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Experimental Parasitology 164 (2016) 64e70

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Aspirin treatment exacerbates oral infections by Trypanosoma cruzi

Luana Aparecida Cossentini a, Rosiane Valeriano Da Silva b, Sueli Fumie Yamada-Ogatta c,
 De Almeida Arajo d, Phileno Pinge-Filho a, *
Lucy Megumi Yamauchi c, Eduardo Jose
, Brazil
rio de Imunopatologia Experimental, Departamento de Ci^
gicas, Universidade Estadual de Londrina, Londrina, Parana
encias Patolo
, Brazil
Instituto Carlos Chagas, FIOCRUZ, Curitiba, Parana
, Brazil
Departamento de Microbiologia, Universidade Estadual de Londrina, Londrina, Parana
, Brazil
rio de Neurogastroenterologia, Departamento de Histologia, Universidade Estadual de Londrina, Londrina, Parana

h i g h l i g h t s

g r a p h i c a l a b s t r a c t

 First study to examine the effect of

aspirin in Trypanosoma cruzi infection
by oral route.
 Aspirin reduces nitrite and increases
TNF-a gastric mucosal content.
 Aspirin exacerbates T. cruzi gastric
mucosal invasion capacity upon oral

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 7 August 2015
Received in revised form
8 January 2016
Accepted 20 January 2016
Available online 28 January 2016

Oral transmission of the protozoan parasite Trypanosoma cruzi, the etiological agent of Chagas disease,
has been documented in Latin American countries. The reported cases of infection were due to the
ingestion of contaminated fresh fruit, juices, or sugar cane juice. There have been few studies on the
physiopathology of the disease in oral transmission cases. Gastritis is a common ailment that can be
caused by poor dietary habits, intake of alcohol or other gastric irritants, bacterial infection, or by the
widespread use of non-steroidal anti-inammatory drugs (NSAIDs). This study investigated in a mouse
model whether gastric mucosal injury, induced by aspirin, would affect the course of disease in animals
infected with T. cruzi by the oral route. The CL14 and G strains of T. cruzi, both of low infectivity, were
used. To this end, groups of BALB/c mice were treated during 5 days with aspirin (100 mg kg1) before
oral infection with T. cruzi metacyclic forms (4  105 or 5  107 parasites/mouse). Histological analysis
and determination of nitric oxide and TNF-a were performed in gastric samples obtained 5 days after
infection. Parasitemia was monitored from the thirteenth day after infection. The results indicate that
aspirin treatment of mice injured their gastric mucosa and facilitated invasion by both CL14 and G strains
of T. cruzi. Strain CL14 caused more severe infection compared to the G strain, as larger numbers of
amastigote nests were found in the stomach and parasitemia levels were higher. Our study is novel in

Chagas disease
Gastric mucosa
Trypanosoma cruzi

Abbreviations: ASA, aspirin; COX, cyclooxygenase; MT, metacyclic trypomastigotes; NO, nitric oxide; p.i, post infection; PG, prostaglandins; PGE2, prostagandin
E2; iNOS, inducible nitric oxide synthase; NSAIDs, non-steroidal anti-inammatory
^ncias Patolo
gicas, Centro de Cie
^n* Corresponding author. Departamento de Cie
gicas, Universidade Estadual de Londrina, CEP: 86051-970, Londrina,
cias Biolo
a, Brazil.
E-mail address: (P. Pinge-Filho).
0014-4894/ 2016 Elsevier Inc. All rights reserved.

L.A. Cossentini et al. / Experimental Parasitology 164 (2016) 64e70


that it shows that gastric mucosal damage caused by aspirin, a commonly used NSAID, facilitates T. cruzi
infection by the oral route.
2016 Elsevier Inc. All rights reserved.

1. Introduction
Chagas disease is caused by the protozoan parasite Trypanosoma
cruzi. It is still a major public health problem in Latin America and a
potentially serious emerging threat in a number of countries
(Bonney, 2014; Carlier, 2011; Coura and Vinas, 2010). Transmission
occurs by blood-sucking triatomine bugs; metacyclic forms of the
parasite present in the triatomine feces contaminate the nearby
bite wound or mucous membranes and conjunctiva (ShikanaiYasuda and Carvalho, 2012). However, transmission by ingestion
of contaminated food or beverages has often been reported during
the last two decades and is presently considered an emergent
health problem (Benchimol-Barbosa, 2010).
Ingestion of fruit or fruit juices contaminated with infected
triatomines or their feces, which contain metacyclic trypomastigotes (MTs) of T. cruzi, is the most common cause of human
infection by the oral route (Yoshida et al., 2011). Gastric invasion
appears to be the main portal of entry for systemic T. cruzi infection
after oral challenge (Hoft et al., 1996). The parasites invade the
gastric epithelium where they initially replicate (de Meis et al.,
In addition, it was shown that infection by insect-derived MTs in
BALB/c mice was more severe when the parasites were administered via the mucosal route in comparison to the cutaneous route,
which emphasizes the hazard of oral contamination (Eickhoff et al.,
2013). However, mice inoculated with culture-derived MTs by
gavage or intraperitoneal routes developed comparable infections
(Dias et al., 2013). A recent study compared groups of mice infected
with T. cruzi by parasites inoculated in the oral cavity (oral infection) or by gavage (gastrointestinal infection); the orally infected
group developed more severe hepatic lesions and had higher
mortality rates than the latter, in which heart inammation was
predominant (Barreto-de-Albuquerque et al., 2015).
The variation in the prevalence and severity of contamination
among persons exposed to a common source of T. cruzi-infected
food or beverage indicates a wide range of individual susceptibility
(Yoshida, 2008). The numbers of ingested parasites as well as the
genetic background of each person certainly are major determinants of each person's susceptibility. Nevertheless, given the
prevalence of gastritis of different etiologies in the population, it is
conceivable that gastric mucosal injury might favor invasion by
ingested T. cruzi parasites.
In order to investigate this question we chose to verify the effect
of aspirin-induced gastric injury on the outcome of oral infection by
T. cruzi metacyclic forms. Gastric mucosal damage is a common side
effect of nonsteroidal anti-inammatory drugs (NSAIDs) (Katzka
et al., 1987).
Aspirin and other NSAIDs, such as celecoxib and indomethacin,
act on cyclooxygenases and inhibit the synthesis of prostaglandins
(PGs). Mice infected by the intraperitoneal route with T. cruzi blood
forms and treated with NSAIDs showed a worsening of the infection, regardless of the mouse or parasite strain under investigation
(Celentano et al., 1995; Hideko Tatakihara et al., 2008, Mukherjee
et al., 2011; Pinge-Filho et al., 1999; Sterin-Borda et al., 1996). The
increased synthesis of arachidonic acid-derived lipids and of nitric
oxide (NO) seen in the early phase of T. cruzi infection of mice was
correlate with resistance; however, at later stages of infection these

molecules were associated with tissue damage (Cardoni and

Antunez, 2004).
On the other hand, other investigators, also working on intraperitoneal infections by T. cruzi blood forms, found that inhibition
of PG synthesis/release decreases parasitemia and extends the
survival of mice (Abdalla et al., 2008; Freire-de-Lima et al., 2000;
Michelin et al., 2005; Paiva et al., 2007); these results correlated
with a reduction in circulating levels of the cytokines TNF-a, IFN-g,
and IL-10 (Michelin et al., 2005).
The present study investigated the effect of aspirin-induced
gastric mucosal injury in mice on the course of infection by metacyclic forms of the low-virulence T. cruzi strains, CL14 and G,
administered by the oral route.
2. Material and methods
2.1. Ethics statement
This study was performed in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory
Animals of the Brazilian National Council of Animal Experimentation and the Federal Law 11.794 (10/2008). The protocols were
approved by the Internal Scientic Commission and the Ethics in
Animal Experimentation Committee of State University of Londrina
(CEUA/UEL: 26369.2014.66, and 8504.2015-71).
2.2. Mice
Six-to eight-week-old BALB/c, female and male mice were purchased from Multi-Institutional Center for Biological Investigation,
State University of Campinas, Brazil. Mice were maintained under
standard conditions in the animal house of the Department of
Pathological Sciences, Centre for Biological Sciences, State University of Londrina. Commercial rodent diet (Nuvilab-CR1, QuimtiaNuvital, Colombo, Brazil) and sterilized water were given ad libitum.
2.3. Parasites and oral infection
Metacyclic trypomastigote forms from the low-virulence strains
CL 14 (Lima et al., 1995) and G (Yoshida, 2006) of T. cruzi were used
to infect the mice. Parasites harvested from cultures at the stationary growth phase were puried to obtain metacyclic forms by
passage through DEAE-cellulose columns, as described previously
(Teixeira and Yoshida, 1986).
Metacyclic forms were inoculated by gavage in lightly anesthetized mice that had been treated with a suspension of ASA or
with the vehicle (control groups). Mice infected with 5  107 parasites were used to collect the stomach for histological analysis and
determination of nitric oxide (NO) and TNF-a. Mice infected with
4  105 parasites were used to collect blood samples for parasitemia determinations (Cortez et al., 2006).
2.4. ASA treatment and gastric mucosal injury
Mice were fasted for 16 h before administration of one of the
following oral suspensions: ASA (100 mg kg1) or vehicle
(PBS DMSO 0.05%). The oral treatment was given daily during 5


L.A. Cossentini et al. / Experimental Parasitology 164 (2016) 64e70

days before T. cruzi infection (Fig. 1).

ASA-treated and untreated mice were euthanized in order to
collect the stomach for histological analysis. Initially, tissue samples
from non-infected ASA-treated mice were analyzed to verify gastric
mucosal injury. For this, half of each collected stomach was xed in
10% neutral buffered formalin for 24 h and then submitted to histological processing. Sections were stained with hematoxylin and
eosin. Gastric mucosal damage was assessed as described previously (Fiorucci, 2009; Fiorucci et al., 2011). The scoring was performed blindly by an observer who assessed the following
parameters: edema (0e4), hemorrhage (0e4), loss of epithelial
cells (0e3) and inammatory inltration (0e3).
2.5. Evaluation of infection
The intensity of parasitism at the infection site was determined
by counting the number of parasite nest in 5 mm-thick sections of
the stomach stained with hematoxylin and eosin. The stomachs of
ASA treated mice and of untreated T. cruzi-infected mice were
collected 4 days after infection (Fig. 1), xed and processed as
described in Section 2.4. All amastigote nests present in four nonserial sections obtained from each mouse were counted.
Follow up of the infection was evaluated by counting the
number of parasites in fresh preparations of 5 mL samples of tailvein blood mounted under standard coverslips as described
(Brener, 1962). Blood samples were obtained every second day,
starting on the 13th day after infection.
2.6. Determination of nitric oxide and TNF-a in gastric tissue
Nitric oxide (NO) concentration in stomach homogenates obtained from non-infected and infected mice (day 4) was estimated
by measuring nitrite as described by Navarro-Gonzalez and collaborators with some modications. It is a method based on the
Griess reaction, modied to include a shortened incubation period
of nitrate with cadmium (Navarro-Gonzalvez et al., 1998;
Tatakihara et al., 2015). Cadmium treatment is used to convert all
nitrate into nitrite in biological samples, thus providing a more
accurate estimation of total NO in the original samples. To determine the nitrite content in stomach samples (100 mg/mL), a

calibration curve was prepared by diluting NaNO2 (Merck) in

distilled sterile water in order to create concentrations ranging
from 0 to 125 mM. Griess reagent (100 mL) was added to each well
and to the calibration curve run in triplicate in each microtiter
plate. The absorbance was read at 550 nm using a Synergy HT
microplate reader (Biotek Instruments, Winooski, USA), and the
results are expressed in mM nitrite.
The levels of TNF-a in stomach homogenates were measured
using a commercial ELISA kit (Mouse TNF alpha ELISA Ready-SETGo! , eBioscience, San Diego, CA), according to the manufacturer's instructions. Each sample was tested in duplicate. The optical densities were read using an ELISA reader (Biotek Instruments,
Winooski, USA) at wavelengths of 430 nm. The sensitivity of this
ELISA test is 8 pg/mL. The inter-assay coefcient of variation for
ELISA assay was 5% (to vehicle) and 10% (to aspirin).
2.7. Statistical analysis
The program GraphPad Prism 5.0 (GraphPad Software, San
Diego, CA, USA) was used to determine signicance by Student's t
test. Values are presented as the mean standard error of mean
(SEM). The results were considered signicant when P < 0.05.
3. Results
3.1. Aspirin treatment provoked gastric mucosal injury
Aspirin (ASA) given orally to mice at a dose of 100 mg kg1
during 5 days induced gastric mucosal injury as indicated by the
high score of mucosal damage (Fig. 2A) and signicantly reduced
the gastric mucosal nitrite level by 50% (Fig. 2B) and increased TNFa level by 25% compared to the control value (Fig. 2C). These
ndings are indicative of gastric mucosal damage by ASA treatment
(Fiorucci et al., 1999).
3.2. Treatment with aspirin exacerbated gastric mucosal parasitism
in mice infected by CL14 strain of T. cruzi
The intensities of gastric parasitism in vehicle-treated control
mice infected with T. cruzi strains G or CL14 were compared

Fig. 1. Experimental design. BALB/c mice were treated with aspirin (ASA, 100 mg kg1) for ve days before T. cruzi infection. Control mice received vehicle (DMSO PBS) alone. The
mice were infected by gavage with 5  107 or 4  105 living forms of T. cruzi, strains G or CL14. Four days after infection the stomach of each animal was collected and processed for
histological analysis and quantication of nitric oxide and TNF-a. Parasitemia was monitored in alternate days starting from day 13 until day 31 after infection.

L.A. Cossentini et al. / Experimental Parasitology 164 (2016) 64e70


Fig. 2. Effect of ASA treatment on the gastric mucosa. ASA (100 mg kg1) treatment during 5 days caused: elevated gastric mucosal damage scores (A), and reduced nitrite (B) and
increased TNF-a levels (C) in the gastric mucosa in comparison to samples obtained from vehicle treated mice. The means SEM from 3 mice/group are presented (two different
sections from each mouse were evaluated). *P < 0.05, compared to the control mice that received vehicle.

(Fig. 3A). Prior treatment by gavage with ASA of mice infected with
CL14 caused a four-fold increased in the number of amastigote
nests in the stomach in comparison with control mice given only
vehicle solution. In contrast, gastric parasitism of mice infected
with G strain was not changed by similar ASA treatment (Fig. 3A).
These numerical results are illustrated by photomicrographs in
Fig. 3B and C showing T. cruzi gastric parasitism by strains G and
CL14 respectively. To examine the effect of ASA in the intracellular
parasite development in vivo, BALB/c mice treated with ASA
(100 mg kg1) were inoculated orally with 5  107 MT forms of CL
14 and G (both lowly infective). It was observed that the number of
CL14 strain-amastigote nests was four times higher as compared to
G strain-ones (Fig. 3A). No difference was observed in the number
of amastigote nests in the stomach of ASA-treated mice inoculated
with G strain (Fig. 3A). The distribution of parasite nests of G strain
was sparser (Fig. 3B) than that for the CL14 strain (Fig. 3C).
3.3. Treatment with aspirin augmented the frequency of mice
developing patent and elevated parasitemia levels
The frequency of mice that developed patent parasitemia when
infected with strains G or CL14 was increased in the groups given
ASA prior to oral inoculation (Table 1). As expected, no mortality
was observed in either group of animals (Table 1). Parasites became
detectable by the 13th day and the peak of parasitemia occurred on
the 17th day after infection for both T. cruzi strains (Fig. 4A and B).
Peak parasitemia counts in CL14-infected mice were approximately
twice those observed in G-infected mice. By day 31 parasite counts
in the blood fell below the detection threshold of the method
(Fig. 4A and B).
4. Discussion
Invasion of the vertebrate host by T. cruzi depends primarily on
events at the point of entry. In the case of oral ingestion, the gastric
mucosa appears to be the major entry portal. We chose to verify
infectivity by the oral route of the laboratory-adapted strains CL14
and G because they are representative of the low-infectivity T. cruzi
strains that predominate in endemic areas (Atayde et al., 2004;
Yoshida, 2006). As expected, parasites in the blood were detected
only in a limited percentage of mice when the infective inoculum
was deposited inside normal stomachs.

Our main nding is that aspirin caused injury to the stomach

and facilitated infection by T. cruzi administered by the oral route.
The gastric toxicity of aspirin is believed to be mainly due to its
non-selective inhibition of cyclooxygenases and consequent
reduction of PGE2 synthesis (Hunt and Yuan, 2011; Nishino et al.,
Aspirin is a member of the NSAIDs family that share the ability
of inhibiting fever, pain, and inammation by blocking the formation of prostaglandins by either reversibly or irreversibly (in the
case of aspirin) inhibiting the rate-limiting enzyme COX. There are
at least fteen NSAIDs on the market at present and, because of
their increased potency to inhibit COX activity, they are frequently
prescribed (70 million NSAID prescriptions are written per year) for
individuals suffering from chronic inammation and pain. One of
the major problems with this trend is that NSAID usage is associated with a number of side-effects, mostly affecting the upper
gastrointestinal tract and the kidney (Lichtenberger, 2001). Therefore, PGE2 protects the gastric mucosa from lesions. In contrast, the
inhibition of PGE2 production by NSAIDs, such as aspirin [acetylsalicylic acid (ASA)], induces gastric lesions.
This damage can be associated with an inhibition of epithelial
cell autophagy, which enhances the vulnerability of gastric
epithelial cells (Hernadez et al., 2015). Thus, the low-infectivity
T. cruzi strains used in this study could reach the lamina propria
easier. Once inside the mucosa, the parasites could proliferate to
form amastigote nests, as we observed in mice infected with G and
CL14 strains. Theses strains would not be observed inside the
mucosa if the gastric mucosa was intact. We suggest that the
elevated numbers of CL14 parasites in the blood is a consequence of
the higher parasitism of the gastric mucosa in aspirin-treated mice.
We also consider that aspirin pre-treatment facilitated G strain
infection, although to a lesser degree; however, this facilitation was
not accompanied by increase in gastric mucosa parasitism.
The pathogenic mechanisms inducing these lesions are
considered to involve other factors, such as a decrease in mucin
amount, inhibition of glycoprotein synthesis, and gastric hypermotility (Shimamoto et al., 2005; Takao et al., 1993).
High efciency of metacyclic forms in establishing infection by
oral route is associated with expression of gp82, a stage-specic
surface molecule that binds to gastric mucin and to epithelial
cells. Gp82 promotes parasite entry by triggering the signaling
cascades leading to intracellular Ca (2) mobilization. T. cruzi


L.A. Cossentini et al. / Experimental Parasitology 164 (2016) 64e70

Fig. 3. Effect of ASA treatment on the invasion capacity of strains G and CL14 of T. cruzi in the gastric mucosa. Stomach tissue sections of mice (n 3/group) were performed 5 days
after oral infection with metacyclic trypomastigotes (5  107). Number of amastigotes nests and distribution of amastigote-containing nests of G (B) and CL14 (C) strains. Note the
multiple parasite nests of strain CL14 and a single nest of strain G, in equivalent sections of the stomach stained by were stained by Hematoxylin-Eosin (H.E). Bar: 25 mm. Inserts
show amastigote nests.*P < 0.05, compared to the untreated mice.

Table 1
Parasitological parameters of the infection with T. cruzi (CL14 and G strains) in ASA treated and untreated mice.

(For 5 days)a

No. of parasites orally inoculatedb






No. of mice with positive parasitemia/No. of mice inoculated

% of survival
30 days post infection



Mice were fasted for 16 h before administration of one of the following oral suspensions: ASA (100 mg kg1) or vehicle (PBS DMSO 0.05%) by gavage.
Suspension of metacyclic trypomastigotes (MT) was used as the inoculum.

strains decient in gp82 can effectively invade cells in vitro, by

engaging the Ca (2) signal-inducing surface glycoprotein gp30.

However, they are poorly infective in mice by oral route because

gp30 has low afnity for gastric mucin. Metacyclic forms also

L.A. Cossentini et al. / Experimental Parasitology 164 (2016) 64e70


revealed very scarce parasites. These observations are consistent

with the fact that this strain expresses high levels of a gp90 isoform
(Cortez et al., 2006).
In aspirin-treated mice, detectable parasitemia was observed in
more mice of the CL14 strain (but not of the G strain); the higher
frequency and parasitemia levels could be correlated to more
intense parasitism of gastric mucosa.
A possible explanation for the difference between the two
strains is that, in the stomach, metacyclic forms of different isolates
can resist destruction by pepsin and acidic pH because they are
protected by protease-resistant gp35/50 mucins. MTs of CL and G
isolates bind to gastric mucin via gp82 as the rst step to traversing
the mucin layer and reaching the underlying epithelial cells. Once
the epithelial cells are reached, MTs of the CL14 strain attach to and
efciently invade them in a gp82-dependent manner, whereas MTs
of the G strain enter epithelial cells poorly, owing to preferential
adhesion through gp35/50. Finding proteases and/or conditions
that preserve the gp35/50 molecules and degrade gp90 would
facilitate researchers to gain insight into the role that mucins play
in infection (Yoshida, 2006).
NSAID administration results in TNF-a-mediated activation of
apoptosis and damage to endothelial cells (Fiorucci et al., 1999). NO
and other nitrogen oxides (e.g., NO2, NO
3 ) counteract damaging
events that occur following suppression of PG biosynthesis
(MacNaughton et al., 1989). Nevertheless, we found a reduction in
NO levels in the gastric mucosa of aspirin-treated mice despite
increased levels of TNF-a. Because NO is a potent inhibitor of T. cruzi
growth (Aliberti et al., 1999; Fichera et al., 2004), the low levels of
NO may favor survival and growth of the parasite in the damaged
mucosa. Caution should be exercised when employing COX inhibitors to control fever or pain in patients with acute Chagas disease (Hideko Tatakihara et al., 2008, Machado et al., 2011).
5. Conclusions
This is the rst report that examines the effect of ASA treatment
on T. cruzi infection by oral route. We conclude that ASA treatment
caused gastric mucosal injury and facilitated invasion of T. cruzi
metacyclic forms administered by the oral route. Our results may
stimulate researchers to obtain new knowledge about the role that
mucins play in T. cruzi infection. People living in areas at risk for
Chagas disease transmission who take NSAIDs or who have gastric
lesions of other causes may be more susceptible to infection by
ingested parasites. Hygienic processing of foods, fruits and fruit
juices is still the most important way to avoid contamination.
Fig. 4. Effect of ASA in the course of infection in mice orally inoculated with G and
CL14 metacyclic forms (MT). Differential infectivity of T. cruzi isolates G (A) and CL14
(B). Each data point corresponds to the mean parasitemia of four animals/group from
at least two independent experiments.

express gp90, a stage-specic surface glycoprotein that binds to

host cells and acts as a negative regulator of invasion. T. cruzi strains
expressing gp90 at high levels, in addition to gp82 and gp30, are all
poor cell invaders in vitro. Nevertheless, their infectivity by oral
route may vary because, unlike gp82 and gp30, which resist
degradation by pepsin in the gastric milieu, the gp90 isoforms of
different strains have varying susceptibility to peptic digestion
(Yoshida, 2009; Yoshida et al., 2011).
G strain metacyclic forms are poorly infective when given orally
into mice and fail to produce detectable parasitemia upon microscopic examination of blood samples. Analysis of histological
preparations of stomach from mice infected with G strain has

The authors thank Dr. Nobuko Yoshida (UNIFESP-SP, Brazil) and

Dr. Iriane Eger (UEPG-PR, Brazil) for providing G and CL-14 strains,
respectively. Dr. Ises de Almeida Abramsohn helped with English
editing of the manuscript. Cossentini and R.V. da Silva received
~o de Aperfeioamento de Pessoal de
scholarships from Coordenaa
Nvel Superior (CAPES, 40002012026M9) PPF received research
fellowship from CNPq (306497/2012).
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