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. 2021 Mar 11;16(3):e0247560. doi: 10.1371/journal.pone.0247560

Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum

Valéria da Costa Oliveira 1,#, Artur Augusto Velho Mendes Junior 1,‡, Luiz Claudio Ferreira 1,‡, Tatiana Machado Quinates Calvet 1,‡, Shanna Araujo dos Santos 1,‡, Fabiano Borges Figueiredo 2,‡, Monique Paiva Campos 2,‡, Francisco das Chagas de Carvalho Rodrigues 1,‡, Raquel de Vasconcellos Carvalhaes de Oliveira 1,‡, Elba Regina Sampaio de Lemos 3,‡, Tatiana Rozental 3,‡, Raphael Gomes da Silva 3,‡, Maria Regina Reis Amendoeira 3,‡, Rayane Teles-de-Freitas 3,‡, Rafaela Vieira Bruno 3,4,‡, Fernanda Nazaré Morgado 3,‡, Luciana de Freitas Campos Miranda 1,‡, Rodrigo Caldas Menezes 1,*,#
Editor: Angela Monica Ionica5
PMCID: PMC7951870  PMID: 33705437

Abstract

In canine leishmaniosis caused by the protozoan Leishmania infantum, little is known about how co-infections with or co-seropositivities for other pathogens can influence aggravation of this disease. Therefore, the objectives of this study were to evaluate the frequency of co-infections with or co-seropositivities for certain pathogens in dogs seropositive for L. infantum and their relationship with clinical signs, histological changes and L. infantum load. Sixty-six L. infantum-seropositive dogs were submitted to clinical examination, collection of blood and bone marrow, culling, and necropsy. Antibodies against Anaplasma spp., Borrelia burgdorferi sensu lato, Ehrlichia spp. and Toxoplasma gondii and Dirofilaria immitis antigens were investigated in serum. Samples from different tissues were submitted to histopathology and immunohistochemistry for the detection of Leishmania spp. and T. gondii. Quantitative real-time PCR was used to assess the L. infantum load in spleen samples. For detection of Coxiella burnetii, conventional PCR and nested PCR were performed using bone marrow samples. All 66 dogs tested positive for L. infantum by qPCR and/or culture. Fifty dogs (76%) were co-seropositive for at least one pathogen: T. gondii (59%), Ehrlichia spp., (41%), and Anaplasma spp. (18%). Clinical signs were observed in 15 (94%) dogs monoinfected with L. infantum and in 45 (90%) dogs co-seropositive for certain pathogens. The L. infantum load in spleen and skin did not differ significantly between monoinfected and co-seropositive dogs. The number of inflammatory cells was higher in the spleen, lung and mammary gland of co-seropositive dogs and in the mitral valve of monoinfected dogs. These results suggest that dogs infected with L. infantum and co-seropositive for certain pathogens are common in the region studied. However, co-seropositivities for certain pathogens did not aggravate clinical signs or L. infantum load, although they were associated with a more intense inflammatory reaction in some organs.

Introduction

In Brazil, visceral leishmaniosis (VL) caused by the protozoan Leishmania (Leishmania) infantum is a zoonosis of important public health concern. From 1990 to 2019, there were 93,614 confirmed human cases of VL in Brazil, with an average of 3,120 new cases per year [1]. The main vector responsible for the transmission of this agent in the country is the sand fly Lutzomyia longipalpis [2]. In urban areas, the dog (Canis familiaris) is the main reservoir of L. infantum and a source of vector infection [3].

Co-infections with or co-seropositivities for other pathogens are common in dogs infected with L. infantum. These pathogens include the protozoa Babesia spp., Cystoisospora spp., Giardia duodenalis, Hepatozoon canis, Neospora caninum, Toxoplasma gondii and Trypanosoma spp. and bacteria such as Anaplasma spp., Bartonella henselae, Borrelia burgdorferi, Ehrlichia canis and Rickettsia spp., as well as the helminths Acanthocheilonema reconditum, Ancylostoma caninum, A. braziliense, Dioctophyme renale, Dipylidium caninum, Dirofilaria immitis, Toxocara canis and Trichuris vulpis [4–13]. The presence of co-infections in dogs with leishmaniosis caused by L. infantum can aggravate the disease and increase animal mortality [7, 10, 13, 14]. However, studies that evaluate the parasite load and histological changes in different organs together with clinical changes in co-infections with or co-seropositivities for L. infantum in dogs are scarce. Such investigations would be important to determine whether dogs infected with L. infantum and co-infected with or co-seropositive for certain pathogens have a greater potential for transmission of L. infantum, and to subsequently develop preventive and control measures for the involved agents. Within this context, the objectives of this study were to evaluate the frequency of co-infections with or co-seropositivities for certain pathogens in dogs infected with L. infantum and their relationship with clinical signs, histological changes and L. infantum load.

Materials and methods

Dog population

This is a descriptive study of 66 dogs (38 males and 28 females) that tested seropositive for L. infantum during the period from August 2016 to January 2019. Fifty-six of these dogs were mongrel, three were Pinschers, two were Pit Bulls, two were Rottweilers, one was a Dachshund, one was a Poodle, and one was a Chow-Chow. The age of the dogs ranged from 1 to 7 years in 58 (87.9%) animals, seven (10.6%) were older than 7 years, and one (1.5%) was less than 11 months old. All dogs were from the town of Barra Mansa, state of Rio de Janeiro, Brazil. This town is located in the south of the state (22°32’25.19” S and 44°10’35.33” W) and is an endemic area for human and canine leishmaniosis caused by L. infantum [15, 16]. All animals had owners and tested seropositive for anti-Leishmania antibodies by the rapid dual-path platform (DPP®) assay (TR DPP®) [17] and by enzyme immunoassay (ELISA) [18]. Both serological tests are produced by BioManguinhos (Fiocruz, Rio de Janeiro, Brazil). These tests were performed by public health services participating in the VL surveillance and control program of the state of Rio de Janeiro, with permission of the owners. Since they tested positive, the dogs were sent by the Municipal Health Department of Barra Mansa to be culled at the Evandro Chagas National Institute of Infectious Diseases (INI-Fiocruz). Culling was performed according to the recommendations of the Brazilian Ministry of Health for the control of VL [2] and the owners provided signed consent for culling. The dogs were not housed for any period of time prior to culling. The sample size included all dogs of the study population, i.e., all dogs that tested seropositive for L. infantum in the town of Barra Mansa and that were sent to INI-Fiocruz during the study period.

Sample collection

Immediately after arrival at INI-Fiocruz, the dogs were restrained mechanically and submitted to clinical evaluation, including inspection of behavior, alertness, posture, gait, skin, and oral and ocular mucosae, as well as palpation of the superficial lymph nodes and organs. The following clinical signs of canine leishmaniosis caused by L. infantum (CanL) were considered: thinness or cachexia; diffuse or localized alopecia; apathy; cutaneous lesions such as ulcers and desquamation; onychogryphosis; enlargement of the superficial lymph nodes, liver or spleen on palpation; keratoconjunctivitis; pale ocular or oral mucosae, and skeletal muscle atrophy [19, 20]. The animals were divided into three groups according to the clinical signs of CanL: no clinical signs, few clinical signs (up to three clinical signs), and multiple clinical signs (more than three clinical signs) [21].

After clinical examination, the animals were sedated by intramuscular administration of ketamine hydrochloride (10 mg/kg) plus acepromazine maleate (0.2 mg/kg). Bone marrow was then aspirated from the sternal manubrium. The bone marrow samples were collected into sterile tubes containing EDTA and stored at -20°C for further analysis by conventional PCR and nested PCR for the detection of Coxiella burnetii DNA. Blood (1 to 3 mL) was collected from the cephalic vein into a sterile vacuum tube without anticoagulant. After coagulation, the blood samples were centrifuged at 1125 x g and the serum obtained was separated and stored at -20°C until the time of analysis. The serum was used for the detection of antibodies against A. platys/A. phagocytophilum, B. burgdorferi, E. canis/E. ewingii and T. gondii and for the investigation of D. immitis antigens. Next, the dogs were culled with an intravenous overdose of sodium thiopental and potassium chloride in accordance with the guidelines of the Federal Council of Veterinary Medicine of Brazil [22], and immediately necropsied.

During necropsy, the organs were examined macroscopically and samples of skin, spleen, liver, lung, heart valves (tricuspid and mitral), uterus, and mammary gland were collected. These tissue samples were fixed in 10% buffered formalin and embedded in paraffin (FFPE) [23] for immunohistochemistry (IHC) (detection of amastigote forms of Leishmania spp.) and histopathology. In addition, FFPE samples of the spleen, lungs and mammary glands obtained from T. gondii-seropositive dogs in which an inflammatory infiltrate was identified by histopathology were submitted to IHC for the detection of cysts or tachyzoites of this parasite. A second spleen fragment was collected and stored at -20°C in a sterile RNAse- and DNAse-free tube for subsequent detection of L. infantum DNA by singleplex qPCR. For Leishmania detection by parasitological culture, samples of skin, spleen, popliteal lymph node and bone marrow were collected aseptically and immersed in sterile saline.

Histopathology and immunohistochemistry for detection of Leishmania and T. gondii

Serial sections (5μm) were cut from the paraffin blocks containing the tissues and mounted on non-silanized slides for histopathology and on silanized slides for IHC.

For histopathology, the tissues were stained with hematoxylin-eosin (HE) [23]. The inflammatory infiltrate in the tissues was classified as follows: granulomatous, predominance of cells of the monocyte-macrophage system (activated macrophages, epithelioid macrophages, or multinucleate giant cells); pyogranulomatous, predominance of cells of the monocyte-macrophage system amidst a high number of neutrophils; non-granulomatous, predominance of other types of inflammatory cells (lymphocytes, plasma cells, and neutrophils). In addition, inflammatory cells were quantified using a 1-mm2 optical grid and a manual cell counter under a light microscope. The cells were counted in one field of the HE-stained histological sections at 400× magnification, in the most cellular area of the lesion.

For IHC aimed at detecting amastigote forms of Leishmania spp., the tissues were submitted to the steps of deparaffinization, rehydration, blocking of endogenous peroxidase, antigen retrieval, blockade of nonspecific protein binding, and incubation with polyclonal rabbit anti-Leishmania serum diluted 1:500, according to the protocol of Boechat et al. [24]. The polymer-based HiDef Detection HRP™ Polymer System (Cell Marque, Rocklin, CA, USA) was used for the detection of amastigote forms of Leishmania according to manufacturer recommendations. Histological sections of organs intensely parasitized with amastigote forms of Leishmania were incubated with non-immune homologous serum as negative control and with polyclonal rabbit anti-Leishmania serum as positive control.

For the evaluation of skin parasite load by IHC, Leishmania amastigote forms were quantified as described for the quantification of inflammatory cells. However, the parasites were counted in five fields at 400× magnification in the most parasitized areas. The average number of Leishmania amastigote forms was calculated.

For IHC aimed at detecting T. gondii cysts and tachyzoites, the tissues (lung, mammary glands, and spleen) were deparaffinized in xylene and rehydrated in decreasing concentrations of ethanol. Endogenous peroxidase was blocked by incubating the histological sections in a solution of 30% hydrogen peroxide and methanol (45 ml of hydrogen peroxide and 55 ml of methanol) for 40 min at room temperature. Antigen retrieval was performed by incubating the histological sections in Declere ™ buffer (Cell Marque, Rocklin, CA, USA) at 110°C in a Decloaking Chamber™ (Biocare Medical, Pacheco, CA, USA). For the blockade of nonspecific protein binding, the histological sections were incubated with Background Block protein blocking solution (Cell Marque, Rocklin, CA, USA) for 10 min at room temperature. The sections were then incubated with polyclonal anti-T. gondii antibody (rabbit) (Cell Marque, Rocklin, CA, USA) diluted 1:100 for 1 hour at room temperature. The HiDef Detection HRP™ Polymer System (Cell Marque, Rocklin, CA, USA) was used for the detection of T. gondii according to manufacturer recommendations. The enzyme-substrate-chromogen reaction was developed using diaminobenzidine (DAB) plus hydrogen peroxide (Sigma-Aldrich, St. Louis, MO, USA). The sections were counterstained with modified Mayer’s hematoxylin (Thermo Scientific, Fremont, CA, USA) for 2 min. Histological sections of tissues intensely parasitized with parasite forms of T. gondii were incubated with non-immune homologous serum as negative control and with primary polyclonal anti-T. gondii antibody (rabbit) as positive control.

Parasitological culture and identification of Leishmania spp.

The fragments were cultured at 26–28°C in Novy-MacNeal-Nicolle medium plus Schneider’s Drosophila medium (Sigma-Aldrich, St. Louis, MO, USA) supplemented with 10% fetal bovine serum and penicillin and streptomycin as antibiotics [25]. The detailed protocol of parasite isolation in culture is registered at https://dx.doi.org/10.17504/protocols.io.22tggen. Parasites isolated in culture were identified as L. infantum by multilocus enzyme electrophoresis [26].

Singleplex qPCR for the diagnosis and quantification of L. infantum load

DNA was extracted from the samples using the DNeasy Blood & Tissue kit (Qiagen, Hilden, Germany) according to manufacturer recommendations. Tissue fragments ≤ 10 mg were used. DNA was quantified in a Qubit 2.0 Fluorometer (Thermo Fisher Scientific, Waltham, MA, USA) using the Qubit dsDNA HS Assay kit (Thermo Fisher Scientific, Waltham, MA, USA) according to manufacturer instructions. Amplification was performed with the StepOne™ System (Applied Biosystems, Foster City, CA, USA) using 0.9 μM of LEISH-1 (5’-AACTTTTCTGGTCCTCCGGGTAG-3’) and LEISH-2 (5’-ACCCCCAGTTTCCCGCC3’) primers and the TaqMan MGB probe (FAM-5’AAAAATGGGTGCAGAAAT-3’-NFQ), following a previously described protocol [6].

For the quantification of parasite load, a standard curve was constructed with serial dilutions (101 to 105 parasites) of L. infantum DNA (MHOM/BR/1974/PP75). Positive and negative controls were included in each amplification plate and a threshold of 0.1 was established. The DNA of 1 × 105 promastigote forms of L. infantum obtained by parasitological culture was used as positive control and ultrapure water as negative control. Samples in which DNA amplification occurred after the 37th cycle were classified as undetectable. The L. infantum load was expressed as the natural logarithm of the number of parasite genome equivalents (gEq)/ng of DNA.

Conventional PCR for the detection of C. burnetii DNA

Forty-five bone marrow samples were submitted to conventional PCR as previously described [27]. The QBT-1 (5’TATGTATCCACCGTAGCCAGT C-3’) and QBT-2 (5’-CCCAACAACACCTCCTTATTC-3’) primers were used for the amplification of a 687-bp fragment. The reaction mixture contained 0.2 μM of each primer (Invitrogen, Life Technologies, São Paulo, Brazil), 200 μM of dNTP (20 mM of each deoxynucleotide triphosphate), 1.5 mM MgCl2, 0.5 U Platinum® Taq DNA polymerase (Invitrogen, Carlsbad, CA, USA), 4 μL DNA, and nuclease-free water (Promega, Madison, WI, USA) in a final volume of 25 μL. The cycling conditions were described previously [28]. To confirm the amplification, the generated products were separated on an agarose gel stained with 10 μL of Gel RED solution (10,000X) per 100 μL of agarose gel, visualized, and recorded with a photodocumentation system. The target products were then purified using the BigDye Terminator® X-Purification kit (Applied Biosystems, Foster City, CA, USA). The products obtained were sequenced using the BigDye® Terminator V3.1 Cycle Sequencing kit (Applied Biosystems, Foster City, CA, USA) and the ABI PRISM® 3100 software (Applied Biosystems, Foster City, CA, USA). Partial sequences were compared with the htpAB gene from BLAST®.

Nested PCR for the detection of C. burnetii DNA

To increase the sensitivity and specificity of PCR for the detection of C. burnetii DNA, all samples were submitted to a second reaction (“nested”) using the QBT N3+ (5’-AAG CGT GTG GAG GAG CGA ACC-3’) and QBT N4- (5’-CTC GTA ATC ACC AAT CGC TTC GTC-3’) primer pair [29]. The positive controls used in PCR were extracted from cultures of cells infected with C. burnetii. A volume of the DNA solution of 4 μL was used in the conventional PCR assay and of 2 μL in the nested PCR assay.

For amplification, the reaction contained 1X PCR buffer 10 X, 0.2 μM of each primer (Invitrogen, Life Technologies Brazil), 1.5 mM MgCl2, 200 μM dNTP mixture (20 mM of each deoxynucleotide triphosphate), 0.5 U Platinum Taq DNA polymerase (Invitrogen, Carlsbad, CA, USA), 2 μL of sample DNA, and nuclease-free water (Promega, Madison, WI, USA) in a volume of 25 μL. The amplification was performed in a thermocycler (Applied Biosystem Veriti 96) using the previously described cycling conditions [29]. To confirm the amplification, the generated products were separated on a 1% agarose gel stained with 10 μL of RED Gel solution (10,000X) per 100 μL of agarose gel. The target products were purified, sequenced, and compared as described in the previous item for conventional PCR.

Serological detection of antibodies to Anaplasma spp., B. burgdorferi and Ehrlichia spp., and of D. immitis antigens

The ELISA 4 Dx® Plus test (IDEXX®, Westbrook, ME, USA) was used for the serological detection of antibodies to A. platys/A. phagocytophilum, B. burgdorferi and E. canis/E. ewingii, and of D. immitis antigens following the recommendations of the manufacturer. According to the manufacturer, this test has the following sensitivities and specificities, respectively: 90.3% and 94.3% for Anaplasma spp., 94.1% and 96.2% for B. burgdorferi, 99.0% and 99.3% for D. immitis, and 97.1% and 95.3% for Ehrlichia spp.

Detection of anti-T. gondii antibodies in serum

The indirect immunofluorescence antibody test (IFAT) was used as described previously [30]. Anti-dog IgG (whole molecule) FITC antibody produced in rabbits was used as conjugate (Sigma-Aldrich Co., MO, USA). The sera were first diluted 1:16 and then at a ratio of four until 1:256. Samples with a titer of 1:16 or higher were considered positive. Previously known positive and negative controls were included in each analysis. IFAT is considered to have good specificity and sensitivity and is recommended for the immunodiagnosis of T. gondii infection in dogs, where it can be used as the only test [31].

Statistical analysis

Data were analyzed using the free R software, version 3.5.1 [32]. Clinical signs, positivity in the diagnostic tests, and histological changes are described as simple frequencies. For the description of continuous variables (number of inflammatory cells and parasite load), the median (50th percentile) was calculated and the minimum and maximum values are reported. For inflammatory cells, the 75th percentile was also calculated.

The normality of the quantitative variables (parasite load and inflammatory cells) was rejected by the Shapiro-Wilk test at a significance level of 5%, which indicated the use of non-parametric tests for the analysis of these variables. The Mann-Whitney test and Fisher’s exact test were used for comparison of the quantitative and qualitative variables, respectively, between the monoinfected and co-seropositive groups. Boxplots were constructed for the graphical presentation of the comparison of parasite load. The median parasite load in the spleen was expressed as the natural logarithm of the parasite genome equivalents/nanogram of DNA (gEq/ng). A p-value < 0.05 indicates statistical significance.

Ethics statement

This study was carried out in strict accordance with the recommendations of the Brazilian Ministry of Health and the Federal Council on Veterinary Medicine, with permission of the owners. The study protocol was approved by the Ethics Committee on Animal Use of the Oswaldo Cruz Foundation (CEUA/Fiocruz; Permit Numbers: LW-54/13 and LW-24/17). The dogs were sedated by intramuscular administration of ketamine hydrochloride and acepromazine maleate and culled with an intravenous overdose of sodium thiopental and potassium chloride. All efforts were made to minimize suffering.

Results

All 66 L. infantum-seropositive dogs investigated in this study had infection with L. infantum confirmed by qPCR and/or culture, as described below. Among these 66 dogs, 50 (76%) had antibodies against at least one pathogen other than L. infantum (co-seropositive group). The remaining 16 dogs (24%) did not have antibodies against certain pathogens other than L. infantum and were thus considered monoinfected with L. infantum (monoinfected group). The following frequencies of co-seropositivity for certain pathogens were observed in the 66 dogs investigated: T. gondii (59%), Ehrlichia spp. (41%), and Anaplasma spp. (18%). None of the animals was positive for B. burgdorferi, C. burnetii, or D. immitis. Among the 50 co-seropositive dogs, 19 (38%) were co-seropositive only for T. gondii, 12 (24%) for T. gondii and Ehrlichia spp., 7 (14%) only for Ehrlichia spp., 5 (10%) for Ehrlichia spp., Anaplasma spp. and T. gondii, 3 (6%) for Ehrlichia spp. and Anaplasma spp., 3 (6%) for Anaplasma spp. and T. gondii, and 1 (2%) only for Anaplasma spp. Statistical analysis of the association of breed with the monoinfected and co-seropositive groups was not possible because of the small number of breed dogs.

Clinical signs compatible with CanL were present in 60 (91%) of the 66 dogs evaluated and absent in six (9%). Clinical signs were observed in 15 (94%) of the 16 dogs monoinfected with L. infantum and in 45 (90%) of the 50 co-seropositive dogs. When the frequency of clinical signs of CanL was compared between monoinfected and co-seropositive dogs, no significant difference was observed (p = 0.407). Table 1 shows the frequency of each clinical sign observed in monoinfected and co-seropositive dogs and no significant difference was observed between the two groups.

Table 1. Frequency of clinical signs in dogs infected with Leishmania infantum, August 2016 to January 2019 (Barra Mansa, Rio de Janeiro, Brazil).

Clinical sign Monoinfected (n = 16) Co-seropositive (n = 50) p-value a
Splenomegaly 10 (62.5%) 30 (60.0%) 1.000
Onychogryphosis 8 (50.0%) 21 (42.0%) 0.773
Furfuraceous desquamation of skin 8 (50.0%) 21 (42.0%) 0.238
Dehydration 7 (43.8%) 18 (36.0%) 0.768
Thinness 6 (37.5%) 13 (26.0%) 0.526
Local alopecia 6 (37.5%) 12 (24.0%) 0.340
Regional lymphadenomegaly 5 (31.3%) 12 (24.0%) 0.743
Opaque hair 6 (37.5%) 11 (22.0%) 0.324
Skin ulcers 3 (18.8%) 14 (28.0%) 0.532
Keratoconjunctivitis 5 (31.3%) 11 (22.0%) 0.509
Hepatomegaly 5 (31.3%) 10 (20.0%) 0.493
Apathy 4 (25.0%) 9 (18.0%) 0.719
Pale mucosae 4 (25.0%) 9 (18.0%) 0.719
Generalized alopecia 3 (18.8%) 5 (10.0%) 0.390
Cachexia 1 (6.3%) 5 (10.0%) 1.000
Limb edema 2 (12.5%) 2 (4.0%) 0.245
Generalized lymphadenomegaly 0 (0.0%) 4 (8.0%) -b
Hyperemic mucosae 0 (0.0%) 2 (4.0%) -b
Lower limb paresis 0 (0.0%) 2 (4.0%) -b
Arthralgia 1 (6.3%) 0 (0.0%) -b
Epistaxis 0 (0.0%) 1 (2.0%) -b
Jaundice 0 (0.0%) 1 (2.0%) -b
Pain when palpating the kidneys 0 (0.0%) 1 (2.0%) -b
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n: number of dogs. Co-seropositive: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and antibodies against at least one pathogen other than L. infantum. Monoinfected: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and without antibodies against certain pathogens other than L. infantum.

a The p-values were calculated using Fisher’s exact test (p ≤ 0.05).

b Statistical analysis was not possible because of the absence of the clinical sign in one of the groups.

Evaluation of L. infantum load in the spleen revealed positive results in all 66 dogs and a median parasite load of 6.912 gEq/ng. The median L. infantum load was 8.589 gEq/ng in the monoinfected group and 6.364 gEq/ng in the co-seropositive group (Fig 1). However, this difference in the median L. infantum load in the spleen between the two groups was not significant (p = 0.45). The following median L. infantum loads expressed as gEq/ng were found in the spleen of co-seropositive animals: 11.967 when co-seropositive for Anaplasma spp. (n = 1), 7.166 (-0.256 to 14.603) when co-seropositive for T. gondii (n = 19), 6.340 (-1.808 to 12.054) when co-seropositive for with Ehrlichia spp. and Anaplasma spp. (n = 3), 5.828 (-1.420 to 16.621) when co-seropositive for T. gondii and Ehrlichia spp. (n = 12), 5.725 (0.048 to 9.667) when co-seropositive for Ehrlichia spp. (n = 7), 5.190 (2.117 to 6.331) when co-seropositive for Ehrlichia spp., Anaplasma spp. and T. gondii (n = 5), and 4.905 (0.986 to 7.705) when co-seropositive for Anaplasma spp. and T. gondii (n = 3).

Fig 1. Leishmania infantum load expressed as the median natural logarithm of the number of parasite genomic equivalents (gEq)/ng of DNA in the spleen of monoinfected (n = 16) and co-seropositive (n = 50) dogs.

Fig 1

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The horizontal black lines indicate the median parasite load. The vertical dotted lines indicate the interquartile range. The dotted horizontal lines indicate the lower limit of positivity (threshold). The blue dots indicate the parasite load of each dog.

Histopathology revealed changes in at least one of the organs studied in 15 (93.8%) of the 16 monoinfected dogs. All 50 (100%) co-seropositive dogs exhibited some type of histological alteration in the examined tissues. Table 2 shows the frequencies of the main histological changes observed in monoinfected and co-seropositive dogs.

Table 2. Main histological changes in dogs infected with Leishmania infantum, August 2016 to January 2019 (Barra Mansa, Rio de Janeiro, Brazil).

Sample Histological changes Monoinfected (n = 16) Co-seropositive (n = 50) p-valuea
Skin (n = 66) Granulomatous dermatitis 12 (75.0%) 34 (68.0%) 0.758
Non-granulomatous dermatitis 0 (0.0%) 6 (12.0%) -d
Hyperkeratosis 10 (62.5%) 28 (56.0%) 1.000
Total 14 (87.5%) 45 (90.0%) 0.204
Spleen (n = 66) Granulomatous splenitis 7 (43.7%) 37(74.0%) 0.068
Pyogranulomatous splenitis 2 (12.5%) 2 (4.0%) 0.245
Non-granulomatous splenitis 1 (6.2%) 2 (4.0%) 1.000
Total 10 (62.5%) 41 (82.0%) 0.019c
Liver (n = 66) Granulomatous hepatitis 12 (75.0%) 39 (78.0%) 1.000
Pyogranulomatous hepatitis 2 (12.5%) 1 (2.0%) 0.143
Non-granulomatous hepatitis 2 (12.5%) 5 (10.0%) 1.000
Vacuolar degeneration of hepatocytes 9 (56.2%) 12 (24.0%) 0.068
Total 16 (100.0%) 46 (92.0%) 1.000
Lung (n = 66) Granulomatous pneumonia 3 (18.7%) 22 (44.0%) 0.083
Pyogranulomatous pneumonia 3 (18.7%) 7 (14.0%) 0.695
Non-granulomatous pneumonia 2 (12.5%) 6 (12.0%) 1.000
Total 8 (50.0%) 35 (70.0%) 0.538
Tricuspid (n = 66) Granulomatous endocarditis 2 (12.5%) 7 (14.0%) 1.000
Non-granulomatous endocarditis 1 (6.2%) 2 (4.0%) 1.000
Total 3 (18.7%) 9 (18.0%) 1.000
Mitral (n = 66) Granulomatous endocarditis 2 (12.5%) 3 (6.0%) 0.588
Pyogranulomatous endocarditis 2 (12.5%) 0 (0.0%) -d
Non-granulomatous endocarditis 2 (12.5%) 2 (4.0%) 0.245
Total 6 (37.5%) 5 (10.0%) 0.019c
Mammary glandb (n = 28) Granulomatous mastitis 4 (44.4%) 9 (47.4%) 0.719
Non-granulomatous endocarditis 0 (0.0%) 5 (26.3%) -d
Total 4 (44.4%) 14 (73.6%) 1.000
Uterusb (n = 28) Granulomatous metritis 0 (0.0%) 4 (21.0%) -d
Pyogranulomatous metritis 0 (0.0%) 1 (5.3%) -d
Non-granulomatous metritis 0 (0.0%) 1 (5.3%) -d
Total 0 (0.0%) 6 (31.6%) -d
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n: number of dogs. Total: total number of dogs with histological changes in the organ. Co-seropositive: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and with antibodies against at least one pathogen other than L. infantum. Monoinfected: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and without antibodies against certain pathogens other than L. infantum.

a The p-values were calculated using Fisher’s exact test (p ≤ 0.05).

b The frequencies were calculated and statistical analysis was performed in 9 dogs of the monoinfected group and in 19 dogs of the co-seropositive group.

c Statistically significant difference (p ≤ 0.05).

d Statistical analysis was not possible because of the absence of certain histological changes in one of the groups.

The number of inflammatory cells observed in each organ of monoinfected and co-seropositive animals is shown in Table 3. The number of inflammatory cells/mm2 observed in each organ according to the co-seropositivity for certain pathogens is given in the S1 Table.

Table 3. Number of inflammatory cells/mm2 observed in tissues of Leishmania infantum monoinfected and co-seropositive dogs, August 2016 to January 2019 (Barra Mansa, state of Rio de Janeiro, Brazil).

Samples Monoinfected (n = 16) Co-seropositive (n = 50) p-valuea
Min 50th percentile 75th percentile Max Min 50th percentile 75th percentile Max
Skin (n = 66) 0 195.0 243.2 481 0 132.5 241.2 587 0.538
Spleen (n = 66) 0 410.0 518.7 707 0 531.5 616.7 753 0.031c
Liver (n = 66) 0 197.0 331.2 534 0 291.5 385.0 936 0.170
Lung (n = 66) 0 103.5 326.5 434 0 321.0 463.2 618 0.049c
Tricuspid (n = 66) 0 0 0 686 0 0 0 300 0.888
Mitral (n = 66)b 0 0 101.5 471 0 0 0 371 0.046c
Uterus (n = 28)b 0 0 0 0 0 0 127.0 544 -d
Mammary gland (n = 28) b 67 149.0 240.0 267 0 323.5 427.5 581 0.041c
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n: number of dogs examined; Min: minimum; 50th percentile: median; Max: maximum. Co-seropositive: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and with antibodies against at least one pathogen other than L. infantum. Monoinfected: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and without antibodies against certain pathogens other than L. infantum.

a The p-values were calculated using the Mann-Whitney test (p ≤ 0.05).

b The number of inflammatory cells were calculated and statistical analysis was performed in 9 dogs of the monoinfected group and in 19 dogs of the co-seropositive group.

c Statistically significant difference (p ≤ 0.05).

d Statistical analysis of the organ was not possible because of the absence of inflammatory cells in the monoinfected group.

Immunohistochemistry revealed the presence of amastigote forms of Leishmania spp. in all types of organs studied. In addition, amastigote forms were detected in at least one of the organs in 12 (75%) monoinfected dogs and in 39 (78%) co-seropositive dogs. There was no difference in the positivity for amastigote forms of Leishmania spp. between monoinfected and co-seropositive dogs in any of the organs studied (Table 4).

Table 4. Frequency of positivity for Leishmania amastigotes forms in different organs of dogs infected with Leishmania infantum using immunohistochemistry, August 2016 to January 2019 (Barra Mansa, state of Rio de Janeiro, Brazil).

Samples Monoinfected (n = 16) Co-seropositive (n = 50) p-valor a
Positive Negative Positive Negative
Skin (n = 66) 10 (62.5%) 6 (37.5%) 29 (58.0%) 21 (42.0%) 1.000
Spleen (n = 66) 9 (56.3%) 7 (43.7%) 31 (62.0%) 19 (38.0%) 0.772
Liver (n = 66) 10 (62.5%) 6 (37.5%) 30 (60.0%) 20 (40.0%) 1.000
Lung (n = 66) 0 (0.0%) 16 (100.0%) 4 (8.0%) 46 (92.0%) -c
Tricuspid (n = 66) 2 (12.5%) 14 (87.5%) 1 (2.0%) 49 (98.0%) 0.143
Mitral (n = 66) 2 (12.5%) 14 (87.5%) 0 (0.0%) 50 (100.0%) -c
Uterus (n = 28)b 1 (11.1%) 8 (88.9%) 3 (15.8%) 16 (84.2%) 1.000
Mammary gland (n = 28)b 5 (55.6%) 4 (44.4%) 10 (52.6%) 9 (47.4%) 0.173
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n: number of dogs. Total: total number of dogs with histological changes in the organ. Co-seropositive: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and with antibodies against at least one pathogen other than L. infantum. Monoinfected: L. infantum-seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and without antibodies against certain pathogens other than L. infantum.

a The p-values were calculated using Fisher’s exact test (p ≤ 0.05).

b The frequencies were calculated and statistical analysis was performed in 9 dogs of the monoinfected group and in 19 dogs of the co-seropositive group.

c Statistical analysis was not possible because of the absence of positivity in one of the groups.

The histological changes and amastigote forms detected by IHC in monoinfected and co-seropositive dogs are shown in Fig 2A–2H.

Fig 2. Histological findings in 66 dogs naturally infected with Leishmania infantum.

Fig 2

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(A) Hyperkeratosis and granulomatous dermatitis consisting mainly of macrophages, as well as lymphocytes and plasma cells, in a monoinfected dog. HE. (B) Brown-stained amastigote forms of Leishmania (arrows) inside macrophages in the skin of the same monoinfected dog. IHC. (C) Diffuse granulomatous dermatitis consisting mainly of macrophages, as well as lymphocytes and plasma cells, in a dog co-seropositive for Ehrlichia spp. and Toxoplasma gondii. HE. (D) Brown-stained amastigote forms of Leishmania (arrows) inside macrophages in the skin of the same dog co-seropositive for Ehrlichia spp. and T. gondii. IHC. (E) Granulomatous infiltrate around the teat canals and sinuses of the mammary gland in a dog co-seropositive for T. gondii. HE. (F) Granulomatous inflammatory infiltrate in the tricuspid valve of a monoinfected dog. HE. (G) Diffuse granulomatous interstitial pneumonia consisting mainly of macrophages in a dog co-seropositive for T. gondii. Note the large numbers of lymphocytes and plasma cells and few neutrophils. HE. (H) Multifocal granulomatous endocarditis and myocarditis consisting mainly of macrophages in a dog co-seropositive for T. gondii. Note the large numbers of lymphocytes and few plasma cells. HE.

The median load of amastigote forms of Leishmania spp. per mm2 skin quantified by IHC was 2.3 (0–19.6) in monoinfected dogs and 0.9 (0–70.6) in co-seropositive dogs (Fig 3), but the difference was not statistically significant (p = 0.704).

Fig 3. Leishmania load expressed as number of amastigote forms per mm2 in the skin of monoinfected and co-seropositive dogs detected by immunohistochemistry.

Fig 3

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The horizontal black lines indicate the median parasite load. The vertical dotted lines indicate the interquartile range. The blue dots indicate the parasite load of each dog.

Among the 39 T. gondii-seropositive dogs, an inflammatory infiltrate was observed in 33 spleens, 26 lungs, and 14 mammary glands. These samples were processed for IHC to detect T. gondii cysts or tachyzoites. One spleen sample and two lung samples were lost during processing. None of the samples examined by IHC were positive for this parasite.

Using parasitological culture for the detection of Leishmania, 13 (81.3%) of the monoinfected dogs had positive results in at least one sample studied; 2 dogs (12.5%) did not test positive for Leishmania by culture or IHC. Among the co-seropositive dogs, 40 (80%) were positive for Leishmania in the parasitological culture, while 5 (10%) did not test positive for Leishmania by culture or IHC. In total, 59 dogs (89.4%) tested positive for Leishmania by IHC and/or parasitological culture. All parasitological culture isolates from the samples examined were identified as L. infantum.

Discussion

A high frequency of co-seropositivity for certain pathogens in L. infantum-seropositive dogs with infection with this parasite confirmed by PCR and/or culture was found, especially co-seropositivity for T. gondii. Considering the breed, the results of this study can only be extrapolated to other similar populations composed mainly of mongrel dogs (85%). A high frequency of anti-T. gondii (62.9%) antibodies was also detected in dogs from a CanL-endemic area in the state of São Paulo, Brazil [33]. However, in studies conducted in areas not endemic for CanL in Brazil, the authors found frequencies of anti-Leishmania and anti-T. gondii antibodies of 11.6% in dogs from Londrina, state of Paraná [34], and of 10.2% in dogs from the central region of the state of Rio Grande do Sul [35]. These percentages are lower than those observed in the present study. Paulan et al. [33] found a significant association between reactivity to anti-L. infantum and anti-T. gondii antibodies in dogs. The authors suggested that the immunosuppression caused by Leishmania may increase the susceptibility of these animals with CanL to this coccidium. Additionally, Zulpo et al. [34] observed a higher frequency of anti-Leishmania antibodies in dogs seropositive for T. gondii and Neospora. However, in the present study, it was not possible to assess whether dogs with L. infantum are at increased risk of infection with T. gondii or vice-versa because of the lack of a control group of dogs not infected with L. infantum. The presence of L. infantum may have not increased the susceptibility to T. gondii infection in this study, as observed in cats [36, 37], since a high frequency of anti-T. gondii antibodies has been reported in pigs (65.8%) and chickens (47.8%) in the same area [38]. These results suggest high environmental contamination with T. gondii in Barra Mansa, which may explain its high frequency also in dogs.

In the present study, the frequency of L. infantum and Ehrlichia spp. co-seropositivity was high (41%) and higher than those reported in studies carried out on dogs from Cyprus (36.2%) [39], Côte d’Ivoire (4.9%) [12], and Portugal (2.2%) [40]. This frequency was also higher than those found in dogs from Campo Grande, Mato Grosso do Sul (31.7%) [41], and Cuiabá, Mato Grosso (2.5%) [42], Brazil. On the other hand, higher frequencies of L. infantum and Ehrlichia spp. co-seropositivity or co-infection than that observed here were reported in Ilha Solteira, São Paulo, Brazil (74.3%) [33], and Catalonia, Spain (55.7%) [7]. Furthermore, the frequency of L. infantum and Anaplasma spp. co-seropositivity in the present study was higher than that reported in dogs from Cyprus (10.6%) [39] and Portugal (1.1%) [40], but lower than the 52.5% observed among dogs from Spain [7]. In the United States, frequencies similar to those of the present study were observed in dogs with CanL and co-infected with Ehrlichia spp. (41.7%) or Anaplasma spp. (41.7%) [10]. Taken together, the results of these surveys and the present findings demonstrate that co-infection with or co-seropositivity for Ehrlichia spp. and Anaplasma spp. is common among dogs infected with L. infantum in different parts of the world.

The frequency of co-infection with or co-seropositivity for Ehrlichia spp. and Anaplasma spp. can be quite high in regions with favorable environmental conditions for ticks, which are the vectors of these pathogens [43]. According to Figueredo et al. [43], the presence of ticks and the occurrence of pathogens transmitted by these vectors tend to be more common among dogs in regions where the socioeconomic status of the population is low and dogs are not in close contact with their owners (kept in the backyard or semi-restricted). In the city of Barra Mansa, seropositivity of dogs for the proteobacteria Rickettsia rickettsii and/or R. parkeri, which are also transmitted by ticks, has been demonstrated, with a frequency of 19.2% [44]. In addition, anti-R. rickettsii antibodies and anti-L. infantum antibodies were simultaneously detected in 7.7% of the examined dogs [45]. These studies and the present results suggest that dogs from Barra Mansa are frequently exposed to ticks and to the agents transmitted by these arthropods. The investigation of these co-infections or co-seropositivities is important since dogs with CanL can exhibit clinical signs similar to those caused by tick-borne diseases, a fact that makes the diagnosis of L. infantum difficult [39, 46]. Consequently, the dog remains in the environment for a longer period and thus serves as a source of L. infantum infection for sandflies.

In the present study, the absence of co-seropositivity for B. burgdorferi, C. burnetii or D. immitis in L. infantum-seropositive and infected dogs suggests that the circulation of these pathogens is low or does not occur in the area studied. Additional tests such as PCR for the detection of D. immitis and B. burgdorferi may be useful to identify possible infected and non-seropositive dogs. The absence of C. burnetii-positive dogs may be explained by the lack of proximity of the dogs studied with infected sheep and goats, which act as important sources of contamination with this bacterium [28]. However, co-infection with D. immitis and L. infantum has been reported in dogs in Brazil [47, 48]. In addition, studies on L. infantum-seropositive dogs conducted in Europe demonstrated co-infection with or co-seropositivity for D. immitis and B. burgdorferi, but the prevalence was low [10, 14, 39, 40, 49–52]. In these surveys, the reported prevalence of D. immitis and L. infantum co-infection or co-seropositivity in dogs was 1.2% to 8.3% in Portugal [40, 49], 4.3% in Cyprus [39], and 0.16% to 0.6% in Greece [11, 52]. Additionally, clinical cases of this co-infection in three dogs were reported in Italy [50]. Twenty-nine out of 98 (29.6%) dogs were co-infected with L. infantum and filariae, including D. immitis, in Spain [14]. Co-seropositivity of dogs for L. infantum and B. burgdorferi was observed in 14 of 2,620 dogs (0.5%) in Greece [11] and in 1 of 1,185 dogs (0.08%) in Portugal [40]. However, this co-seropositivity or co-infection was not found in Cyprus [39] or Côte d’Ivoire [12], in agreement with the present study. Although C. burnetii, D. immitis and B. burgdorferi were not found in the area studied, the detection of C. burnetii in two dogs [28] and a prevalence of D. immitis of 16.3 to 62.2% [53] and of B. burgdorferi of 1.4 to 41.9% [54] have been reported in other cities in the state of Rio de Janeiro. Further studies on the occurrence of co-infection with these three pathogens in L. infantum-seropositive dogs are necessary not only because they are zoonoses, but also because co-infections with filariae have been shown to increase the severity of clinical signs of CanL [14].

In the study of Toepp et al. [10], the risk of L. infantum seropositivity was 1.68 times higher among dogs seropositive for agents transmitted by ticks, such as Ehrlichia spp. and Anaplasma spp., than among dogs that were not co-infected with these agents. In addition, in a study carried out in the Campania region in Italy, the presence of antibodies against Neospora caninum was the main risk factor for L. infantum seropositivity, while the presence of antibodies against L. infantum was the main risk factor for N. caninum seropositivity [4]. Investigating the occurrence of co-infections in dogs living in VL-endemic areas is important since Leishmania infection can trigger an ineffective immune response that renders dogs more susceptible to other infections, while co-infections can increase the dog’s susceptibility to Leishmania [4, 7, 10]. These hypotheses are reinforced by the high frequency of co-seropositivities among dogs seropositive for and/or infected with L. infantum found in this study and in other studies [4, 7, 10].

Toepp et al. [10] also observed a significant association between exposure to agents transmitted by ticks, such as Ehrlichia spp. and Anaplasma spp., and the progression of clinical signs of CanL and a higher mortality rate in these dogs. These authors believe that co-infections alter the immunity of dogs, allowing L. infantum infection to thrive within the phagocytes leading to clinical disease. In another study [7], the frequency of anti-A. phagocytophilum antibodies was significantly higher in dogs with CanL than in healthy dogs; in addition, these antibodies were more frequent in dogs with more severe clinicopathological changes and with more severe CanL. A study using histopathology found that the percentage of dogs with L. infantum amastigote forms on the skin was almost double (36%) in the group of dogs co-infected with L. infantum and E. canis when compared to the group of L. infantum-monoinfected dogs (19%) [55]. The authors attributed this result to the fact that E. canis caused a reduction in the class II histocompatibility complex, leading to depression of the immune system and favoring the multiplication of L. infantum. An experimental study on mice showed that Ehrlichia spp. is able to reduce autophagy in infected macrophages, allowing the growth and replication of bacteria and, consequently, of other intracellular agents such as Leishmania [56]. However, in the present study, no significant association was found with clinical signs, frequency of positivity for amastigote forms of Leishmania spp. in different tissues or L. infantum load in co-seropositive dogs when compared to monoinfected dogs. This divergence to the literature may be due to the small number of monoinfected animals in the present study, which may have influenced the statistical analysis. Another explanation is the fact that we did not perform a longitudinal analysis, unlike Toepp et al. [10] who evaluated dogs for the progression of clinical signs and death over a 10-month period. Evaluation of the dogs for the same or a longer period of time than that used by Toepp et al. [10] might have resulted in the observation of worsening of the clinical status and a higher L. infantum load in co-seropositive dogs.

Another hypothesis for the lack of aggravation of CanL due to co-seropositivity for certain pathogens in the present study is that the seropositive dogs may not be co-infected or infection with these pathogens is not active, but they were previously exposed to the pathogens and exhibited detectable memory antibodies. Anti-E. canis antibodies can persist in the circulation for a long time even after elimination of the agent [57]. In contrast, very recent infections may have also contributed to false-negative results of the serological tests since most of them detect IgG antibodies that are produced later [57]. As a result, dogs classified as monoinfected with L. infantum may be infected with the other pathogens investigated but did not have enough time to produce late-phase antibodies against these pathogens.

The possibility of a serological cross-reaction of other pathogens with L. infantum must also be taken into account. Other Leishmania species [58], E. canis, Babesia canis, N. caninum, T. gondii [59], Leptospira interrogans [58], Trypanosoma cruzi [59], and T. caninum [60] can cross-react, thus causing false-positive results in serological L. infantum tests. However, previous studies reported that cross-reactivity with L. infantum in serological tests for B. canis and E. canis is rare [61, 62] and the ELISA 4 Dx® Plus test has high sensitivity and specificity. Additionally, in the present study, about 90% of the dogs studied tested positive for Leishmania by culture and/or IHC, and all of them tested positive for L. infantum by qPCR. Therefore, cross-reactivity with antibodies of other agents is unlikely.

The possibility that the L. infantum-monoinfected dogs were actually co-infected with other pathogens not investigated here, such as Babesia spp. and helminths, cannot be ruled out. This fact may have contributed to the similarities in clinical signs, L. infantum positivity and parasite load between monoinfected and co-seropositive dogs. However, the present results do not rule out the possibility that co-infection with L. infantum and other pathogens may exert immunomodulatory activity, preventing a synergistic effect on the aggravation of diseases caused by these agents. Therefore, further studies are needed to better understand the role of co-infections in modulating the immune system of dogs.

Although the number of clinical signs or parasite load was not higher in co-seropositive dogs, a larger number of inflammatory cells was observed in the spleen, lung and mammary gland of these dogs. Studies have associated the inflammatory reaction observed in these organs with L. infantum infection in dogs [24, 63]. However, this inflammatory reaction is not a specific histological alteration and it was not possible to correlate its presence with L. infantum parasitism in all cases. Nevertheless, the participation of L. infantum in these histological changes cannot be ruled based on the lack of detection of amastigote forms of this parasite since these forms are heterogeneously distributed and may not be visualized depending on the histological section examined, even if they are present in the tissue. In addition, even in the absence of amastigote forms, the inflammatory reaction can be triggered by peripheral stimuli such as parasite antigens, DNA or inflammatory mediators, as well as by the deposition of immune complexes in tissues [64, 65]. In a previous study [6], the intensity of the inflammatory infiltrate was higher in the central nervous system of dogs co-infected with T. gondii and E. canis when compared to dogs infected only with L. infantum. Similarly, co-infections may have contributed to aggravate the intensity of the inflammatory infiltrate in the spleen, lung and mammary gland of the co-seropositive dogs studied here. However, the inflammatory infiltrate in these organs was not associated with the detection of T. gondii by IHC. This result suggests that T. gondii infection was latent in these animals, which is commonly seen in dogs [66] and was not reactivated by co-infection with L. infantum. On the other hand, co-infection with Ehrlichia spp. and Anaplasma spp. may have contributed to a more intense inflammatory infiltrate in the spleen and lung of the co-seropositive dogs in this study. This can be explained by the fact that a perivascular inflammatory infiltrate consisting of macrophages and lymphocytes is the main histological alteration observed in the lungs and spleen of dogs infected with E. canis and Anaplasma spp. [67, 68]. These dogs may have been in an early stage of the histological changes associated with L. infantum co-infections and the time was not sufficient to develop apparent clinical signs related to the affected organ(s). This hypothesis could explain why co-seropositivity for certain pathogens did not exacerbate the intensity of clinical signs in the dogs studied.

Conclusions

The present results suggest that co-seropositivities for Anaplasma spp., Ehrlichia spp. and T. gondii are common among dogs infected with L. infantum in the region studied. However, these co-seropositivities did not aggravate clinical signs or L. infantum load, although they were associated with a more intense inflammatory reaction in some organs.

Supporting information

S1 Table. Median number of inflammatory cells observed in each organ of dogs infected with Leishmania infantum according to the co-seropositivity for certain pathogens, August 2016 to January 2019 (Barra Mansa, state of Rio de Janeiro, Brazil).

(DOC)

Click here for additional data file. (42.5KB, doc)

Acknowledgments

We thank the Municipal Health Department of Barra Mansa and the Central Laboratory of Public Health (LACEN) for their collaboration; Adilson Benedito de Almeida and Antonio Carlos da Silva from INI, Fiocruz, Igor Falco Arruda from IOC, Fiocruz, and Ricardo Baptista Schmidt from the Oswaldo Cruz Institute (IOC), Fiocruz, for processing the figures.

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

This study was supported by the state funding agency Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (Grants: CNE E-26/203.069/2016 and TCT E-26/202.561/2017), http://www.faperj.br/, and by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil (Finance Code 001), https://www.capes.gov.br/. FBF, ERSL and RCM are recipients of productivity fellowships from Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq), Brazil, http://www.cnpq.br/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Angela Monica Ionica

30 Dec 2020

PONE-D-20-37262

Frequency of co-infections and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum

PLOS ONE

Dear Dr. Caldas Menezes,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

A well written manuscript, which deserves consideration. However, the authors should consider to not generalise their results. Also, seropositivity is not equivalent of infection.

Please submit your revised manuscript by 31.01.2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Angela Monica Ionica, Ph.D.

Academic Editor

PLOS ONE

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[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Under my review criteria, this is a well-written manuscript, which deserves to be considered for publication after the necessary explanations and adaptations as described below. My main concern is whether the number of dogs may be considered as numerically sufficient, together with the hypothesis that these animals might not be representative of dogs from other breeds.

Line 27 – delete “visceral”, as canine leishmaniasis caused by L. infantum is a generalized disease – change accordingly throughout the manuscript

Line 32 – the word “euthanasia” presupposes that the dogs were sick – if this was not the case, use “culling” instead

Line 39 – “co-infected” may not be the right word for all the pathogens; for example, regarding T. gondii, seropositivity may not mean infection – change accordingly (i.e., from co-infected to seropositive) for this and other agents

Line 54 – delete “biological” – including this word suggests that there are also mechanical vectors and this is not the case

Line 59 – whenever possible, display agents alphabetically – change accordingly throughout the manuscript

Line 60 – Isospora is now Cystoisospora; there is more than one species, so please write “Cystoisospora spp.”

Line 64 – replace VL with leishmaniasis

Materials and methods – which criteria have determined a sample size of 66 dogs? Furthermore, this sample composition may not allow extrapolation of results to other breeds.

Line 92 – not clear whether the owners provided signed consent for euthanasia (which is a legal imposition) or to sample collection – please make clearer

Line 112 – abbreviate as T. gondii

Line 174 – Leishmania spp.

Line 181 – L. infantum

Line 234 – Serological detection of antibodies to Anaplasma spp., B. burgdorferi and Ehrlichia spp., and of D. immitis antigens

Line 239 – inform on the per cent sensitivity and specificity for each agent

Line 242 – replace Diagnosis with Detection

Line 247 – which values for this IFAT?

Line 254 – median was calculated, but minimum and maximum were just copied (not calculated)

Line 290 – these dogs may not be infected but only seropositive; please, take this into account in the text

Line 415 – rates are different from percentages; and this is the case of percentages

Discussion – comparison with results from other studies could have included a statistical assessment.

Reviewer #2: It is a very interesting research and very well presented. Please use the term leishmaniosis, instead of leishmaniasis (usually used in human medicine).

My main concern is that you have selected some common and important pathoges to test and if negative you present the dog as a single infection case. However, there are many other important pathogens to be present and contribute. For example sarcoptic mange or worms. I did not see other tests for them. I would suggest to revise the text and title using the phrase certain or common pathogens, which is closer to your work. Also please revise your conclusions accordingly.

**********

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2021 Mar 11;16(3):e0247560. doi: 10.1371/journal.pone.0247560.r002

Author response to Decision Letter 0

28 Jan 2021

Dear Dr. Caldas Menezes,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

A well written manuscript, which deserves consideration. However, the authors should consider to not generalise their results. Also, seropositivity is not equivalent of infection.

Please submit your revised manuscript by 31.01.2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Angela Monica Ionica, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

RESPONSE TO REVIEWER #1

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: Under my review criteria, this is a well-written manuscript, which deserves to be considered for publication after the necessary explanations and adaptations as described below. My main concern is whether the number of dogs may be considered as numerically sufficient, together with the hypothesis that these animals might not be representative of dogs from other breeds.

Line 27 – delete “visceral”, as canine leishmaniasis caused by L. infantum is a generalized disease – change accordingly throughout the manuscript

Response:

Line 27. The word “visceral” was deleted and the word “leishmaniasis” was replaced with “leishmaniosis”, as recommended by the reviewer#2.

In addition, following the recommendations of both reviewers, the word “visceral” was deleted, the word “leishmaniasis” was replaced with “leishmaniosis” and the abbreviation “CVL” was replaced with “CanL” along the text, as indicated below:

Line 101. “canine visceral leishmaniasis (CVL)” was replaced with “ canine leishmaniosis caused by L. infantum (CanL)”

Lines 105, 292, 295, 446, 447, 453, 513, 530, 531 and 549. The abbreviation “CVL” was replaced with the abbreviation “CanL”.

Lines 487 and 527. “VL” was replaced with “CanL”.

Lines 27, 52, 64, 85 and 101. The word “leishmaniasis” was replaced with “leishmaniosis”.

Line 472- “clinical VL caused by caused by L. infantum” was replaced by “CanL”

Line 32 – the word “euthanasia” presupposes that the dogs were sick – if this was not the case, use “culling” instead

Response:

Lines 33, 92 and 93. The word “euthanasia” was replaced with “culling”.

Lines 91, 117 and 274. The word “euthanized” was replaced with “culled”.

Line 39 – “co-infected” may not be the right word for all the pathogens; for example, regarding T. gondii, seropositivity may not mean infection – change accordingly (i.e., from co-infected to seropositive) for this and other agents

In fact, we can’t prove the infection by the pathogens investigated in this study except for L. infantum. Therefore, the terms “co-infected”, “co-infection” and “co-infections” were replaced with “co-seropositive”, “co-seropositivity” and “co-seropositivities” along all the text, respectively, when refers to the results of this study or to the results of other authors when appropriate. We preferred these terms other than “seropositive”or “seropositivity” for the results of this manuscript, because all the dogs were seropositive for L. infantum. The term “monoinfected” was maintained, because we confirmed the infection with L. infantum by qPCR and/or culture in all the 66 dogs investigated in this study.

These modifications were done in the following parts of the text:

The title of the manuscript was altered to: “Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum”

The short title “Co-infections in dogs naturally infected with L. infantum” was replaced with “Co-seropositivities in dogs naturally infected with L. infantum”

The keyword “Co-infection” was replaced with “Co-seropositivity”

Abstract

Lines 28, 29-30. The text “co-infection with other pathogens” was replaced with “co-infections with or co-seropositivities for”.

Line 30. The text “infected with” was replaced with “seropositive for”.

Line 39. The text “co-infected with” was replaced with “co-seropositive for”.

Line 41. The text “co-infected dogs” was replaced with “dogs co-seropositive for certain pathogens”.

Lines 42-43 and 44. The text “co-infected dogs” was replaced with “co-seropositive dogs”.

Line 45. The text “co-infections with L. infantum and other pathogens” was replaced with “infected with L. infantum and co-seropositive for certain pathogens”.

Line 46. The text “ these co-infections” was replaced with” “co-seropositivities for certain pathogens”.

Introduction

Line 58. The text “Co-infections with” was replaced with “Co-infections with or co-seropositivities for”.

Line 67. The text “co-infections with” was replaced with “co-infections with or co-seropositivities for”.

Lines 68-70. The text “co-infected with other pathogens” was replaced with “co-infected with or co-seropositive for certain pathogens”.

Lines 71-72. The text “of co-infections with pathogens” was replaced with” co-infections with or co-seropositivities for certain pathogens”.

Methods

Line 264. The word “co-infected” was replaced with “co-seropositive”.

Results

Lines 283-284. The text “The following pathogens causing co-infections and their frequencies were detected in the 66 dogs investigated:” was replaced with “The following frequencies of co-seropositivity for certain pathogens were observed in the 66 dogs investigated:”

Lines 281, 286, 287, 294, 295, 297, Table 1, 309, 318, 321-326, 330-331, 336, 338, Table 2, 355, 361, 365-366, 370, Table 3, 372, 378, 385-386, Table 4, 392, 398, 401-402, 409, 411, 412, 414-415, 417, 421, 425 and 435. “The word “co-infected” was replaced with “co-seropositive”.

Lines 321-326. The text “ for co-infection with” was replaced with “when co-seropositive for”.

Line 367. The text “coinfecting pathogen” was replaced with “the co-seropositivity for certain pathogens”.

Figures 1 and 3. The word “co-infected” was replaced with “co-seropositive” in the legend.

Discussion

Lines 442-444. The phrase “A high frequency of seropositivity for pathogens coinfecting dogs naturally infected with L. infantum was found, especially co-infection with T. gondii” was replaced with the “A high frequency of co-seropositivity for certain pathogens in L. infantum seropositive dogs with infection with this parasite confirmed by PCR and/or culture was found, especially co-seropositivity for T. gondii.

Lines 442, 443, 462, 469 and 505. The word “co-infection” was replaced with “co-seropositivity”.

Line 474 and 476. The text “co-infection with” was replaced with “co-infection with or co-seropositivity for”.

Line 482. The text “infection of dogs with” was replaced with “seropositivity of dogs for”.

Lines 483. The text “by serology” was deleted.

Line 487 and 501. The texts “or co-seropositivities” or “or co-seropositivity” were added.

Line 507. The text “this co-infection” was replaced with “this co-seropositivity or co-infection”.

Lines 523-524. The text “frequency of co-infections among dogs with VL found in this and other studies [4, 7, 10].” was replaced with “frequency of co-seropositivities among dogs seropositive for and/or infected with L. infantum found in this study and in other studies [4, 7, 10].

Lines 541, 548, 572, 577, 591 and 596. The word “co-infected” was replaced with “co-seropositive”.

Lines 549-552. The text “Another hypothesis for the lack of aggravation of CVL due to co-infection with other pathogens in the present study was the use of serological techniques for the detection of most of the pathogens investigated. This methodology may have contributed to the classification of exposed animals, but without active infection, as co-infected when, in fact, serological tests may have detected memory antibodies.” was replaced with the text below:

“Another hypothesis for the lack of aggravation of CanL due to co-seropositivity for certain pathogens in the present study is that the seropositive dogs may not be co-infected or infection with these pathogens is not active, but they were previously exposed to the pathogens and exhibited detectable memory antibodies.”

Lines 566 to 568. The phrase “However, 12.5% of monoinfected dogs and 10% of co-infected dogs did not have a positive culture or IHC result, suggesting that infection with L. infantum was not active in these dogs” was deleted.

Line 602. The text “why co-infections” was replaced with “why co-seropositivity for certain pathogens”.

Conclusions

Lines 605 and 607. The word “co-infections” was replaced with “co-seropositivities”.

Other alterations

In addition, due to the alterations in the terms and to make clearer that all the dogs investigated were infected with L. infantum and not only seropositive for this parasite, we reviewed the definition of the groups of dogs of our study, as follows:

Co-seropositive: L. infantum seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and antibodies against at least one pathogen other than L. infantum.

Monoinfected: L. infantum seropositive dogs with confirmed infection with this parasite by qPCR and/or culture and without antibodies against certain pathogens other than L. infantum.

These new definitions of the groups were described in lines 309-312, 355-358, 372-375 and 392-395.

The term “monoinfected” was maintained, because we confirmed the infection with L. infantum by qPCR and/or culture in all the 66 dogs investigated in this study.

The titles of Tables 1, 2, 4 and S1 were also modified as shown below:

Tables 1, 2, 4 and S1. The text “Leishmania infantum-seropositive dogs” was replaced with “dogs infected with Leishmania infantum”.

Table S1. The text “according to the co-infecting pathogen” was replaced with “according to the co-seropositivity for certain pathogens”.

In addition, the following texts were included:

Abstract

Lines 38 to 39. “All 66 dogs tested positive for L. infantum by qPCR and/or culture.”

Results

Lines 279 and 280. “All 66 L. infantum-seropositive dogs investigated in this study had infection with L. infantum confirmed by qPCR and/or culture, as described below.”

Discussion

Lines 442-443

“…co-seropositivity for certain pathogens in L. infantum-seropositive dogs with infection with this parasite confirmed by PCR and/or culture…”

Line 54 – delete “biological” – including this word suggests that there are also mechanical vectors and this is not the case

Response:

Line 54. The word “biological” was deleted, as recommended.

Line 59 – whenever possible, display agents alphabetically – change accordingly throughout the manuscript

Response:

We desplayed agents alphabetically whenever possible in the following parts of the text:

• Abstract

Lines 33 to 34.

• Introduction

Lines 59 to 64.

• Materials and methods

Lines 115 to 116, 236 to 237 and 239-240.

• Results

Line 286.

• Discussion

Lines 491-492 and 559-560.

• Conclusions

Line 605.

Line 60 – Isospora is now Cystoisospora; there is more than one species, so please write “Cystoisospora spp.”

Line 59. “ Isospora sp.” was replaced with ““Cystoisospora spp.”, as recommended.

Line 64 – replace VL with leishmaniasis

Response:

VL was replaced with “with leishmaniosis caused by L. infantum”. We replace “leishmaniasis” with “leishmaniosis” along the text, as recommended by the other reviewer (indicated above).

Materials and methods – which criteria have determined a sample size of 66 dogs?

The sample size included all dogs of the study population, i.e., all dogs that tested seropositive for L. infantum in the town of Barra Mansa and that were sent to INI-Fiocruz during the study period (n=66).

In order to make clearer the criteria for sample size, the following text was included in the materials and methods

Lines 94 to 96. “The sample size included all dogs of the study population, i.e., all dogs that tested seropositive for L. infantum in the town of Barra Mansa and that were sent to INI-Fiocruz during the study period.”

Furthermore, this sample composition may not allow extrapolation of results to other breeds.

Response:

This is a limitation of the study. Considering the breed, the results of this study can only be extrapolated to other similar populations, composed mainly by mongrel dogs (85%). In addition, statistical analysis of the association of breed with the monoinfected and co-seropositive groups was not possible because of the small number of breed dogs (n=10).

In order to make these limitations clearer in the text, the following texts were included:

Results

Lines 290-291. “Statistical analysis of the association of breed with the monoinfected and co-seropositive groups was not possible because of the small number of breed dogs.”

Discussion

Lines 444-445. Considering the breed, the results of this study can only be extrapolated to other similar populations composed mainly of mongrel dogs (85%).

Line 92 – not clear whether the owners provided signed consent for euthanasia (which is a legal imposition) or to sample collection – please make clearer

Response:

The owners provided signed consent for culling. We clarify this in the line 93.

Line 112 – abbreviate as T. gondii

Response:

Line 116. Toxoplasma gondii was abbreviated as T. gondii.

Line 174 – Leishmania spp.

Response:

Line 177. “Leishmania species” was replaced with “Leishmania spp.”

Line 181 – L. infantum

Response:

Line 184. “Leishmania infantum” was replaced with “L. infantum”.

Line 234 – Serological detection of antibodies to Anaplasma spp., B. burgdorferi and Ehrlichia spp., and of D. immitis antigens

Response:

Lines 236 to 237. The text “Detection of antibodies against Ehrlichia spp., Anaplasma spp. and B. burgdorferi and D. immitis antigens in serum” was replaced with:

“Serological detection of antibodies to Anaplasma spp., B. burgdorferi and Ehrlichia spp., and of D. immitis antigens”

Lines 238 to 240. The text “...to detect antibodies against E. canis/E. ewingii, A. platys/A. phagocytophilum and Borrelia burgdorferi and antigens of D. immitis…” was replaced with:

“... for the serological detection of antibodies to A. platys/A. phagocytophilum, B. burgdorferi and E. canis/E. ewingii, and of D. immitis antigens...”

Line 239 – inform on the per cent sensitivity and specificity for each agente

Response:

Lines 241-243. The following text was included, as recommended:

“…has the following sensitivities and specificities, respectively: 90.3% and 94.3% for Anaplasma spp., 94.1% and 96.2% for B. burgdorferi, 99.0% and 99.3% for D. immitis, and 97.1% and 95.3% for Ehrlichia spp.

Line 242 – replace Diagnosis with Detection

Response:

Line 245. “Diagnosis” was replaced with “Detection”.

Line 247 – which values for this IFAT?

Response:

There is no information in the literature about the values of specificity and sensibility of IFAT for the detecion of anti-T. gondii antibodies in the serum of dogs (Dubey et al., 2020; Leal and Coelho, 2014). However, IFAT is considered to have good specificity and sensitivity and is recommended for the immunodiagnosis of T. gondii infection in dogs, where it can be used as the only test (Leal and Coelho, 2014).

References:

Dubey JP, Murata FHA, Cerqueira-Cézar CK, Kwok OCH, Yang Y, SU C. Toxoplasma gondii infections in dogs: 2009-2020. Vet Parasitol. 2020; 287:109223.

Leal PDS, Coelho CD. Toxoplasmosis in dogs: a brief review. Coccidia. 2014; 2: 2-39.

Line 254 – median was calculated, but minimum and maximum were just copied (not calculated)

Response:

Lines 256 to 258. The text “For the description of continuous variables (number of inflammatory cells and parasite load), the median (50th percentile) and the minimum and maximum values were calculated.” was replaced with:”

“For the description of continuous variables (number of inflammatory cells and parasite load), the median (50th percentile) was calculated and the minimum and maximum values are reported.”

Line 290 – these dogs may not be infected but only seropositive; please, take this into account in the text

Response:

The terms “co-infected”, “co-infection” and “coinfections” were replaced with “co-seropositive”, co-seropositivity” and “co-seropositivities”, respectively, along all the text, when refers to the results of this study or to the results of other authors, when appropriate. These alterations are explained in more details above.

Line 415 – rates are different from percentages; and this is the case of percentages

Response:

Line 450. The word “rates” was replaced with “percentages”, as recommended.

Discussion – comparison with results from other studies could have included a statistical assessment.

Response:

This study had a descriptive observational design. Therefore, we chose to compare the findings of our study with the others in the discussion, punctuating whenever possible, the differences in the characteristics of the compared population such as geographical location and study design. To compare specific measurements of our findings with those of other studies using statistical analysis, this study should be designed for systematic review and meta-analysis, with a review carried out with key terms in a systematic way. In addition, detailed results of specific measurements and variability described in the various studies will be necessary, which is outside the scope of this article.

RESPONSE TO REVIEWER #2

Reviewer #2: It is a very interesting research and very well presented. Please use the term leishmaniosis, instead of leishmaniasis (usually used in human medicine).

Response:

Lines 27, 52, 64, 85, and 101. The term “leishmaniasis” was replaced with”leishmaniosis”.

My main concern is that you have selected some common and important pathoges to test and if negative you present the dog as a single infection case. However, there are many other important pathogens to be present and contribute. For example sarcoptic mange or worms. I did not see other tests for them. I would suggest to revise the text and title using the phrase certain or common pathogens, which is closer to your work. Also please revise your conclusions accordingly.

Response:

The text was revised and the term “pathogens” was replaced with “certain pathogens”, when reffered to the pathogens investigated in this study.

Therefore, the following modifications were done:

The title of the manuscript was altered to: “Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum”

The word “pathogens” was replaced with “certain pathogens” in the following parts of the text:

Abstract. Lines 30, 41, 45 and 46.

Introduction. Lines 69 and 72.

Results. Lines 282, 284, 312, 358, 363, 367, 375 and 395.

Discussion. Lines 442, 549 and 602.

Legend of S1 Table. Line 816.

Attachment

Submitted filename: Response to reviewers_PONE-D-20-37262.docx

Click here for additional data file. (36KB, docx)

Decision Letter 1

Angela Monica Ionica

10 Feb 2021

Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum

PONE-D-20-37262R1

Dear Dr. Caldas Menezes,

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Reviewer #3: Yes

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Reviewer #3: The manuscript PONE-D-20-37262R1 'Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum' is a well-written and concise manuscript well worth publishing in PLOS ONE. The article presents complex data involving co-infections associated with CanL. The article is very clear and objective and the authors have adequately addressed all comments raised in the previous round of review. This Reviewer has very little else to comment.

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Acceptance letter

Angela Monica Ionica

22 Feb 2021

PONE-D-20-37262R1

Frequency of co-seropositivities for certain pathogens and their relationship with clinical and histopathological changes and parasite load in dogs infected with Leishmania infantum

Dear Dr. Menezes:

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. Median number of inflammatory cells observed in each organ of dogs infected with Leishmania infantum according to the co-seropositivity for certain pathogens, August 2016 to January 2019 (Barra Mansa, state of Rio de Janeiro, Brazil).

    (DOC)

    Click here for additional data file. (42.5KB, doc)
    Attachment

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