Susceptibility to chemotherapeutic agents of strains of Schistosoma mansoni isolated from treated and untreated patients

Praziquantel: its use in control of schistosomiasis in sub-Saharan Africa and current research needs

Treatment with praziquantel (PZQ) has become virtually the sole basis of schistosomiasis control in sub-Saharan Africa and elsewhere, and the drug is reviewed here in the context of the increasing rate that it is being used for this purpose. Attention is drawn to our relative lack of knowledge about the mechanisms of action of PZQ at the molecular level, the need for more work to be done on schistosome isolates that have been collected recently from endemic areas rather than those maintained in laboratory conditions for long periods, and our reliance for experimental work mainly on Schistosoma mansoni, little work having been done on S. haematobium. There is no evidence that resistance to PZQ has been induced in African schistosomes as a result of its large-scale use on that continent to date, but there is also no assurance that PZQ and/or schistosomes are in any way unique and that resistant organisms will not be selected as a result of widespread drug usage. The failure of PZQ to produce complete cures in populations given a routine treatment should therefore solicit considerable concern. With few alternatives to PZQ currently available and/or on the horizon, methods to monitor drug-susceptibility in African schistosomes need to be devised and used to help ensure that this drug remains effective for as long a time as possible.

Microsatellite typing reveals strong genetic structure of Schistosoma mansoni from localities in Kenya

Genetic diversity and population structure of seven populations of Schistosoma mansoni sampled in Kenya were assessed using five microsatellite markers. The mean number of alleles per locus, expected heterozygosity in Hardy-Weinberg equilibrium and pairwise F(ST) values ranged from 5.2 to 10.7, 0.5-0.8 and 3.6-27.3%, respectively. These data reveal that S. mansoni populations in Kenyan have relatively high levels of genetic diversity and is significantly differentiated. Our data combined with information on biogeography support the hypothesis that the strong genetic structure in Kenyan schistosomes is as a result of limited gene flow and large population sizes. Resistance to anthelminthics has not been reported among the Kenyan schistosomes, we hypothesize that this is probably due to the very little gene flow among populations, thereby limiting opportunities for the spread of rare alleles that might confer resistance to the drugs.

Populational structure of Schistosoma mansoni assessed by DNA microsatellites

DNA microsatellites were used as molecular markers to analyse the population structure of the laboratory LE strain and of 10 field isolates of Schistosoma mansoni, the aetiologic agent of schistosomiasis. Out of 16,000 DNA sequences analysed in databases, 622 microsatellite loci were identified in 481 sequences (3.0%). The AT repetitions were the most frequent, followed by AAT and AC. Six loci showing perfect repetitions were selected and used in the polymerase chain reaction to evaluate polymorphisms in the number of repeats. Two groups of worms were studied. The first group consisted of 78 individuals, 39 of each sex, of the LE strain. The second group of worms consisted of 10 field isolates: seven from humans and three from snails. Four of the six loci were polymorphic, containing 11-17 alleles per locus. No linkage disequilibrium was observed among loci and none of the loci was sex linked. In both groups of worms, a significant deviation from Hardy-Weinberg equilibrium was observed. The observed heterozygosity was always lower than the expected one. The polymerase chain reaction primers were S. mansoni specific. The LE strain showed a lower total number of alleles or a lower average number of alleles/polymorphic locus than the field isolates, suggesting that 41 years of laboratory maintenance exerted selective pressure on the LE strain. The S. mansoni populations from the field were most genetically undifferentiated (R(ST)<0.027), suggesting a high gene flow among them. Our results showed the usefulness of microsatellites for population analysis of S. mansoni, offering a new alternative for a better understanding of schistosomiasis epidemiology.

Hepatic schistosomiasis

Schistosomiasis is a major, worldwide cause of morbidity and mortality. Disease from the organism Schistosoma mansoni results from egg deposition in the liver, intestines, and other organs and is associated with an intense, granulomatous response from the human host. Clinical manifestations range from mild to severe intestinal forms, and hepatosplenic schistosomiasis, which is associated with hepatic fibrosis, portal hypertension, esophageal varices, and splenomegaly. This article presents information about the epidemiology, immunopathogenesis and clinical aspects of the disease, the relationship between hepatic schistosomiasis and viral infections, diagnosis, therapy, and control strategies for schistosomiasis.

Study of Schistosoma mansoni isolates from patients with failure of treatment with oxamniquine

After three successive treatments with oxamniquine the continuing elimination of Schistosoma mansoni eggs was observed in patients, who came from various regions of Brazil, with different clinical forms of schistosomiasis. The objective of the present study was to determine the experimental behaviour of five different S. mansoni isolates in Swiss Webster mice that were submitted to treatment with the same drug. The experimental group with failure of treatment showed higher mean number of surviving male worms when it was compared to the group without failure of treatment. These date suggest the possibility of resistance to oxamniquine.

[Problems in the development of a vaccine against schistosomiasis mansoni]

During the last two decades, studies on antigens that may confer protective immunity to experimental infection with Schistosoma mansoni have made great advances, due largely to increased knowledge in the fields of molecular biology and immunology. Although these studies have made new and important contributions, at the present time the degree of protection conferred remains at approximately 50% in reducing the number of flukes and, with some antigens, the number of eggs. The many questions still to be answered indicate the necessity of carrying out further research on small and large animals before these antigen candidates for vaccines can be used in clinical tests.

Contrasting genomic variability between clones from field isolates and laboratory populations of Schistosoma mansoni

The extent of genomic variability of clones of Schistosoma mansoni obtained from field isolates was compared with that of strains that have been laboratory maintained. Analysis was undertaken using randomly amplified polymorphic DNAs (RAPDs) generated with three primers. Phenograms showing the similarity among the clones were constructed. The data showed that while the laboratory strain is highly homogeneous the clones derived from the field populations were highly variable with 43% of RAPDs exhibiting polymorphisms among 23 clones. Clones isolated from the same infected individual were always more closely grouped than clones from different individuals. The data clearly demonstrated that earlier analyses of the genomic variability in S. mansoni have underestimated this phenomenon due to the failure to examine field isolates.

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.

[Susceptibility to chemotherapeutic agents of Schistosoma mansoni isolates from patients treated with oxamniquine and praziquantel and not cured]

Ten inhabitants of Itaquara, Bahia, Brazil treated with oxamniquine and subsequently praziquantel were not cured. Schistosoma mansoni isolates derived from these patients were studied. Snails were infected with miracidia derived from the feces of these patients and the cercariae produced used to infect albino mice. The animals were then treated with a single oral dose of oxamniquine (25, 50 and 100mg/kg) or praziquantel (100, 200 and 400 mg/kg). The response to chemotherapy was significantly different in some of the isolates although it was not possible to characterize any of them as resistant. In addition, DNA analysis of the isolates by means of "Random Amplified Polymorphic DNA" indicated a low degree of variability as compared with a laboratory strain, LE. Thus, it was not possible to characterize these organisms at a genetic level as a distinct strain.

Antischistosomal activity of acridanone-hydrazones in Cebus monkeys experimentally infected with the SJ strain of Schistosoma mansoni

In this study, four compounds were utilized at the dose of 12.5 mg/kg body weight, p.o., to treat Cebus monkeys experimentally infected with about 200 cercariae of Schistosoma mansoni (SJ strain), via transcutaneous route. The oograms performed with rectal snips, as well as stool examinations carried out periodically, showed no viable eggs of the parasite, from day 29 to 226 post-treatment. The perfusion undertaken after killing the animals showed absence of worms in the treated monkeys, whereas 83 worms were recovered from the control, thus corroborating the results obtained by means of oograms and coproscopy. These results confirm the efficacy of 9-acridanone-hydrazones previously tested against the LE strain of S. mansoni. The low curative dose and apparent absence of toxicity render these drugs an important therapeutic reserve, taking into consideration the reports on the resistance of S. mansoni to the modern drugs oxamniquine and praziquantel.

Genetic diversity of Schistosoma mansoni: quantifying strain heterogeneity using a polymorphic DNA element

Intraspecific genetic variation among 14 geographic isolates of Schistosoma mansoni was quantified using a molecular marker to examine individual genotypes. Genetic crosses demonstrated maternal inheritance of S. mansoni DNA element pSM750. This element revealed diagnostic banding profiles, which allowed accurate strain identification. Most strains had similarity indices greater than 0.75 indicating that within-strain variation in these laboratory parasite populations was low. However, individual parasites from the NMRI strain were quite diverse (S = 0.40). Genetic heterogeneity among strains was quantified using a phenogram of mean genetic distance. Strain diversity between two geographic regions was quantified using a similarity index and was estimated to be substantial among isolates collected from a single local site.

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.

The random amplification of polymorphic DNA allows the identification of strains and species of schistosome

The use of arbitrarily selected primers (10-24 nucleotides) and very low stringency annealing conditions (30 degrees C followed by 40 degrees C) for the polymerase chain reaction amplification of 1.0 ng of schistosome DNA resulted in relatively complex patterns of products. Amongst the primers tested some, for example 5'-TCGTAGCCAA, produced patterns that included bands that were polymorphic between strains of Schistosoma mansoni. Other primers, for example 5'-TCACGATGCA, produced apparently identical products using DNA from 5 S. mansoni strains but highly variable patterns when DNA from different schistosome species was used. The results indicate that the random amplification of polymorphic DNA (RAPD) may be an extremely useful approach to the identification of schistosome strains and species.

Schistosoma mansoni: preclinical studies with 9-Acridanone-hydrazones in Cebus monkeys experimentally infected

Derivatives of acridine (9-Acridanone-hydrazones) were tested in Cebus monkeys experimentally infected with Schistosoma mansoni, at the dosages of 50, 25, and 12.5 mg/kg (p.o., single dose). At least, four compounds seemed to be very promising, promoting alterations in the oogram and reducing the worm burden drastically, even at the lowest dose (12.5 mg/kg). No side effects could be detected after drug administration.

Efficacy of oxamniquine, praziquantel and a combination of both drugs in schistosomiasis mansoni in Brazil

A randomized clinical trial was carried out to compare the efficacy of a low-dosage combination of oxamniquine (7.5 mg/kg) plus praziquantel (20 mg/kg) against either agent, oxamniquine (15 mg/kg) or praziquantel (40 mg/kg) alone, in the treatment of schistosomiasis mansoni in the Brazilian north-east. The drugs were randomly administered per os to 91 patients. Six and twelve months after treatment 89% of those admitted to the trial were reexamined by Kato-Katz method (ten slides) and MIF technique (one gram of stool) The achieved cure rates, as defined by absence of S. mansoni eggs in the faeces of individual patients at all points during the parasitological follow-up, were 81.8%, 81.2% and 67.6% for praziquantel, oxamniquine and the combination respectively. The reduction of eggs excretion in non cured patients six months after therapy ranged from 93.8-96.8% with praziquantel, 32.5-97% with oxamniquine and 76.9-99.5% with the combination. It is concluded that, at the used dosages, the three therapeutical regimens give similar and satisfactory results in the treatment of uncomplicated S. mansoni infection in Brazil.

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.

Enzymatic differences between hycanthone-resistant and sensitive strains of Schistosoma mansoni

1. Hycanthone-sensitive and resistant adult worms of Schistosoma mansoni were found to have generally similar specific activities in ten enzymes of carbohydrate metabolism. 2. Kinetic analyses revealed that pyruvate kinase, glucose-6-phosphate (G6P) dehydrogenase and malate dehydrogenase from both strains possessed similar Michaelis-Menten constants and were not inhibited by hycanthone. 3. Hexokinase and lactate dehydrogenase from the drug-resistant strain were not inhibited by hycanthone and showed three to five times greater Km values than those from the drug-sensitive worms which were also inhibitable by hycanthone. 4. Hycanthone more drastically affected the Vmax of phosphofructokinase from the hycanthone-sensitive parasite. 5. These data showed that the hycanthone inhibitable enzymes were generally from the drug-sensitive strain whereas the enzymes from drug-resistant worms are mostly hycanthone insensitive.

A review of clinical experience with oxamniquine

Oxamniquine has now been in general use for 11 years for the treatment of schistosomiasis mansoni. Dosage varies with the geographical origin of the parasites due to different susceptibilities of local strains, and the appropriate regimen can be expected to cure over 80% of patients and reduce egg excretion in others by over 90%. The drug has been used safely in all stages of the disease. Some late-stage and complicated forms have shown clinical improvement, and prognosis has been improved in all by the removal of the causative organisms. Toleration is usually good with side effects limited to a mild, transient dizziness. Neuropsychiatric disturbances have been recorded in a small number of patients, and care should be taken in treating subjects with a history of such disorders. Nevertheless, these effects have not limited use of the drug which has been used widely for the field treatment of several million people in rural communities. These schemes have led to reductions in incidence, prevalence and the occurrence of hepatosplenic involvement.

[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.

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.

Population dynamics of human helminth infections: control by chemotherapy

An analysis is presented of the population dynamics of the major helminth parasites of man with the aim of understanding observed patterns in the age-specific prevalence and intensity of infection. Mathematical models are used to investigate the possibility of controlling helminth diseases by mass chemotherapy, and to explore the advantages of selective treatment of the most heavily infected individuals in a community.

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.