Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Heme oxygenase-1 and carbon monoxide suppress the pathogenesis of experimental cerebral malaria

Nature Medicine volume 13, pages 703–710 (2007)Cite this article

Abstract

Cerebral malaria claims more than 1 million lives per year. We report that heme oxygenase-1 (HO-1, encoded by Hmox1) prevents the development of experimental cerebral malaria (ECM). BALB/c mice infected with Plasmodium berghei ANKA upregulated HO-1 expression and activity and did not develop ECM. Deletion of Hmox1 and inhibition of HO activity increased ECM incidence to 83% and 78%, respectively. HO-1 upregulation was lower in infected C57BL/6 compared to BALB/c mice, and all infected C57BL/6 mice developed ECM (100% incidence). Pharmacological induction of HO-1 and exposure to the end-product of HO-1 activity, carbon monoxide (CO), reduced ECM incidence in C57BL/6 mice to 10% and 0%, respectively. Whereas neither HO-1 nor CO affected parasitemia, both prevented blood-brain barrier (BBB) disruption, brain microvasculature congestion and neuroinflammation, including CD8+ T-cell brain sequestration. These effects were mediated by the binding of CO to hemoglobin, preventing hemoglobin oxidation and the generation of free heme, a molecule that triggers ECM pathogenesis.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Expression of HO-1 prevents the pathogenesis of ECM in BALB/c mice infected with P. berghei ANKA.
Figure 2: Induction of HO-1 or exposure to CO suppresses ECM onset in C57BL/6 mice infected with P. berghei ANKA.
Figure 3: HO-1 and CO prevent BBB disruption and brain microvascular congestion.
Figure 4: CO inhibits neuroinflammation and CD8+ T-cell brain sequestration.
Figure 5: HO-1 and CO prevent BBB disruption and the development of ECM by inhibiting free heme release from oxidized hemoglobin.
Figure 6: Mechanism underlying the protective actions of HO-1 and CO.

Similar content being viewed by others

References

  1. Francis, S.E., Sullivan, D.J., Jr. & Goldberg, D.E. Hemoglobin metabolism in the malaria parasite Plasmodium falciparum. Annu. Rev. Microbiol. 51, 97–123 (1997).

    Article  CAS  Google Scholar 

  2. Balla, J. et al. Heme, heme oxygenase and ferritin in vascular endothelial cell injury. Mol. Nutr. Food Res. 49, 1030–1043 (2005).

    Article  CAS  Google Scholar 

  3. Orjih, A.U., Banyal, H.S., Chevli, R. & Fitch, C.D. Hemin lyses malaria parasites. Science 214, 667–669 (1981).

    Article  CAS  Google Scholar 

  4. Balla, G. et al. Ferritin: a cytoprotective antioxidant strategem of endothelium. J. Biol. Chem. 267, 18148–18153 (1992).

    CAS  PubMed  Google Scholar 

  5. Tenhunen, R., Marver, H.S. & Schmid, R. The enzymatic conversion of heme to bilirubin by microsomal heme oxygenase. Proc. Natl. Acad. Sci. USA 61, 748–755 (1968).

    Article  CAS  Google Scholar 

  6. Sato, K. et al. Carbon monoxide generated by heme oxygenase-1 suppresses the rejection of mouse to rat cardiac transplants. J. Immunol. 166, 4185–4194 (2001).

    Article  CAS  Google Scholar 

  7. Otterbein, L.E., Soares, M.P., Yamashita, K. & Bach, F.H. Heme oxygenase-1: unleashing the protective properties of heme. Trends Immunol. 24, 449–455 (2003).

    Article  CAS  Google Scholar 

  8. Clark, I.A., Cowden, W.B. & Rockett, K.A. The pathogenesis of human cerebral malaria. Parasitol. Today 10, 417–418 (1994).

    Article  CAS  Google Scholar 

  9. Schofield, L. & Grau, G.E. Immunological processes in malaria pathogenesis. Nat. Rev. Immunol. 5, 722–735 (2005).

    Article  CAS  Google Scholar 

  10. Lou, J., Lucas, R. & Grau, G.E. Pathogenesis of cerebral malaria: recent experimental data and possible applications for humans. Clin. Microbiol. Rev. 14, 810–820 (2001).

    Article  CAS  Google Scholar 

  11. Hansen, D.S., Siomos, M.A., Buckingham, L., Scalzo, A.A. & Schofield, L. Regulation of murine cerebral malaria pathogenesis by CD1d-restricted NKT cells and the natural killer complex. Immunity 18, 391–402 (2003).

    Article  CAS  Google Scholar 

  12. Basilico, N., Monti, D., Olliaro, P. & Taramelli, D. Non-iron porphyrins inhibit beta-haematin (malaria pigment) polymerisation. FEBS Lett. 409, 297–299 (1997).

    Article  CAS  Google Scholar 

  13. Yamashita, K. et al. Biliverdin, a natural product of heme catabolism, induces tolerance to cardiac allografts. FASEB J. 18, 765–767 (2004).

    Article  CAS  Google Scholar 

  14. Favre, N. et al. Role of ICAM-1 (CD54) in the development of murine cerebral malaria. Microbes Infect. 1, 961–968 (1999).

    Article  CAS  Google Scholar 

  15. Thumwood, C.M., Hunt, N.H., Clark, I.A. & Cowden, W.B. Breakdown of the blood-brain barrier in murine cerebral malaria. Parasitology 96, 579–589 (1988).

    Article  Google Scholar 

  16. Good, M.F., Xu, H., Wykes, M. & Engwerda, C.R. Development and regulation of cell-mediated immune responses to the blood stages of malaria: implications for vaccine research. Annu. Rev. Immunol. 23, 69–99 (2005).

    Article  CAS  Google Scholar 

  17. Grau, G.E. et al. Tumor necrosis factor (cachectin) as an essential mediator in murine cerebral malaria. Science 237, 1210–1212 (1987).

    Article  CAS  Google Scholar 

  18. Engwerda, C.R. et al. Locally up-regulated lymphotoxin alpha, not systemic tumor necrosis factor alpha, is the principle mediator of murine cerebral malaria. J. Exp. Med. 195, 1371–1377 (2002).

    Article  CAS  Google Scholar 

  19. Grau, G.E. et al. Monoclonal antibody against interferon gamma can prevent experimental cerebral malaria and its associated overproduction of tumor necrosis factor. Proc. Natl. Acad. Sci. USA 86, 5572–5574 (1989).

    Article  CAS  Google Scholar 

  20. Belnoue, E. et al. On the pathogenic role of brain-sequestered alphabeta CD8+ T cells in experimental cerebral malaria. J. Immunol. 169, 6369–6375 (2002).

    Article  CAS  Google Scholar 

  21. Yanez, D.M., Manning, D.D., Cooley, A.J., Weidanz, W.P. & van der Heyde, H.C. Participation of lymphocyte subpopulations in the pathogenesis of experimental murine cerebral malaria. J. Immunol. 157, 1620–1624 (1996).

    CAS  PubMed  Google Scholar 

  22. Balla, J. et al. Endothelial-cell heme uptake from heme proteins: induction of sensitization and desensitization to oxidant damage. Proc. Natl. Acad. Sci. USA 90, 9285–9289 (1993).

    Article  CAS  Google Scholar 

  23. Berendt, A.R., Tumer, G.D. & Newbold, C.I. Cerebral malaria: the sequestration hypothesis. Parasitol. Today 10, 412–414 (1994).

    Article  CAS  Google Scholar 

  24. Reiter, C.D. et al. Cell-free hemoglobin limits nitric oxide bioavailability in sickle-cell disease. Nat. Med. 8, 1383–1389 (2002).

    Article  CAS  Google Scholar 

  25. Gramaglia, I. et al. Low nitric oxide bioavailability contributes to the genesis of experimental cerebral malaria. Nat. Med. 12, 1417–1422 (2006).

    Article  CAS  Google Scholar 

  26. Bouton, C. & Demple, B. Nitric oxide-inducible expression of heme oxygenase-1 in human cells. Translation-independent stabilization of the mRNA and evidence for direct action of nitric oxide. J. Biol. Chem. 275, 32688–32693 (2000).

    Article  CAS  Google Scholar 

  27. Clark, A.R., Dean, J.L. & Saklatvala, J. Post-transcriptional regulation of gene expression by mitogen-activated protein kinase p38. FEBS Lett. 546, 37–44 (2003).

    Article  CAS  Google Scholar 

  28. Schluesener, H.J., Kremsner, P.G. & Meyermann, R. Heme oxygenase-1 in lesions of human cerebral malaria. Acta Neuropathol. (Berl.) 101, 65–68 (2001).

    CAS  Google Scholar 

  29. Grau, G.E. et al. Tumor-necrosis-factor (cachectin) as an essential mediator in murine cerebral malaria. Science 237, 1210–1212 (1987).

    Article  CAS  Google Scholar 

  30. McGuire, W., Hill, A.V.S., Allsopp, C.E.M., Greenwood, B.M. & Kwiatkowski, D. Variation in the Tnf-alpha promoter region associated with susceptibility to cerebral malaria. Nature 371, 508–511 (1994).

    Article  CAS  Google Scholar 

  31. Grau, G.E. et al. Tumor necrosis factor and disease severity in children with falciparum-malaria. N. Engl. J. Med. 320, 1586–1591 (1989).

    Article  CAS  Google Scholar 

  32. Wilson, A.G., Symons, J.A., McDowell, T.L., McDevitt, H.O. & Duff, G.W. Effects of a polymorphism in the human tumor necrosis factor alpha promoter on transcriptional activation. Proc. Natl. Acad. Sci. USA 94, 3195–3199 (1997).

    Article  CAS  Google Scholar 

  33. Grau, G.E. et al. Late administration of monoclonal-antibody to leukocyte function-antigen 1 abrogates incipient murine cerebral malaria. Eur. J. Immunol. 21, 2265–2267 (1991).

    Article  CAS  Google Scholar 

  34. Ockenhouse, C.F. 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. 176, 1183–1189 (1992).

    Article  CAS  Google Scholar 

  35. Hunt, N.H. & Grau, G.E. Cytokines: accelerators and brakes in the pathogenesis of cerebral malaria. Trends Immunol. 24, 491–499 (2003).

    Article  CAS  Google Scholar 

  36. Exner, M., Minar, E., Wagner, O. & Schillinger, M. The role of heme oxygenase-1 promoter polymorphisms in human disease. Free Radic. Biol. Med. 37, 1097–1104 (2004).

    Article  CAS  Google Scholar 

  37. Takeda, M. et al. Microsatellite polymorphism in the heme oxygenase-1 gene promoter is associated with susceptibility to cerebral malaria in Myanmar. Jpn. J. Infect. Dis. 58, 268–271 (2005).

    CAS  PubMed  Google Scholar 

  38. Bach, F.H., Hancock, W.W. & Ferran, C. Protective genes expressed in endothelial cells: a regulatory response to injury. Immunol. Today 18, 483–486 (1997).

    Article  CAS  Google Scholar 

  39. Nathan, C. Points of control in inflammation. Nature 420, 846–852 (2002).

    Article  CAS  Google Scholar 

  40. Yet, S.F. et al. Hypoxia induces severe right ventricular dilatation and infarction in heme oxygenase-1 null mice. J. Clin. Invest. 103, R23–R29 (1999).

    Article  CAS  Google Scholar 

  41. Franke-Fayard, B. et al. A Plasmodium berghei reference line that constitutively expresses GFP at a high level throughout the complete life cycle. Mol. Biochem. Parasitol. 137, 23–33 (2004).

    Article  CAS  Google Scholar 

  42. Otterbein, L.E. et al. Carbon monoxide has anti-inflammatory effects involving the mitogen-activated protein kinase pathway. Nat. Med. 6, 422–428 (2000).

    Article  CAS  Google Scholar 

  43. van der Heyde, H.C. et al. Assessing vascular permeability during experimental cerebral malaria by a radiolabeled monoclonal antibody technique. Infect. Immun. 69, 3460–3465 (2001).

    Article  CAS  Google Scholar 

Download references

Acknowledgements

We thank S.-F. Yet (Pulmonary and Critical Care Division, Brigham and Women's Hospital) for providing the original Hmox1 mouse breeding pairs from which all Hmox1−/− used in this study were derived. We also thank A. Rodriguez, F. Bach, T. Pais and C. Gregoire for critically reviewing the manuscript, S. Rebelo for performing the mouse breeding and genotyping, Departamento de Anatomia Patológica (Universidade de Lisboa) for help in histopathology studies, and N. Sepúlveda for statistical analysis. This work was partially supported by Fundação para a Ciência e Tecnologia (POCTI/SAU-IMI/57946/2004 to M.M.M. and POCTI/SAU-MNO/56066/2004 to M.P.S.), the European Science Foundation (EURYI 2004 to M.M.M.), the Gemi Fund (to M.M.M.) and by the Hungarian government (OTKA-61546 and RET-2/2 to J.B.). A.P., A.F., C.D.R., A.C., S.E. and M.C.R. were supported by Fundação para a Ciência e Tecnologia fellowships (BPD/10510/2002, BPD/21707/2005, BD/14232/2003, BD/3106/2000, BPD/12188/2003 and BD/8435/2002, respectively). M.M.M. is a fellow of the EMBO Young Investigator Program and is a Howard Hughes Medical Institute International Research Scholar.

Author information

Author notes

  1. Miguel P Soares and Maria M Mota: These authors contributed equally to this work.

Authors and Affiliations

  1. Instituto Gulbenkian de Ciência, Oeiras, 2780-156, Portugal

    Ana Pamplona, Ana Ferreira, Sabrina Epiphanio, Ângelo Chora, Cristina D Rodrigues, Isabel Pombo Gregoire, Margarida Cunha-Rodrigues, Silvia Portugal, Miguel P Soares & Maria M Mota

  2. Unidade de Malária, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisboa, 1649-028, Portugal

    Ana Pamplona, Sabrina Epiphanio, Cristina D Rodrigues, Margarida Cunha-Rodrigues, Silvia Portugal & Maria M Mota

  3. Departments of Medicine and Neonatology, Medical and Health Science Center, University of Debrecen, Debrecen, 4032, Hungary

    József Balla, Viktória Jeney & György Balla

Authors
  1. Ana Pamplona
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ana Ferreira
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. József Balla
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Viktória Jeney
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. György Balla
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sabrina Epiphanio
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ângelo Chora
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Cristina D Rodrigues
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Isabel Pombo Gregoire
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Margarida Cunha-Rodrigues
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Silvia Portugal
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Miguel P Soares
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Maria M Mota
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

A.P. performed the majority of the experimental work. A.F. contributed critically to defining the role of free heme in the onset of ECM. Both A.P. and A.F. contributed to the study design and helped in drafting the manuscript. J.B., V.J. and G.B. performed the in vitro studies that defined the ability of CO to inhibit hemoglobin oxidation. S.E. performed all histological procedures and analysis. A.C., C.D.R., I.P.G., M.C.-R. and S.P. contributed to the experimental work. M.M.M. formulated the initial hypothesis that HO-1 and CO might counter the onset of ECM, and M.P.S. formulated the hypothesis that CO might act on hemoglobin to arrest ECM triggered by free heme. Both M.P.S. and M.M.M. conceived and designed the experimental procedures and wrote the manuscript. All authors read and approved the manuscript.

Corresponding authors

Correspondence to Miguel P Soares or Maria M Mota.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Supplementary information

Supplementary Fig. 1

Kinetics of HO-1 and HO-2 protein expression in the brain during malaria infection. (PDF 168 kb)

Supplementary Fig. 2

HO-1 expression in the liver and lungs during malaria infection. (PDF 97 kb)

Supplementary Fig. 3

CO, but not biliverdin, suppresses the pathogenesis of ECM. (PDF 90 kb)

Supplementary Fig. 4

Assessment of BBB disruption and parenchymal brain hemorrhage in P. berghei ANKA infected mice. (PDF 883 kb)

Supplementary Fig. 5

CO prevents Hb oxidation. (PDF 95 kb)

Supplementary Fig. 6

CO does not inhibit red blood cell lysis. (PDF 95 kb)

Supplementary Fig. 7

Correlation between circulating free-heme and susceptibility to ECM. (PDF 122 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pamplona, A., Ferreira, A., Balla, J. et al. Heme oxygenase-1 and carbon monoxide suppress the pathogenesis of experimental cerebral malaria. Nat Med 13, 703–710 (2007). https://doi.org/10.1038/nm1586

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nm1586

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing