Objectives The coagulation-inflammation cycle has been implicated as a critical component in malaria pathogenesis. Defibrotide (DF), a mixture of DNA aptamers, displays anticoagulant, anti-inflammatory, and endothelial cell (EC)-protective activities and has been successfully used to treat comatose children with veno-occlusive disease. DF was investigated here as a drug to treat cerebral malaria (CM). Methods and Results DF blocks tissue factor (TF) expression by ECs incubated with parasitized red blood cells (pRBCs), attenuates prothrombinase activity, platelet aggregation, and complement activation. In contrast, it does not affect nitric oxide bioavailability. We also demonstrated that Plasmodium falciparum glycosylphosphatidylinositol (Pf-GPI) induces TF expression in ECs and cytokine production by dendritic cells (DCs). Notably, DCs – known to modulate coagulation and inflammation systemically – were identified as a novel target for DF. Accordingly, DF inhibits Toll-like receptor (TLR) ligand-dependent DCs activation by a mechanism that is blocked by adenosine receptor (AR) antagonist (8-p-sulfophenyltheophylline), but not reproduced by synthetic poly-A,-C,-T,-G. These results imply that aptameric sequences and AR mediate DCs responses to the drug. DF also prevents rosetting formation, RBC invasion by P. falciparum and abolishes oocysts formation in Anopheles gambiae. In a murine model of CM, DF affected parasitemia, decreased IFN-γ levels, and ameliorated clinical score (day 5) with a trend for increased survival. Conclusions Therapeutic use of DF in malaria is proposed.

Malaria has had the largest impact of any infectious disease on shaping the human genome, exerting enormous selective pressure on genes that improve survival in severe malaria infections. Modern humans originated in Africa and lost skin melanization as they migrated to temperate regions of the globe. Although it is well documented that loss of melanization improved cutaneous Vitamin D synthesis, melanin plays an evolutionary ancient role in insect immunity to malaria and in some instances melanin has been implicated to play an immunoregulatory role in vertebrates. Thus, we tested the hypothesis that melanization may be protective in malaria infections using mouse models. Congenic C57BL/6 mice that differed only in the gene encoding tyrosinase, a key enzyme in the synthesis of melanin, showed no difference in the clinical course of infection by Plasmodium yoelii 17XL, that causes severe anemia, Plasmodium berghei ANKA, that causes severe cerebral malaria or Plasmodium chabaudi AS that causes uncomplicated chronic disease. Moreover, neither genetic deficiencies in vitamin D synthesis nor vitamin D supplementation had an effect on survival in cerebral malaria. Taken together, these results indicate that neither melanin nor vitamin D production improve survival in severe malaria.