Long-term Hematopoietic Stem Cells as Sanctuary Niche during Treatment Failure in Visceral Leishmaniasis
Abstract The increasing frequency of treatment failure in visceral leishmaniasis (VL) has already resulted in discontinuation of various first-line drugs. Although most studies focus on associations with parasitic drug resistance, a knowledge gap remains about other factors determining cure versus relapse. The present study used double bioluminescent/fluorescent Leishmania infantum and L. donovani reporter lines to study relapse at the tissue and cellular level. In combination with 123 different treatments in golden Syrian hamsters, the observations provide evidence of parasites surviving in the bone marrow (BM), identifying this tissue as a sanctuary site from where the host can be recolonized. Long-term hematopoietic stem cells (LT-HSC; Lin- Sca1 + cKit + CD48- CD150+) were found to become readily infected through invasion rather than phagocytosis. Compared to other BM cells and macrophages, LT-HSCs constitute a hospitable cellular niche with low nitric oxide and reactive oxygen species levels and harbouring enormous parasite burdens. Moreover, we found that infected LT-HSCs are less sensitive to antileishmanial reference drugs in comparison to macrophages. Given the important clinical implications for the current field situation of increasing post-treatment relapse rates, this study represents an essential step by identifying the BM cellular niches responsible for Leishmania persistence and treatment failure.