F.W. Jennings

Subcurative chemotherapy and fatal post-treatment reactive encephalopathies in African trypanosomiasis

The treatment of late-stage African sleeping sickness in man is often complicated by a post-treatment reactive encephalopathy. The bases of this pathological reaction was investigated in a mouse model of African trypanosomiasis. Subcurative treatment with diminazene aceturate, which did not clear parasites from the central nervous system, resulted in a post-treatment meningoencephalitis similar to that seen in man. By contrast, a curative regimen of melaminylthioarsenite and 5-nitroimidazole, which cleared parasites from the central nervous system, did not cause any pathological reaction in the mice. This result indicates that subcurative treatment leads to the development of the post-treatment encephalopathy. Evidence that this may also be the case in man was provided by the detection of trypanosome DNA with the polymerase chain reaction in the brains of 9 patients who had died as the result of a post-treatment reaction. Our findings suggest that more aggressive treatment regimens, which ensure the elimination of trypanosomes from the central nervous system, may prevent post-treatment reactions in patients.

Future prospects for the chemotherapy of human trypanosomiasis: 2. Combination chemotherapy and African trypanosomiasis

This paper reviews the progress which has been achieved with combination chemotherapy of experimental murine central nervous system trypanosomiasis. Successful treatments have been achieved with suramin followed by 5-nitroimidazoles; difluoromethylornithine in combination with bleomycin, 9-deazainosine, suramin, arsenicals, antimonials and diamidines; and also the arsenicals in combination with the 5-nitroimidazoles or nifurtimox. Pretreatment with prednisolone and azathioprine, to minimize reactive encephalopathies, and supportive treatment with oxygen are both indicated.

Human African trypanosomiasis: potential therapeutic benefits of an alternative suramin and melarsoprol regimen.

Treatment of late-stage human African trypanosomiasis is complicated by the presence of trypanosomes within the central nervous system (CNS). The regimen commonly prescribed to treat CNS-stage disease involves the use of the trypanocidal drugs suramin and melarsoprol. Suramin does not cross the blood-brain barrier efficiently and therefore, at normal dosages, will not cure CNS-stage infections. An initial treatment with suramin is given to eliminate the parasites from the peripheral tissues. This is followed by a course of intravenous melarsoprol, which can enter the CNS. However, melarsoprol not only produces severe adverse reactions but also is extremely painful to administer. One possible method to help alleviate these problems is to reduce the total amount of melarsoprol in the treatment regimen. This study indicates a synergism between suramin and melarsoprol and demonstrates that experimental murine CNS-trypanosomiasis can be cured with a single intraperitoneal dose of 20 mg/kg suramin followed almost immediately by 0.05 ml (4.5 micromol) topical melarsoprol. These dosages will not cure the infection when administered as monotherapies. Moreover, the timing of the drug administration appears to be crucial to the successful outcome of the regimen. If the interval between injection of suramin and application of topical melarsoprol is extended from 15 min to 3 or 7 days, the infections are not cured. Although extended relapse times occur following these regimens when compared with monotherapy approaches. Thus, there is strong evidence that injected suramin and topical melarsoprol should be given almost simultaneously to achieve the most effective combination of the two drugs.

Treatment with suramin and 2-substituted 5-nitroimidazoles of chronic murine Trypanosoma brucei infections with central nervous system involvement

Mice infected with either of two isolates of Trypanosoma brucei, GVR 23/1 or GVR 35/1, develop a chronic infection in which trypanosomes are localized in the central nervous system. These infected mice were used to evaluate the efficacy of a combination drug treatment comprising suramin and one of three 2-substituted 5-nitroimidazoles. None of the three 5-nitroimidazoles tested alone, cured mice when administered 21 days after infection. However, it was found that T. brucei GVR 23/1 infections could be cured by a single dose of 20 mg/kg suramin followed by a single dose of 80 mg/kg L611,744 [3a,4,5,6,7,8,9,9a-octahydro-3-(1-methyl-5-nitroimidazol-2yl)cycloocta(D) isoxazole]. The single dose of 20 mg/kg suramin had to be followed by four doses of 80 mg/kg L611,744 to cure mice infected with another stabilate, T. brucei GVR 35/1. A single dose of 20 mg/kg suramin followed either by four doses of 250 mg/kg MK 436 [3a,4,5,6,7,7a-hexahydro-3-(1-methyl-5nitro-1H-imidazol-2-yl)-1, 2-benzisoxazole] or four doses of 70 mg/kg of a dihydroxy analogue of MK 436 [cis-3a,4,5,6,7,7a-hexahydro-3-(1-methyl-5-nitro-1H-imidazol-2-yl)-1, 2-benzisoxazole-6,7-diol] also permanently cured all T. brucei GVR 35/1.

Correlation of autoantibody titres with central nervous system pathology in experimental African trypanosomiasis

CD-1 mice infected with the protozoan parasite Trypanosoma brucei brucei developed few signs of central nervous system pathology associated with the invasion of the central nervous system by these parasites and did not survive beyond 5-6 weeks with deaths common before this time point. However, use of the trypanocidal drug diminazene aceturate (40 mg/kg), which fails to cross the blood-brain barrier, on day 21 post-infection led to the development of central nervous system pathology similar to that seen in the fatal post-treatment reactive encephalopathies that can occur in human African trypanosomiasis. Enzyme-linked immunosorbent assays were used to measure autoantibody titres to double-stranded DNA, myelin basic protein and to the myelin-specific galactocerebrosides and gangliosides in groups of infected mice, with or without the post-treatment reaction, on day 30 post-infection and compared with uninfected controls. Infection with T. brucei brucei raised the titres of all of these autoantibodies. Treatment of infected mice with diminazene aceturate resulted in elevated levels of all of these autoantibodies compared to the untreated animals. There was a strong positive correlation between the central nervous system pathology and the levels of autoantibodies to myelin basic protein, galactocerebrosides and gangliosides, but not to double-stranded DNA. The elevated titres observed may be a consequence of the polyclonal B cell activation that is believed to occur in African trypanosomiasis, parasite epitopes that are cross-reactive with these central nervous system (CNS)-specific antigens or result from the CNS damage associated with sub-curative chemotherapy.

'Berenil' and nitroimidazole combinations in the treatment of Trypanosoma brucei infection with central nervous system involvement.

Abstract Three nitroimidazole compounds were tested for trypanocidal activity against early (3-day) T. brucei TREU 667 infections. Compound 1 (1-methyl-2-carbamoyl-oxy-methyl-5-nitroimidazole) at both 5 and 20 mg/kg given as four daily doses was ineffective, while Compound 2 (3-(1-methyl-5-nitroimidazole-2-yl)-3α, 4,5,6,7, 7α-hexahydro-1, 2-benz-isoxazole) at 4 × 80 mg/kg and Compound 3 (3-(1-methyl-5-nitroimidazole-2-yl)-4, 5-hexamethylene-Δ 2 -isoxazoline) at 4 × 20 mg/kg both elicited a permanent cure. When tested against late (21-day) infections of T. brucei 667 neither Compound 2 nor Compound 3 given singly, or in various combinations was effective in that parasitaemias returned rapidly in nearly all mice. When the trypanocidal drug ‘Berenil’ was administered followed by the Compound 3, the majority of the mice with a 21-day infection of T. brucei TREU 667 or T. brucei LUMP 1001 were cured permanently. When ‘Berenil’ alone was used the mice usually relapsed within a few weeks of treatment. The isolate used affected the outcome of the treatment. Higher dosages of ‘Berenil’ followed by Compound 3 were required to cure infections with T. brucei LUMP 1001 than with T. brucei TREU 667. The importance of these findings in the treatment of human sleeping sickness with central nervous system involvement is discussed.

The use of azathioprine to ameliorate post-treatment encephalopathy associated with African trypanosomiasis

The treatment of human African sleeping sickness is complicated by a post‐treatment meningo‐encephalitis that may be fatal. Using a mouse model this study assesses the use of the non‐steroidal anti‐inflammatory drug, azathioprine, in the management of this post‐treatment reaction. Female NIH mice treated with the trypanocidal compound diminazene aceturate (40 mg/kg), 28 days after infection, developed a similar post‐treatment reaction to that seen in humans. Administration of azathioprine (100 mg/kg) for 5 days before and 5 days after trypanocidal chemotherapy abrogated the pathology in the central nervous system although this returned approximately 15 days after cessation of azathioprine. Activated astrocytes associated with the later stages of the infection did not appear to be affected by the use of azathioprine.

The role of the polyamine inhibitor eflornithine in the neuropathogenesis of experimental murine African trypanosomiasis

The treatment of late‐stage human African trypanosomiasis is complicated by a post‐treatment reactive encephalopathy, also referred to as a ‘reactive arsenical encephalopathy’, that may be fatal. This study used a well established experimental mouse system to assess the use of the trypanostatic drug, eflornithine, in the management of this post‐treatment reaction. Female CD‐1 mice infected with an eflornithine‐resistant trypanosome stabilate and treated with the trypanocidal compound diminazene aceturate on or after day 21 post‐infection develop a reactive encephalopathy and relapsing parasitaemia. If these animals are re‐treated with diminazene aceturate, a severe encephalopathy develops histologically comparable with that of human cases and characterized by a severe meningoencephalitis and astrogliosis. Histopathological and immunocytochemical examination shows that administration of eflornithine before or after the development of this reactive encephalopathy prevented or ameliorated the inflammatory reaction. Since an eflornithine resistant stabilate was used, this effect appears to be independent of the drugs trypanostatic action and illustrates an important, previously unrecognized, pharmacological property of eflornithine. Consideration can now be given to the use of eflornithine for the management of human trypanosomiasis cases, even where trypanosome resistance to eflornithine exists.

Successful treatment of experimental murine Trypanosoma brucei infection with topical melarsoprol gel

Melarsoprol gel applied topically (0.1 mL for at least 2 d) can cure late-stage Trypanosoma brucei brucei and T. b. rhodesiense infections in mice. The best regimen was 3 applications at approximately 0, 6, and 24 h. The melarsoprol gel retained its activity at room temperature for at least 63 d. There was only minimal skin irritation and no sign of toxicity.

Changes in atrial natriuretic factor and plasma renin activity in dogs infected withTrypanosoma brucei

When beagle dogs were infected withTrypanosoma brucei, a marked reduction in the plasma concentration of atrial natriuretic factor (ANF) occurred in the terminal stage of the disease during weeks 3 and 4. At the same time there was an increase in plasma renin activity (PRA) after infection. Ultrastructural studies of the atria of these dogs demonstrated a reduction in ANF granules. The changes in ANF and PRA occurred in association with severe pancarditis and the development of heart failure. By impairing the ability of the heart and kidneys to regulate blood volume, the alterations in ANF and PRA could be involved in the pathogenesis of heart failure inT. brucei-infected dogs.