Hycanthone resistance in a human strain of Schistosoma mansoni

Praziquantel for Schistosomiasis: Single-Drug Metabolism Revisited, Mode of Action, and Resistance

Schistosomiasis, a major neglected tropical disease, affects more than 250 million people worldwide. Treatment of schistosomiasis has relied on the anthelmintic drug praziquantel (PZQ) for more than a generation. PZQ is the drug of choice for the treatment of schistosomiasis; it is effective against all major forms of schistosomiasis, although it is less active against juvenile than mature parasites. A pyrazino-isoquinoline derivative, PZQ is not considered to be toxic and generally causes few or transient, mild side effects. Increasingly, mass drug administration targeting populations in sub-Saharan Africa where schistosomiasis is endemic has led to the appearance of reduced efficacy of PZQ, which portends the selection of drug-resistant forms of these pathogens. The synthesis of improved derivatives of PZQ is attracting attention, e.g., in the (i) synthesis of drug analogues, (ii) rational design of pharmacophores, and (iii) discovery of new compounds from large-scale screening programs. This article reviews reports from the 1970s to the present on the metabolism and mechanism of action of PZQ and its derivatives against schistosomes.

Susceptibility or resistance of praziquantel in human schistosomiasis: a review

Since praziquantel was developed in 1970s, it has replaced other antischistosomal drugs to become the only drug of choice for treatment of human schistosomiases, due to high efficacy, excellent tolerability, few and transient side effects, simple administration, and competitive cost. Praziquantel-based chemotherapy has been involved in the global control strategy of the disease and led to the control strategy shifting from disease control to morbidity control, which has greatly reduced the prevalence and intensity of infections. Given that the drug has been widely used for morbidity control in endemic areas for more than three decades, the emergence of resistance of Schistosoma to praziquantel under drug selection pressure has been paid much attention. It is possible to induce resistance of Schistosoma mansoni and Schistosoma japonicum to praziquantel in mice under laboratorial conditions, and a reduced susceptibility to praziquantel in the field isolates of S. mansoni has been found in many foci. In addition, there are several schistosomiasis cases caused by Schistosoma haematobium infections in which repeated standard treatment fails to clear the infection. However, in the absence of exact mechanisms of action of praziquantel, the mechanisms of drug resistance in schistosomes remain unclear. The present review mainly demonstrates the evidence of drug resistance in the laboratory and field and the mechanism of praziquantel resistance and proposes some strategies for control of praziquantel resistance in schistosomes.

Drug resistance in schistosomes

Drug resistance in schistosomes is confined essentially to compounds of the hyconthone/oxamniquine family, since no documented case of resistance has so far been reported for the widely used drug praziquantel. The availability of strains of Schistosoma mansoni that are resistant to hyconthone and oxomniquine has permitted a detailed genetic and biochemical study of the mechanism of action of these compounds. Drugs must be activated by enzymatic esterification and this ultimately results in the production of an electrophilic moiety capable of alkylating DNA and other parasite macromolecules. As reviewed here by Donato Cioli, Livia Pica-Mattoccia and Sydney Archer, resistance is due to the loss of a drug-activating enzyme that is present in sensitive schistosomes and absent in resistant worms and in the mammalian hosts. Further study of this enzyme may yield valuable clues for drug design and for a basic understanding of parasite metabolism.

In vitro responses of praziquantel-resistant and -susceptible Schistosoma mansoni to praziquantel

The resistance status of five praziquantel-susceptible and five praziquantel-resistant isolates was confirmed by chemotherapy in CD(1) mice with 3 x 200mg/kg micronised praziquantel. Micronised praziquantel had higher efficacy than two other praziquantel formulations (prepared without milling). The five resistant isolates were less responsive to praziquantel than the five susceptible isolates (59-74% reduction in worm burden in resistant isolates compared with 92-100% in susceptible isolates). Observations were made on the in vitro responses of different stages of 10 isolates to praziquantel. There were different in vitro responses to praziquantel at the egg, miracidial, cercarial and adult stages of Schistosoma mansoni between praziquantel-resistant and praziquantel-susceptible isolates. There were differences in the response of resistant and susceptible isolates following exposure of freshly hatched miracidia to 10(-6)M praziquantel for 1 min and observing the percent change in shape. Using this test it should be possible to determine whether failed therapy in patients infected with S. mansoni is due to the presence of praziquantel-resistant worms. Similarly, by exposing freshly shed cercariae to 4 x 10(-7)M praziquantel and observing the percent of tail shedding over 80 min it should be possible to monitor for the presence of praziquantel-resistant worms in snails collected in the field.

Resistance to oxamniquine of a Schistosoma mansoni strain isolated from patient submitted to repeated treatments

A strain of Schistosoma mansoni (R1) was isolated from patient previously submitted to four treatments with oxamniquine, and to another one with praziquantel. The results obtained with chemotherapeutic test, by using oxamniquine in mice infected with the strains R1 and LE (standard), showed an evident resistance to the drug in worms of the strain R1. Thus, at the dose of 250 mg/kg oxamniquine, all mice (17) infected with the LE strain did not show surviving worms, whereas 12 out of 17 mice infected with the R1 strain presented surviving worms. At the dose of 200 mg/kg, the LE strain showed recovery rates of 1.06% and 20.58%, whereas the R1 strain presented 18.57% and 61.14%, for male and female worms, respectively. At the dose of 100 mg/kg, the recovery of male worms was 2.6% for the LE strain, and 29.9% for the R1 strain. At the same dose, the recovery of females did not show statistically significant differences between the two strains (LE = 76.38%, R1 = 79.12%). Praziquantel showed similar antischistosomal activity against both studied strains, when administered at the dose of 500 mg/kg.

Antischistosomal drugs: past, present ... and future?

The major antischistosomal drugs that have been or still are in use against infections with schistosomes are considered here together with some compounds that have not been in clinical use, but show interesting characteristics. Each individual compound presents aspects that may be enlightening about parasite biochemistry, parasite biology, and host-parasite relationships. Special attention is given to the mechanisms of action, an understanding of which is seen here as a major factor of progress in chemotherapy. Three compounds are currently in use, i.e., metrifonate, oxamniquine, and praziquantel, and all three are included in the World Health Organization list of essential drugs. They are analyzed in some detail, as each one presents advantages and disadvantages in antischistosomal therapy. The reported occurrence of drug-resistant schistosomes after treatment with oxamniquine and praziquantel suggests strict monitoring of such phenomena and encourages renewed efforts toward the development of multiple drugs against this human parasite.

Drug resistance to schistosomicides and other anthelmintics of medical significance

It is usual for people to be infected for some period in life with parasitic worms, which may cause morbidity or even kill. Anthelmintics are used for the treatment and control of the human helminthiases, since no vaccines are yet available. Despite the widespread use of these compounds, drug resistance has become apparent only with antischistosomal chemotherapy, in contrast to the situation with other anti-infective agents in human medicine and with veterinary anthelmintics, where resistance is widespread. This paper reviews research on drug resistance in human helminthiasis with emphasis on schistosomicidal drugs.

Hycanthone resistance in schistosomes correlates with the lack of an enzymatic activity which produces the covalent binding of hycanthone to parasite macromolecules

Crude extracts of hycanthone sensitive Schistosoma mansoni incubated at 37 degrees C in the presence of ATP and Mg2+ induced the covalent binding of tritiated hycanthone (HC) to macromolecules. The same behavior was shown by the HC sensitive species, Schistosoma rodhaini, whereas two independently isolated HC resistant S. mansoni strains had no detectable activity. Sensitive male schistosomes had more activity than females or immature worms. Virtually no activity was present in mouse liver, in human liver, in HeLa cells or in the naturally resistant species Schistosoma japonicum. The activity was destroyed by boiling or by Proteinase K treatment. Covalent binding of tritiated HC to macromolecules could be inhibited by cold HC, oxamniquine or IA-4, while none of the in vitro ineffective analogs, like lucanthone, UK-3883 or 4-desmethyl lucanthone, were inhibitory. These results strongly support the previously advanced suggestion that HC is activated by enzymatic mechanisms which are present only in drug sensitive schistosomes.

Parasitic infection and autoimmunity

The studies summarized in this paper indicate that parasitic infections can serve as a trigger factor of autoimmune reactivity by several mechanisms. The relationship between parasites and autoimmunity could be manifested by the presence of autoantibodies or T-cells with autoreactivity. In spite of the evidence that has accumulated, the specific association between infection and autoimmunity is still obscure. The reasons for tissue damage in parasitic diseases are controversial. Some believe it is the result of pathogenic autoantibodies or autoreactive T-cells. Others argue against the causative role of autoimmunity in the formation of tissue lesions. The parasite itself could be the cause of tissue destruction, thus releasing high amounts of self antigens which might stimulate the autoreactivity. There is now little doubt that some degree parasite/host cross-reactivity occurs, and definition of cross-reacting antigens and epitopes is now taking place. It seems likely that a combination of events could result in cross-reactivity including: parasites themselves have cross reactive molecules and altered self antigens by adsorbing of parasite material to surrounding host cells. The mechanisms involved in parasites autoimmunity are complex and numerous, requiring a rigorous experimental approach to rationalize each step and determine its clinical importance. The developed methods in immunochemistry, monoclonal antibodies and hybridoma technology, and recombinant DNA research not only facilitate this kind of approach but also allow optimism for a successful outcome.

Tolerance of Kenyan Schistosoma mansoni to oxamniquine

Although 30 mg/kg oxamniquine produced high levels (85.5 to 99.5%) of egg reduction in Kenyan children infected with Schistosoma mansoni after a single oral treatment, cure rates from children at Mwea in Kirinyaga district were lower than those from Machakos (58% v. 74%). Redosing uncured children confirmed this lower cure rate (36% v. 83%). Isolates from infected children were passaged into mice and dosed with oxamniquine. Lower than expected reductions in worm numbers were obtained, suggesting that oxaminiquine tolerant S. mansoni are present in the normal worm population in Kenya. It is concluded that mass use of oxamniquine at 30 mg/kg may produce problems of drug resistance.

[Behavior of Schistosoma mansoni strain LE, after passage through an accidentally infected human host]

Uma auxiliar de laboratório infectou-se acidentalmente, com cercárias de Schistosoma mansoni, cepa LE, mantida rotineiramente em nossos laboratórios. Decorridos 5 meses, o exame parasitológico de fezes revelou 108 ovos/g . A pacientefoi tratada com oxamniquine, porém a infecção continuou ativa (6 ovos/g). Foi então obtido o isolado SSF mantido no modelo Biomphalaria glabrata - camundongo albino. Os resultados obtidos no estudo comparativo, entre o isolado SSF e a cepa LE, que lhe deu origem, mostraram que a duração do período pré-patente e o índice de infectividade em camundongos, bem como a resposta aos agentes esquistossomicidas (hycanthone, oxamniquine epraziquantel) não apresentaram diferenças estatisticamente significativas. Por outro lado, o número de miracídios obtidos dos intestinos e fígados dos camundongos infectados foi o dobro com a cepa LE, quando comparados com aquele do isolado SSF. Também a variação do peso dos animais foi bastante diferente. Concluiu-se que apenas uma passagem pelo hospedeiro humano não mudou substancialmente as características da cepa estudada.

Failure at inducing resistance to schistosomicidal drugs in a Brazilian human strain of Schistosoma mansoni

No presente estudo, realizou-se uma tentativa de indução de resistência a 3 drogas esquistossomicidas em uma cepa brasileira de S. mansoni, segundo o esquema de indução de resistência tipo II preconizado por JANSMA et al. em 1977. Houve insucesso nas 3 tentativas realizadas. A geração parental tratada com a droga durante o estágio imaturo do verme mostrou-se menos suscetível aos quimioterápicos do que as gerações F1 e F2 do verme. Uma hipótese é levantada para a explicação do fato.

Treatment of patients with schistosomiasis mansoni: a double blind clinical trial comparing praziquantel with oxamniquine

A double-blind clinical trial involving 120 patients with chronic schistosomiasis was carried out to compare the tolerability and efficacy of praziquantel and oxamniquine. The patients were randomly allocated into two groups. One was treated with praziquantel, 55 mg/kg of body weight CBWT), and the other one with oxamniquine, 15mg/kg bwt, administered in a single oral dose. The diagnosis and the parasitological follow-up was based on stool examinations by quantitative Kato-Katz method and on rectal biopsies. Side-effects — mainly dizziness, sleepness, abdominal distress, headache, nausea and diarrhea — were observed in 87% of the cases. Their incidence, intensity and duration were similar for both drugs but abdominal pain was significantly more frequent after praziquantel intake and severe dizziness was more commonly reported after oxamniquine. A significant increase of alanine-aminotransferase and y-glutamyltransferase was found with the latter drug and of total bilirubin with the former one. A total of 48 patients treated with praziquantel and 46 with oxamniquine completed with negative findings the required three post-treatment parasitological controls — three slides of each stool sample on the first, third and sixth month. The achieved cure rates were 79.2% and 84.8%, respectively, a difference without statistical significance. The non-cured cases showed a mean reduction in the number of eggs per gram of feces of 93.5% after praziquantel and of 84.1% after oxamniquine. This diference also was not significant. Five patients retreated with praziquantel were cured but only one out of three treated a second time with oxamniquine. These findings show that both drugs — despite their different chemical structures, pharmacological properties and mechanisms-of-action — induce similar side-effects as well as a comparable therapeutical efficacy, in agreement with the results reported from analogous investigations.

Stability of Schistosoma mansoni progeny to antischistosomal drugs

The susceptibility of the MAP Brazilian strain (F1 to F5 progenies) of S. mansoni to four antischistosomal drugs has been reported in a previous study. In the present investigation, progeny F14 of the same strain, was tested for stability to the same 4 drugs. A new medication, Oltipraz (35,972 RP), was added to the study. Five groups of 12 mice infected with cercariae by tail immersion were treated with hycanthone, oxamniquine, niridazole, praziquantel and Oltipraz. An untreated group was used as control. Schistosomal activity was assessed by the localization of worms in the portal vein system, by oogram changes, and percentage of parasite reduction. The stability of the susceptibility of progeny F14 did not change in relation to generations F1 to F5; the progeny was resistant to hycanthone and oxamniquine; but sensitive to niridazole, praziquantel and Oltipraz. We emphasize the importance of the phenomenon of resistance of the worm in view of the fact that oxamniquine has been widely used in Brazilian areas where mansonic schistosomiasis is endemic.

A note on the efficacy of a new class of compounds, 9-acridanone-hydrazones, against Schistosoma mansoni in a primate--the baboon

Five 9-acridanone-hydrazone compounds were tested against moderately heavy Schistosoma mansoni infections in baboons. They were administered as a single oral dose at a rate of 50 mg/kg body-weight. Compared with results from an untreated control baboon, four of the compounds showed high levels of activity judged by the reduction or elimination of faecal egg production, adult worms and tissue eggs.

Use of praziquantel in patients with schistosomiasis mansoni previously treated with oxamniquine and/or hycanthone: resistance of Schistosoma mansoni to schistosomicidal agents

Fourteen patients with active schistosomiasis mansoni in spite of previous treatment with oxamniquine and/or hycanthone were treated with praziquantel, single oral dose of 45 to 50 mg/kg body-weight. All underwent clinical, laboratory and electrocardiographic examination before and after treatment. Untoward effects (dizziness, drowziness, nausea and abdominal pain) were observed in ten. Laboratory findings disclosed no significant alteration and the electrocardiograms showed no abnormalities. Monthly follow-up examinations of 13 patients for six consecutive months showed parasitological cure in all. Before praziquantel treatment strains of Schistosoma mansoni were isolated from two patients, one treated three times with oxamniquine and the other with hycanthone once and oxamniquine twice. Progenies of these strains were maintained in Biomphalaria glabrata and mice. Groups of these infected mice were then treated with oxamniquine, hycanthone, niridazole and praziquantel and results compared with the BH strain maintained in our laboratory for many years. Schistosomicidal activity was assessed by the localization of worms in the portal vein system and oogram changes. Progenies from the strains isolated in this study were resistant to oxamniquine and hycanthone but sensitive to niridazole and praziquantel. The BH strain was sensitive to all four drugs. The serial runs of S. mansoni strains through intermediate and definitive hosts have not influenced their reactions to these schistosomicides.