Acquired resistance to proguanil in Plasmodium knowlesi

Plasmodium knowlesi malaria: Overview Focussing on Travel-Associated Infections

In 2004, Plasmodium knowlesi was first recognised as a relevant cause of human malaria in Southeast Asia. Since then, P. knowlesi has been described from all Southeast Asian countries except Laos and has become well-established as the fifth human malaria parasite and the first significant zoonotic Plasmodium species. As countries endemic for P. knowlesi malaria are among the most popular and most highly visited international destinations, travel medicine experts should be aware about disease and risks including prophylactic and therapeutic measures. Between 2005 and 2012, 15 cases of P. knowlesi malaria have been recognised and published in international travellers. Male gender and travel to rural/forested areas with contact to wild monkeys are risk factors for P. knowlesi infection. The present review gives an overview on current literature on the P. knowlesi parasite and summarises recent findings related to epidemiology, diagnostics, treatment and prophylaxis focussing on travellers.

Human infections and detection of Plasmodium knowlesi

Plasmodium knowlesi is a malaria parasite that is found in nature in long-tailed and pig-tailed macaques. Naturally acquired human infections were thought to be extremely rare until a large focus of human infections was reported in 2004 in Sarawak, Malaysian Borneo. Human infections have since been described throughout Southeast Asia, and P. knowlesi is now recognized as the fifth species of Plasmodium causing malaria in humans. The molecular, entomological, and epidemiological data indicate that human infections with P. knowlesi are not newly emergent and that knowlesi malaria is primarily a zoonosis. Human infections were undiagnosed until molecular detection methods that could distinguish P. knowlesi from the morphologically similar human malaria parasite P. malariae became available. P. knowlesi infections cause a spectrum of disease and are potentially fatal, but if detected early enough, infections in humans are readily treatable. In this review on knowlesi malaria, we describe the early studies on P. knowlesi and focus on the epidemiology, diagnosis, clinical aspects, and treatment of knowlesi malaria. We also discuss the gaps in our knowledge and the challenges that lie ahead in studying the epidemiology and pathogenesis of knowlesi malaria and in the prevention and control of this zoonotic infection.

Clinical and parasitological response to oral chloroquine and primaquine in uncomplicated human Plasmodium knowlesi infections

BACKGROUND

Plasmodium knowlesi is a cause of symptomatic and potentially fatal infections in humans. There are no studies assessing the detailed parasitological response to treatment of knowlesi malaria infections in man and whether antimalarial resistance occurs.

METHODS

A prospective observational study of oral chloroquine and primaquine therapy was conducted in consecutive patients admitted to Kapit Hospital, Sarawak, Malaysian Borneo with PCR-confirmed single P. knowlesi infections. These patients were given oral chloroquine for three days, and at 24 hours oral primaquine was administered for two consecutive days, primarily as a gametocidal agent. Clinical and parasitological responses were recorded at 6-hourly intervals during the first 24 hours, daily until discharge and then weekly to day 28. Vivax malaria patients were studied as a comparator group.

RESULTS

Of 96 knowlesi malaria patients who met the study criteria, 73 were recruited to an assessment of the acute response to treatment and 60 completed follow-up over 28 days. On admission, the mean parasite stage distributions were 49.5%, 41.5%, 4.0% and 5.6% for early trophozoites, late trophozoites, schizonts and gametocytes respectively. The median fever clearance time was 26.5 [inter-quartile range 16-34] hours. The mean times to 50% (PCT50) and 90% (PCT90) parasite clearance were 3.1 (95% confidence intervals [CI] 2.8-3.4) hours and 10.3 (9.4-11.4) hours. These were more rapid than in a group of 23 patients with vivax malaria 6.3 (5.3-7.8) hours and 20.9 (17.6-25.9) hours; P = 0.02). It was difficult to assess the effect of primaquine on P. knowlesi parasites, due to the rapid anti-malarial properties of chloroquine and since primaquine was administered 24 hours after chloroquine. No P. knowlesi recrudescences or re-infections were detected by PCR.

CONCLUSIONS

Chloroquine plus primaqine is an inexpensive and highly effective treatment for uncomplicated knowlesi malaria infections in humans and there is no evidence of drug resistance. Further studies using alternative anti-malarial drugs, including artemisinin derivatives, would be desirable to define optimal management strategies for P. knowlesi.

Absence of potentiation between quinine and pyrimethamine in infections of Plasmodium gallinaceum in chicks

The effect of combined doses of pyrimethamine and quinine has been studied in P. gallinaceum. No potentiation of the action of the drugs was observed.

A study of resistance to cycloguanil in Plasmodium gallinaceum in chicks

A cycloguanil-resistant strain of Plasmodium gallinaceum was produced relatively rapidly by passage through chicks treated with low but effective doses of the drug, the dose being increased as resistance developed.

The strain was cross-resistant to proguanil but not to pyrimethamine or chloroquine.

A strain highly resistant to proguanil was resistant to cycloguanil but only slightly resistant to pyrimethamine.

A strain highly resistant to pyrimethamine was resistant to proguanil and cycloguanil.

Passage for 20 months through birds treated with doses of cycloguanil which suppressed infection for relatively long periods failed to change the sensitivity of the strain to this drug or to proguanil. Although the relatively large dose did not eradicate the infection in any of the birds, subinoculations demonstrated that parasites were absent from the blood for a period in some of the birds, though infections finally developed.

I am indebted to Parke Davis and Company for the supply of cycloguanil, to Imperial Chemical Industries Ltd. for the proguanil hydrochloride and chloroquine phosphate and to Burroughs Wellcome and Company for the pyrimethamine base.

The action of 2:4-diamino-6:7-diisopropylpteridine upon Plasmodium gallinaceum and its relation to other compounds which are pteroylglutamic acid antagonists

1. Two strains ofPlasmodium gallinaceumwere made resistant to 2:4-diamino-6:7-diisopropylpteridine (0/129) by treatment with that drug.

2. The 0/129-resistant strains were resistant to proguanil, pyrimethamine, 2:4-diamino-6:7-diphenylpteridine (0/63) and 2:4-diamino-5-(p–chlorophenoxy)-6-methylpyrimidine (48–210), but not to sulphadiazine.

3. In one strain treated with 0/129, the development of resistance to that drug itself preceded resistance to proguanil, and resistance to proguanil preceded resis tance to pyrimethamine.

4. A strain ofP. gallinaceummade resistant to 0/63 was resistant to proguanil, pyrimethamine and 0/129, but not to sulphadiazine.

5. The action of 0/129 and proguanil uponP. gallinaceumwas not antagonized byp–A.B., though in the minimum effective dose their action was antagonized by relatively large doses of P.G.A.

6. Whereas the action of sulphadiazine uponP. gallinaceumwas antagonized competitively byp–A.B., it was antagonized by P.G.A. only when the sulphadiazine was given in small doses.

The chemotherapy of Plasmodium berghei. II. Antagonism of the action of drugs

The action of pyrimethamine, sulphadiazine, proguanil and its active metabolite CPT, and 2:4-diaminopteridines against infections ofPlasmodium bergheiin mice was antagonized byP–aminobenzoic acid and by pteroylglutamic acid. Antagonism was in some instances detected only whenP–aminobenzoic acid was given in solution in the drinking water as well as being injected subcutaneously. No antagonism was detected with a number of amino acids and nucleic acid derivatives.

As all of the above group of drugs can be antagonized byP–aminobenzoic acid and by pteroylglutamic acid, it would seem that they are alike in their mode of action. There must, however, be some differences between the mode of action or absorption of these drugs because species ofPlasmodiumthat are very sensitive to the action of one of these drugs are frequently not very sensitive to the action of others.

AsP. bergheiis dependent onp–aminobenzoic acid, it is suggested that it can utilize this compound in the synthesis of pteroylglutamic acid to a greater extent than canP. gallinaceum, and that it resemblesP. knowlesimore than other species ofPlasmodium.

The chemotherapy of Plasmodium berghei. I. Resistance to drugs

1. Strains of P. berghei resistant to sulphadiazine, pyrimethamine, and methylene blue were produced by treating acute infections with low doses of drug.

2. The strain resistant to methylene blue was sensitive to pamaquin, mepacrine, sulphadiazine, proguanil, pyrimethamine, and 2 : 4-diamino-6 : 7-camphano-pteridine.

3. The pyrimethamine-resistant strain was cross-resistant to proguanil and its active metabolite CPT, 2 : 4-diamino-6 : 7-camphanopteridine, 2 : 4-diamino-6 : 7-(l′-ethylindolo)-pteridine, and 2 : 4-diamino-5-p-chlorophenylpyrimidine.

4. The sulphadiazine-resistant strain was cross-resistant to pyrimethamine, sulphanilamide, proguanil and its active metabolite CPT, 2 : 4-diamino-6 : 7-dinhexylpteridine, and 2 : 4-diamino-6 : 7-diisopropylpteridine. It was as sensitive as the parent strain to quinine, mepacrine, chloroquin, pamaquin, methylene blue, and M 3349.

5. The action of sulphadiazine against the sulphadiazine-resistant strain was inhibited by the same doses of p-aminobenzoic acid and folic acid as were required with the parent strain, although the dose of sulphadiazine was increased 30-fold.