Mathematical Biosciences 276 (2016) 28–43

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Mathematical Biosciences
journal homepage: www.elsevier.com/locate/mbs

Immune response to infection by Leishmania: A mathematical model

Nourridine Siewe a,∗, Abdul-Aziz Yakubu a, Abhay R Satoskar b, Avner Friedman c
a
Department of Mathematics, Howard University, Washington, DC, United States
b
Department of Pathology and Microbiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, United States
c
Department of Mathematics, Mathematical Biosciences Institute, The Ohio State University, Columbus, Ohio, United States

a r t i c l e i n f o a b s t r a c t

Article history: Leishmaniasis is a disease caused by the Leishmania parasites. The injection of the parasites into the host
Received 21 September 2015 occurs when a sand fly, which is the vector, bites the skin of the host. The parasites, which are obligate,
Revised 22 February 2016
take advantage of the immune system response and invade both the classically activated macrophages
Accepted 26 February 2016
(M1 ) and the alternatively activated macrophages (M2 ). In this paper, we develop a mathematical model
Available online 14 March 2016
to explain the evolution of the disease. Simulations of the model show that, M2 macrophages steadily in-
Keywords: crease and M1 macrophages steadily decrease, while M1 + M2 reach a steady state which is approximately
Leishmaniasis the same as at healthy state of the host. Furthermore, the ratio of Leishmania parasites to macrophages
Immune system response depends homogeneously on their ratio at the time of the initial infection, in agreement with in vitro
framework experimental data. The model is used to simulate treatment by existing or potential new drugs, and to
Conceptual mathematical Model compare the efficacy of different schedules of drug delivery.
Granuloma formation
Cytokine © 2016 Elsevier Inc. All rights reserved.

1. Introduction
Leishmaniasis, a parasitic disease, is caused by infection with an
obligate intra-cellular protozoa called Leishmania, the disease par-
asite [1,2]. The disease vector is the female sand fly, phlebotomine.
Infection occurs when a female sand fly bites a human and injects
into his/her body the flagellated form of the Leishmania parasites,
called promastigotes [2,3]. The promastigotes are endocytozed into
phagocytic cells, and quickly transform into amastigotes (non-
flagellated Leishmania). The amastigotes then mature and multiply
by simple division [3,4]. The replication of the amastigotes within
the phagocytic cells eventually causes the cells to burst [5], releas-
ing the amastigotes. At this stage of the life cycle of the parasite
in the host, when a susceptible vector takes a blood meal from the
infected host, it may ingest the Leishmania parasites (amastigotes)
that then develop within the vector, and the cycle repeats [2,3,5].
Other modes of transmission of leishmaniasis to humans, though
less common, include blood transfusion, sharing of contaminated
needles, and mother-to-child transmission during pregnancy [6].
There are more than 20 species of the Leishmania parasite, and
more than 30 different species of the parasite vector, the female
sand fly [1]. Worldwide, over 350 million people are at risk of con-
tracting leishmaniasis. The disease is endemic throughout Africa,
∗
Corresponding author. Tel.: +1 2026297169.
E-mail address: sienourridine@gmail.com, nourridine@aims.ac.za (N. Siewe).
the Americas, Asia and Europe [2,7,8]. Leishmaniasis affects about
two million people and kills 20,0 0 0–40,0 0 0 people annually [2,8].
The two common forms of leishmaniasis are cutaneous leish-
maniasis (CL) and visceral leishmaniasis (VL) [1,2,7]. CL occurs
when the parasite infects the macrophages in the skin tissue (der-
mis) causing skin sores, ulcers and nodules [1,3,5]. Other symp-
toms of CL are stuffy nose, nosebleeds and swallowing difficulty
[6]. Not all CL cases require treatment, as the skin sores are often
self-healing [5,7]. However, skin sores in complicated cases of CL
require treatment, for otherwise they may develop on the mucous
membranes and cause physical deformations [2,9].
VL, the more severe and sometimes fatal form of the disease,
occurs when the Leishmania parasites infect and develop within
macrophages located in internal organs such as the bone-marrow,
liver and spleen [1–3]. Depending on their modes of transmission,
two types of VL are usually identified: zoonotic VL and anthro-
ponotic VL [1]. The primary symptoms of VL include abdominal
pain, fever, shivering and weight loss. However, signs of bacterial
co-infection such as pneumonia, diarrhea or tuberculosis may
lead to death if persistent for several weeks without treatment
[1,2]. More than 90% of the worldwide infections of VL occur
in Bangladesh, Brazil, Ethiopia, India, Sudan and South Sudan
[8].
Following initial infection, there is a recruitment of mono-
cytes from the blood that enter the infected tissue and differen-
tiate into macrophages [10]. Macrophages play a critical role both
in the pathogenesis [11], and in the fight against leishmaniasis
[12].

http://dx.doi.org/10.1016/j.mbs.2016.02.015
0025-5564/© 2016 Elsevier Inc. All rights reserved.
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 29

The macrophages have two “polarized” forms, pro-inflammatory Table 1

List of variables.
(or classically activated) macrophages, denoted by M1 , and
anti-inflammatory (or alternatively activated) macrophages, de- Variable Description Unit
noted by M2 . Macrophage polarization refers to the expression by
D Density of dendritic cells g/ml
macrophages of different functional programs in response to mi- M Density of macrophages (within first g/ml
croenvironmental signals. M1 secretes pro-inflammatory IL-12. M2 three days of infection)
secretes anti-inflammatories IL-10 and IL-13, which enhance Leish- M1 Density of pro-inflammatory g/ml
mania proliferation [13–15]. Resting T cells in the spleen and lym- (classically activated) macrophages
M2 Density of anti-inflammatory g/ml
phoid tissues are primed by antigen presentation of dendritic cells
(alternatively activated) macrophages
(DC) (but also by macrophages [16]). The activated naive T cells P Density of Leishmania (within first g/ml
develop into intermediate stage, and are called Th0 cells. Th0 cells three days of infection)
migrate into the liver and are activated as Th1 cells by contact with P1 Density of Leishmania present in g/ml
macrophages and DC in IL-12 environment. During this contact, the macrophages M1
P2 Density of Leishmania present in g/ml
CD4+ T cells recognize antigens bound to MHC (Major Histocom-
macrophages M2
patibility Complex). I2 Concentration of IL-2 g/ml
CD4+ T cells produce IL-2 [1] which activates CD8+ T cells I10 Concentration of IL-10 g/ml
and promotes the proliferation of CD4+ T cells [17,18]. Both I12 Concentration of IL-12 g/ml
CD4+ T cells and CD8+ T cells produce IFN-γ which stimu- I13 Concentration of IL-13 g/ml
Iγ Concentration of IFN-γ g/ml
lates the macrophages to kill the Leishmania [4,19–21]. IFN-γ T4 Density of CD4+ T cells g/ml
also promotes the polarization from M2 to M1 macrophages. As T8 Density of CD8+ T cells g/ml
in the case of hamster, up-regulation of arginase enzyme indi-
cates predominance of M2 macrophages, while up-regulation of
iNOS (inducible nitric oxide synthase) indicates predominance of
M1 [22–24]. drug currently used to contain leishmaniasis; in particular we
There are no longitudinal data on the growth of Leismania compare the efficacy of the drug under different schedules of
parasites in human liver; such data could only be obtained by delivery.
biopsy, which cannot be frequently repeated. For this reason we
developed here a mathematical model of the disease progres-
sion that can be used to monitor the efficacy of drug treatment 2. The mathematical Leishmania model
in VL.
The present paper develops for the first time a mathemati- The mathematical model of the leishmaniasis disease is based
cal model of leishmaniasis which includes macrophages M1 and on the schematic diagram shown in Fig. 1, and the list of vari-
M2 and the parasites within, dendritic cells, T cells, and a num- ables is given in Table 1. To simplify the model, we combine the
ber of cytokines. The model is also the first of its kind to en- cytokines IL-10 and IL-13 into one, and for simplicity, denote the
able the measurement and prediction of Leishmania parasite loads combination by IL-10. Since the parasites reside in macrophages
during the course of infection, with or without drug treatment. and the macrophage response depends critically on whether it
There are previous models of leishmaniasis; one of SIR-type in is M1 or M2 macrophage, we divide the macrophages into dif-
[25,26] and another that focuses on the Th1/Th2 balance in ferent populations, M1 and M2 . The roles of T4 and T8 in leish-
[27], but these models cannot address the questions considered maniasis are somewhat different, and the cross talk between
here. them is not yet sufficiently clear [29–31]. However, since both
Fig. 1 is a schematic diagram describing the interactions among T4 and T8 produce IFN-γ which is a critical cytokine for acti-
the parasites, cells and cytokines involved in leismaniasis. The vating macrophages, and since the proliferation of both is en-
model is described by a system of differential equations, based on hanced by IL-2, for simplicity we shall combine T4 and T8 into
the network shown in Fig. 1. The model is generic in the sense that one species of cells, and endow it with the combined proper-
it is not specific to the type of the parasite or the infected organ of ties of CD4+ and CD8+ T cells; we denote the combined species
the host; some parameters in the model can be adjusted to reflect by T.
different degrees of severity of the disease. The polarization of macrophages occurs three days after infec-
In the initial stage of the disease, the first three days, the tion, and it depends on the concentrations of IFN-γ (Iγ ), and IL-10
macrophages (M) have not yet been polarized. Hence the model (I10 ) [22,29,30]. Iγ favors the polarization into M1 while I10 favors
will have two stages: We first describe the evolution of the dis- the polarization into M2 . Macrophage M2 bursts when the average
ease after the first three days, and then go back to consider the number of its intracellular Leishmania exceeds a certain number
initial 3–day period when the macrophages have not yet been N. The newly released parasites are then immediately ingested by
polarized. the macrophages, M1 or M2 , depending on the ratio of Iγ to I10 .
Simulations of the model show that the number of Leishma- We denote by N1 and N2 the average numbers of Leishmania con-
nia parasites continues to grow in time, in agreement with the tained in macrophages M1 and M2 , respectively, at the time when
fact that VL cannot be resolved in human subjects. The simula- these cells undergo apoptosis. It is natural to assume that N1 <
tions also show that the number of M2 macrophages decreases N2 because M2 macrophages are more vulnerable to infection than
and the number of M1 macrophages increases, while the total M1 macrophages [13–15]. It is also natural to assume that N2 < N
number of macrophages (M1 + M2 ) remains approximately un- since N is the average number of parasites at the time when the
changed. It is also shown, by simulations, that the ratio of par- macrophage bursts [5].
asites to macrophages at time t is linearly correlated to their Table 1 lists the variables used in the mathematical model. Dur-
ratio at the initial infection if t is small, but the correlation ing the first three days after the initial infection the macrophages
evolves nonlinearly as t increases and eventually stabilizes at a have not yet been polarized to M1 or M2 . We shall first de-
constant value. This result is in agreement with in vitro exper- velop the model for the period following day 3 from in-
iments [28]. We illustrate potential usefulness of the model by fection, and then go back to describe it for the first three
simulating the effect of Sodium Antimony Gluconate (SAG), a days.
30 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43

Fig. 1. Diagram of interactions between various cell types, parasites and cytokines considered in the model. Explanations of the interactions displayed here can be found in
the text descriptions of Eqs. (2.1)–(2.18).

2.1. Macrophage model after three days of initial infection sites inside the macrophage increases to N. For simplicity we take
n = 2; however, calculating with degree n (e.g., n = 3, 4), leads to
Equation for pro-inflammatory macrophage (M1 ): The following similar results (not shown here). The Hill dynamics is used also in
equation describes the dynamics of the density of M1 : modeling the bursting of macrophages in other infections such as
dM1 Iγ tuberculosis [34] and HIV [35]. The last term on the right-hand-
= A + k2 M2 side of Eq. (2.1) represents the death (apoptosis) of M1 .
dt 
M
Iγ + cγ
gain from new recruitment    Equation for anti-inflammatory macrophage (M2 ): The density of
Iγ induced transition from M2 to M1 M2 satisfies the equation:
I10 1 P12
− k3 M1 − k˜ 5 M1 dM2 I10 1 Iγ
I10 + c10 1 + Iγ /cγ P12 + ( NM )
1 2 = k3 M1 − k2 M2
     150
 dt I10 + c10 1 + Iγ /cγ Iγ + cγ
loss due to transition to M2
     
loss due to bursting
I10 induced transition from M1 to M2 loss due to transition to M1
− μM 1 M 1 . (2.1)
P22
   − k5 M2 − μM 2 M 2 . (2.2)
loss due to death P22 + ( NM )
2 2   
The first term on the right-hand side is the recruitment of new   150
 loss due to death
loss due to bursting
macrophages from the host immune system; we assume that three
days after initial infection, newly recruited macrophages enter in
The first term on the right-hand side is complementary to the
the host system through the compartment of classically activated
third term in Eq. (2.1), and the second term is complementary to
macrophages M1 . The second term describes the gain in M1 due
the second term in Eq. (2.1). The third term is the loss of M2 due
to the Iγ –induced transition from M2 to M1 [4,13,20]. When cy-
to bursting [31–33]. This is modeled by the Hill dynamics where N
tokines or cells I appear as a factor I+I K , the value I = K has the
is the average number of parasites in the macrophages at bursting
effect of 1/2 the maximum effect of I as I → ∞; this value, K, is
time.
often referred to as the ‘saturation’ value of I. In particular, cγ is
the saturation value of Iγ .
The third term is the loss of M1 due to the transition to M2 ,
a process stimulated by I10 and inhibited by Iγ [22,29,30]; c10 is 2.2. Leishmania (parasite) model after three days of initial infection
the saturation level of I10 . The fourth term is the loss of M1 due
to bursting [31–33]. We assume that the mass of one macrophage Equation for Leishmania in M1 macrophages (P1 ): The Leishmania
is approximately equal to the mass of 150 Leishmania parasites. density P1 satisfies the equation:
Hence, when one M1 (or M2 ) macrophage bursts, NM1 (or NM2 )   
parasites are released, with total mass of N/150 times the mass of dP1 P Iγ
= max α1 P1 1 − N∗ M1 1 , 0 + k2 P2
the bursting macrophage. dt Iγ + cγ
The signaling pathway leading to burst of macrophages involves   150    
growth in M1 Iγ induced transition from M2 to M1
several enzymatic activities, which suggests that it should be mod-
Pn
eled by the Hill dynamics of the form kM1 Pn +1K n , for some n ≥ 2, NM2 P22 NM1 P12
1 + k5 θ + k˜ 5 θ
NM 150 P + (
2 NM 2
) 2 150 P + ( NM1 )2
2
where K = 1501 ; that is, the rate of bursting is small when P1 is  2
150
  1 150
 
small, and increases sharply to kM1 /2 when the number of para- gain after burst of M2 gain after burst of M1
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 31

NM1 P12 I10 1 macrophage M2 can contain before it bursts. As in the case of
− k˜ 5 − k3 P1 macrophages M1 , we assume that all Leishmania parasites within
150 P + ( NM1 )2
2 I10 + c10 1 + Iγ /cγ
 1

150
    M2 die when M2 dies. Accordingly we get the corresponding death
loss due to burst of M1 loss due to transition from M1 to M2 rate of P2 to be μM2 N2 P2 , where N2 is the average number of Leish-
  mania in one M2 macrophage at the time when the macrophage
I
− μP1 P1 1 + kγ γ − μM N1 P1 , undergoes apoptosis. The remaining terms in Eq. (2.4) are similar
Iγ + cγ  1 
   death due to apoptosis of M1
or complementary to terms in Eq. (2.3).
death augmented by Iγ
2.3. Dendritic cells model after three days of initial infection
0 < θ < 1, 0 < k˜ 5 < k5 . (2.3)
The first term on the right-hand side is a logistic growth of The equation for dendritic cells density D is the following:
Leishmania within M1 , where N∗ is the carrying capacity for P1 in
dD P + P2

I12
 1
M1 ; N∗ ≥ N [31–33]; note that if P1 exceeds NM1 /150, there is no = λD D0 N (M1 +M2 1) 1 + k12
dt + (P1 + P2 ) I12 + c 12 1 + I10 /c10
growth. When M2 polarizes into M1 under Iγ signaling (the second
 150
 
term on the right-hand side of Eq. (2.1)), the parasites P2 in M2 be- dendritic cells activation
come parasites P1 in M1 , and this is accounted by the second term − μD D. (2.5)
on the right-hand side of Eq. (2.3). When M2 bursts, NM2 parasites   
are released. loss due to death

We assume that θ –fraction of them are ingested by M1 Dendritic cells are activated by ingesting parasites whose carrying
macrophages, and this is represented by the third term on the capacity is N (M1 + M2 )/150. This process is enhanced by I12 and
right-hand side of Eq. (2.3); the remaining (1 − θ )–fraction are in- resisted by I10 [37]. In Eq. (2.5), D0 denotes the density of inacti-
gested by M2 macrophages (the third term on the right-hand side vated dendritic cells in homeostasis in the lung.
of Eq. (2.4)). We also assume that the mass of one macrophage is
approximately equal to the mass of 150 Leishmania parasites (as 2.4. T cell model after three days of initial infection
will be explained in the Parameter Estimations section). Hence,
when one M1 (or M2 ) macrophage bursts, NM1 (or NM2 ) para- Naive T cells are activated while in contact with antigen pre-
sites are released, with total mass of N/150 times the mass of the sented by DC (but also by macrophages [16]) and develop into an
bursting macrophage. We assume that θ –fraction of the released intermediate stage, Th0 cells. The Th0 cells migrate into the liver
parasites are ingested by M1 macrophages, as represented in the where they are activated as Th1 cells by macrophages and DC in
fourth term of Eq. (2.3) and (1 − θ )–fraction are ingested by M2 IL-12 environment. We denote by T0 the density of Th0 cells in the
macrophages (fourth term in Eq. (2.4)). liver and by T the density of Th1 cells.
The fifth term in Eq. (2.3) is the parasite–equivalence of the The density of T cells satisfies the equation:
fourth term in Eq. (2.1), while the sixth term is the parasite–
dT D I M +M I
equivalence of the third term in Eq. (2.1). The seventh term on = λDT T0 12
+ λMT T0
1 2 12
dt KD + D I12 + c12 KM + (M1 + M2 ) I12 + c12
the right-hand-side of Eq. (2.3) accounts for the killing of para-      
sites within M1 , which is enhanced by Iγ [4,19,21]. We assume DC activation MHC activation
that when macrophage M1 dies, all Leishmania within it also die. I2
Accordingly, we get the corresponding death rate of P1 to be + kT T − μT T . (2.6)
I2 + c2 
μM1 N1 P1 , where N1 is the average number of Leishmania in one M1    death
macrophage at the time when the macrophage undergoes apopto- I2 –induced proliferation of T cells

sis. The first term is the activation of naive T cells by contact with
Equation for Leishmania in M2 macrophages (P2 ): The equation dendritic cells [37] and the second term is the activation of T cells
for Leishmania density P2 is the following: by contact with M1 and M2 macrophages [14,38]. The third term
   represents the I2 –induced proliferation of T cells [17,18], and the
dP2 P I 1
= max α2 P2 1− N∗ M2 2 , 0 + k3 P1 10 last term is the death of T cells.
dt I10 + c10 1 + Iγ /cγ
  150    
growth in M2 I10 induced transition from M1 to M2 2.5. Cytokine model after three days of initial infection
NM2 P22
+ k5 (1 − θ ) Equation for Interleukin-2 (I2 ): I2 is produced by T cells [19].
150 P 2 + ( NM2 )2 Hence:
 2 150
 
gain after burst of M2 dI2
= k T − μ2 I2 . (2.7)
NM1 P12 dt 
7

+ k˜ 5 (1 − θ ) secretion by T decay
150 P 2 + ( NM1 )2
 1 150
  Equation for I10 (Combination of IL-10 and IL-13): The production
gain after burst of M1 of I10 by M2 is enhanced by I10 [14,19], so that
NM2 P22 Iγ dI10
− k5 − k2 P2 = k10 M2 − μ10 I10 . (2.8)
150 P 2 + ( NM2 )2 Iγ + cγ dt      
 2
 150
    secretion by M2 decay
loss due to burst of M2 loss due to transition from M2 to M1

− μM2 N2 P2 − μP2 P2 . (2.4) Equation for Interleukin-12 (I12 ): I12 is produced by M1 , and this
      process is inhibited by I10 (and I13 ) [12,15,19]. Hence:
death due to apoptosis of M2 natural death of P2
dI12 1
As in [36], the growth of P2 (first term on the right-hand side = k8 M1 − μ12 I12 . (2.9)
dt 1 + I10 /c10   
of Eq. (2.4)) is modeled by the logistic Hill kinetics with a param-    decay
eter that depends on the average number N of Leishmania that secretion by M1
32 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43

Equation for Interferon-γ (Iγ ): Iγ is secreted by the T cells dI2

= k T − μ2 I2 . (2.15)
[12,21,39], so that dt 
7

secretion by T decay
dIγ
= λγ T − μγ Iγ . (2.10)
dt     dI10 M
secretion by T decay = k10 − μ10 I10 . (2.16)
dt  2   
decay
secretion by M
2.6. Leishmania (Parasite) model in the first three days of initial
infection
dI12 M 1
= k8 − μ12 I12 . (2.17)
In Eqs. (2.1)–(2.10), we have modeled the parasite–cell interac- dt 2 1 + I10 /c10   
   decay
tions after the first three days. To describe the Leishmania model secretion by M
during the first three days of the initial infection, we take P1 = P2
and M1 = M2 in Eqs. (2.1)–(2.4), and set M = 2M1 and P = 2P1 . This dIγ
implies that N1 = N2 and μM1 = μM2 ; we denote the latter by μM . = λγ T − μγ Iγ . (2.18)
dt    
During this phase of infection, one could consider the effects of secretion by T decay
time delays on the model; for instance, delays between cellular in-
fection and the production of new parasites that can affect other The initial conditions will be taken to be those of normal
cells. These delays are modeled implicitly by ODEs but the error healthy state; they are defined in Eq. (3.24).
in approximation could be greater in the early phase of infection. Theorem 2.1. Consider a system of differential equations
We also note that during the first three days of an initial infec-
tion, when the parasites load is low, there may be demographic dxi
= f i ( x1 , . . . , xn ), 1 ≤ i ≤ n,
stochasticity and even possibly extinction of the Leishmania para- dt
sites. This may not be a concern if the initial load of parasites is and assume that the fi ’s are continuously differentiable functions sat-
large enough; but even in that case, if the probability of parasite isfying the following conditions in the nonnegative quadrant
death before cellular infection is high, then there may be delayed
x1 ≥ 0, x2 ≥ 0, ..., xn ≥ 0 :
growth even in the absence of extinction.

Adding Eqs. (2.1) and (2.2), we obtain the equation for (i) fi (x1 , . . . , xn ) < A + B nj=1 x j ,
macrophage within three days of infection: (ii) fi (x1 , . . . , xn ) = gi (x1 , . . . , xn ) + hi (x1 , . . . , xn )xi , where

(iii) gi (x1 , . . . , xn ) ≥ 0 and hi (x1 , . . . , xn ) ≥ −A1 − B1 nj=1 x j ,
dM M P2
= A − (k5 + k˜ 5 ) with some positive constants A, B, A1 and B1 .
dt 
M
2 P 2 + ( 150
NM 2
) If xi (0) > 0 for 1 ≤ i ≤ n, then
gain due to recruitment   
(iv) 0 < xi (t ) < AB + Xˆ enBt , for 1 ≤ i ≤ n and all t > 0, where Xˆ =
lost due to burst n
j=1 xi (0 ).
− μM M , 0 ≤ k˜ 5 ≤ k5 , (2.11)
   Proof. The inequality (iv) certainly holds if t is small. Hence, if the
apoptosis
assertion (iv) is not true, then there is a smallest time τ such that
where P1 = P2 and M1 = M2 in Eqs. (2.1)–(2.4), and M = 2M1 and (iv) holds for t < τ but not for t = τ . To derive a contradiction, we
P = 2P1 . begin, using (i), with
Similarly, adding Eqs. (2.3) and (2.4), we obtain the equation for
dxi n
Leishmania parasite within three days of infection: ≤A+B x j.
   dt
j=1
dP P P
= max (α1 + α2 ) 1− N M ,0 n
dt 2 ∗ Setting z = j=1 x j we get
 150
 
dz
for t < τ .
growth in M
≤ nA + nBz,
P Iγ dt
− μP1 kγ − μM N1 P − μP P , (2.12)
2 Iγ + cγ     Hence
   decay death A 
loss due to Iγ z(τ ) ≤ enBτ z(0 ) + 1 − e−nBτ (2.19)
B
where P1 = P2 and M1 = M2 in Eqs. (2.1)–(2.4), and M = 2M1 and
A
P = 2P1 . < + Xˆ enBτ , (2.20)
B
The remaining equations are:

 so the second inequality in (iv) follows with t = τ .
dD P I12 1 We next use the conditions (ii) and (iii) to get
= λD D0 NM 1 + k12 − μD D.  
dt + P I12 + c 12 1 + I10 /c10   
 150
  loss due to death dxi n

dendritic cells production ≥ − A1 + B1 x j xi

dt
(2.13) j=1

and, by the second inequality in (iv),

dT D I12 M I12  
= λDT T0 + λMT T0
n
A
dt KD + D I12 + c12 KM + M I12 + c12 A1 + B1 x j (t ) ≤ A1 + nB1 + Xˆ enBτ ≡ C, for t ≤ τ .
      B
j=1
DC activation MHC activation
I2 Hence
+ kT T − μT T . (2.14)
I2 + c2  dxi d  Ct 
   decay ≥ −Cxi , or e xi ≥ 0,
I2 –induced proliferation of T cells dt dt
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 33

so that Estimate for k10

The secretion rate of IL-10 by macrophages is 5.3 × 10−5 per
xi (τ ) > e−Cτ xi (0 ) > 0. day [57], and the secretion rate of IL-13 by macrophages is 3.98 ×
10−4 per day [56]. Accordingly we take
This completes the proof by contradiction. 
k10 = 2.25 × 10−4 per day.
We observe that the systems (2.11)–(2.18) and (2.1)–(2.10) both
satisfy the conditions of Theorem 2.1. Hence:
Estimate for k12
Corollary 2.2. The solutions of the systems (2.11)–(2.18) and (2.1)– We assume that the activation of DC is doubled when I12 is at
(2.10) are positive and uniformly bounded in every bounded interval the saturation level, and hence take
0 < t ≤ t˜. k12 = 2.
Indeed, after injection of parasites, the density of dendritic cells,
Estimate for kT
D, becomes positive for time t positive and small, and all the other
According to Haynes et al. [58], I2 alone induces T cells prolif-
variables are positive already at t = 0. So Theorem 2.1 can be ap-
eration. Using the dynamics
plied.
dT I2
= kT T − μT T ,
3. Parameter estimations and initial conditions
dt I2 + c2
we see that kT must be greater than μT ; we take
In this section, we set values for the parameters and initial con-
kT = 1.2μT = 1.2 × 0.197 = 0.24 per day.
ditions necessary for simulating Model (2.1)–(2.18). We also use
BIB83 index to perform a local sensitivity analysis in order to iden-
tify critical parameters of the model and quantify how these pa- Estimate for λDT
rameters’ uncertainty impact the model outcome. Dendritic cells are responsible for about 90% of the activation
of T cells [37,59,74]. Accordingly we take

3.1. Parameter estimations

λDT = 10λMT ,
where λMT = 5.7 × 10−4 per day (see Table 2).
The list of all parameters of the model and their numerical val-
ues is given in Table 2. Most of the parameters are taken, or es- Estimate for μ10
timated, from the experimental literature, although some of the The decay rate of IL-10 is 16.64 per day [67], and the decay rate
parameters that involve macrophages are taken from the literature of IL-13 is 12.47 per day [68]. Since we use I10 to represent also I13 ,
dealing with lung macrophages [34,47]. In this section we estimate we take
the remaining parameters.
Recalling that N1 < N2 < N (but N1 = N2 in the first three days μ10 = 14.5 per day.
of infection), we take N1 = 2, N2 = 20 and N = 50; we also take
N∗ = N in (2.3) and (2.12). We assume that the mass of a cell is Estimate for μM , μM1 and μM2
between 1–10 ×10−10 g. The Leishmania parasite is approximately According to experimental results reported in Wacker et al. [61],
3–6 μm in length and 1–3 μm in width. Accordingly we take the the half-life of Kupffer cells, the resident macrophages in the liver,
mass of the parasite to be 7 × 10−13 g, so that the mass of 150 par- is 12.4 days. Other studies have contrasting values for the half-life
asites is equal to the mass of one cell. The choices of N, N1 and N2 of Kupffer cells; for instance van Furth et al. [62,75] proposed a
are based on [44]; however, a more precise determination of these smaller half-life, while Takahashi [76] proposed a much larger half-
parameters will require data from time-lapsed cell imaging which life. We take half-life t1M/2 = 12.4 days. Then
are currently unavailable.
1
M ( 0 ) = M ( 0 ) e − μP t 1 / 2 ,
M
M1 macrophages, being pro-inflammatory, are more prone to
resist the proliferation of in-host parasites than M2 macrophages. 2
Therefore α 1 < α 2 ; we take [44,45] so that
ln 2 0.693
α1 = 2.06 and α2 = 1.24α1 = 2.55. μM = = = 0.056 per day.
M
t1/2 12.4

Estimate for k5 and k˜ 5 We take μM1 = μM as the apoptosis rate of pro-inflammatory

In [51], the measurement of bursting of macrophages was done
under H2 O2 conditions in order to imitate the situation that occurs
in physiological conditions. About 8% of H2 O2 exposed L. donovani-
infected macrophages burst after 24 h (1 day) of infection. So, in
terms of the approximated bursting dynamics gleaned from Eq.
k
(2.11), namely dMdt
= − 25 M, we obtain
k5 k5
M (1 ) = M (0 )e− 2 (1) ⇒ 0.92M (0 ) = M (0 )e− 2 ⇒ k5
= 2 ln(1/0.92 ) = 0.17 per day.
The rate of bursting in the first three days of infection when sig-
nificant infection has not yet developed should be considerably
smaller, and we take
k˜ 5 = k5 /10.
macrophage M1 , but a smaller apoptosis rate μM2 of macrophage
M2 ,
μM2 = μM /4 = 0.014 per day,
since M2 has a higher parasite burden.
Estimate for M0 , D0 and T0 and AM
We note that in mouse liver there are 1.5 × 107 macrophages
[40], 107 T cells [72] and 7 × 106 DC [49]. The weight of a mouse
liver is 2 g [77,78], which corresponds to volume of 2 ml. Hence
the density of macrophages in mouse liver is 7.5 × 106 cells/ml;
the density of T cells is 5 × 106 cells/ml, and the density of DC is
3.5 × 106 cells/ml.
Assuming that a stellate macrophage in the liver has volume of
10 × 10 × 2 μm3 , the mass of 1 macrophage cell is approximately
34 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43

Table 2
Descriptions, value ranges, and sources of the parameters used in system (2.1)–(2.18).

Parameter Description Value/range Reference

−5
AM a
Basal production rate of macrophages 8.4 × 10 g/ml per day [40–43]est.
α1 a Intrinsic growth rate of P1 within M1 2.06 per day [44,45]est.
α2 a Intrinsic growth rate of P2 within M2 2.55 per day [44,45]est.
c2 I2 value for 1/2 maximum effect of IL-2 2 × 10−6 g/ml [46]
c10 I10 value for 1/2 maximum effect of IL-10 5 × 10−5 g/ml [47]
c12 I12 value for 1/2 maximum effect of IL-12 1.5 × 10−4 g/ml [47]
cγ Iγ value for 1/2 maximum effect of IFN-γ 2 × 10−6 g/ml [47,48]
D0 a Density of DC in health state 0.7 × 10−3 g/ml [49]est.
θa Fraction of P phagocyted by M1 after macrophage bursts 0.8 Fitted
k2 Transition rate from M2 to M1 0.69 per day [47,50]
k3 Transition rate from M1 to M2 3.61 per day Fitted
k5 a Bursting rate of M2 0.17 per day [51]est.
k˜ 5 a Bursting rate of M1 k5 /10 [52]est.
k7 a Production rate of I2 by T 1.15 × 10−4 per day [53,54]
k8 a Production rate of I12 by M1 2.4 × 10−3 per day [55]est.
k10 a Production rate of I10 by M2 2.25 × 10−4 per day [56,57]est.
est.
k12 Activation rate of DC by I12 2
kγ a Iγ -indeuced deat rate of parasites 6.2 × 10−1 [34]fitted
KD D value for 1/2 maximum effect of DC 0.7 × 10−3 g/ml (D0 ) est.

KM M (or M1 + M2 ) value for 1/2 maximum effect of macrophage 1.5 × 10−3 g/ml (M0 ) est.

kT a I2 –induced rate of proliferation of T cells 0.24 per day [58]est.

λD a Production rate of dendritic cells 0.5 per day [34]
λDT a Production rate of T cells by DCs and I12 10λMT [37,59]est.
λγ a Production rate of IFN-γ by T cells 2 × 10−6 per day [55]
λMT a Activation rate of T cells by macrophages and I12 5.7 × 10−4 per day [60]fitted
Na Average number of P as macrophage bursts 50 (30–50) parasites [44]
N1 Average number of Leishmania in M1 2 parasites [44]
N2 Average number of Leishmania in M2 20 parasites [44]
N∗ Maximum number of Leishmania in M1 50 parasites [44]est.
μD Death rate of D 0.1 per day [47]
μM Death rate of M 0.056 per day [61]
μM1 Death rate of M1 0.056 per day [61]est.
μM2 Death rate of M2 0.014 per day [61]est.
μP Death rate of P 1.85 per day [62,63]
μP1 Death rate of P1 1.85 per day [62,63]est.
μP2 Death rate of P2 2.22 per day [62,63]est.
μT Death rate of T cells 0.197 per day [55,64,65]
μ2 Degradation rate of I2 330 per day [66]
μ10 Degradation rate of I10 14.5 (6.3–17.33) per day [67–69]
μ12 Degradation rate of I12 1.39 per day [70]
μγ Degradation rate of Iγ 33 per day [71]
T0 Density of T cells in health state 10−3 g/ml [72,73]est.
est.
= and estimated.
a
= used for sensitivity analysis.

1
5 × 10
−9 gram. Hence, the mass density of macrophages in mouse At steady state of healthy normal liver, we get AM = M0 × μM ,
liver is and since μM = 0.056 per day [61], we have

M0 = 7.5 × 106 ×
1
× 10−9 = 1.5 × 10−3 g/ml. (3.21)
AM = 1.5 × 10−3 × 0.056 = 8.4 × 10−5 g/ml.
5
The diameter of a CD4+ T cell is approximately 8 μm [73], so we Estimate for μP , μP1 and μP2
estimate its volume to be 200 μm3 . Accordingly, the mass of one According to experimental results in Phillips et al. [52], the
T cell is then approximately 15 × 10−9 g. Hence the mass density of half-life of Leishmania within infected macrophage is six to twelve
T cells in mouse liver is hours (in vitro with no Iγ ); earlier results by Green et al. [63] re-
ported longer time. Accordingly, we take the half-life of Leishmania
1
T0 = 5 × 106 × × 10−9 = 10−3 g/ml. (3.22) in infected macrophage without Iγ to be t1P/2 = 0.375 day (9 h).
5
Then
We assume that the mass density of DC is smaller than that of M0 ,
1
P ( 0 ) = P ( 0 ) e − μP t 1 / 2 ,
P
and we take
2
1
D0 = M0 = 1.5 × 10−4 g/ml. (3.23) which implies that
10
ln 2 0.693
The immunological and functional aspects of macrophages, T cells μP = = = 1.85 per day.
and dendritic cells in human are similar to those in mice
P
t1/2 0.375
[43,79,80]. We therefore assume that the density of macrophages,
We take the death rate μP1 of Leishmania in macrophage M1 to be
T cells and dendritic cells in the human liver are as given in
equal to μP . Because the parasite load in macrophage M2 is larger
(3.21), (3.22) and (3.23), respectively. Note that this density of
than the parasite load in M1 , the death rate μP2 of Leishmania in
macrophages is consistent with the density of macrophages in the
M2 , is larger than the death rate μP1 [29,44]; we take
human lung (where tissue + air makes up the lung volume) which
is 10−3 g/ml [41]. μP2 = 1.2μP = 2.22 per day.
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43
Fig. 2. Sensitivity of the total number of Leishmania parasites, after 150 days of infection, to changes in parameters in the leishmaniasis model (2.1)–(2.18) as computed by
the Latin hypercube sampling–Partial rank correlation coefficient (LHS–BIB83) index. The horizontal axis lists the parameters that were used for the analysis, and the vertical
axis scales the BIB83 index. All the values for the parameters ranged between half to twice of their current values in Table 2. The most sensitive parameters are AM which is
positively correlated, and λγ which is negatively correlated. The p-Values for AM , α 1 , α 2 and λγ are less than 0.03, and the p-Values for all other variables are less than 0.1.
3.2. Initial conditions
We take the initial conditions to be the healthy state of the
host, that is, the state without Leishmania infection.
Setting P = 0 in the steady state of Eqs. (2.11)–(2.18), and con-
sidering the values of M and T at healthy state in Eqs. (3.21) and
(3.22), we obtain the following values:
M (0 ) = M0 = 1.5 × 10−3 g/ml, D(0 ) = 0 g/ml, T (0 ) = 10−3 g/ml,
I2 (0 ) = 3.5 × 10−10 g/ml, I10 (0 ) = 1.16 × 10−8 g/ml, I12 (0 )
= 1.5 × 10−6 g/ml,
Iγ (0 ) = 6.06 × 10−11 g/ml.
The number of parasites inoculated in the host skin by one vector
can vary between 10 and 10 0,0 0 0 [81,82]. We will first consider
the case where the sand fly bite injects 5 × 103 parasites into the
host, then the case where it injects 10 × 103 parasites.
3.3. Sensitivity analysis
In order to identify critical parameters of the model and quan-
tify how these parameters’ uncertainty impact model outcome, we
performed a local sensitivity analysis. The parameters in this analy-
sis were chosen either because they seem to be most influential on
the progression of the infection, or because their estimation was
rather crude. The computations were done using a Matlab pack-
age by Kirschner et al. [83,84], with the 18 parameters indicated in
Table 2. All the values for the parameters ranged between half to
twice of their current values in Table 2.
Fig. 2 shows the sensitivity of the number of Leishmania para-
sites after 150 days of infection to changes in the 18 parameters in
the leishmaniasis model (2.1)–(2.18). The p-Values for AM , α 1 , α 2
and λγ were less than 0.03, and the p-Values for all other vari-
ables were less than 0.1 The most positively correlated parameter
is AM , while the most negatively correlated parameter is λγ .
AM is the basal rate of production of tissue macrophages in
steady state and it represents the primary source for the re-
cruitment of new macrophages into the disease host system; it
depends on the rate of monocyte output from the bone mar-
row and the generation of monocytes in the spleen. These new
macrophages are assumed to enter the system through the M1
compartment (Eq. (2.1)). M1 macrophages eventually become the
35
dominant macrophages, together with the (P1 ) parasites within,
as residuals. Hence increasing AM favors Leishmania infection the
most. The parameters α 1 and α 2 are also highly positively corre-
lated; they represent the replication rates of Leishmania parasites
within M1 macrophages and M2 macrophages, respectively. Hence
that the severity of the disease increases with the aggressiveness
of the parasites.
On the other hand, λγ , the rate of secretion of IFN-γ by T cells
(Eq. (2.10)), is the most negatively correlated because IFN-γ en-
hances the killing of parasites within M1 macrophages. The p-Value
for the sensitivity of λγ is less than 0.03. Hence increasing λγ re-
(3.24) duces Leishmania infection at day 150 the most. This suggests that
a possible drug for leishmaniasis should enhance the production
of IFN-γ , either by acting on IFN-γ directly, or by promoting the
proliferation of T cells which produce IFN-γ .
4. Simulations and results
In this section, we first simulate our model. Then, to validate
our model, we compare our findings with experimental results of
Jain et al. [28].
4.1. Simulations
All the computations were done using Python 2.7.6. As stated
above, we take the mass of 1 macrophage to be (1/5 ) × 10−9 g,
and the mass of 1 Leishmania parasite to be (1/150 ) × (1/5 ) ×
10−9 g, while the simulations were done in picogram (i.e., 10−12 g).
However, the results are displayed in terms of the number of cells
and parasites. The parameters are taken from Table 2, and the ini-
tial conditions from (3.24).
At day 3, we divide the macrophages into
M (3 ) 3M ( 3 )
M1 ( 3 ) = , M2 ( 3 ) = ; (4.25)
4 4
and correspondingly
P (3 ) 3P ( 3 )
P1 (3 ) = , P2 (3 ) = . (4.26)
4 4
36 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43
Fig. 3. Simulations of System Eqs. (2.1)–(2.18) under the initial conditions (3.24) and the assumptions (4.25)–(4.26) with P (0 ) = 5 × 103 parasites (or 6.67 × 10−9 g/ml).
Leishmania parasites P1 and P2 increase monotonically with an “S” shape to a maximum of approximately 17 × 106 and 2 × 106 in 150 days, respectively.
4.2. Leishmaniasis when P (0 ) = 5 × 103 parasites
The number of parasites inoculated in the host skin by one vec-
tor can vary between 500 and 10 0,0 0 0 [81,82]. We first consider
the case where the sand fly bite injects 5 × 103 parasites into the
host.
Fig. 3 displays the dynamics of parasites P1 and P2 for a period
of 150 days. We see that Leishmania parasites P1 increase mono-
tonically with an “S” shape to a maximum of approximately 17 ×
106 /ml after 150 days of infection, while at the same time P2 in-
crease monotonically with an “S” shape to a maximum of approx-
imately 2 × 106 /ml.
Fig. 4 shows the dynamics of macrophages M1 and M2 for a pe-
riod of 150 days. We see that the M2 are initially dominant, then
at day 15, the M1 take over, and the M2 decrease while the M1 in-
crease and the total number of macrophages, M1 + M2 , eventually
stabilize as residual macrophages to approximately the same initial
number.
From Figs. 3 and 4, we deduce that, at least after about two
months of infection, P1 /M1 is larger than P2 /M2 . This is probably
due to the fact that M2 undergoes frequent bursting, and it sug-
gests that P1 eventually remains predominant as residuals.
4.3. Leishmaniasis when P (0 ) = 10 × 103 parasites
The simulations shown in Figs. 3 and 4 do not qualitatively
change if the initial injection of parasites is taken to be smaller or
larger than 50 0 0, while it remains within the biologically relevant
range of 50 0–10 0,0 0 0 parasites. We illustrate this in Figs. 5 and 6
by considering the case with initial injection P (0 ) = 10 × 103 para-
sites. We note that the disease dynamics in Figs. 5 and 6 is faster
than in the case of Figs. 3 and 4. In particular, for any fixed time,
the ratio (P1 + P2 )/(M1 + M2 ) deduced from Figs. 5 and 6 is larger
than the same ratio corresponding to Figs. 3 and 4. This is also true
of the ratio P1 /M1 .
4.4. Model validation
There are no longitudinal data on the growth of Leismania par-
asites in human liver; such data could only be obtained by biopsy,
which cannot be frequently repeated. But we can compare our
model simulations with in vitro experimental results with human
cells infected with Leishmania donovani. Experimental results by
Jain et al. [28] show that there exists a homogenous correlation
between the total number of Leishmania parasites per macrophage,
at early time of infection, and the initial load of parasites. Through
a well-documented in vitro procedure, Jain et al. [28] infected hu-
man acute monocytic leukemia cells (alternative for macrophages)
with different initial loads of Leishmania donovani within a cat-
alyzed environment, and then recorded the number of parasites
per macrophage after 5–6 days of infection.
They initially injected Leishmania parasites at respective Par-
asites/Macrophages ratios of 1.25:1, 2.5:1, 5:1 and 10:1, and
recorded the number of Leishmania parasites per 100 macrophages.
They found that by doubling the initial load of parasites, the total
number of parasites per macrophage had doubled.
In Fig. 7, we show simulations of our model where we plot-
ted the correlation between the total number of parasites per
macrophage as a function of the initial load of parasites, for six
different loads and 12 different time points. We injected 5 ×
103 , 10 × 103 , 15 × 103 , 20 × 103 , 25 × 103 and 30 × 103 Leish-
mania parasites and marked the ratios of Leishmania/Macrophages
at days 12.5, 25, 37.5, 50, 62.5, 75, 87.5, 100, 112.5, 125, 137.5 and
150.
The simulations show a linear dependence between the ratio
P/M of Leishmania/Macrophages and different initial loads of para-
sites, for small time interval, as in Jain et al. [28]. However, as time
increases, the relation between the ratio Leishmania/Macrophages
and the initial loads of parasites becomes nonlinear. Furthermore,
after 150 days, this ratio is independent of the initial infection, pro-
vided the infection is large enough (e.g., larger than 5 × 103 /ml).
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 37

Fig. 4. Simulations of System Eqs. (2.1)–(2.18) under the initial conditions (3.24) and the assumptions (4.25)–(4.26) with P (0 ) = 5 × 103 parasites (or 6.67 × 10−9 g/ml).
Macrophages M2 decrease to less than 2 × 106 cells while macrophages M1 increase to about 7.5 × 106 cells. The total number of macrophages stabilize at essentially the
same number as the initial number.

Fig. 5. Simulations of System Eqs. (2.1)–(2.18) under the initial conditions (3.24) and the assumptions (4.25)–(4.26) with P (0 ) = 10 × 103 parasites (or 13.33 × 10−9 g/ml).
Leishmania parasites P1 and P2 increase monotonically with an “S” shape to approximately about 17 × 106 and 2 × 106 in 150 days, respectively. Note that the dynamics of
the parasites is faster than in the case of infection with 5 × 103 parasites (Fig. 3).
38 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43

Fig. 6. Simulations of System Eqs. (2.1)–(2.18) under the initial conditions (3.24) and the assumptions (4.25)–(4.26) with P (0 ) = 10 × 103 parasites (or 13.33 × 10−9 g/ml).
Macrophages M2 decrease less than 2 × 106 cells while macrophages M1 increase to about 7.5 × 106 cells. The total number of macrophages stabilize at essentially the same
number as the initial number.

Fig. 7. Simulations of the model at different days of infection. The horizontal axis scales the initial loads of parasites and the vertical axis scales the ratio (number of
parasites)/(number of macrophages). The model shows an increasing linear correlation between the number of parasites per macrophage and the initial loads of parasites
when the time of counting is small enough, and a constant correlation when the time of counting is large enough.
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 39

Fig. 8. Simulation of the model with treatment. The horizontal axis scales the time in days and the vertical axis scales the number of Leishmania parasites in unit of 106 .
The initial conditions are given in (3.24) with P (0 ) = 5 × 103 parasites. We applied the drug (SAG) so that the proliferation of T cells is enhanced as in Eq. (5.29), and studied
the efficacy of treatment at day 60 of infection; efficacy is measured by computing the relative difference between the number of Leishmania parasites without and with
treatment. The number of parasites at day 60 is reduced by approximately 27.30% when the drug is given within the first 30 days of infection.

Fig. 9. Simulation of the model with treatment. The horizontal axis scales the time in days and the vertical axis scales the number of Leishmania parasites. The initial
conditions are given in (3.24) with P (0 ) = 5 × 103 parasites. We applied the same amount of drug (SAG) for 30 days as in Eq. (5.29) so that the proliferation of T cells is
enhanced, starting the treatment at each time a bit later; we also studied the efficacy of the treatment at day 60 of infection. The efficacy is measured by computing the
relative difference between the number of Leishmania parasites without and with treatment. The number of parasites at day 60 was reduced by approximately (A) 48.95%
for the time period 3.5–32.5 days, (B) 12.21% for 10.5–39.5 days, (C) 1.17% for 22.5–51.5 days, and (D) 0.11% for 31–60 days.
40 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43

Fig. 10. Simulation of the model with treatment. The horizontal axis scales the time in days and the vertical axis scales the number of Leishmania parasites. The initial
conditions are given in (3.24) with P (0 ) = 5 × 103 parasites. We applied twice the amount of drug (SAG) so that the proliferation of T cells is doubly enhanced as compared
to Eq. (5.29), that is 0.96, for half the treatment period (15 days), and studied the efficacy of the treatment at day 60 of infection. The efficacy is measured by computing the
relative difference between the number of Leishmania parasites without and with treatment. The number of parasites at day 60 was reduced by approximately (A) 82.26%
for the time period 1–15 days, (B) 89.39% for 10.5–24.5 days, (C) 9.96% for 22.5–36.5 days, and (D) 1.02% for 34.5–48.5 days.

5. Leishmaniasis therapy We fix a terminal time t = 60 days and define the efficacy of the
drug as follows:
The mathematical model can be used to evaluate the efficacy
of a drug for the treatment of VL. We take, for illustration, the (P1 + P2 )no drug (60 ) − (P1 + P2 )drug (60 )
E f f icacy = × (100% );
drug SAG (Sodium Antimony Gluconate) which enhances antileish- (P1 + P2 )no drug (60 )
manial T cells proliferation and response [85]. In our model this is (5.30)
represented as a source term in Eqs. (2.6) and (2.14), which then
take the form note that the efficacy varies between 0% and 100%.
The results described below remain qualitatively the same if we
dT D I M I
= λDT T0 12
+ λMT T0
12 take different terminal times.
dt KD + D I12 + c12 KM + M I12 + c12 Fig. 8 shows the simulations of the model with and without
     
DC activation MHC activation treatment, from which we deduce, in particular, that the efficacy
I2 of the drug is 27.30%.
+ kT T − μT T + cT (t )T , (5.27) We next consider several different protocols for treatment. The
I2 + c2    
   decay source term first case is when instead of starting the treatment (5.29) at t = 0,
I2 –induced proliferation of T cells we start it at some later time t1 :
during the first three days of infection, and 
0.48, if t1 ≤ t ≤ t1 + (30 − 1 )
cT (t ) = (5.31)
dT D I12 M1 + M2 I12 0, if t < t1 or t1 + (30 − 1 ) < t ≤ 60.
= λDT T0 + λMT T0
dt KD + D I12 + c12 KM + (M1 + M2 ) I12 + c12
      From Figs. 8 and 9, we see that it is better not to start the treat-
DC activation MHC activation
ment too early (i.e., t1 = 3.5 is a better choice than t1 = 0) and not
I2
+ kT T − μT T + cT (t )T , (5.28) too late (i.e., t1 = 3.5 is better than t1 = 10.5, 22.5, or 31). Our
I2 + c2    
   death source term
model shows that treating an infected host with the drug leads to
I2 –induced proliferation of T cells fewer parasites in the host system. However, it is much better not
to start treatment too early because, at very early stage of the in-
after the first three days, where the effect of the drug is repre- fection, the macrophages have not yet been polarized; that is, they
sented by the source term cT (t)T. do not express microenvironmental signals due to infection. As a
The initial conditions are given in (3.24) with P (0 ) = 5 × 103 result, the immune system (which includes T cells) has not been
parasites, and the parameters are as in Table 2. We first consider alerted yet. Hence, the drug, SAG, which enhances the proliferation
the case where the drug, at a given amount, is administered for of T cells will not be very effective. The reason why we should not
the first 30 days of infection. For illustration, we take the intrinsic wait too long to start treatment is that, during this long wait, par-
rate of proliferation of T cells due to the drug to be: asites will have multiplied so much that the effect of drug will be
 diminished.
0.48, if 0 ≤ t ≤ 30
cT (t ) = (5.29) It is natural to ask whether treatment can be improved if
0, if 30 < t ≤ 60. we double the amount of drug and reduce by half the time of
 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43 41

Fig. 11. Efficacy of treatment as a function of the drug (SAG) effects. The horizontal axis scales the effect of the drug in per day and the vertical axis scales the relative
efficacy of treatment with SAG. We took the initial conditions as in (3.24) with P (0 ) = 5 × 103 parasites. We fixed the amount of drug as in Fig. 10 and considered the
treatment period to be the 15–days interval 10.5–24.5. The efficacy of the drug increases like an “S”-shaped curve that stabilizes at 100% when η > 1.0.

treatment. The corresponding protocol is then given by
 sults:
0.96, if t1 ≤ t ≤ t1 + (15 − 1 )
cT (t ) =
0, if t < t1 or t1 + (15 − 1 ) < t ≤ 60.
Fig. 10 illustrates the dynamics of the parasites for t1 =
1, 10.5, 22.5, and 34.5, from which we deduce the corresponding
efficacies. We see, as before, that it is better to start the treatment
not too early and not too late. At the same time, by comparing
Fig. 10 with Figs. 8 and 9, we see that protocol (5.32) (with dou-
ble amount of drug over half the treatment time) is better than
protocol (5.31).
We also found (not shown here) that, given a fixed total amount
of the drug, intermittent treatment of leishmaniasis with SAG is
not as effective as continuous treatment.
We next consider the optimal protocol (Fig. 10(B)) with variable
amounts of drug:

η, if 10.5 ≤ t ≤ 24.5
cT (t ) =
0, if 0 ≤ t < 10.5 and 24.5 < t < 60,
for general η > 0.
Fig. 11 shows the efficacy of treatment as a function of the (ef-
fect of) drug, η. We see that the efficacy first increases slowly with
η, then begins to increase sharply around η = 0.9, before it stabi-
lizes at 100% when η = 1.0
6. Discussion and conclusion
There are no longitudinal data on the growth of Leismania par-
asites in human liver; such data could only be obtained by biopsy,
which cannot be frequently repeated. For this reason, we devel-
oped in this paper a mathematical model for leishmaniasis (with
focus on visceral leishmaniasis) that can be used to monitor the
efficacy of treatment of the disease. The model simulations are
shown to agree with in vitro experimental results with human
cells infected with Leishmania donovani [28]. The model included
macrophages M1 and M2 (and the parasites within), dendritic cells,
T cells and a number of cytokines. We obtained the following re-
(5.32)
1. Increasing the basal rate of recruitment of macrophages, AM ,
greatly favors Leishmania infection, while increasing the rate of
production of IFN-γ , λγ , greatly reduces Leishmania infection.
2. There is a linear correlation between the ratio Leishma-
nia/macrophages across different amounts of infection and dif-
ferent periods of time during the early stage of infection. This
is in agreement with in vitro experimental results by Jain et al.
[28]; at later times, the correlation is nonlinear as illustrated in
Fig. 7.
3. A drug which promotes the proliferation of T cells (and hence
the production of IFN-γ ) will effectively reduce the growth of
leishmaniasis.
4. When the drug is administered over a fixed period of time, at
fixed amount, it is better to give it not too early and not too
late.
(5.33) 5. As shown in Figs. 8–10, by doubling the amount of drug and
correspondingly shortening the period of treatment (keeping
the total drug fixed) we may get better results in reducing the
infection [negative side effects are ignored].
6. If we fix the period of treatment but keep increasing the
amount of drug, η, the efficacy of the treatment increases like
an “S”-shaped curve, and becomes 100% if η > 1.0. Since hu-
mans cannot fully recover from the disease (even when treated
with Sodium Antimony Gluconate (SAG)), it follows that the
maximum tolerated dose (MTD) is below η = 1.0.
The above conclusions, however, need to be verified experimen-
tally and clinically.
The mathematical model developed in this paper for visceral
leishmaniasis is generic in the sense that it can be applied to dif-
ferent infected organs by simply adjusting some of the parameters.
However, in developing the model, we have made significant sim-
plifications:
(i) We lumped together T4 and T8 cells.
42 N. Siewe et al. / Mathematical Biosciences 276 (2016) 28–43
(ii) We did not take into account time delays between cellu-
lar infection and production of new parasites that can affect
other cells; these delays should be included in the ODE sys-
tem, especially in the early phase of the infection.
(iii) We did not address the possibility of small parasite density,
in which case random movement and possible extinction of
parasites should be taken into account.
Despite these simplifications, our simplified model results, for
small time intervals, are in agreement with in vitro experimental
results of Jain et al. [28]. The present model should be viewed only
as a first step toward predicting the course of the disease and its
treatment. The hallmark of visceral leishmaniasis is the formation
of granulomas in the liver or the spleen whereby the host immune
response tries to contain the infection [86]. Mathematical modeling
of such granulomas will require extension of the system of differ-
ential Eqs. (2.1)–(2.18) to a spatial model, for instance, to a system
of partial differential equations.
Acknowledgments
This research was supported by the Mathematical Biosciences
Institute of The Ohio State University. Nourridine Siewe and Abdul-
Aziz Yakubu were partially supported by DHS Center Of Excellence
for Command, Control and Interoperability at Rutgers University.
Abhay R Satoskar was partially supported by Grant W81XWH-14-
2-0168 from US Army Medical Res Acquisition Activity. We also
thank the reviewers for their comments and suggestions.
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