You are on page 1of 8

Clinical Immunology 116 (2005) 271 278 www.elsevier.

com/locate/yclim

Relationship between the clinical heterogeneity of neurocysticercosis and the immune-inflammatory profiles
Anah Chavarr aa, Agnes Fleuryb, Esperanza Garc ab, Carlos Ma rquezb, a a,* Gladis Fragoso , Edda Sciutto
a

Departamento de Inmunolog a, Instituto de Investigaciones Biome dicas, Universidad Nacional Auto noma de Me xico, UNAM, AP70228, Me xico D.F. 04510, Me xico b Instituto Nacional de Neurolog a y Neurocirug a, Insurgentes Sur 3877, Me xico D.F. 14269, Me xico Received 25 October 2004; accepted with revision 13 April 2005 Available online 2 June 2005

Abstract Human neurocysticercosis is caused by the establishment of Taenia solium cysticerci in the central nervous system. Neurocysticercosis may be asymptomatic or manifested by non-specific mild to severe neurological symptoms. Host factors may be involved in this heterogeneous clinical picture. An immune-inflammatory profile that underlies neurocysticercosis presentation was determined in 45 cerebral spinal fluid (CSF), from clinical and radiologically characterized neurocysticercosis patients, measuring specific IgG subclasses and cytokines. Severity related with increased cellularity in the CSF which was characterized by increased levels of IgG subclasses, IL6/IL5/IL10, proteins, and eosinophils. Multiple neurocysticercosis showed higher levels of IL5/IL6 than single neurocysticercosis. Women presented increased IL6/IL5/IL10 levels pointing out immunological differences due to gender. Severe symptomatology was found when cysticerci were located intraventricular or in the subarachnoid space of the base, inducing an exacerbated response in the CSF. These results constitute an integrative insight to understand the immune-inflammatory response that underlies symptomatic neurocysticercosis. D 2005 Elsevier Inc. All rights reserved.
Keywords: Taenia solium ; Neurocysticercosis; CNS; Inflammation; Immunological profiles

Introduction Different expression profiles of cytokines and antibodies associate with different disease status either of autoimmune, traumatic, or infectious etiologies, in which the immuneinflammatory response is closely related to symptomatology and severity [1,2]. In the human central nervous system (CNS), the local immune response induced by infections has been poorly studied because of the difficulties to obtain biological samples from well-characterized patients. This is the case of neurocysticercosis (NC), a frequent and serious parasitic disease of the CNS, caused by Taenia solium larvae.

* Corresponding author. Fax: +1 52 5556223369. E-mail address: edda@servidor.unam.mx (E. Sciutto). 1521-6616/$ - see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.clim.2005.04.008

In Mexico, it is the cause of 11% of neurological consultations [3], 25% of craniotomies [4], and the first cause of adult onset epilepsy [5,6]. NC is a pleomorphic neurological disease that presents a significant heterogeneity clinically and radiologically. Indeed, NC can be completely asymptomatic [7 9] or be manifested by a variety of non-specific symptoms: headache, epilepsy, dementia, depression, and even intracranial hypertension. The causes that underlie this heterogeneity are not completely understood, although it is speculated that host, parasite, and/or exposure factors are involved [8,10 13]. Differences in NC severity due to host immunological factors have been barely explored. To begin approaching this issue, we carried out a correlation study in which the immunological profiles were matched to the clinical categories of the disease. The effects of gender and age

272

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

were also considered because previous studies showed that women display increased inflammatory CSF cellularity and age was related to increased number of vesicular cysts [13,14]. We previously proposed that different clinical NC phenotypes (asymptomatic or mild to severe NC) might be related to specific immune-inflammatory profiles. In a previous study, the immunological profile related to asymptomatic NC cases was characterized by increments in the concentration of IL4, IL5, and IL13 in supernatants of peripheral mononuclear cells after specific antigenic stimulation and increased specific IgG4 levels in plasma [9]. Thus, it seems that a TH2 profile promotes a silent resolution of the NC infection. In this study, we explored if an exacerbated immune-inflammatory profile relates with the heterogeneity of the NC clinical presentation in wellcharacterized symptomatic patients.

two neurologists. Based on symptomatology, patients were grouped in three classes: (1) Mild: headache or no symptoms; (2) Moderate: focal deficits and/or seizures; and (3) Severe: intracranial hypertension (defined by presence of headache, nausea, vomiting, and papilledema). Immune-inflammatory profile The following features were measured in the CSF to define an immune-inflammatory profile related to NC: T. solium specific anti-cysticercal IgG subclasses (IgG1, IgG2, IgG3, IgG4) and IgE antibodies, TH1 (IL12, IFNg), TH2 (IL4, IL5, IL10), and inflammatory (IL1h, IL6) cytokines. Cytokine titration Sandwich ELISAs were performed in 96-well, flatbottom microtiter plates (Nunc-Immuno Plate Maxisorp, Rosekilde, Denmark). Microplates were coated for 18 h at 4-C with the capture antibody (BD Pharmingen, San Diego, CA for IL1h, IL4, IL5, IL6, IL10, IL12, and INFg), washed three times with PBS-Tween 20 (0.05%), blocked for 30 min at room temperature with PBS-BSA 2%, washed three times. Thereafter, plates were incubated for 18 h at 4-C with cytokine standards and CSF diluted 1:3 with PBS-Tween 20 (0.05%) BSA 0.5%, washed three times, and incubated with the detection antibody (BD Pharmingen for IL1h, IL4, IL5, IL6, IL10, IL12, and INFg) for 2 h at room temperature. Bound detection antibodies were detected using streptavidin phosphatase conjugate (1:3000; Zymed Laboratories, San Francisco, CA) and p -nitrophenyl phosphate (Sigma, St. Louis, MO) as substrate. Optical density (OD) readings were performed at 405 nm, after 30 and 60 min of incubation. All assays were performed in duplicate and their sensitivity was 9.4 pg/ml for all cytokines. IgG subclasses and IgE antibody detection by ELISA CSF antibody levels were measured by indirect ELISA. T. solium cyst fluid (1 Ag/100 Al/well) was incubated 18 h at 4-C in carbonate buffer pH 9.5. The wells were washed, incubated with CSF diluted 1:10 for 1 h at 37-C. Bound immunoglobulins were developed using rabbit anti-human IgG1, IgG2, IgG3, or IgG4 coupled to biotin (1:1000; Zymed Laboratories, San Francisco CA), streptavidin alkaline phosphatase conjugate (1:3000; Zymed) and p -nitrophenyl phosphate (Sigma) as substrate. Plates were read at 405 nm following 30 min of incubation. All assays were performed in duplicate. Statistical analysis Data were processed in Excel 7.0 (Microsoft) and Spss 10.0 for Windows. The Mann Whitney non-parametric U test, univariate analysis of variances, and the two-tailed Fishers exact test were used to identify the differences in

Materials and methods Patients The 45 patients included in this study were attended at the Instituto Nacional de Neurolog a y Neurocirug a (INNN) in Mexico City and had never been treated for NC before. INNN only admits patients older than 15 years of age. Available CSF of these untreated patients was included in the study that lasted from 2001 to 2003. Age and gender data were collected from each patient. Characterization of the disease NC diagnosis was based on computed tomography (CT) and magnetic resonance imaging (MRI) before receiving specific treatment. Parasite stage was determined based on the CT and/or MRI image: (1) vesicular (the parasite is viable, a cerebrospinal fluid-like signal within a cyst is seen); (2) colloidal (the cyst fluid is turbid, there is an intense inflammatory reaction in the surrounding brain parenchyma); (3) calcified (the parasite debris appear as a mineralized granuloma). From radiological studies of each NC case, the following information was collected: number of lesions (single vs. multiple), stage of cysticerci [vesicular, colloidal, calcified, or mixed (colloidal and vesicular) forms] and CNS location [subarachnoid space of the base (SA base) or of the sulci (SA sulci), parenchymal, or intraventricular]. CSF cellularity, content of proteins, and the presence of eosinophils was recorded. CSF was considered inflammatory when the number of cells exceeded 5/ml. High CSF inflammation was considered when cells exceeded 15/ml, three times the normal value. The severity of symptoms associated with the disease was established by clinical examination of the patients by

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

273

the immunological response between groups. P was considered significant.

0.05

of 32, 25%) and single lesions were mainly located in SA sulci (7 cases of 13, 53.8%) (Table 1). Cellular and immune-inflammatory profile determined in the CSF General CSF description of NC patients Lumbar puncture showed that CSF cellularity varied between 0 and 260 cells/ml (mean = 37.6 T 53.6) and was greater than 5 cells/ml in 30 cases (66.7%). High CSF inflammation was presented by 51.1% (23) of the patients. Lymphocytes were most frequently found in CSF. Univariate analysis of variances showed that increased CSF cellularity was associated with SA base and intraventricular location (P = 0.009) and to the vesicular stage of the cysticerci (P = 0.023). Increased CSF cellularity was not associated with parasite number. The concentration of CSF proteins ranged between 2 and 926 mg/dl (mean = 81.2 T 167.7) and in 21 (46.7%) patients the value was above 40 mg/dl. Severity is related to high CSF inflammation level and an immune-inflammatory profile Symptomatology was mild in 20% of the patients, moderate in 60%, and severe in 20% (Table 1, Fig. 1). The relationship between clinical severity and high CSF inflamation in the NC patients is presented in Fig. 1. The percent of NC cases with high inflammation level was significantly higher in patients with severe than in those with mild symptoms (OR = 0.036; 95% CI 0.003 0.48, P = 0.015). Patients with moderate symptomatology more frequently presented eosinophils (P = 0.07, data not shown) in the CSF compared with mild cases. In contrast, the latter showed higher levels of IL10 (P = 0.022, data not shown) and were older (P = 0.039, data not shown). Severe patients presented consistently higher values of protein content, cellularity, and eosinophils than the other two groups of patients (P < 0.04, data not shown), and showed higher levels of IL5, IL10, IgG1, IgG2, IgG3, and IgE when compared to the moderate cases (P < 0.05, data not shown). Increased CSF cellularity is related to an immune-inflammatory profile Of all measured cytokines and specific antibodies, only those that exhibited significant differences are depicted in Table 2 and Figs. 2 and 3. No significant differences in the concentrations of IL1h, IL4, IL12, and IFNg were detected. NC patients with increased CSF cellularity presented higher levels of protein content (P = 0.015), eosinophils (P = 0.005), and all specific IgG subclasses (P < 0.001) but not of the IgE class. Of all measured cytokines, only IL5 (P = 0.05), IL6 (P < 0.001), and IL10 (P = 0.002) were increased in NC patients with increased CSF cellularity (Table 2). Twelve patients (26.7%) of the 45 NC patients presented eosinophils in the CSF as well as an increase in all four specific IgG subclasses (IgG1 P = 0.001, IgG2 P = 0.002,

Results Radiological description of NC patients The radiological signs that defined each clinical group are shown in Table 1. Number and stage of brain cysticerci Multiple cysticerci were found in 71.1% of the patients (32). The remaining 28.9% had single cysticerci. While vesicular cysticerci were found in 53.3% of the patients, 24.4% showed colloidal cysticerci and only 13.3% had calcified cysticerci. Mixed forms were found in 8.9% of the patients; they presented parasites in colloidal and vesicular stages (Table 1). Parasite location The exact CNS location of the cysts could not be determined in 4 patients (8.9%). In these cases, it was impossible to distinguish between parenchymal or SA sulci location. A single parasite location was in the ventricular cavities in 11.1% of the patients, in the parenchyma in 13.3%, in the SA sulci in 33.3%, and in the SA base in 20%. In contrast, six patients presented a mixed location: 3 (6.7%) in the SA sulci and parenchyma, 2 (4.4%) in SA base and intraventricular, and 1 patient (2.2%) with intraventricular and SA sulci cysticerci (Table 1). Multiple lesions were mainly located in SA base cisterns (8 cases of 32, 25%) or in the SA sulci (8 cases

Table 1 Clinical and radiological description of 45 NC patients Severity Women/ Single/ N.P.*/Parasite Men Multiple location lesions 7/2 2/7 1 2 3 1 1 1 14 3 3 1 1 2 3 4 3 1 1 N.P./Parasite stage

Mild

Moderate 11/16

10/17

Severe

6/3

1/8

SA sulci 4 Vesicular SA base 2 Colloidal Parenchyma 3 Calcified Intraventricular SA sulci + parenchyma Parenchyma or SA sulci SA sulci 12 Vesicular SA base 8 Colloidal Parenchyma 3 Calcified Intraventricular 4 Mixed SA base + intraventricular SA sulci + parenchyma Parenchyma or SA sulci SA base 8 Vesicular Intraventricular 1 Colloidal SA base + intraventricular SA sulci + intraventricular

* Number of patients.

274

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

Fig. 1. Frequency of NC cases with high (!15 cells/mm3, black bars) or low (<15 cells/mm3, gray bars) inflammation level according to the clinical severity (mild, moderate, or severe). The percent of NC cases with high inflammation level was significantly higher in patients with severe than with mild symptomatology (Fischers exact test, P = 0.023, OR = 14).

IgG3 P < 0.001, IgG4 P < 0.001), IL6 (P = 0.005), CSF proteins (P < 0.001), and cellularity (P = 0.001) (Table 2). The immune-inflammatory profile in the CSF differs according to gender The CSF samples analyzed were taken from 24 women (15 70 years old) and 21 men (16 68 years old). Women had higher levels of IL5, IL6, and IL10 cytokines (P = 0.057, P = 0.015, P = 0.025, respectively) than men. Although the antibody response was remarkably increased in women, the difference was not statistically significant (IgG2 P = 0.053, IgG3 P = 0.059; Table 2). No significant differences were found between men and women when the clinical presentation, the number, stage, and location of established cysticerci were compared. Radiological and immune-inflammatory profile correlations The immune-inflammatory profile is related to parasite stage, location and disease severity A clear immune-inflammatory profile was displayed by NC patients with cysticerci located in the SA base or intraventricularly. Most of them had severe symptomatology and vesicular parasites, and exhibited increased levels of most specific IgG subclasses, IL5, IL6, and IL10 (P < 0.05) (Figs. 2 and 3), and of CSF cells (P = 0.01, data not shown) and eosinophils (P = 0.047, data not shown). IgG1 levels were higher in patients with cysticerci located in the SA base (P = 0.05), while those having parasites with an intraventricular location showed higher levels of IL10 (P = 0.065) and IL1h (P = 0.08, data not shown). In contrast, patients with cysticerci located in the SA sulci or parenchyma showed lower cytokine levels, while patients with parasites located in the sulci showed higher levels of IgG1, IgG2, IgG4 (P = 0.008, P = 0.02, P = 0.02, respectively), and IFNg (P = 0.005, data not shown) than patients with parenchymal location (Figs. 2 and 3).

Mixed parasite location induced a heterogeneous immune-inflammatory response. Two patients with cyst location in the SA base and intraventricular cavities showed the same profile as those with cysts in the SA base or intraventricular. They presented higher levels of IL6, IL10, IL5, IgG2, and IgG4 (P = 0.01, P = 0.001, P = 0.07, P = 0.07, P = 0.07, respectively, data not shown) than patients with cysticerci located only in SA sulci, and higher levels of all IgG subclasses (P 0.046, data not shown) and IL10 (P = 0.076, data not shown) than patients with parenchymal NC. Mixed cyst location in the SA sulci and parenchyma in 3 patients showed higher levels of IL4, IL6, and IFNg (P = 0.03, P = 0.003, P = 0.002, respectively, data not shown) than patients with only SA sulci cysticerci, and higher levels of IgG2, IgG3, and IL6 (P = 0.07, data not shown) than patients with only parenchymal cysts. This mixed location did not show a significant difference when compared to intraventricular cysts location and presented only higher IL4 levels when compared to SA base cysts (P = 0.7, data not shown). Patients with multiple parasites exhibited increased levels of IL5 and IL6 (P = 0.03, P = 0.015, respectively), while antibody levels, though increased, were not significant as

Table 2 Immune-inflammatory profile determined in CSF of 45 NC patients Immunological profile With/Without increased CSF cellularity (30/15) 2.2/0.11a,b 2.7/0.21c 0.79/0.08b 2.6/0.14 0.43/0.07b 0.76/0.09 2.3/0.13b 2.7/0.22 <9.4/<9.4b 36.5/<9.4 24.5/<9.4b 129.5/<9.4 12.5/<9.4b 48.3/<9.4 53/31b 77/43 Women/ Men (24/21) Single/ Multiple lesions (13/32) 0.35/1.01 1.8/2.7 0.18/0.25 0.65/2.5 0.14/0.2 0.36/0.6 0.31/1.4 1.4/2.7 <9.4/<9.4b <9.4/37 <9.4/20.2b 10.5/65 <9.4/<9.4 9.8/43 43/35.5 55/66.8 6/15 69.5/59.8 0/0 0.5/1 With/ Without eosinophils (12/33) 2.7/0.21b 2.7/1.8 2.3/0.15b 2.6/0.86 0.76/0.09b 1.3/0.45 2.7/0.2b 2.7/1.7 <9.4/<9.4 58.3/18 38.5/<9.4b 1015.3/22 12/<9.4 208/15 68.5/33b 131.3/45.5 53/6b 123.3/37

IgG1 (OD) IgG2 (OD) IgG3 (OD) IgG4 (OD) IL5 (pg/ml) IL6 (pg/ml) IL10 (pg/ml) CSF proteins CSF cells CSF Eosinophils

0/0b 1/0

1.5/0.21 2.7/1.5 0.77/0.15d 2.6/0.6 0.28/0.10d 0.79/0.4 1.8/0.31 2.7/1.7 <9.4/<9.4d 66/<9.4 20/<9.4b 227/23 10/<9.4b 43/<9.4 37.5/39 81.8/55.5 23/6 66/41.5 0/0 1/0

Immunological features from different clinical variables were compared by the non-parametric Mann Whitney U test. Each column shows the median and the 75% upper percentile of two groups being compared. Increased CSF cellularity was considered when >5 cells/ml. a Cytokine levels and antibody levels are in median values. b P 0.05. c The 75% upper percentile values. d P 0.08. ODoptical density.

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

275

Fig. 2. T. solium -specific IgG subclasses in CSF of NC cases according to parasite location (SA Base = Subarachnoid space of the base, Intraventricular, SA Sulci = Subarachnoid space of the sulci, Parenchyma). Each patient is represented according to his/her symptomatology (mild in white, moderate in gray, severe in black) and the respective parasite stage (vesicular in diamonds, colloidal in squares, calcified in circles, and mixed in triangles). Medians of each location are represented by lines. The non-parametric Mann Whitney U test was performed, only when **P 0.05 and *P 0.08 are indicated. OD, optical density.

compared with patients with a single parasite (Table 1). Five patients (11.1%) with radiological evidence of arachnoiditis showed elevated IgG3, IgG4, IL6, CSF proteins, CSF cells, and eosinophils (P = 0.07, P = 0.056, P = 0.068, P = 0.065, P = 0.07, P = 0.001, respectively, data not shown).

Discussion This study provides new insights into the immune response related to the heterogeneous clinical and radiological picture exhibited by NC patients. To better illustrate the possible relationship between the clinical heterogeneity of the disease and the immunological profiles, the clinical and radiological data were included as well as a careful NC patient classification. This is an important advance considering that previous NC studies have not reported this medical information [15,16].

An important finding of this work is the clear relation between increased CSF cellularity and clinical NC severity (Fig. 1). This factor was accompanied by increased levels of specific IgG subclasses, eosinophils, IL5, inflammatory IL6, and the immunoregulatory cytokine IL10. Most of these inflammatory NC cases occurred when the parasite was vesicular and was established in the SA base or in the ventricles (Figs. 2 and 3). Interestingly, the parasite exhibited no radiological evidence of damage, thus suggesting that the inflammatory response might be ineffective. In contrast, parasites found in the SA sulci or in the parenchyma appeared frequently damaged with low CSF inflammation and only mild or moderate symptomatology. The differences in parasite condition may be the result of the interaction between the local antigen-presenting cells (APC), immigrated lymphocytes and eosinophils and the cysticerci. When parasites are located in brain parenchyma or SA sulci, a closer contact with activated immune competent cells could

276

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

Fig. 3. Cytokine levels in CSF of NC cases according to parasite location (SA Base = Subarachnoid space of the base, Intraventricular, SA Sulci = Subarachnoid space of the sulci, Parenchyma). Each patient is represented according to his/her symptomatology (mild in white, moderate in gray, severe in black) and the respective parasite stage (vesicular in diamonds, colloidal in squares, calcified in circles, and mixed in triangles). Cytokine values are measured in pg/ml and presented in a logarithmic scale. Medians of each location are represented by lines. The non-parametric Mann Whitney U test was performed, only when **P 0.05 and *P 0.08 are indicated.

favor cyst death and may explain the higher frequency of calcified or colloidal forms in these compartments. However, it cannot be discarded that parasite death could be due to its own biological clock. IL5, IL6, and IL10 are produced locally by APC of the CNS (e.g., microglia and perivascular macrophages; [17,18]) or by infiltrating T cells. IL5 and IL6 participate in cell and eosinophil recruitment [19 21]. Patients with parasites located in the ventricles or in the SA base or with inflammatory CSF had higher levels of IL5 and IL6, which could explain the increased cellularity and the presence of eosinophils in the CSF. The recruited B cells may become plasmatic cells and be the local source of antibodies [1], while eosinophils could degranulate within the CNS, damaging the parasite and the nervous tissue [22,23]. It has been previously reported that the presence of eosinophils in CSF associates with severity and/or inflammatory CSF in NC [4]. The present data support this finding and relate the presence of eosinophils with high levels of IL6 and specific antibodies. Regarding the increased levels of

IL10, that may be also produced by regulatory CD4+ T cells [24], and considering its immune-suppressive and regulating functions, this cytokine could be possibly feeding back the inflammatory effect of IL5 and IL6 in NC patients with the immune-inflammatory profile. On the other hand, one should not discard the possibility that, although CSF IL10 levels are high, the molecule may be not functional or present some kind of polymorphism, as reported in patients with multiple sclerosis, another inflammatory disease of the CNS [25 27]. Another point to be considered is that higher levels of cysticercal antigens could drain to secondary lymphoid organs more effectively when the parasite is located in ventricles or the SA base than in the brain parenchyma. Thus, secreted antigens could initiate an immune response, activated T and B cells should then be able to cross the blood brain barrier promoting the CSF inflammation [28 30]. Interestingly, our data also point to a sexual dimorphism of the immune response. Although in this cohort of patients,

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278

277

there was no clinical or radiological differences between women and men, women produced higher levels of IL5, IL6, and IL10, revealing an increased inflammatory local response. This observation is not due to differences in the location or the stage of the parasite. This profile is in agreement with previous reports in which an exacerbated inflammatory response was found in women in CSF cellularity and radiological imaging [13,14]. In addition, our data support the hypothesis of a compartmentalized immune response within the CNS. In this study, parasite location is associated with different immune responses in the CNS. Indeed, parasites in the brain parenchyma induced a response with low cytokines and specific antibodies in the CSF. Parasites in the SA sulci showed a similar profile but with higher CSF antibody levels, while intraventricular parasites or those in the SA base induced a pronounced response with high levels of IL5, IL6, IL10, and specific IgG subclasses. The increased CSF inflammation could be responsible not only for the severe clinical symptoms induced by the parasites presence in these two locations, but also for additional CNS damage as a sequel of the disease. The balance between the benefit and damage caused by inflammation, especially when this event occurs in a CNS compartment, is an active area of research. It is also relevant to consider that inflammation in the CNS does not usually exert a repair function, rather, its tendency is to decline to damage, which would explain most of the CNS pathologies. This study belongs to a program designed to identify biological factors related to the susceptibility to NC infection and disease. The observation of the immuneinflammatory profile found related to NC severity allows us to consider IL5, IL6, and IL10 as candidate genes related to severity. Nevertheless, understanding why in some patients, NC produces none or only mild symptomatology and in others, it leads to a severe clinical picture and death, will contribute to improve the design of therapeutic measures of NC, and perhaps to an early treatment of the disease before the struggles between parasite and host cause major damage to the CNS. The CNS compartmentalized immune response opens new perspectives to explore in the pathology of the NC and possibly of other neurological diseases.

M), Me xico; and Howard Hughes Medical Institute (55000643). References


[1] P.M. Knopf, C.J. Harling-Berg, H.F. Cserr, D. Basu, E.J. Sirulnick, S.C. Nolan, J.T. Park, G. Keir, E.J. Thompson, W.F. Hickey, Antigendependent intrathecal antibody synthesis in the normal rat brain: tissue entry and local retention of antigen-specific B cells, J. Immunol. 161 (1998) 692 701. [2] M. Oprica, C. Eriksson, M. Schultzberg, Inflammatory mechanisms associated with brain damage induced by kainic acid with special reference to the interleukin-1 system, J. Cell. Mol. Med. 7 (2003) 127 140. [3] V. Va zquez, J. Sotelo, The course of seizures after treatment for cerebral cysticercosis, N. Engl. J. Med. 327 (1992) 696 701. [4] J. Sotelo, V. Guerrero, F. Rubio, Neurocysticercosis: a new classification based on active and inactive forms. A study of 753 cases, Arch. Intern. Med. 14 (1985) 442 445. [5] M.T. Medina, E. Rosas, F. Rubio-Donnadieu, J. Sotelo, Neurocysticercosis as the main cause of late-onset epilepsy in Mexico, Arch. Intern. Med. 150 (1990) 325 327. [6] O.H. Del Brutto, Prognostic factors for seizure recurrence after withdrawal of antiepileptic drugs in patients with neurocysticercosis, Neurology 44 (1994) 1706 1709. [7] J. Villagra n, J.E. Olvera, Cisticercosis humana: estudio cl nico patolo gico de 481 casos de autopsia, Patolog a 26 (1988) 149 156. [8] A. Fleury, T. Gomez, I. Alvarez, D. Meza, M. Huerta, A. Chavarria, R.A. Carrillo Mezo, C. Lloyd, A. Dessein, P.M. Preux, M. Dumas, C. Larralde, E. Sciutto, G. Fragoso, High prevalence of calcified silent neurocysticercosis in a rural village of Mexico, Neuroepidemiology 22 (2003) 139 145. [9] A. Chavarria, B. Roger, G. Fragoso, G. Tapia, A. Fleury, M. Dumas, A. Dessein, C. Larralde, E. Sciutto, TH2 profile in asymptomatic Taenia solium human neurocysticercosis, Microbes Infect. 5 (2003) 1109 1115. [10] G. Fragoso, E. Lamoyi, A. Mellor, C. Lomeli, M. Hernandez, E. Sciutto, Increased resistance to Taenia crassiceps murine cysticercosis in Qa-2 transgenic mice, Infect. Immun. 66 (1998) 760 764. [11] E. Sciutto, G. Fragoso, M.L. Diaz, F. Valdez, R.M. Montoya, T. Govezensky, C. Lomeli, C. Larralde, Murine Taenia crassiceps cysticercosis: H-2 complex and sex influence on susceptibility, Parasitol. Res. 77 (1991) 243 246. [12] R. Vega, D. Pinero, B. Ramanankandrasana, M. Dumas, B. Bouteille, A. Fleury, E. Sciutto, C. Larralde, G. Fragoso, Population genetic structure of Taenia solium from Madagascar and Mexico: implications for clinical profile diversity and immunological technology, Int. J. Parasitol. 33 (2003) 1479 1485. [13] A. Fleury, A. Dessein, P.M. Preux, M. Dumas, G. Tapia, C. Larralde, E. Sciutto, Symptomatic human neurocysticercosis: age, sex and exposure factors relating with disease heterogeneity, J. Neurol. 251 (2004) 830 837. [14] O.H. Del Brutto, E. Garcia, O. Talamas, J. Sotelo, Sex-related severity of inflammation in parenchymal brain cysticercosis, Arch. Intern. Med. 148 (1988) 544 546. [15] E.C. Bueno, L. dos Ramos Machado, J.A. Livramento, A.J. Vaz, Cellular immune response of patients with neurocysticercosis (inflammatory and non-inflammatory phases), Acta Trop. 91 (2004) 205 213. [16] E. Medina-Escutia, Z. Morales-Lopez, J.V. Proano, J. Vazquez, V. Bermudez, V.O. Navarrete, V. Madrid-Marina, J.P. Laclette, D. Correa, Cellular immune response and Th1/Th2 cytokines in human neurocysticercosis: lack of immune suppression, J. Parasitol. 87 (2001) 587 590. [17] E. Saliba, A. Henrot, Inflammatory mediators and neonatal brain damage, Biol. Neonate 79 (2001) 224 227.

Acknowledgments We thank Mercedes Baca, Marisela Herna ndez, and Rau l Bobes for technical assistance, Gabriel Gutie rrez for his valuable comments on the manuscript, Silvia Ruiz-Velasco for the statistical advice and Roger Carrillo-Mezo for radiological counsel. Isabel Pe rez Montfort corrected the English version of the manuscript. This study was funded by Direccio n General de Asuntos de Personal Acade mico (IN220999, IN213102), Universidad Nacional Auto noma de Me xico; CONACYT (31378-

278

A. Chavarr a et al. / Clinical Immunology 116 (2005) 271 278 Groux, A comparative study between T regulatory type 1 and CD4+CD25+ T cells in the control of inflammation, J. Immunol. 171 (2003) 5018 5026. K.M. Myhr, K.S. Vagnes, T.H. Maroy, J.H. Aarseth, H.I. Nyland, C.A. Vedeler, Interleukin-10 promoter polymorphisms in patients with multiple sclerosis, J. Neurol. Sci. 202 (2002) 93 97. M. Maurer, N. Kruse, R. Giess, K.V. Toyka, P. Rieckmann, Genetic variation at position 1082 of the interleukin 10 (IL10) promotor and the outcome of multiple sclerosis, J. Neuroimmunol. 104 (2000) 98 100. B.A. De Jong, R.G. Westendorp, J. Eskdale, B.M. Uitdehaag, T.W. Huizinga, Frequency of functional interleukin-10 promoter polymorphism is different between relapse-onset and primary progressive multiple sclerosis, Hum. Immunol. 63 (2002) 281 285. W. Hickey, Basic principles of immunological surveillance of the normal central nervous system, Glia 36 (2001) 118 124. L.B. Gordon, P.M. Knopf, H.F. Cserr, Ovalbumin is more immunogenic when introduced into brain or cerebrospinal fluid than into extracerebral sites, J. Neuroimmunol. 40 (1992) 81 87. C. Harling-Berg, P.M. Knopf, J. Merriam, H.F. Cserr, Role of cervical lymph nodes in the systemic humoral immune response to human serum albumin microinfused into rat cerebrospinal fluid, J. Neuroimmunol. 25 (1989) 185 193.

[18] K. Williams, N. Dooley, E. Ulvestad, B. Becher, J.P. Antel, IL-10 production by adult human derived microglial cells, Neurochem. Int. 29 (1996) 55 64. [19] A.S. MacDonald, P. Loke, R. Martynoga, I. Dransfield, J.E. Allen, Cytokine-dependent inflammatory cell recruitment patterns in the peritoneal cavity of mice exposed to the parasitic nematode Brugia malayi , Med. Microbiol. Immunol. 192 (2003) 33 40. [20] S.M. Pope, E.B. Brandt, A. Mishra, S.P. Hogan, N. Zimmermann, K.I. Matthaei, P.S. Foster, M.E. Rothenberg, IL-13 induces eosinophil recruitment into the lung by an IL-5- and eotaxin-dependent mechanism, J. Allergy Clin. Immunol. 108 (2001) 594 601. [21] O. Ghaffar, F. Lavigne, A. Kamil, P. Renzi, Q. Hamid, Interleukin-6 expression in chronic sinusitis: colocalization of gene transcripts to eosinophils, macrophages, T lymphocytes, and mast cells, Otolaryngol.-Head Neck Surg. 118 (1998) 504 511. [22] A.L. Taratuto, S.M. Venturiello, Trichinosis, Brain Pathol. 7 (1997) 663 672. [23] H. Sugaya, M. Aoki, T. Yoshida, K. Takatsu, K. Yoshimura, Eosinophilia and intracranial worm recovery in interleukin-5 transgenic and interleukin-5 receptor alpha chain-knockout mice infected with Angiostrongylus cantonensis , Parasitol. Res. 83 (1997) 583 590. [24] A. Foussat, F. Cottrez, V. Brun, N. Fournier, J.P. Breittmayer, H.

[25]

[26]

[27]

[28] [29]

[30]