Blood 122:842C851. study was to provide such data. We used an enzyme-linked immunosorbent assay (ELISA) to measure DBL-specific IgG in plasma from Ghanaian children with malaria. The ability of human immune plasma bHLHb38 and DBL-specific rat antisera to inhibit the interaction between ICAM-1 and DBL was assessed using ELISA and assays of IE adhesion under flow. The acquisition of DBL_motif-specific IgG coincided with age-specific susceptibility to CM. Broadly cross-reactive antibodies inhibiting the interaction between ICAM-1 and DBL_motif domains were detectable in immune plasma and in sera of rats immunized with specific DBL_motif antigens. Importantly, antibodies against the DBL_motif inhibited ICAM-1-specific adhesion of erythrocytes infected by four of five isolates from cerebral malaria patients. We conclude that natural exposure to as well as immunization with specific DBL_motif antigens can induce cross-reactive antibodies that inhibit the interaction between ICAM-1 and a broad range of DBL_motif domains. These findings raise hope that a vaccine designed specifically to prevent CM is feasible. KEYWORDS: DBL cross-reactive antibodies, ICAM-1-binding motif, PfEMP1, is the major cause of the estimated 430,000 deaths due to malaria that are reported annually (1). The pathogenesis of is linked to sequestration of infected erythrocytes (IEs) in various tissues, which can lead to tissue-specific inflammation, circulatory obstruction, and organ dysfunction (reviewed in reference 2). IE sequestration is mediated by members of the erythrocyte membrane protein 1 (PfEMP1) family. These proteins are encoded by approximately 60 genes per genome and are expressed on the IE surface, where they bind to a range of host receptors (reviewed in reference 3). Despite extensive inter- and intraclonal diversity, the PfEMP1 proteins can be classified into three major groups (A, B, and C), based on gene sequence and chromosomal context (4, 5). Group A is less diverse than the other groups, and expression of group A PfEMP1 proteins on the IE surface has repeatedly been linked to the development of severe malaria (6, 7). This is consistent with the restricted serological diversity of parasites from patients with severe malaria (8, 9). It also fits the observation that acquisition of immunity to complicated disease often precedes development of protection from uncomplicated malaria and asymptomatic parasitemia and that PfEMP1 expression is modulated by PfEMP1-specific immunity (10,C12). More recently, the PfEMP1 groups have been further subdivided according to their constituent Duffy-binding-like (DBL) and cysteine-rich interdomain region (CIDR) domains, and a number of multidomain blocks, known as domain cassettes (DCs), have been identified (13,C16). Three of these, DC4, DC8, and DC13, have been linked to severe malaria in children (6, 14, 17, 18). DC4 consists of three domains (DBL1.1/1.4, CIDR1.6, and DBL3) and defines a subfamily of group A PfEMP1 proteins that mediates binding to intercellular adhesion Norfloxacin (Norxacin) molecule 1 (ICAM-1) (15). IE adhesion to ICAM-1 appears associated with severe malaria, implicating DC4-specific antibodies in clinical protection, as they are acquired early in life by children living in areas where malaria is endemic and are associated with clinical protection from malaria (6, 15, 19). However, until recently, the role of IE adhesion to ICAM-1 specifically in CM has been unclear (20,C24). DC8 consists of four domains (DBL2, CIDR1.1, DBL12, and DBL4/6) Norfloxacin (Norxacin) and is found among group B/A genes, while the two-domain (DBL1.7, CIDR1.4) DC13 is found in some group A PfEMP1 proteins (14). Endothelial protein receptor C (EPCR) is the cognate receptor for DC8- and DC13-containing PfEMP1 proteins (25). Some studies have reported high transcript levels of genes encoding EPCR-binding PfEMP1 variants in parasites from children with severe malaria, including CM, and perturbed EPCR expression in brain tissue of CM patients (26,C28). While these findings point to a role for EPCR in Norfloxacin (Norxacin) severe malaria in general, and cerebral malaria (CM) in particular, the available evidence overall remains equivocal (29,C31). We have previously proposed that the above ambiguities may reflect that the pathogenesis of CM involves parasites expressing PfEMP1 capable of mediating IE adhesion to both ICAM-1 (via DBL) and EPCR (via CIDR1) (3). A few such dual receptor-binding PfEMP1 proteins were identified shortly after, although the study did not link them to CM specifically and did not document concomitant binding to both receptors (32). However, those gaps were recently closed by our demonstration of a link between CM and.