This article has Open Peer Review reports available.
Phenotypic profiling of CD8+ T cells during Plasmodium vivax blood-stage infection
© Hojo-Souza et al.; licensee BioMed Central. 2015
Received: 1 October 2014
Accepted: 15 January 2015
Published: 31 January 2015
For a long time, the role of CD8+ T cells in blood-stage malaria was not considered important because erythrocytes do not express major histocompatibility complex (MHC) class I proteins. While recent evidences suggest that CD8+ T cells may play an important role during the erythrocytic phase of infection by eliminating parasites, CD8+ T cells might also contribute to modulate the host response through production of regulatory cytokines. Thus, the role of CD8+ T cells during blood-stage malaria is unclear. Here, we report the phenotypic profiling of CD8+ T cells subsets from patients with uncomplicated symptomatic P. vivax malaria.
Blood samples were collected from 20 Plasmodium vivax-infected individuals and 12 healthy individuals. Immunophenotyping was conducted by flow cytometry. Plasma levels of IFN-γ, TNF-α and IL-10 were determined by ELISA/CBA. Unpaired t-test or Mann–Whitney test was used depending on the data distribution.
P. vivax-infected subjects had lower percentages and absolute numbers of CD8+CD45RA+ and CD8+CD45RO+ T cells when compared to uninfected individuals (p ≤ 0.0002). A significantly lower absolute number of circulating CD8+CD45+CCR7+ cells (p = 0.002) was observed in P. vivax-infected individuals indicating that infection reduces the number of central memory T cells. Cytokine expression was significantly reduced in the naïve T cells from infected individuals compared with negative controls, as shown by lower numbers of IFN-γ+ (p = 0.001), TNF-α+ (p < 0.0001) and IL-10+ (p < 0.0001) CD8+ T cells. Despite the reduction in the number of CD8+ memory T cells producing IFN-γ (p < 0.0001), P. vivax-infected individuals demonstrated a significant increase in memory CD8+TNF-α+ (p = 0.016) and CD8+IL-10+ (p = 0.004) cells. Positive correlations were observed between absolute numbers of CD8+IL-10+ and numbers of CD8+IFN-γ+ (p < 0.001) and CD8+TNF-α+ T cells (p ≤ 0.0001). Finally, an increase in the plasma levels of TNF-α (p = 0.017) and IL-10 (p = 0.006) and a decrease in the IFN-γ plasma level (p <0.0001) were observed in the P. vivax-infected individuals.
P. vivax infection reduces the numbers of different subsets of CD8+ T cells, particularly the memory cells, during blood-stage of infection and enhances the number of CD8+ memory T cells expressing IL-10, which positively correlates with the number of cells expressing TNF-α and IFN-γ.
Human malaria is caused by protozoa that belong to the genus Plasmodium, mainly P. falciparum and P. vivax. In Brazil, the Amazon region is endemic for malaria, and there is a high prevalence of P. vivax malaria (85% of cases), which has elevated the morbidity rate . For malaria, naturally acquired protective immunity (lower risk of disease/lower parasitemia/asymptomatic disease) can be achieved only after repeated infections  and does not confer sterile immunity. For example, even though naturally acquired immunity protects against symptomatic malaria, a recent study on individuals living in the Mali endemic area found no evidence of acquired sterile immunity to P. falciparum infection .
B cells and CD4+ T lymphocytes play an important protective role during the blood stage of malaria infection , and CD8+ T cells play a critical role in pre-erythrocytic immunity. Studies using experimental models have shown that these cells directly promote the lysis of infected hepatocytes and parasite death, and these events are mediated by IFN-γ, perforin and granzyme B . For a long time, the role of CD8+ T cells in the blood stage of malaria was considered minor because erythrocytes do not express major histocompatibility complex (MHC) class I proteins [6,7]. Very few studies focusing on the function of CD8+ T cells during blood-stage infection have been reported because there is some agreement among researchers that these cells only play an important role in the liver-stage of malaria. However, recent studies have suggested that CD8+ T cells may play a role in eliminating parasites during the blood stage of infection [8,9]. An increase in the number of effector memory CD8+ T cells in response to infection with lethal P. yoelli was observed in recipient mice that received CD8+ T cells from immune mice . Using animals genetically deficient for PD-1 (a molecule with particular importance in cell exhaustion), it was shown that there is a loss in the number and functional capacity of CD8+ T cells during the acute phase of P. chabaudi malaria, which is mediated by PD-1 .
Several studies have shown that there is a reduction in the percentage and/or absolute number of CD8+ T cells in the peripheral blood during acute P. falciparum or P. vivax infection [10-14], and these reductions have been attributed to the apoptosis of these cells [15,16], the reallocation of T cells to sites of inflammation [12,17] or other factors such as the suppression of CD8+ T cells induced by sporozoites or infected red blood cells . In regard to P. vivax infection, however, reports have shown that there is no significant difference in the percentage of CD8+ T cells during an acute malaria infection compared with that in uninfected individuals [19,20].
Considering the existing controversy regarding the role of CD8+ T cells during blood-stage infection, this study was conducted to quantify and evaluate the phenotypic profiling of these cells during uncomplicated symptomatic P. vivax malaria infection. We show that there are reduced percentages and absolute numbers of CD8+ naïve (CD45RA+), double-positive (CD45RA+CD45RO+) and memory (CD45RO+) T cells. Additionally, statistically significant increases in the number of CD8+ memory (CD45RO+) T cells expressing TNF-α and the number of CD8+ memory (CD45RO+) T cells expressing IL-10 were observed in P. vivax-infected donors, and a reduced absolute number of these cells expressing IFN-γ was also observed. Taken together our results suggest that P. vivax malaria infection reduce the number of circulating memory cells and elicit a profile of CD8+ T cells expressing both pro-inflammatory and anti-inflammatory cytokines, which might contribute to the clearance of the parasite without the possible harmful effect of the immunopathology.
Study participants and blood samples
Demographic and hematological parameters of malaria-naïve donors and P. vivax -infected donors (mean ± SD)
Value for group
P. vivax-infected donors
(n = 11)
(n = 20)
14.28 ± 1.76
13.52 ± 1.21
44.00 ± 4.67
38.39 ± 3.16
4980000 ± 580000
4630000 ± 510000
7958 ± 2700
5900 ± 2235
2306 ± 861.4
1583 ± 1558
842.4 ± 320.1
352.8 ± 205.2
154.3 ± 120.8
298.7 ± 183.3
5293 ± 2409
3686 ± 1064
225.7 ± 98.75
115.2 ± 80.76
233300 ± 78170
124100 ± 55550
Peripheral venous blood was collected in heparin tubes before beginning the antimalarial treatment. These blood samples were used for cell phenotyping and to obtain plasma for the cytokine assay.
The present study was approved by the Ethics Committee of the Centro de Pesquisa em Medicina Tropical (CAAEs: 0008.0.046.000-11, 0449.0.203.000-09) and the Ethics Committee of the Universidade Federal de Minas Gerais (CAAE: 27466214.0.0000.5149). Written informed consent was obtained from each participant.
Flow cytometric analysis
The CD8+ T cell analysis was conducted using four-color flow cytometry. Cell phenotyping was performed using the following monoclonal antibodies: FITC anti-human CD8 (clone HIT8a); PE anti-human IFN-γ (clone F12), TNF-α (clone MAb11), IL-10 (clone JES3-9D7), CCR7 (clone 3D12) and CD62L (clone DREG-56); PE-Cy5 anti-human CD45RO (clone UCHL1) and APC anti-human CD45RA (clone HI100). Briefly, 100 μL of fresh whole blood samples were incubated with undiluted surface monoclonal antibodies for 30 minutes at room temperature under dark conditions. Next, the erythrocytes were lysed with ammonium chloride (150 mM) for 10 minutes and washed twice in PBS-W (0.5% BSA, 0.1% sodium azide). Cells were then permeabilized with PBS-P (0.5% BSA, 0.1% sodium azide, 0.5% saponin) for 10 minutes and washed twice with PBS-W. The cells were stained with undiluted intracellular monoclonal antibodies for 30 minutes at room temperature under dark conditions, washed with PBS-W and fixed with FACS fixation solution (10 g/L paraformaldehyde, 10.2 g/L sodium cacodylate, 6.65 g/L sodium chloride) for at least 15 minutes at 4°C. Phenotypic analyses were performed using flow cytometry in a FACSCalibur flow cytometer (BD Biosciences, USA). Data were collected on 1x105 lymphocytes (gated by forward and side scatter) and analyzed using Flow Jo software (Tree Star Inc., USA). The gating strategy used to characterized CD8+ T cells subsets was showed in Additional file 1.
The plasma levels of IFN-γ and TNF-α were determined by enzyme-linked immunosorbent assay (ELISA) (R&D Systems) according to the manufacturer’s instructions. Biotin-labeled antibodies were used for detection and revealed with streptavidin-HRP (Amersham Biosciences, USA) and the OPD substrate system (Sigma). The colorimetric reaction was read using an automated ELISA microplate reader at 492 nm. The cytokine concentration was calculated from the standard curve using seven-parameter curve fitting software (SOFTmaxH Pro 5.3, Molecular Devices, USA), and the results were expressed in pg/mL. The limit of detection for the assay was 15.6 pg/mL for both cytokines. The IL-10 plasma level was determined using a cytometric bead array (CBA) (BD Bioscience) according to the manufacturer’s instructions. The data was collected with a FACSCan flow cytometer (BD Biosciences, USA), and the results were expressed in pg/mL. The limit of detection of the assay was 4.5 pg/mL.
Statistical analyses were conducted using the Prism software 5.0 for Windows. Initially, the Kolmogorov-Smirnoff test was applied to verify whether the obtained data represent a normal distribution. Grubb’s test was used to verify the outliers. The unpaired t-test or Mann–Whitney test was used depending on the data distribution. A P-value < 0.05 was considered significant.
Subsets of CD8+ T cells are reduced during the blood stage of P. vivax malaria
Central memory CD8+ T cells are reduced during P. vivax infection
CD8+ naïve T cells of P. vivax patients present a phenotypic cytokine profile similar to that of malaria-naïve donors
CD8+ double-positive and memory T cells expressing TNF-α and IL-10 are enhanced during the blood stage of P. vivax malaria
In the P. vivax-infected donors, a reduced number of double-positive T cells (CD8+CD45RA+CD45RO+) expressing IFN-γ (p = 0.007) was observed. On the other hand, the number of these CD8+ T cells expressing either TNF-α+ or IL-10+ tended to increase in the P. vivax-infected donors (Figure 3B). Despite the reduced number of CD8+ memory T cells (CD8+CD45RO+) that expressed IFN-γ+ (p < 0.0001), the P. vivax-infected donors presented a significant increase in the number of memory CD8+ T cells expressing either TNF-α+ (p = 0.016) or IL-10+ (p = 0.004) (Figure 3C), which suggests that a different immune response occurs during blood–stage malaria infection.
Absolute number of IL-10-producing CD8+ T cells correlates with the number of CD8+ T cells expressing IFN-γ and CD8+ T cells expressing TNF-α during P. vivax infection
Plasma levels of IFN-γ, TNF-α and IL-10 in P. vivax-infected donors
Although studies have shown that the percentage and/or absolute number of CD8+ T cells are reduced during human malaria infection, the phenotypic and functional profile of these cells remain poorly characterized. Using cell surface and intracellular cytokine markers, this study aimed to identify the occurrence of different subsets of CD8+ T cells in individuals naturally infected with P. vivax during an uncomplicated symptomatic infection. For this study, blood samples obtained from patients with a P. vivax malarial infection and malaria-naïve donors were stained with specific monoclonal antibodies.
Our results demonstrate that during blood-stage P. vivax infection, there is a significant reduction in the percentages and absolute numbers of CD8+ naïve (CD45RA+) and memory (CD45RO+) T cells (Figure 1A and 1C). As previously discussed in the Introduction section, a number of reports have shown an overall reduction in the number of CD8+ T cells during an acute malaria infection in humans [10-14]. Other studies, however, have reported conflicting findings [19,20]. Several hypotheses have been proposed to explain the reduction in CD8+ T cell number. An interesting experimental study showed that the response of CD8+ T cells induced by irradiated sporozoites of P. yoelli in Balb/c mice is abrogated by either the simultaneous injection of nonirradiated sporozoites or the direct inoculation of blood-stage forms of the parasite . Therefore, it is possible that the low number of CD8+ T cells observed during P. vivax malaria is caused by parasite-induced suppression. As an alternative possibility, Horne-Debets et al. (2013) proposed that this low number could be the result of exhaustion and a loss of CD8+ T cells mediated by Programmed Cell Death-1 (PD-1). Apoptosis [15,16] and the temporary reallocation of these cells to the liver and other tissues are additional alternative mechanisms that should also be considered [12,17].
Furthermore, using the CCR7 and CD62L surface markers , the reduced number of CD8+CD45RO+ T cells presented a central memory profile (Figure 2A). Effector memory cells migrate to tissues , and it is possible that the extremely low number of these cells circulating in the blood may reflect an earlier liver stage of infection. Importantly, despite the overall reduction in CD8+ T cells during P. vivax malaria, significant relative increases in the numbers of CD8+TNF-α+ and CD8+IL-10+ in the memory (CD45RO+) cell subsets were observed (Figure 3C), which suggests that the functional response may be different during a malaria infection. Given that double-positive (CD8+CD45RA+CD45RO+) T cells may represent a transition to form memory (CD8+CD45RO+) T cells, the increasing trend in the number of IL-10+ cells observed in P. vivax malaria patients may indicate the induction of a mostly immunoregulatory profile during the blood stage of this disease, as also corroborated by the analysis of the ratio between pro- and anti-inflammatory cytokines. Indeed, the number of these IL-10+ cells was positively correlated with the number of cells expressing IFN-γ and the number of cells expressing TNF-α. Moreover, these cell profiles are consistent with the plasma cytokine levels observed during blood-stage infection in these patients. The higher plasma levels of TNF-α and IL-10 observed in the P. vivax-infected donors are consistent with the results reported in other previous studies [23-25]. While the results might suggest that CD8+ T cells may contribute to the broad systemic changes during acute infection, it is not possible, however, to know whether these cells contribute to cytokine secretion at this stage because the number of effector cells was very low. Further studies using experimental models focusing in the depletion of specific cell populations should be carried out in order to support the importance of these cells to the broad systemic changes in the host. Conversely, the profile of the memory cells may reflect a previous exposure to the pre-erythrocytic stage antigen. From this perspective, a more immunoregulatory profile may explain the difficulty in achieving sterile immunity [3,6].
Taken together, our results highlight the following two important findings: i) there is a significant reduction in specific subsets of CD8+ T cells, and particularly in memory cells, during the blood stage of a P. vivax infection; and ii) there are relatively high numbers of cells expressing IL-10 in the memory CD8+ T cell subsets, which positively correlates with the number of cells expressing TNF-α and the number of cells expressing IFN-γ. The results suggest that these CD8+ T cells co-expressing both pro-inflammatory and anti-inflammatory cytokines might contribute to the clearance of the parasite and prevent the immunopathology conferred by the excessive pro-inflammatory response. Additional studies are required to determine whether the phenotypic profiles observed represent a homeostatic immune response that benefits the host, by preventing immunopathology, or a response that is harmful due to the formation of immunomodulatory memory that would allow the persistent presence of the parasite.
This work was financially supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico/CNPq (Grant # 478379/2013-7) and FAPEMIG (Grant # APQ-02399-14). Lilian Lacerda Bueno is supported by Coordenação de Aperfeiçoamento de Nível Superior/CAPES and FAPEMIG. Natália Satchiko Hojo de Souza is supported by a doctoral degree fellowship from CNPq/Brazil. Ricardo Fujiwara and Daniella Bartholomeu are supported by Brazilian National Research Council (CNPq) fellowships.
- WHO. Country profile. In: World Malaria Report 2013. World Health Organization. 2013. http://www.who.int/malaria/publications/world_malaria_report_2013/en/. Accessed 18 Set 2014
- Doolan DL, Doban C, Baird JK. Acquired immunity to malaria. Clin Microbiol Rev. 2009;22(1):13–36.View ArticlePubMedPubMed CentralGoogle Scholar
- Tran TM, Li S, Doumbo S, Doumtabe D, Huang CY, Dia S, et al. An intensive longitudinal cohort study of malian children and adults reveals no evidence of acquired immunity to Plasmodium falciparum infection. Clin Infect Dis. 2013;57(1):40–7.View ArticlePubMedPubMed CentralGoogle Scholar
- Wipasa J, Elliott S, Xu H, Good MF. Immunity to asexual blood stage malaria and vaccine approaches. Immunol Cell Biol. 2002;80(5):401–14.View ArticlePubMedGoogle Scholar
- Tse SW, Radtke AJ, Zavala F. Induction and maintenance of protective CD8+ T cells against malaria liver stages: implications for vaccine development. Mem Inst Oswaldo Cruz. 2011;106(1):172–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Struik SS, Riley EM. Does malaria suffer from lack of memory? Immunol Rev. 2004;201:268–90.View ArticlePubMedGoogle Scholar
- Hisaeda H, Yasutomo K, Himeno K. Malaria: immune evasion by parasites. Int J Biochem Cell Biol. 2005;37(4):700–6.View ArticlePubMedGoogle Scholar
- Imai T, Shen J, Chou B, Duan X, Tu L, Tetsutani K, et al. Involvement of CD8+ T cells in protective immunity against murine blood-stage infection with Plasmodium yoelii 17XL strain. Eur J Immunol. 2010;40(4):1053–61.View ArticlePubMedGoogle Scholar
- Horne-Debets JM, Faleiro R, Karunarathne DS, Liu XQ, Lineburg KE, Poh CM, et al. PD-1 dependent exhaustion of CD8+ T cells drives chronic malaria. Cell Reports. 2013;5(5):1204–13.View ArticlePubMedGoogle Scholar
- Lisse IM, Aaby P, Whittle H, Knudsen K. A community study of T lymphocyte subsets and malaria parasitemia. Trans R Soc Trop Med Hyg. 1994;88:709–10.View ArticlePubMedGoogle Scholar
- Worku S, Björkman A, Troye-Blomberg M, Jemaneh L, Färnert A, Christensson B. Lymphocyte activation and subset redistribution in the peripheral blood in acute malaria illness: distinct γδ+ T cell patterns in Plasmodium falciparum and P. vivax infections. Clin Exp Immunol. 1997;108(1):34–41.View ArticlePubMedPubMed CentralGoogle Scholar
- Hviid L, Kurtzhals JAL, Goka BAQ, Oliver-Commey JO, Nkrumah FK, Theander TH. Rapid reemergence of T cells into peripheral circulation following treatment of severe and uncomplicated Plasmodium falciparum malaria. Infect Immun. 1997;65:4090–3.PubMedPubMed CentralGoogle Scholar
- Kassa D, Petros B, Mesele T, Hailu E, Wolday D. Characterization of peripheral blood lymphocyte subsets in patients with acute Plasmodium falciparum and P. vivax malaria infections at Wonji Sugar Estate, Ethiopia. Clin Vaccine Immunol. 2006;13:376–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Borges QI, Fontes CJF, Damazo AS. Analysis of lymphocytes in patients with Plasmodium vivax malaria and its relation to the annexin-A1 and IL-10. Malar J. 2013;12:455.View ArticlePubMedPubMed CentralGoogle Scholar
- Touré-Baldé A, Sarthou JL, Roussilhon C. Acute Plasmodium falciparum infection is associated with increased percentages of apoptotic cells. Immunol Lett. 1995;46:59–62.View ArticleGoogle Scholar
- Riccio EKP, Júnior IN, Riccio LR, das Graças Alecrim M, Corte-Real S, Morgado M, et al. Malaria associated apoptosis is not significantly correlated with either parasitemia or the number of previous malaria attacks. Parasitol Res. 2003;90:9–18.View ArticlePubMedGoogle Scholar
- Hviid L, Kemp K. What is the cause of lymphopenia in malaria? Infect Immun. 2000;68:6087–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Ocaña-Morgner C, Mota MM, Rodriguez A. Malaria blood stage suppression of liver stage immunity by dendritic cells. J Exp Med. 2003;197(2):143–51.View ArticlePubMedPubMed CentralGoogle Scholar
- Srisurapanon S, Wiwattanakul S, Apibal S, Suwannuruk R, Sujimanaskul S, Petchsuwan B, et al. Lymphocyte subpopulations in malaria infected individuals living in an endemic area, Southeast Asian. J Trop Med Public Health. 2003;34:310–5.Google Scholar
- Jangpatarapongsa K, Sirichaisinthop J, Sattabongkot J, Cui L, Montgomery SM, Looareesuwan S, et al. Memory T cells protect against Plasmodium vivax infection. Microbers Infect. 2006;8(3):680–6.View ArticleGoogle Scholar
- Snounou G, Viriyakosol S, Zhu XP, Jarra W, Pinheiro L, Rosário VE, et al. High sensitivity of detection of human malaria parasites by the use of nested polymerase chain reaction. Mol Biochem Parasit. 1993;61:315–20.View ArticleGoogle Scholar
- Sallusto F, Geginat J, Lanzavecchia A. Central memory and effector memory T cell subsets: function, generation and maintenance. Annu Rev Immunol. 2004;22:745–63.View ArticlePubMedGoogle Scholar
- Gonçalves RM, Salmazi KC, Santos BAN, Bastos MS, Rocha SC, Boscardin SB, et al. CD4+CD25+Foxp3+ regulatory T cells, dendritic cells, and circulating cytokines in uncomplicated malaria: do different parasite species elicit similar host responses? Infect Immun. 2010;78 Suppl 11:4763–72.View ArticlePubMedPubMed CentralGoogle Scholar
- Andrade BB, Reis-Filho A, Souza-Neto SM, Clarência J, Camargo LMA, Barral A, et al. Severe Plasmodium vivax malaria exhibits marked inflammatory imbalance. Malar J. 2010;9:13.View ArticlePubMedPubMed CentralGoogle Scholar
- Mendonça VRR, Queiroz ATL, Lopes FM, Andrade BB, Barral-Neto M. Networking the host immune response in Plasmodium vivax malaria. Malar J. 2013;12:69.View ArticlePubMedPubMed CentralGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.