Livia Pica-Mattoccia

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.

Praziquantel for the treatment of schistosomiasis: its use for control in areas with endemic disease and prospects for drug resistance

Praziquantel became available for the treatment of schistosomiasis and other trematode-inflicted diseases in the 1970s. It was revolutionary because it could be administered orally and had very few unwanted side effects. As a result of marked reductions in the price of praziquantel, the rate at which it is used has accelerated greatly in recent years. For the foreseeable future it will be the mainstay of programs designed to control schistosome-induced morbidity, particularly in sub-Saharan Africa where schistosomiasis is heavily endemic. There is currently no evidence to suggest that any schistosomes have developed resistance to praziquantel as a result of its widespread use. Nevertheless, while resistance may not pose an obvious or immediate threat to the usefulness of praziquantel, complacency and a failure to monitor developments may have serious consequences in the longer term since it will be the only drug that is readily available for large-scale treatment of schistosomiasis.

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.

Genetic and Molecular Basis of Drug Resistance and Species-Specific Drug Action in Schistosome Parasites

Blood Fluke Resistance The larval stages of the blood fluke Schistosoma mansoni are disseminated via a replicative cycle in freshwater snails. When people come into contact with contaminated water, the larvae attach to and penetrate the skin. The resulting disease, bilharzia or schistosomiasis, afflicts approximately 67 million people in Africa and South America. Unfortunately, the parasite is showing resistance to one of the available therapeutic drugs, oxamniquine, which means that schistosome control relies on a single drug, praziquantel. Valentim et al. (p. 1385, published online 21 November) analyzed the genetic and molecular basis of resistance to oxamniquine through a combination of genetic linkage mapping, genome sequencing, functional genomics analysis, and x-ray crystallography. Mutations in a distinctive sulfotransferase are responsible for oxamniquine resistance in a human blood fluke. Oxamniquine resistance evolved in the human blood fluke (Schistosoma mansoni) in Brazil in the 1970s. We crossed parental parasites differing ~500-fold in drug response, determined drug sensitivity and marker segregation in clonally derived second-generation progeny, and identified a single quantitative trait locus (logarithm of odds = 31) on chromosome 6. A sulfotransferase was identified as the causative gene by using RNA interference knockdown and biochemical complementation assays, and we subsequently demonstrated independent origins of loss-of-function mutations in field-derived and laboratory-selected resistant parasites. These results demonstrate the utility of linkage mapping in a human helminth parasite, while crystallographic analyses of protein-drug interactions illuminate the mode of drug action and provide a framework for rational design of oxamniquine derivatives that kill both S. mansoni and S. haematobium, the two species responsible for >99% of schistosomiasis cases worldwide.

Genetic analysis of decreased praziquantel sensitivity in a laboratory strain of Schistosoma mansoni

A laboratory strain of Schistosoma mansoni subjected to repeated in vivo praziquantel (PZQ) treatments for several generations has been previously found to have lesser sensitivity to the drug than the original unselected strain. In this study we have collected evidence on the mode of inheritance of the partial insensitivity exhibited by the PZQ-selected schistosomes. A single male and a single female worm of the two strains, assorted in the four possible combinations, were introduced into the mesenteric veins of mice and the eggs produced by each pair were used as the source of the F(1) progeny. PZQ sensitivity was assessed using both in vivo and in vitro methods. In the first approach, the PZQ ED(50) was determined by infecting mice with cercariae of the strains to be tested, treating at seven weeks with different drug doses and counting the number of surviving worms three weeks later. For the in vitro approach, adult schistosomes kept in culture were exposed overnight to different PZQ concentrations and their survival was monitored during the subsequent 7 days. Results from both approaches lead to the conclusion that hybrid schistosomes of the F(1) generation have a drug sensitivity intermediate between those of the two parental strains and are thus suggestive of a pattern of partial dominance for the trait under study.

Schistosoma mansoni: Hycanthone/oxamniquine resistance is controlled by a single autosomal recessive gene

Individual schistosomes of an hycanthone/oxamniquine-sensitive strain were crossed with individual schistosomes of the opposite sex and belonging either to the same sensitive population or to a different strain which exhibited high resistance to the two drugs. Schistosome crosses were performed by transfer of single worm pairs into the mesenteric veins of mice and the drug sensitivity/resistance of individual progeny worms was assessed using an in vitro test. Drug resistance behaved as an autosomal recessive trait, as shown by the results of the F1 and F2 generation and of the backcrosses. Drug-resistant worms appeared to be slightly less viable than their sensitive counterpart at all stages of the life cycle. The results are relevant for an interpretation of drug resistance and drug mechanisms and the approach used in this study may be applicable to different genetic markers in schistosomes.

Sequence and level of endogenous expression of calcium channel β subunits in Schistosoma mansoni displaying different susceptibilities to praziquantel

Kohn et al. [J. Biol. Chem. 276 (2001) 36873] demonstrated that cells expressing the structurally unusual schistosome beta subunit SmCavbeta1 in their voltage-operated calcium channels, exhibit an increased current amplitude in the presence of praziquantel (PZQ). This suggests that the beta subunit is involved in PZQ activity and is consistent with the known pharmacological effects of the drug. If this is so, the low susceptibility to PZQ noted in some Schistosoma mansoni strains could be due to some mutation(s) in the gene coding for this protein. We have sequenced the cDNAs coding for the SmCavbeta1 and SmCavbeta2 subunits of different sensitive and resistant strains and we have not been able to detect any meaningful differences. As an alternative hypothesis, the different sensitivity of schistosomes to PZQ action could be due to the expression of different beta subunits in the parasite. This interpretation could also explain the low PZQ susceptibility of immature worms (28 days). We analyzed Northern blots of various strains and various developmental stages, but we were unable to demonstrate major quantitative differences in the expression of the beta subunits.

Mode of action of the schistosomicide Hycanthone: site of DNA alkylation

Condensation of hycanthone N-methylcarbamate (HNMC) with deoxyguanosine (dG) furnished a mixture of the N-1 and N2 adducts which were purified and characterized as their acetates. Condensation of HNMC with thymidine (T) gave the N-3 adduct in poor yield. Adenosine (A) and cytidine (C) did not react with HNMC. Incubation of schistosomes with either [3H]hycanthone (HC) or [3H]HNMC furnished DNA to which [3H]HC was covalently bound. The alkylated DNA was degraded enzymically and the radiolabeled nucleosides were separated using HPLC. Two major peaks were observed which coincided in retention time with the synthetic N-1 and N2 alkylated dG. Alkylated T was absent. Thus, the site of alkylation of DNA by either HC or HNMC is dG.

Binding of tritiated hycanthone and hycanthone N-methylcarbamate to macromolecules of drug-sensitive and drug-resistant schistosomes

Adult Schistosoma mansoni of the hycanthone-sensitive and of the hycanthone-resistant strain were exposed in vitro to tritium-labeled hycanthone. The drug was taken up in similar amounts by the two strains, a result which is not compatible with hypothetical mechanisms of resistance based on reduced drug entry into the schistosomes. Labeled hycanthone was found to bind irreversibly to macromolecules of sensitive schistosomes, whereas the binding was minimal in resistant worms. In particular, the DNA of sensitive schistosomes showed high levels of tightly bound hycanthone, while the corresponding fraction of resistant schistosomes failed to do so. Female schistosomes and immature worms, which are less sensitive to hycanthone, showed a diminished drug-DNA binding with respect to adult males. Tritiated hycanthone N-methylcarbamate, which is effective against sensitive and resistant schistosomes, bound in similar amounts to the DNA of both strains. These results strongly support a previously proposed mechanism of action of hycanthone, which is based essentially on the alkylation of worm macromolecules by a drug derivative produced in sensitive schistosomes.

Rapamycin insensitivity in Schistosoma mansoni is not due to FKBP12 functionality

Rapamycin (RAPA) is a well-known immunosuppressant, the action of which is mediated by the immunophilin FKBP12. Upon RAPA binding, FKBP12 forms ternary complexes with phosphatidyl inositol related kinases known as the target of RAPA (TOR), which can lead to a mitotic block at the G1-S phase transition. Such an antiproliferative effect makes RAPA an attractive anticancer, antifungal or antiparasitic compound. In this study, we found the helminth parasite Schistosoma mansoni to be insensitive to the drug. In order to elucidate the mechanism underlying RAPA resistance, the S. mansoni drug receptor FKBP12 (SmFKBP12) was cloned for functional analysis. Western blot experiments showed that the protein is constitutively expressed in all life cycle stages and in both male and female parasites. The Escherichia coli-synthesised recombinant protein possessed enzymatic activity, which was inhibitable by RAPA. Moreover, SmFKBP12 was able to complement mutant Saccharomyces cerevisiae cells lacking FKBP12 in their RAPA sensitivity phenotype, leading us to conclude that SmFKBP12 is expressed in yeast in a functional form and capable of interacting with the drug and yeast TOR kinase. Even though the wild type SmFKBP12 appeared to restore a large part of RAPA sensitivity, a mutation of Asp(89)-Lys(90) to Pro(89)-Gly(90) in the schistosome protein was found to be more effective and restored drug sensitivity to the same level as the endogenous yeast protein. Despite ternary complex formation, our results suggest that additional unknown factors other than a functional drug receptor are implicated in drug resistance mechanisms.