphocytes
plus monocytes by increasing the inhibition of
P falciparumvia a mechanism unrelated to phagocytosis. These
data suggest that TNF has a pleiotropic antimalaria effect and
that this protective effect depends on the interplay of different
factors, such as monocytes/macrophages, lymphocytes, and
antibodies, in addition to other cells and molecules.
41
TNF has a role in the regulation of macrophage
interleukin 12 production, and it has been shown that TNF is
an important co-factor for interleukin-12-induced production
of interferon by NK cells.
42
Plasma TNF and NO
concentrations are associated with rapid resolution of fever
and parasite clearance. However, it must be noted that TNF
also seems to have, in roughly 1% of individuals with malaria,
detrimental properties such as fever, aches and pains correlated
to acute illness, hypoglycaemia, shock, bleeding, and reversible
coma.
43
Moreover Luty et al
34
showed a close association
between the presence of severe anaemia, high TNF
concentrations, and large numbers of circulating haemozoin-
containing monocytes, suggesting that haemozoin-induced
TNF-production plays a part in either initiation or
exacerbation of anaemia as a clinical outcome of chronic,
uncontrolled parasitaemia.
Interferon
Interferon is a macrophage-activating factor involved in
the innate immune response to malaria. It is mainly produced
by CD8+ and CD4+ T lymphocytes in a specific
immunoresponse and by NK cells in a non-specific response.
44
Studies of experimental murine models as well as human
models suggest an important role for interferon in protective
immune responses to blood stage malaria. In fact, interferon
production by CD4+ T cells to specific erythrocytic antigens is
associated with protection against malaria reinfection in
Africa.
45
T cell secretion of interferon may also help to induce
cytophilic IgG blood-stage-specific antibodies and assist
in antibody-dependent cellular inhibitory mechanisms.
46
The target cells of interferon during P falciparum infection
are monocytes/macrophages,
47
neutrophils,
48
Th2 cells,
49
and parasite-infected hepatocytes.
50
Interferon--activated
macrophages release TNF, transforming growth factor-beta
(TGF), interleukin 1, interleukin 6, ROI, and NOI
(figure 2).
25
Interferon , via signal transducers associated with
transcription, activates iNOS and induces the L-arginine-
dependent NO pathway, subsequently eliminating the infected
hepatocytes or the hepatic schizonts within the cells.
11
This
evidence suggests that NO has an important role in the
destruction of intrahepatic malaria parasites in response to
interferon and other cytokines released by T cells and NK
cells. In-vitro treatment of plasmodium-infected hepatocytes
with interferon eliminated P falciparum parasites from
culture, and in-vivo administration of interferon partly
protected against sporozoite challenge with Plasmodium
berghei in mice.
There is evidence that children with P falciparum
hyperparasitaemia have lower concentrations of CD4+ T cells
secreting interferon than children with uncomplicated
malaria.
51
It seems that interferon is essential for the
resolution of primary infection by limiting the initial phase of
parasite replication, but also contributes to the acute
symptoms of malaria infection such as fever, nausea, and
headache through the induction of TNF and interleukin-1.
52
Interferon plasma concentrations are higher in clinical cases
of malaria than in symptomless cases and there is a temporal
association between interferon secretion and fever. Over-
production of interferon or TNF predisposes to a severe
pathology.
52
Regulation of interferon secretion by T cells is
mostly under the control of interleukin 12 and interleukin 18
(figure 2).
Interleukin 12
Interleukin 12 is a potent immunomodulatory cytokine that
has been proven to be effective in conferring protection against
viral, bacterial, and intracellular parasitic infections. This
cytokine not only increases cell-mediated immune response
but also affects humoral immunity by inducing isotype-
switching through both interferon--dependent and
independent mechanisms.
53
Interleukin 12 seems to stimulate
antibody production in B cells and it has been shown that
interleukin 12 is effective in inducing protective immunity
against blood-stage infection in the murine model.
54
It is likely
that even the process of phagocytosis stimulates interleukin 12
production. Interleukin 12 acts on antigen-stimulated CD4+ T
cells, activating signal transducers and activating transcription
4 (STAT 4) and promoting the differentiation of T cells into
the Th1 subset.
55
The Th1 effectors produce interferon ,
which acts on macrophages to stimulate their microbicidal
functions and to increase their production of interleukin
12 (figure 2). The raised concentrations of interleukin 12
modulate macrophage activity, which is associated with
increased erythrocyte destruction and bone marrow
dyserythropoiesis.
34,54
It seems that early events in the cell-mediated immune
response needed for defence against malaria, initiated by the
release of interleukin 12 from monocytes/macrophages, B cells,
and other cell types
34,54
and consequently the concentration of
interleukin 12, reveals a prognostic significance in malaria
infection. The induction of interferon is a direct consequence
of CD4+ and CD8+ T cell activation: interferon production
Review
Immune response to malaria
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 476
precedes and initiates production of interleukin 12, which in
turn induces interferon production by NK cells in a positive
feed-back loop that represents an important amplifying
mechanism (figure 2).
55
Reduced interleukin 12
concentrations in patients with hyperparasitaemia and severe
malaria may be related to the reduced T-cell-mediated
interferon activity. Evidence from our recent results
56
establishes a critical role for interleukin 12 in the adaptive
immune response to malaria and confirms the association
between levels of interleukin 12 and macrophage activation,
with production of TNF, directly related to the effects of
haemozoin on phagocytic cells. Evidence suggests that
interleukin 12, produced by macrophages in response to
infectious agents, is a central mediator of the cell-mediated
immune response by its actions on the development,
proliferation, and activities of Th1 cells.
38
In acute malaria the
constitutive production of interleukin 12 by monocytes is
inhibited after phagocytosis of haemozoin or after interleukin
10 production, which antagonises interleukin 12 activity.
55
Interleukin 18
Interleukin 18, a novel 183 kDa cytokine, has a wide range of
immunoregulatory functions, inducing gene expression and
synthesis of TNF, interferon , and interleukin 1 by
macrophages, induction of NK cell cytotoxicity and increased
Th1 differentiation.
57
Analysis of the aminoacid sequence and
structural motifs places interleukin 18 in the interleukin 1
family of cytokines.
57
Similarly to interleukin 1, interleukin 18
has been shown to be processed by the interleukin-1-
converting enzyme (ICE) and the activity of mature
interleukin 18 is closely related to that of interleukin 1.
58
In
terms of its biological effects, interleukin 18 is closely related to
and acts synergistically with interleukin 12. The combination
of interleukin 18 plus interleukin 12 seems to be more effective
in inducing interferon production by macrophages than
cytokine alone. In fact, it has been postulated that interleukin
12 is needed for interleukin-18-induced interferon
production and that interleukin 18 induces interferon only
when its receptor is upregulated by interleukin 12.
59
In fact, it seems that between the events in the cell-
mediated immune response needed for defence against
malaria, the release of interleukin 12 and interleukin 18 from
monocytes/macrophages, B cells, and other cell types shows a
prognostic significance in the malaria infection. Interleukin 18
by itself induces low concentrations of interferon production
by T cells and B cells.
60
However, interleukin 12 and
interleukin 18 synergistically induce anti-CD3-stimulated T
cells or anti-CD40-stimulated B cells to differentiate into
highly interferon producing cells,
61
which suggest the
hypothesis that interleukin 12 induces interleukin 18 receptor
on T cells or B cells. Hence, interleukin 12 is needed
for interleukin-18-induced interferon production and
interleukin 18 induces interferon only when its receptors are
upregulated by interleukin 12.
61
A significant increase in serum
concentrations of interleukin 18 was noted during acute and
recovery phases of uncomplicated P falciparum, which may
suggest a proinflammatory role of interleukin 18 in these
patients.
62
On the basis of our recent results, it seems that in a
very early phase of P falciparum infection, the production of
interleukin 12 is uncontrolled, but interleukin 18 balances the
interleukin 12 increase (unpublished observation). Interleukin
18 could have a critical role in the adaptive immune response
to malaria through macrophage activation with production of
interferon , directly related to the effects of haemozoin on
phagocytic cells, which has a central role in the cell-mediated
immune response by its actions on the development,
proliferation, and activation of Th1 cells. The synchronistic
interleukin 18 and interleukin 12 production could have an
important role in the defence against the systemic damage
induced by the presence of P falciparum.
Anti-inflammatory cytokines and malaria
Early proinflammatory cytokine responses seem to mediate
protective immunity, whereas late responses contribute to
pathology. This suggests that a crucial balance might exist
during the inflammatory response to malaria infection. Of
course, unbalanced response leads to severe disease. In fact, in
mild malaria, inflammatory response might be downregulated
by anti-inflammatory cytokines, including interleukin 4,
interleukin 10, and TGF
Interleukin 4
Interleukin 4 is produced by Th2 and activated basophil/mast
cells, and it has been seen to be involved in the activation of
CTL, NK cells, and macrophages. Interleukin 4 is an important
component of the immune response stimulating growth of
Th2 and inhibiting Th1 response by depressing the production
of interferon .
34
Interleukin 4 and Th2 cells are important in
the antibody response to plasmodia. CD4+ T cells are crucial
to the development of CD8+ T-cell responses to hepatocytes
infected with malaria parasites.
63
In the absence of CD4+ T
cells, CD8+ T cells initiate a seemingly normal differentiation
and proliferation during the first few days after immunisation,
suggesting that interleukin 4 is a mediator of CD4/CD8 cross-
talk, leading to the development of immunity against malaria.
64
Production of interleukin 4 by T cells stimulated by
malaria antigens in vitro was seen to be associated with
increased concentrations of serum antibodies to the same
activating malaria antigens in vivo. Interleukin 4 has been
shown to inhibit the ability of malaria-naive human
macrophages to kill P falciparum (figure 2).
64
This observation
seems to contradict the study showing that interleukin 4 helps
the antibody response directed against malaria parasites.
65
TGF
TGF, produced by a wide range of cells such as macrophages,
NK, T, and B cells, has a pivotal role in the control of the
transition between proinflammatory (Th1-type) and anti-
inflammatory (Th2-type) response during the acute and
resolving phases of malaria infection.
66
In experimental malaria the concentration of TGF is
crucial for macrophage activation.
66
Immature monocytes/
macrophages have high concentrations of TGF receptors and
are sensitive to low concentrations of TGF, which promote
macrophage maturation and render them susceptible to
activation of TGF. When the concentrations of TGF rise,
TGF production is downregulated, the macrophages become
refractory, and the activation process is halted.
66
Review
Immune response to malaria
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 477
Moreover, TGF inhibits interferon and TNF
production, upregulates interleukin 10,
67
and downregulates
the expression of adhesion molecules.
68
The sequestration of
parasitised erythrocytes in the brain and other organs by
attachment to endothelial adhesion molecules has been
implicated in the development of severe malaria.
69
An early
production of TGF in malaria infection activates
monocytes/macrophages to induce phagocytosis of parasitised
red blood cells and killing of ingested parasites.
70
Hence the
kinetics of TGF seem to be crucial for the effective control of
parasite density. Too much TGF too early prevents Th1-cell-
mediated immunitythrough the inhibition of interferon
and TNFfrom repressing a rapid escalation of
parasitaemia. Too little TGF too late leads to overwhelming
parasitaemia and death associated with an overproduction of
Th1-type cytokines.
71
These findings suggest that TGF has
two important roles in malaria, which vary depending on the
time of the infection. Early in the infection the TGF might
promote Th1-mediated mechanisms that control parasite
growth. Later in the infection TGF downregulates Th1-like
responses to limit inflammation-associated pathology.
TGF might affect the outcome of malaria infection via its
effects on B cells. Low concentrations of TGF stimulate B cells
to secrete Ig subclasses,
72
but at higher concentrations antibody
production is inhibited.
73
This fact reminds us of the dynamic
balance between the immunosuppressive and antiparasitic
roles of NO during acute blood-stage malaria, which also varies
depending on the time of the infection.
74
Less is known about the role of TGF in the evolution of
human malaria. Lower concentrations of circulating TGF
have been reported in the plasma of acute P falciparum malaria
patients.
75
In this study on the role of TGF in severe human
malaria, plasma TGF concentrations were seen to be below
the normal range, although no significant differences were seen
in concentrations of total TGF between cases of mild malaria,
cerebral malaria, or severe anaemia.
Other studies have shown that focal accumulation
of TGF1, TGF2, and TGF3 are involved in the
reorganisation process of the brain parenchyma,
immunological dysfunction, and endothelial cell activation in
patients with cerebral malaria.
76
Interleukin 10
Interleukin 10 has been reported in the plasma of patients with
acute malaria.
77
Interleukin 10 is produced by monocytes, Th2
cells, and B cells. It inhibits cytokine production in Th 1 and
CD8+ cells, but not in Th2 cells. Nevertheless, interleukin 10
does not affect the proliferation of Th1 and CD8+ cells, but
induces B-cell proliferation, and immunoglobulin production,
which is essential for the development and maturation of
antimalarial antibodies (figure 2). Interleukin 10 seems to have
an important role in defining the T helper cell response to
malaria. Moreover, interleukin 10 downregulates MHC class II
molecules on macrophages, leading to decreased antigen
presentation,
78
inhibits ROI and NOI production, prevents T-
cell priming and proliferation, and suppresses the production
of interferon , interleukin 6, TNF, and GM-CSF by T cells.
78
The inhibition of interferon and TNF secretion by
interleukin-10 synthesis has been reported to be important to
counteract the pathological role of macrophages in cerebral
malaria.
79
A study of malaria-infected children and adults in Gabon
recorded many interleukin-10-producing CD4+ and CD8+
T cells co-expressing interferon .
51
These cells may provide a
fertile ground for parasite-driven immune modulation. It was
shown that the increase of interleukin 10 is more pronounced
and more specific than interleukin 6 and interleukin 8 in
patients with malaria parasitaemia compared with other
infections.
80
However, it is not yet clear whether the increased
concentrations of interleukin 10 have a beneficial role by
reducing the parasite-induced inflammatory response, or a
detrimental one by decreasing the cellular immune responses.
Nevertheless it has been shown that severe anaemia is
associated with reduced concentrations of circulating
interleukin 10,
81
and an increased ratio between TNF and
interleukin 10 contributes to the reversible bone-marrow
suppression seen in malaria patients.
82
Conclusion
The importance of immune cell effectors and associated
cytokines during the presentation of various malaria parasite
stages and their general role in the management of the hosts
immune response to malaria has been, and continues to
be, under investigation. However, abnormal macrophage
activation and anti-inflammatory, as well as proinflammatory,
cytokines may be associated with heightened disease severity
and mortality of malaria, most likely by stimulating other
factors such as NOI and ROI. Understanding the cytokine
interactions that produce both control and pathology will be
helpful in the design of future immune treatment to prevent
millions of malarial deaths in future generations.
Conflict of interest
We declare that we do not have any financial interest or personal
relationships with other persons or organisations that could influence our
work.
Review
Immune response to malaria
References
1 Meuwissen JH, Ponnudurai T. Biology and
biochemistry of sexual and sporogenic stages of
Plasmodium falciparum: a review. Biol Cell 1988; 64:
24549.
2 Holder AA. Malaria vaccines. Proc Natl Acad Sci USA
1999; 99: 116769.
3 Doolan DL, Beck HP, Good MF. Evidence for limited
activation of distinct CD4+ T cell subsets in response
to the Plasmodium falciparumcircumsporozoite
protein in Papua New Guinea. Parasite Immunol 1994;
16: 12936.
4 Esparza I, Mannel D, Ruppel A, Falk W, Krammer
PH. Interferon and lymphotoxin or tumor necrosis
factor act synergistically to induce macrophage killing
of tumor cells and schistosomula or Schistosoma
mansoni. J Exp Med 1987; 166: 58994.
5 Djeu JY, Serbousek D, Blanchard DK. Release of
tumor necrosis factor by human polymorphonuclear
neutrophils. Blood 1990; 76: 140509.
6 Yokota S, Geppert TD, Lipsky PE. Enhancement of
antigen- and mitogen-induced human T lymphocyte
proliferation by tumor necrosis factor alpha.
J Immunol 1988; 140: 53136.
7 stensen ME, Thiele DL and Lipsky PE. Tumor
necrosis factor enhances cytolitic activity of human
natural killer cells. J Immunol 1987; 138: 418591.
Search strategy and criteria selection
Source material for this review was obtained from Pubmed.
Our research was confined to the past 15 years, and only
English language papers were reviewed. Keywords were
macrophages and malaria, interferon gamma and malaria,
NO and malaria,TNF alfa and malaria, IL-1, IL-4, IL-10, IL-
12, IL-18 and malaria", TGF-beta and malaria, NK, CTL,
and T and B lymphocytes and malaria.
For personal use. Only reproduce with permission from The Lancet Publishing Group.
THE LANCET Infectious Diseases Vol 2 August 2002 http://infection.thelancet.com 478
8 Weiss W R, Mellouk S, Houghten RA, et al. Cytotoxic
T cells recognize a peptide from the circumsporozoite
protein on malaria-infected hepatocytes. J Exp Med
1990; 171: 76373.
9 Wang R, Charoenvit Y, Corradin G, De La Vega P,
Franke ED, Hoffman SL. Protection against malaria by
Plasmodium yoelii sporozoite surface protein 2 linear
peptide induction of CD4+ T cell- and IFN-gamma-
dependent elimination of infected hepatocytes.
J Immunol 1996; 157: 406167.
10 Kwiatkowski D. Malarial toxins and the regulation of
parasite density Parasitol Today 1995; 11: 20612.
11 Snounou G, Jarra W, Preiser PR. Malaria multigene
families: the price of chronicity. Parasitol Today 2000;
16: 2830.
12 Riley EM, Allen SJ, Wheeler JG, Blackman MJ, Bennett
S, Takacs B. Naturally acquired cellular and humoral
immune responses to the major merozoite surface
antigen (PfMSP1) of Plasmodium falciparumare
associated with reduced malaria morbidity. Parasite
Immunol 1992; 14: 32137.
13 Miller LH, Good MF, Kaslow DC. Vaccines against the
blood stages of falciparum malaria. Adv Exp Med Biol
1998; 452: 193205.
14 Saul A. The role of variant surface antigens on malaria-
infected red blood cells. Parasitol Today 1999; 15:
45557.
15 Schofield and Hackett. Signal transduction in host cells
by a glycosyl phospatidylinositol toxin of malaria
parasites. J Exp Med 1993; 177: 14553.
16 Pichyangkul S, Saengkrai P, Webster HK. Plasmodium
falciparumpigment induces monocytes to release high
levels of tumor necrosis factor-alpha and interleukin-1
beta. Am J Trop Med Hyg 1994; 51: 43035.
17 Ghigo D, Todde R, Ginsburg H, et al. Erythrocyte
stages of Plasmodium falciparumexhibit a high nitric
oxide synthase (NOS) activity and release an NOS-
inducing soluble factor. J Exp Med 1995; 182: 67788.
18 Goldie P, Roth EF Jr, Oppenheim J, Vanderberg JP.
Biochemical characterization of Plasmodium
falciparumhaemozoin. Am J Trop Med Hyg 1990; 43:
58496.
19 Metzger WG, Mordmuller BG, Kremsner PG. Malaria
pigment in leucocytes. Trans R Soc Trop Med Hyg
1995; 89: 63738.
20 Yamada-Tanaka MS, Ferreira-da-Cruz MF, Alecrim
MG, Mascarenhas LA, Daniel-Ribeiro CT. Tumor
necrosis factor alpha interferon gamma and
macrophage stimulating factor in relation to the
severity of Plasmodium falciparummalaria in the
Brazilian Amazon. Trop Geogr Med 1995; 47: 28285.
21 Prada J, Malinowski J, Muller S, Bienzle U, Kremsner
PG. Effects of Plasmodium vinckei haemozoin on the
production of oxygen radicals and nitrogen oxides in
murine macrophages. Am J Trop Med Hyg 1996; 54:
62024.
22 Schwarzer E, Turrini F, Ulliers D, Giribaldi G,
Ginsburg H, Arese P. Impairment of macrophage
functions after ingestion of Plasmodium falciparum-
infected erythrocytes or isolated malarial pigment.
J Exp Med 1992; 176: 103341.
23 Taramelli D, Basilico N, Pagani E, et al. The heme
moiety of malaria pigment (beta-hematin) mediates
the inhibition of nitric oxide and tumor necrosis
factor-alpha production by lipopolysaccharide-
stimulated macrophages. Exp Parasitol 1995; 81:
50111.
24 Schwarzer E, Alessio M, Ulliers D, Arese P.
Phagocytosis of the malarial pigment, haemozoin,
impairs expression of major histocompatibility
complex class II antigen, CD54, and CD11c in human
monocytes. Infect Immun 1998; 66:160106.
25 Clark IA, al Yaman FM, Jacobson LS. The biological
basis of malarial disease. Int J Parasitol 1997; 27:
123749.
26 Sedegah M, Finkelman F, Hoffman SL. Interleukin 12
induction of interferon gamma-dependent protection
against malaria. Proc Natl Acad Sci USA 1994;
91:1070002.
27 Tachado SD, Gerold P, McConville MJ, et al.
Glycosylphosphatidylinositol toxin of Plasmodium
induces nitric oxide synthase expression in
macrophages and vascular endothelial cells by a
protein tyrosine kinase-dependent and protein kinase
C-dependent signaling pathway. J Immunol 1996; 156:
189707.
28 Maneerat Y, Viriyavejakul P, Punpoowong B, et al.
Inducible nitric oxide synthase expression is increased
in the brain in fatal cerebral malaria. Histopathology
2000; 37: 26977.
29 Al Yaman FM, Mokela D, Genton B, Rockett KA,
Alpers MP, Clark IA. Association between serum levels
of reactive nitrogen intermediates and coma in
children with cerebral malaria in Papua New Guinea.
Trans R Soc Trop Med Hyg 1996; 90: 27073.
30 Anstey NM, Weinberg JB, Hassanali MY, et al. Nitric
oxide in Tanzanian children with malaria: inverse
relationship between malaria severity and nitric oxide
production/nitric oxide synthase type 2 expression.
J Exp Med 1996; 184: 55767.
31 Hviid L, Theander TG, Abu-Zeid YA, et al. Loss of
cellular immune reactivity during acute Plasmodium
falciparummalaria. FEMS Microbiol Immunol 1991; 4:
21927.
32 Plebanski M, Hill AVS. The immunology of malaria.
Curr Opin Immunol 2000; 12: 43741.
33 McGuire W, Hill AV, Allsopp CE, Greenwood BM,
Kwiatkowski D. Variation in the TNF-alpha promoter
region associated with susceptibility to cerebral
malaria. Nature 1994; 371: 50810.
34 Luty AJ, Perkins DJ, Lell B, et al. Low interleukin-12
activity in severe Plasmodium falciparummalaria. Infect
Immun 2000; 68: 390915.
35 Schofield L, Tachado SD. Regulation of host cell
function by glycosylphosphatidylinositols of the
parasitic protozoa. Immunol Cell Biol 1996; 74: 55563.
36 Bate CA, Kwiatkowski D. A monoclonal antibody that
recognizes phosphatidylinositol inhibits induction of
tumor necrosis factor alpha by different strains of
Plasmodium falciparum. Infect Immun 1994; 62:
526166.
37 Peyron F, Vuillez JP, Barbe G, Boudin C, Picot S,
Ambroise-Thomas P. Plasma levels of tumor necrosis
factor during a longitudinal survey in an endemic area
of malaria. Acta Trop 1990; 47: 4751.
38 Essner R, Rhoades K, McBride WH, Morton DL,
Economou JS. IL-4 down-regulates interleukin-1 and
TNF gene expression in human monocytes. J Immunol
1989; 142: 385761.
39 Fiorentino DF, Zlotnik A, Mosmann TR, Howard M,
OGarra A. IL-10 inhibits cytokine production by
activated macrophages. J Immunol 1991; 147: 381522.
40 Allan RJ, Beattie P, Bate C, et al. Strain variation in
tumor necrosis factor induction by parasites from
children with acute falciparum malaria. Infect Immun
1995; 63: 117375.
41 Muniz-Junqueira MI, dos Santos-Neto LL, Tosta CE.
Influence of tumor necrosis factor-alpha on the ability
of monocytes and lymphocytes to destroy
intraerythrocytic Plasmodium falciparumin vitro. Cell
Immunol 2001; 208: 7379.
42 Tripp CS, Wolf SF, Unanue ER. Interleukin 12 and
tumor necrosis factor alpha are costimulators of
interferon gamma production by natural killer cells in
severe combined immunodeficiency mice with
listeriosis, and interleukin 10 is a physiologic
antagonist. Proc Natl Acad Sci USA 1993; 90: 372529.
43 Beutler B, Grau GE. Tumor necrosis factor in the
pathogenesis of infectious diseases. Crit Care Med
1993; 21: S42335.
44 Weiss WR, Sedegah M, Berzofsky JA, Hoffman SL. The
role of CD4+ T cells in immunity to malaria
sporozoites. J Immunol 1993; 151: 269098.
45 Luty AJ, Lell B, Schmidt-Ott R, et al. Interferon-
gamma responses are associated with resistance to
reinfection with Plasmodium falciparumin young
African children. J Infect Dis 1999; 179: 98088.
46 Bouharoun-Tayoun H, Oeuvray C, Lunel F, Druilhe P.
Mechanisms underlying the monocyte-mediated
antibody-dependent killing of Plasmodium falciparum
asexual blood stages. J Exp Med 1995; 182: 40918.
47 Bate CA, Taverne J, Playfair JH. Malarial parasites
induce TNF production by macrophages. Immunology
1988; 64: 22731.
48 Kumaratilake LM, Ferrante A, Rzepczyk C. The role of
T lymphocytes in immunity to Plasmodium falciparum.
Enhancement of neutrophil-mediated parasite killing
by lymphotoxin and IFN-gamma: comparisons with
tumor necrosis factor effects. J Immunol 1991; 146:
76267.
49 Taverne J. Transgenic mice in the study of cytokine
function. Int J Exp Pathol 1993; 74: 52546.
50 Klotz FW, Scheller LF, Seguin MC, et al. Co-
localization of inducible-nitric oxide synthase and
Plasmodium berghei in hepatocytes from rats
immunized with irradiated sporozoites. J Immunol
1995; 154: 339195.
51 Winkler S, Willheim M, Baier K, et al. Frequency of
cytokine-producing T cells in patients of different age
groups with Plasmodium falciparummalaria. J Infect
Dis 1999; 179: 20916.
52 Riley EM. Is T cell priming required for initiation of
pathology in malaria infections? Immunol Today 1999;
20: 22833.
53 Trinchieri G. Interleukin-12: a proinflammatory
cytokine with immunoregulatory functions that bridge
innate resistence and antigen-specific adaptative
immunity. Ann Rev Immunol 1995; 12: 25127.
54 Crutcher J M, Stevenson MM, Sedegah M, Hoffman
SL. Interleukin 12 and malaria. Res Immunol 1995; 146:
55259.
55 OGarra A, Arai N. The molecular basis of T helper1
and T helper 2 cell differentiation. Trends Cell Biol
2000; 10: 54250.
56 Malaguarnera L, Imbesi R, Pignatelli S, Simpor J,
Malaguarnera M, Musumeci S. Increased levels of
Interleukin-12 in Plasmodium falciparummalaria:
correlation with the severity of disease. Parasite
Immunol 2002; 24: in press.
57 Okamura H, Tsutsui HH, Komatsu T, et al. Cloning a
new cytokine that induces IFN cells by T cells.
Nature 1995; 378: 8891
58 Bazan JF, Timans JC, Kastelein RA. A newly defined
interleukin-1? Nature 1996; 379: 591.
59 Dinarello CA. Interleukin 18. Methods 1999; 19:
12132.
60 Xu D, Chan WL, Leung BP, et al. Selective expression
and functions of interleukin 18 receptor on T helper
(Th) type 1 but not Th2 cells. J Exp Med 1998; 188:
148592.
61 Yoshimoto T, Takeda K, Tanaka T, et al. IL-12 up-
regulates interleukin-18 receptor expression on T-cells,
Th1 cells, and B cells: synergism with interleukin-18
for IFN- production. J Immunol 1998; 161: 340007.
62 Torre D, Giola M, Speranza F, Matteelli A,
Basilico C, Biondi G. Serum levels of interleukin-18 in
patients with uncomplicated Plasmodium falciparum
malaria. Eur Cytokine Netw 2001; 2: 36164.
63 Carvalho LH, Sano Gi G, Hafalla JC, Morrot A, de
Lafaille MA, Zavala F. IL-4-secreting CD4+ T cells are
crucial to the development of CD8+ T-cell responses
against malaria liver stages. Nat Med 2002; 8: 16670.
64 Kumaratilake LM, Ferrante A. IL-4 inhibits
macrophage-mediated killing of Plasmodium
falciparumin vitro. A possible parasite-immune
evasion mechanism. J Immunol 1992; 149: 19499.
65 Troye-Blomberg M, Riley EM, Kabilan I, et al.
Production of activated T cells of interleukin 4 but not
interferon-gamma is associated with elevated levels of
serum antibodies to activating malaria antigens. Proc
Natl Acad Sci USA 1990; 87: 548488.
66 Tsunawaki S, Sporn M, Ding A, Nathan C.
Deactivation of macrophages. Nature 1988; 334:
26062.
67 Maeda H, Shiraishi A. TGF- contributes to the shift
toward Th2-type response through direct and
interleukin-10-mediated pathways in tumor bearing
mice. J Immunol 1996; 156: 7378.
68 Nakabayashi T, Letterio JJ, Geiser AG, et al. Up-
regulation of cytokine mRNA, adhesion molecule
proteins, and MHC class II proteins in salivary glands
of TGF-beta1 knockout mice: MHC class II is a factor
in the pathogenesis of TGF-beta1 knockout mice.
J Immunol 1997; 158: 552735.
69 Ockenhouse CF, Tegoshi T, Maeno Y, et al. Human
vascular endothelial cell adhesion receptors for
Plasmodium falciparum-infected erythrocytes: roles for
endothelial leukocyte adhesion molecule 1 and
vascular cell adhesion molecule 1. J Exp Med 1992; 176:
118389.
70 Ferrante A, Kumaratilake L, Rzepczyk CM,
Dayer JM. Killing of Plasmodium falciparumby
cytokine activated effector cells (neutrophils and
macrophages). Immunol Lett 1990; 25: 17987.
71 Omer FM , Kurtzhals JA, Riley EM. Maintaining the
immunological balance in parasitic infections: a role
for TGF-beta? Parasitol Today 2000; 16:1823.
72 Snapper CM, Waegell W, Beernink H, Dasch JR.
Transforming growth factor-beta 1 is required for
secretion of IgG of all subclasses by LPS-activated
murine B cells in vitro. J Immunol 1993; 151: 462536.
73 Stavnezer J. Regulation of antibody production and
class switching by TGF-beta. J Immunol 1995; 155:
164751.
74 Taylor-Robinson AW, Smith EC. A dichotomous role
for nitric oxide in protection against blood stage
malaria infection. Immunol Lett 1999; 67: 19.
75 Wenisch C, Parschalk B, Burgmann H, Looareesuwan
S, Graninger W. Decreased serum levels of TGF-beta in
patients with acute Plasmodium falciparummalaria.
J Clin Immunol 1995; 15: 6973.
76 Deininger MH, Kremsner PG, Meyermann R,
Schluesener HJ. Differential cellular accumulation of
transforming growth factor-beta1, -beta2, and -beta3
in brains of patients who died with cerebral malaria.
J Infect Dis 2000; 181: 211115.
77 Wenish C, Parschalk B, Narzt E, Looareesuwan S,
Graninger W. Elevated serum levels of interleukin-10
and IFN-gamma in patients with acute Plasmodium
falciparum malaria. Clin Immunol Immunopathology
1995; 74: 11517.
78 Akdis CA, Blaser K. IL-10-induced anergy in
peripheral T cell and reactivation by
microenvironmental cytokines: two key steps in
specific immunotherapy. FASEB J 1999; 19: 60309.
79 Kossodo S, Monso C, Juillard P, Velu T, Goldman M,
Grau GE. Interleukin-10 modulates susceptibility in
experimental cerebral malaria. Immunology 1997; 91:
53640.
80 Jason J, Archibald LK, Nwanyanwu OC, et al.
Cytokines and malaria parasitemia. Clin Immunol
2001; 100: 20818.
81 Kurtzhals JA, Adabayeri V, Goka BQ, et al. Low
plasma concentrations of interleukin 10 in severe
malarial anaemia compared with cerebral and
uncomplicated malaria. Lancet 1998; 351: 176872.
82 Othoro C, Lal AA, Nahlen B, Koech D, Orago AS,
Udhayakumar V. A low IL-10 tumor necrosis factor-
alpha ratio is associated with malaria anemia in
children residing in a holoendemic malaria region in
western Kenya. J Infect Dis 1999; 179: 27982.
Review
Immune response to malaria