Vaccine-linked chemotherapy with a low dose of benznidazole plus a bivalent recombinant protein vaccine prevents the development of cardiac fibrosis caused by Trypanosoma cruzi in BALB/c mice
Authors: Dzul-Huchim Victor Manuel , Ramirez-Sierra Maria Jesus , Martinez-Vega Pedro Pablo , Rosado-Vallado Miguel Enrique , Arana-Argaez Victor Ermilo , Ortega-Lopez Jaime , Gusovsky Fabian , Dumonteil Eric , Cruz-Chan Julio Vladimir , Hotez Peter , Bottazzi María Elena , Villanueva-Lizama Liliana Estefania 
Published: February 2022

AbstractBackgroundChagas disease (CD) is caused by Trypanosoma cruzi and affects 6-7 million people worldwide. Approximately 30% of chronic patients develop chronic chagasic cardiomyopathy (CCC) after decades. Benznidazole (BNZ), one of the first-line chemotherapy approved for CD, induces toxicity and fails to halt the progression of CCC in chronic patients. The recombinant parasite-derived antigens, including Tc24, Tc24-C4, TSA-1, and TSA-1-C4 with Toll-like receptor 4 (TLR-4) agonist-adjuvants reduce cardiac parasite burdens, heart inflammation, and fibrosis, leading us to envision their use as immunotherapy together with BNZ. Given genetic immunization (DNA vaccines) encoding Tc24 and TSA-1 induce protective immunity in mice and dogs, we propose that immunization with the corresponding recombinant proteins offers an alternative and feasible strategy to develop these antigens as a bivalent human vaccine. We hypothesized that a low dose of BNZ in combination with a therapeutic vaccine (TSA-1-C4 and Tc24-C4 antigens formulated with a synthetic TLR-4 agonist-adjuvant, E6020-SE) could provide antigen-specific T cell immunity and prevent cardiac fibrosis progression.Methodology/ Principal findingsWe evaluated the therapeutic vaccine candidate plus BNZ (25 mg/kg/day/7 days) given at days 72 and 79 post-infection (p.i) (early chronic phase). Fibrosis, inflammation, and parasite burden were quantified in heart tissue at day 200 p.i. (late chronic phase). Further, spleen cells were collected to evaluate antigen-specific CD4+ and CD8+ T cell immune responses, using flow cytometry. We found that vaccine-linked BNZ treated mice had lower cardiac fibrosis compared to the infected untreated control group. Moreover, cells from mice that received the immunotherapy had higher stimulation index of antigen-specific CD8+Perforin+ T cells as well as antigen-specific central memory T cells compared to infected untreated control.ConclusionsOur results suggest that the bivalent immunotherapy together with BNZ treatment protects mice against cardiac fibrosis and activates strong CD8+ T cell responses by in vitro restimulation, evidencing the induction of a long-lasting T. cruzi-immunity.Author summaryChagas disease (CD) is a neglected tropical disease caused by the parasite Trypanosoma cruzi, transmitted through contact with infected feces of vectors bugs. CD can induce cardiac abnormalities including the development of fibrosis and eventually death. Benznidazole (BNZ) is the first-line drug approved against CD, however, its toxicity and lack of efficacy in the chronic phase have limited its use. Previous studies have demonstrated the feasibility of reducing doses of BNZ given in combination with therapeutic vaccines during the acute phase of CD, which increases its tolerability and reduces adverse side effects. Considering that patients are often diagnosed until prolonged stages of the disease, its necessary to evaluate therapies given in the chronic phase of CD. In this study, we evaluated a vaccine formulated with the recombinant T. cruzi-antigens TSA-1-C4 and Tc24-C4 and the adjuvant E6020-SE in combination with a low dose of BNZ given during the chronic phase of T. cruzi-infection using a murine model. The authors found that the combination therapy protects mice against cardiac fibrosis, allow the activation of a CD8+ T cell response and induce a prolonged memory response against T. cruzi. This study supports the development of the vaccine-linked chemotherapy approach in order to prevent T. cruzi chronic infection.