Diethylcarbamazine (DEC): immunopharmacological interactions of an anti-filarial drug

Progress and challenges in the discovery of macrofilaricidal drugs

Control of human filarial infections currently depends on chemotherapeutic strategies predominantly directed at microfilariae. Doxycycline therapy in an extended daily dose regimen sterilizes and kills adult stages, but the utility of this drug for routine field use remains an issue of concern. No macrofilaricidal drugs with efficacy after one or two doses are available for use, delaying the achievement of the elimination or eradication of onchocerciasis and lymphatic filariasis. Moxidectin, a macrocyclic lactone, is currently in clinical trials for onchocerciasis. A few other drugs that have already been approved for use in veterinary practice or in human medicine for other indications are available for investigation. Early drug discovery pipelines are poorly populated and the process of macrofilaricide discovery and development remains highly challenging. In particular, the lack of convenient, validated animal models in an antifilarial drug discovery pathway is an unresolved issue.

Effect of Diethylcarbamazine (DEC) on prostaglandin levels in Wuchereria bancrofti infected microfilaraemics

Diethylcarbamazine (DEC) interferes with arachidonic acid metabolism for the clearance of microfilariae in Wuchereria bancrofti infected individuals. In this study, we have quantified the plasma concentrations of prostaglandin E2 (PGE2) and 6-keto-PGF1α, the end products of arachidonic acid metabolic pathway in microfilaraemics (DEC treated and untreated), and normal healthy individuals at pre- and 3,9,12,36, and 72 h of post-DEC treatment. We have also determined the microfilariae counts at pre and post day 2 (36 h) and day 3 (72 h) of DEC treatment by membrane filtration technique. Significant reduction in PGE2 and 6-keto-PGF1α concentrations was found at 12 h of DEC treatment. Rapid reduction in microfilarial counts was observed at 36 h of post-DEC treatment. Higher levels of prostaglandins were found at pre-treatment hours in microfilaraemics compared to normal healthy individuals (P < 0.05). Our findings indicate that DEC inhibits prostaglandins for the clearance of microfilariae, and increased levels of prostaglandins in microfilaraemics may be contributed by the parasite or host upon stimulation.

Novel microfilaricidal activity of nanosilver

PURPOSE

The currently available drug repertoire against lymphatic filariasis, a major health hazard in the developing world, is inadequate and is fraught with serious limitations. Thus, the development of an effective antifilarial strategy has become a global research thrust mandated by the World Health Organization. Nanoparticles of silver endowed with antibacterial potency are known to induce apoptosis in eukaryotic cells. The present study was designed to investigate the possible microfilaricidal efficacy of silver nanoparticles and to establish the validity of apoptotic rationale in antifilarial drug designing.

METHODS

This report analyzed the effect of nanoparticles of silver as well as gold (size range: 10-15 nm) on the microfilariae of Brugia malayi obtained from the lavage of peritoneal cavities of infected jirds (Meriones unguiculatus). The study included a microfilarial motility assay, a trypan blue exclusion test, a poly(adenosine diphosphate-ribose) polymerase activity study, ethidium bromide/acridine orange differential staining, and transmission, as well as scanning electron microscopic evaluation of ultrastructural changes in microfilariae.

RESULTS

The study demonstrates that nanoparticles of silver, but not of gold, elicited significant loss in microfilarial motility. Differential staining of parasites with ethidium bromide and acridine orange, poly(adenosine diphosphate-ribose) polymerase activity in microfilarial lysate, and electron microscopic findings underscored apoptotic death of parasites attributable to nanosilver. In a trypan blue exclusion test, the 50% lethal dose of nanosilver was measured to be 101.2 μM, which was higher than the recorded complete inhibitory concentration value (50.6 μM), thus supporting nanosilver as a potential drug candidate against lymphatic filariasis.

CONCLUSION

The present report provides the first ever conclusive proof in support of apoptosis as a novel stratagem in antifilarial drug designing and nanoscale silver as a valid lead in research on antifilarial therapeutics. The main embargo about the current drug diethylcarbamazine citrate is its empirical use without rationale. Effective microfilaricidal activity of nanosilver at relatively low concentrations as reported in this study, with evidence of the induction of apoptosis in microfilariae, projects nanosilver as a potential drug adjuvant against lymphatic filariasis. The much higher 50% lethal dose value of nanosilver compared to the complete inhibitory concentration value reported in this study argues in favor of a safe therapeutic window of this agent in its antifilarial efficacy.

Targeted killing of a mammalian cell based upon its specialized metabolic state

Mouse ES cells use a mitochondrial threonine dehydrogenase (TDH) enzyme to catabolize threonine into glycine and acetyl-CoA. Measurements of mRNA abundance have given evidence that ES cells express upwards of 1,000-fold higher levels of TDH mRNA than any of seven other mouse tissues tested. When cell culture medium is deprived of threonine, ES cells rapidly discontinue DNA synthesis, arrest cell division, and eventually die. Such studies led to the conclusion that mouse ES cells exist in a threonine-dependent metabolic state. Proceeding with the assumption that the active TDH enzyme should be essential for the growth and viability of mouse ES cells, we performed a drug screen in search of specific inhibitors of the purified TDH enzyme. Such efforts led to the discovery of a class of quinazolinecarboxamide (Qc) compounds that inhibit the ability of the TDH enzyme to catabolize threonine into glycine and acetyl-CoA. Administration of Qc inhibitors of TDH to mouse ES cells impeded cell growth and resulted in the induction of autophagy. By contrast, the same chemicals failed to affect the growth of HeLa cells at concentrations 300-fold higher than that required to kill mouse ES cells. It was likewise observed that the Qc class of TDH inhibitors failed to affect the growth or viability of ES cell-derived embryoid body cells known to have extinguished TDH expression. These studies demonstrate how it is possible to kill a specific mammalian cell type on the basis of its specialized metabolic state.

The effect of oral anthelmintics on the survivorship and re-feeding frequency of anthropophilic mosquito disease vectors

In the Tropics, there is substantial temporal and spatial overlap of diseases propagated by anthropophilic mosquito vectors (such as malaria and dengue) and human helminth diseases (such as onchocerciasis and lymphatic filariasis) that are treated though mass drug administrations (MDA). This overlap will result in mosquito vectors imbibing significant quantities of these drugs when they blood feed on humans. Since many anthelmintic drugs have broad anti-invertebrate effects, the possibility of combined helminth control and mosquito-borne disease control through MDA is apparent. It has been previously shown that ivermectin can reduce mosquito survivorship when administered in a blood meal, but more detailed examinations are needed if MDA is to ever be developed into a tool for malaria or dengue control. We examined concentrations of drugs that follow human pharmacokinetics after MDA and that matched with mosquito feeding times, for effects against the anthropophilic mosquito vectors Anopheles gambiae s.s. and Aedes aegypti. Ivermectin was the only human-approved MDA drug we tested that affected mosquito survivorship, and only An. gambiae s.s. were affected at concentrations respecting human pharmacokinetics at indicated doses. Ivermectin also delayed An. gambiae s.s. re-feeding frequency and defecation rates, and two successive ivermectin-spiked blood meals following human pharmacokinetic concentrations compounded mortality effects compared to controls. These findings suggest that ivermectin MDA in Africa may be used to decrease malaria transmission if MDAs were administered more frequently. Such a strategy would broaden the current scope of polyparasitism control already afforded by MDAs, and which is needed in many African villages simultaneously burdened by many parasitic diseases.

Setaria equina: in vivo effect of diethylcarbamazine citrate on microfilariae in albino rats

Although diethylcarbamazine citrate (DEC) is successful drug in eliminating human filariasis, yet, its mode of action is still debatable. Herein, the effect of DEC to treat albino rats infected with the animal filarial parasite Setaria equina was tested. Microfilarial (mf) counts and sections from liver, lung, kidney as well as spleen were investigated at different time points after treatment by light microscopy. After 45 and 300min of treatment, a significant decrease in blood mf was observed accompanied by adherence of degenerated mf to both kupffer cells and leukocyte in liver sections. In lung sections, loss of sheath was observed at 45min, while degeneration was observed at later time points. In kidney sections, more mf counts and less matrix were observed in the glomeruli at all time points after treatment. Degenerated mf were observed in spleen sections only at, late time point, 480min after treatment. In conclusion, one of the possible mechanisms by which DEC reduces blood microfilarial count is trapping larvae in organs and killing them through cellular adherence.

Towards novel antifilarial drugs: challenges and recent developments

Filariasis is caused by thread-like nematode worms, classified according to their presence in the vertebrate host. The cutaneous group includes Onchocerca volvulus, Loa loa and Mansonella streptocerca; the lymphatic group includes Wuchereria bancrofti, Brugia malayi and Brugia timori and the body cavity group includes Mansonella perstans and Mansonella ozzardi. Lymphatic filariasis, a mosquito-borne disease, is one of the most prevalent diseases in tropical and subtropical countries and is accompanied by a number of pathological conditions. In recent years, there has been rapid progress in filariasis research, which has provided new insights into the pathogenesis of filarial disease, diagnosis, chemotherapy, the host–parasite relationship and the genomics of the parasite. Together, these insights are assisting the identification of novel drug targets and the discovery of antifilarial agents and candidate vaccine molecules. This review discusses the antifilarial activity of various chemical entities, the merits and demerits of antifilarial drugs currently in use, their mechanisms of action, in addition to antifilarial drug targets and their validation.

Filariasis: diagnosis and treatment

Filariasis is an infectious disease of the lymphatics and subcutaneous tissues caused by nematodes or filariae. Carried by mosquito vectors, this disease causes millions of people to suffer from lymphedema and elephantiasis, characteristics of filariasis infection. This disease can be diagnosed through the identification of microfilariae in blood or skin samples, antigen detection, radiographic imaging, or polymerase chain reaction. Mass drug administration by the World Health Organization has helped to diminish the incidence of filariasis. However, continued research on new drugs and vaccinations will be needed to control and reduce the microfilarial levels in the human population.

Efficacy of bioactive compounds from Curcuma aromatica against mosquito larvae

With the development of resistance to conventionally used synthetic insecticides, vector management has become acutely problematic. Hence more attention has been focused on botanicals. Therefore our present study was aimed to evaluate the efficacy of extracts from rhizomes of Curcuma aromatica against the larvae of filariasis vector mosquitoes, Culex quinquefasciatus employing standard WHO procedure at Mysore. The soxhlet extraction was carried out using non-polar organic solvent, petroleum ether. The efficacy of petroleum ether extract seemed to be effective with LC(50) and LC(90) values of 11.42 and 18.00 ppm respectively. Bioassay-guided fractionation through flash chromatography lead to the isolation of two larvicidal compounds namely 9-oxoneoprocurcumenol and neoprocurcumenol. Between the two, 9-oxoneoprocurcumenol exerted significant toxicity (P<0.01) on mosquito larvae with LC(50) value of 5.81 ppm and LC(90) being 9.99 ppm compared to neoprocurcumenol with 13.69 and 23.92 ppm of LC(50) and LC(90) values respectively. From the results, C. aromatica could be considered as one of the powerful candidate to bring about useful botanicals so as to prevent the resurgence of mosquito vectors.

Inducible nitric oxide synthase/CD95L-dependent suppression of pulmonary and bone marrow eosinophilia by diethylcarbamazine

RATIONALE

The mechanism of action of diethylcarbamazine (DEC), an antifilarial drug effective against tropical pulmonary eosinophilia, remains controversial. DEC effects on microfilariae depend on inducible NO synthase (iNOS). In eosinophilic pulmonary inflammation, its therapeutic mechanism has not been established. We previously described the rapid up-regulation of bone marrow eosinophilopoiesis in ovalbumin (OVA)-sensitized mice by airway allergen challenge, and further evidenced the down-regulation of eosinophilopoiesis by iNOS- and CD95L-dependent mechanisms.

OBJECTIVES

We investigated whether: (1) DEC can prevent the effects of airway challenge of sensitized mice on lungs and bone marrow, and (2) its effectiveness depends on iNOS/CD95L.

METHODS

OVA-sensitized BALB/c mice were intranasally challenged for 3 consecutive days, with DEC administered over a 12-, 3-, or 2-day period, ending at the day of the last challenge. We evaluated: (1) airway resistance, cytokine (IFN-gamma, IL-4, IL-5, and eotaxin) production, and pulmonary eosinophil accumulation; and (2) bone marrow eosinophil numbers in vivo and eosinophil differentiation ex vivo.

MEASUREMENTS AND MAIN RESULTS

DEC effectively prevented the effects of subsequent challenges on: (1) airway resistance, Th1/Th2 cytokine production, and pulmonary eosinophil accumulation; and (2) eosinophilopoiesis in vivo and ex vivo. Recovery from unprotected challenges included full responses to DEC during renewed challenges. DEC directly suppressed IL-5-dependent eosinophilopoiesis in naive bone marrow. DEC was ineffective in CD95L-deficient gld mice and in mice lacking iNOS activity because of gene targeting or pharmacological blockade.

CONCLUSIONS

DEC has a strong impact on pulmonary eosinophilic inflammation in allergic mice, as well as on the underlying hemopoietic response, suppressing the eosinophil lineage by an iNOS/CD95L-dependent mechanism.

Ultrastructural analysis of microfilariae of Wuchereria bancrofti obtained from persistent carriers after repeated courses of diethylcarbamazine

Single dose of diethylcarbamazine (DEC) used in control programs is effective in breaking the transmission of filariasis. In order to investigate the effect of aggressive therapy on Wuchereria bancrofti (Wb) microfilariae, DEC was given to 29 patients who were positive for the circulating filarial antigen (CFA) assay but did not have clinical manifestations of filariasis, at 6 mg/kg/day for 12 days and again six months later using the same dosing regimen. For each patient, microfilarial density and serum CFA were followed up for two years. Ultrastructural analyses on Wb microfilariae obtained after repeated treatment with DEC were also performed. Microfilaremia and antigenemia decreased significantly after 12 months but returned to the initial levels after 24 months. This could indicate, as shown by other authors, that aggressive repeated therapy with DEC alone is ineffective in eradicating adult W. bancrofti, particularly in infected but asymptomatic individuals. The objective of the present study was to analyze the microfilaremic and antigenemic behavior and ultrastructural changes caused by different DEC concentrations in vitro in Wb microfilariae obtained from individuals who were sensitive and refractory to treatment. After in vitro treatment of the microfilariae using 5 and 10 microg/ml of DEC for 1h, ultrastructural analysis revealed low levels of cell damage compared with embryos obtained from individuals from a different area who had never received DEC treatment before. The results obtained suggest that microfilariae from patients who receive repeated aggressive therapy are less sensitive to DEC in vitro.

Changes in mouse Leydig cells ultrastructure and testosterone secretion after diethylcarbamazine administration

Diethylcarbamazine (DEC) has been proven to be highly effective against lymphatic filariasis, although its effect on vertebrate cells remains uncertain. Mice Leydig cells after treatment with 200mg/kg of DEC for 12 days showed numerous lipid droplets, degenerated mitochondria, residual bodies and several giant whorl-like smooth endoplasmic reticulum, some of them encircling large lipids droplets. Treatment with lower dosages showed similar alterations on Leydig cells and the morphological effects decreased directly proportional to the drug concentration. Serum testosterone levels were significantly lower only in 200 mg/kg DEC-treated group when compared to the controls. However, no significant changes were observed in the pregnancy rates and offspring number of DEC-treated male-mated female mice in any doses studied. The results obtained in the present study are consistent with the hypothesis that DEC has some effects on mice Leydig cells, although they were not sufficient enough to interfere with the rodent fertility.

Molecular evidence for apoptosis in microfilariae of Wuchereria bancrofti induced by diethylcarbamazine

Apoptosis, a programmed cell death, is characterized by chromatin condensation, numerous vacuoles, reduction in cell volume, and endonuclease cleavage DNA degradation detected in gel electrophoresis as nucleosomal ladder. Here we report that diethylcarbamazine induces DNA fragmentation in microfilariae of Wuchereria bancrofti revealed by ligation-mediated polymerase chain reaction and by in situ terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling at the light and electron transmission level.

Comparative analysis of a chemotherapy effect on the cuticular surface of Wuchereria bancrofti adult worms in vivo

Wuchereria bancrofti is the main species responsible for human lymphatic filariasis and remains a major public health problem in tropical countries around the world. Diethylcarbamazine (DEC) has been used for decades in control programs as an effective microfilaricide, although its efficacy in killing adult worms is only around 50% and its direct mode of action is unclear. Recently, in an attempt to control and eliminate lymphatic filariasis, WHO has recommended albendazole (ALB), a broad-spectrum anthelminthic combined with DEC or ivermectin for mass treatment. Some studies have shown that DEC alone blocks oogenesis, fertilization in adult worms, and loss of the microfilarial sheath of several filarial species, whereas ALB is thought to target nematode tubulin. So far, the direct effect of ALB in combination with DEC has not been described in W. bancrofti adult worms. Therefore, the purpose of this study is to investigate by scanning electron microscopy if DEC coadministered with ALB can induce in vivo morphological alterations of the W. bancrofti adult worm surface obtained from a patient in whom the adult worm remained alive, checked serially by ultrasonography for 2 months after antifilarial treatment. Our analysis demonstrates that worms presented morphologic alterations in some regions suggesting cuticular surface damage. On the other hand, adult worms that were recovered from a patient treated with DEC alone after a single dose did not show such any abnormalities.

Morphological changes in the testis induced by diethylcarbamazine

Diethylcarbamazine (DEC) had been proved to be highly effective against lymphatic filariasis, however its effect on vertebrate cells remains uncertain. After 12 days treatment with DEC, most of the Leydig cells were hypertrophied with several lipid droplets, and others had no nucleus and presented characteristic steatosis features. Vacuolization of Sertoli cells was also noted. Ultrastructural analyses of DEC-treated testes revealed spermatogonies with morphological characteristics of apoptosis, as shrinkage of cytoplasm and increased chromosomal density. In addition, Leydig cells showed numerous lipid droplets scattered throughout the cytoplasm, multivesicular bodies and giant whorl-like smooth endoplasmic reticulum. Several spermatids presented vacuolated mitochondriae, which were disorganized in relation to the microtubular axis of the flagellae. These results indicate that DEC probably affects the microtubular function, however the present data does not exclude the possibility that DEC also can act directly on enzymatic hormonal pathways.

The effects of diethylcarbamazine on the ultrastructure of lung cells in vivo

The pulmonary surfactant synthesis is disturbed in experimentally induced asthma, as are the intracellular storage capacity and its physical activity. These alterations may also be present in chronic asthmatic patients, and therefore the dysfunction of the pulmonary surfactant system may play an important role in the pathophysiology of asthma. Some clinical reports have described favorable results with the use of diethylcarbamazine (DEC) in patients with bronchial asthma showing that DEC is effective in terminating acute attacks of bronchial asthma. The present study aimed to analyze the ultrastructural alterations of lung cells after treatment in vivo with diethylcarbamazine. After 12 days of treatment with DEC, when compared with control samples, type II pneumocytes showed active nuclei with abundant euchromatin and evident nucleoli, and a substantially greater number of mature secretion vesicle. On the other hand, type I pneumocytes showed no morphological alterations. After DEC treatment, lung macrophages also presented several characteristics of cellular activation such as nuclei with a prominence of euchromatin and central nucleoli as well as an abundance of early and late endossomes distributed throughout the cytoplasm. These results confirm that DEC exerts a role in the activation of important pulmonary cellular pathways, which are probably related to the clinical improvement of asthma symptoms after DEC treatment.

Diethylcarbamazine activity against Brugia malayi microfilariae is dependent on inducible nitric-oxide synthase and the cyclooxygenase pathway

Background

Diethylcarbamazine (DEC) has been used for many years in the treatment of human lymphatic filariasis. Its mode of action is not well understood, but it is known to interact with the arachidonic acid pathway. Here we have investigated the contribution of the nitric oxide and cyclooxygenase (COX) pathways to the activity of DEC against B. malayi microfilariae in mice.

Methods

B. malayi microfilariae were injected intravenously into mice and parasitaemia was measured 24 hours later. DEC was then administered to BALB/c mice with and without pre-treatment with indomethacin or dexamethasone and the parasitaemia monitored. To investigate a role for inducible nitric oxide in DEC's activity, DEC and ivermectin were administered to microfilaraemic iNOS^-/- mice and their background strain (129/SV). Western blot analysis was used to determine any effect of DEC on the production of COX and inducible nitric-oxide synthase (iNOS) proteins.

Results

DEC administered alone to BALB/c mice resulted in a rapid and profound reduction in circulating microfilariae within five minutes of treatment. Microfilarial levels began to recover after 24 hours and returned to near pre-treatment levels two weeks later, suggesting that the sequestration of microfilariae occurs independently of parasite killing. Pre-treatment of animals with dexamethasone or indomethacin reduced DEC's efficacy by almost 90% or 56%, respectively, supporting a role for the arachidonic acid and cyclooxygenase pathways in vivo. Furthermore, experiments showed that treatment with DEC results in a reduction in the amount of COX-1 protein in peritoneal exudate cells. Additionally, in iNOS^-/- mice infected with B. malayi microfilariae, DEC showed no activity, whereas the efficacy of another antifilarial drug, ivermectin, was unaffected.

Conclusion

These results confirm the important role of the arachidonic acid metabolic pathway in DEC's mechanism of action in vivo and show that in addition to its effects on the 5-lipoxygenase pathway, it targets the cyclooxygenase pathway and COX-1. Moreover, we show for the first time that inducible nitric oxide is essential for the rapid sequestration of microfilariae by DEC.

Tomocomd-Cardd, a novel approach for computer-aided ? rational? drug design: I. Theoretical and experimental assessment of a promising method for computational screening and in silico design of new anthelmintic compounds

In this work, the TOMOCOMD-CARDD approach has been applied to estimate the anthelmintic activity. Total and local (both atom and atom-type) quadratic indices and linear discriminant analysis were used to obtain a quantitative model that discriminates between anthelmintic and non-anthelmintic drug-like compounds. The obtained model correctly classified 90.37% of compounds in the training set. External validation processes to assess the robustness and predictive power of the obtained model were carried out. The QSAR model correctly classified 88.18% of compounds in this external prediction set. A second model was performed to outline some conclusions about the possible modes of action of anthelmintic drugs. This model permits the correct classification of 94.52% of compounds in the training set, and 80.00% of good global classification in the external prediction set. After that, the developed model was used in virtual in silico screening and several compounds from the Merck Index, Negwer's handbook and Goodman and Gilman were identified by models as anthelmintic. Finally, the experimental assay of one organic chemical (G-1) by an in vivo test coincides fairly well (100%) with model predictions. These results suggest that the proposed method will be a good tool for studying the biological properties of drug candidates during the early state of the drug-development process.

Some morphological aspects of Wuchereria bancrofti uterus after treatment with diethylcarbamazine

Confocal and EM analyses revealed that some female Wuchereria bancrofti, obtained from volunteers that received recommended diethylcarbamazine dose regimens, showed few or no embryos. Furthermore, inside the gravid uterus of female W. bancrofti treated with DEC we observed a finely granular, electron-dense material organised as strings of pearls, approximately 70 nm in maximal length surrounding intra-uterine microfilariae and apparently secreted by the embryo. Over the eggshells a similar material was also observed, possibly secreted by the uterine wall. The surface of intra-uterine microfilariae presented a material with identical electron-density to the scattered structures observed inside the egg. Similarly, the sheath of blood microfilariae of W. bancrofti also showed electron-dense projections, with shape and size similar to that observed inside the uterus.

The ultrastructure of infective larvae (L3) of Wuchereria bancrofti after treatment with diethylcarbamazine

Although the large use of diethylcarbamazine (DEC), as the major anti-filaricide drug, its mechanism of action remains a matter of controversy. Several authors defend the hypothesis that DEC has no direct effect on nematodes. This study demonstrated that infective larvae (L3) of Wuchereria bancrofti treated in vitro with DEC presented several behaviour and morphological changes. The first alteration produced by treatment for 2 h with 3, 5, 10 microg/ml of DEC was the reduction of motility. Larvae treated with 5, 10 microg/ml DEC showed severely affected organelles, formation of several vacuoles, mainly in neurocytes and in the muscle cells, and dissolution of cytoplasm. Some larvae showed extreme cellular disorganization with abundance of large and dense mitochondria and numerous large vacuoles containing residual organelles. Lamellar bodies, probably related to an assembly of hipodermal membranes, were also observed in some damaged larvae. Thus, undoubtedly in vitro treatment with concentrations of DEC similar to therapeutic conditions, which are 1-5 microg/ml (Hawking, 1979), had a direct effect on infective larvae of W. bancrofti by causing, primarily neuromuscular alterations with subsequent damage to organelles.

The effects of diethylcarbamazine on the ultrastructure of microfilariae of Wuchereria bancrofti in vivo and in vitro

An ultrastructural study of microfilariae of Wuchereria bancrofti was performed after treatment in vitro and in vivo with diethylcarbamazine citrate (DEC). The morphological alterations produced by treatment in vitro with 5 micro g/ml of DEC were the loss of microfilarial sheaths and lysis of the cytoplasm, with the destruction of all organelles and the formation of several vacuoles, the contents of which presented various degrees of electron-density, or showed an empty appearance. Some of these vacuoles seemed to be extruding from the cytoplasm as apoptotic bodies and others presented organelles inside. Similar alterations were observed after in vivo treatment. At 40 min after treatment of a microfilaremic individual with DEC, almost all microfilariae observed had lost their sheaths; and, in some of them, remains of the microfilarial sheath on the larval surface could be detected. Numerous vacuoles were observed, mainly in the hypodermis and somatic cells, showing organelles inside or an empty appearance. Condensed chromatin was also observed in some somatic cells. At 1 h after treatment of a microfilemic individual with DEC, microfilariae presented drastic morphological alterations, with large vacuoles within somatic cell cytoplasm and complete lysis of all cellular organelles. Therefore, both treatments with DEC in vitro and in vivo had a direct mechanism of action on the microfilariae of W. bancrofti, including organelle damage and apoptosis.

Diethylcarbamazine induces loss of microfilarial sheath of Wuchereria bancrofti

Light microscopy analyses of microfilariae of Wuchereria bancrofti treated with DEC revealed a striking loss of the microfilarial sheath. However, no effect was observed on microfilariae of Litomosoides chagasfilhoi treated with DEC. For quantitative analyses microfilariae of W. bancrofti were processed for SEM. Controls, which have not received DEC, had 29.8% of exsheathed microfilariae. Conversely, the number of exsheathed microfilariae increased as increased DEC concentrations: 5 microg/ml (75.9%), 10 microg/ml (80.1%), and 50 microg/ml (87.7%). After DEC treatment some of sheathed microfilariae showed a wrinkled surface, and in some microfilariae, sheaths were observed being liberated almost intact from the larvae surface. But, frequently residues of the lost sheath over the surface were also observed. No damage was observed in the microfilariae cuticle. The present work shows quantitative data on the loss of the microfilarial sheath of W. bancrofti after treatment with DEC. Since no loss of microfilarial sheath was observed in microfilariae of L. chagasfilhoi submitted to the same conditions, DEC may present different mechanisms of action for distinct filarial species.

Potential antifilarial activity of the leaves and seeds extracts of Psoralea corylifolia on cattle filarial parasite Setaria cervi

The effect of aqueous and alcohol extracts of the leaves and seeds of Psoralea corylifolia, on the spontaneous movements of both the whole worm and the nerve muscle preparation of Setaria cervi and on the survival of microfilariae in vitro was studied. Alcohol extracts of both leaves and seeds caused the inhibition of spontaneous movements of the whole worm and the nerve muscle preparation of S. cervi, characterised by initial, short lasting small increase in tone of contractions followed by paralysis. The initial stimulatory effect was not observed by alcohol extract of leaves on nerve muscle preparation. The concentrations required to inhibit the movements of whole worm and nerve muscle preparations for alcohol extracts of leaves and seeds were 160, 30, and 150, 20 microg/ml, respectively suggesting a cuticular permeability barrier. Alcohol extracts of both leaves and seeds caused death of microfilariae in vitro, LC(50) and LC(90) being 15 and 25 ng/ml for alcohol extract of leaves and 12 and 18 ng/ml for alcohol extract of seeds, respectively.

[Recommendations for the treatment of bancroftian filariasis in symptomless and diseased patients]

The goals of treatment for lymphatic filariasis are: to prevent, reverse, or halt progression of disease; and to interrupt transmission of the parasite. Selecting the appropriate therapy for the patient with lymphatic filariasis requires knowledge of the various clinical features of filarial disease and their pathogenesis. In the past, treatment of lymphatic filariasis has focused primarily on antiparasitic chemotherapy; however, for many of the acute and chronic manifestations of lymphatic filariasis, it is now clear that supportive or other forms of clinical care are even more important than antiparasitic medication in order to prevent worsening of the disease. Regardless of the clinical manifestations of filarial disease in a particular patient, the following three components of treatment should, in general, be considered: supportive or disease specific clinical care (including hygiene and diet), patient education and counseling and finally, antiparasitic chemotherapy with diethylcarbamazine (DEC) and/or the combination of DEC with ivermectin. The authors also describe the proportional efficacy of diethylcarbamazine and ivermectin, alone or in combination, for use in mass treatment aiming at transmission interruption and the use of hygiene as a public health approach for lymphedema prevention.

Wolbachia in filarial nematodes: evolutionary aspects and implications for the pathogenesis and treatment of filarial diseases

The presence of intracellular bacteria in the body of various species of filarial nematodes, including important parasites such as Brugia malayi, Dirofilaria immitis, and Onchocerca volvulus, was observed as early as the mid-1970s. These bacteria were shown to be transovarially transmitted (from the female worm to the offspring) and to be present in significant amounts in the body of the nematode. As highlighted by their discoverers, the potential importance of these bacteria is fairly obvious: (1) bacteria-derived molecules should be considered as having an immunological and pathological role in filarial diseases; (2) the interaction between the bacteria and the filarial host deserves investigation, in view of the possibility that the bacteria are needed by the host nematode and could thus represent a target for therapy. Other authors, independently from the discovery of these intracellular bacteria, showed that the antibiotic tetracycline (which is well known for its efficacy on intracellular bacteria) had detrimental effects on two species of filarial nematodes (Brugia pahangi and Litomosoides sigmodontis). It is therefore surprising that for more than 20 years, no further investigations focused on the bacteria of filarial nematodes, nor on the anti-filarial properties of tetracycline. Recently, the bacteria of filarial nematodes have been independently "rediscovered" by research groups from the schools of Hamburg, Liverpool and Milan. These bacteria are now classified as Wolbachia, and the basic aspects of their phylogenetic history and relationship with the Wolbachia of arthropods have been reconstructed. In addition, their implications for the pathogenesis and treatment of filarial diseases have started to be uncovered. This paper, which is authored by representatives of the three European schools who reopened this research area, reviews our present knowledge of these fascinating microorganisms, highlighting the complexity of a symbiotic system which involves, in addition to the nematode and its bacterium, the vertebrate host.

Highlights of human toxocariasis

Human toxocariasis is a helminthozoonosis due to the migration of Toxocara species larvae through human organism. Humans become infected by ingesting either embryonated eggs from soil (geophagia, pica), dirty hands or raw vegetables, or larvae from undercooked giblets. The diagnosis relies upon sensitive immunological methods (ELISA or western-blot) which use Toxocara excretory-secretory antigens. Seroprevalence is high in developed countries, especially in rural areas, and also in some tropical islands. The clinical spectrum of the disease comprises four syndromes, namely visceral larva migrans, ocular larva migrans, and the more recently recognized "common" (in adults) and "covert" (in children) pictures. Therapy of ocular toxocariasis is primarily based upon corticosteroids use, when visceral larva migrans and few cases of common or covert toxocariasis can be treated by anthelmintics whose the most efficient appeared to be diethylcarbamazine. When diagnosed, all of these syndromes require thorough prevention of recontamination (especially by deworming pets) and sanitary education.

Extralymphatic disease due to bancroftian filariasis

Infection with Wuchereria bancrofti, Brugia malayi, or B. timori not only affects the structure and function of lymphatic vessels but is also associated with extralymphatic pathology and disease. Because it is now possible to detect living adult worms by ultrasonography, much emphasis is placed on lymphatic pathology. However, the finding of renal damage in asymptomatic microfilaremic carriers has led to increased recognition of the importance of extralymphatic clinical manifestation in bancroftian filariasis. The authors present a number of clinical syndromes that may be manifestations of extralymphatic filarial disease and discuss possible mechanisms that cause these conditions. The main purpose of this paper is to raise the awareness of students and physicians of the prevalence and the importance of extralymphatic disease in bancroftian filariasis so that it is diagnosed and treated properly and also to alert for the need of additional research in this area.

The role of albendazole in programmes to eliminate lymphatic filariasis

Citing earlier advances in the treatment of lymphatic filariasis [particularly the effectiveness of single-dose diethylcarbamazine (DEC) in reducing microfilaraemia and its enhanced effectiveness when co-administered with single-dose ivermectin], Eric Ottesen, Mahroof Ismail and John Horton consider recent studies on the antifilarial activity of albendazole that have led to the current recommendations for its use in single-dose regimens in conjunction with either DEC or ivermectin for large-scale control/elimination programmes. Furthermore, the potential of albendazole as a macrofilaricide for treating individual patients with lymphatic filarial infections is emphasized as one of a number of important research questions that remain to be explored.

Adverse reactions following diethylcarbamazine (DEC) intake in 'endemic normals', microfilaraemics and elephantiasis patients

This paper reports on adverse reactions following a 12-day course of 6 mg/kg diethylcarbamazine (DEC) therapy in brugian filariasis patients in Indonesia. Microfilaria-positive individuals (n = 26), 'endemic normals' (n = 12) and elephantiasis patients (n = 17) were included in the study. Fever, headache and body aches started between 2 and 24 h after DEC intake. Adverse reactions were categorized into 'no or mild', 'moderate' or 'severe' depending on the total reaction score. Four microfilaraemic individuals (15.4%) suffered from severe adverse reactions and their pre-treatment microfilarial levels (geometric mean, GM = 3060 mf/10 mL) were significantly higher than in the 5 microfilaraemic individuals (19.2%) suffering from moderate reactions (GM = 1268 mf/10 mL) and in the 17 microfilaraemic patients (65.4%) who experienced no or mild reactions (GM = 6 mf/10 mL)(P < 0.001 and P < 0.001, respectively). Endemic normals showed no or mild adverse reactions. No or mild adverse reactions were also recorded in all but 2 elephantiasis patients after DEC intake. Two elephantiasis patients with moderate reactions had high levels of circulating microfilariae at pre-treatment (2097 and 7375 mf/10 mL). Concentrations of DEC were measured in plasma, but could not explain the differences in the severity of adverse reactions.

Modes of action of anthelmintic drugs

Modes of action of anthelmintic drugs are described. Some anthelmintic drugs act rapidly and selectively on neuromuscular transmission of nematodes. Levamisole, pyrantel and morantel are agonists at nicotinic acetylcholine receptors of nematode muscle and cause spastic paralysis. Dichlorvos and haloxon are organophosphorus cholinesterase antagonists. Piperazine is a GABA (gamma-amino-butyric acid) agonist at receptors on nematode muscles and causes flaccid paralysis. The avermectins increase the opening of glutamate-gated chloride (GluCl) channels and produce paralysis of pharyngeal pumping. Praziquantel has a selective effect on the tegument of trematodes and increases permeability of calcium. Other anthelmintics have a biochemical mode of action. The benzimidazole drugs bind selectively to beta-tubulin of nematodes, cestodes and fluke, and inhibit microtubule formation. The salicylanilides: rafoxanide, oxyclozanide, brotianide and closantel and the substituted phenol, nitroxynil, are proton ionophores. Clorsulon is a selective antagonist of fluke phosphoglycerate kinase and mutase. Diethylcarbamazine blocks host, and possibly parasite, enzymes involved in arachidonic acid metabolism, and enhances the innate, nonspecific immune system.

Ivermectin-induced killing of microfilariae in vitro by neutrophils mediated by NO

Rat neutrophil granulocytes isolated after intraperitoneal casein injection of the donors exhibit high cytotoxic efficacy in vitro against microfilariae of Litomosoides carinii in the presence of ivermectin. Optimum effects of 80-90% killing of microfilariae were obtained with 100 ng ivermectin per milliliter and a microfilariae: cell ratio of 1:100. Spleen cells killed approximately 30% of the microfilariae under these conditions. Cytotoxic effects were independent of any adherence of the cell to the larvae. In contrast to the effects of spleen cells, cytotoxicity of neutrophils completely abrogated when cells and targets were separated by a membrane impermeable for the cells, suggesting a very short-living mediator in the latter case. Correspondingly, cytotoxic effects of neutrophils were completely inhibited by the addition of the arginine analogues NG-monomethyl-L-arginine and L-canavanine, indicating the involvement of reactive nitrogen intermediates. The nitric oxide scavenger hemoglobin also protected the microfilariae. Several compounds which are known to interfere with reactive oxygen intermediates were ineffective. An excess of ferrous ions in the medium in the presence of a reducing agent significantly reduced the cytotoxic efficacy of neutrophils.

[Diethylcarbamazine in the treatment of Bancroft's filariasis]

The authors presented a detailed review about the treatment of bancroftian filariasis with diethylcarbamazine. The interesting aspects about the drug discovery and the basic concepts about its pharmacology were reported in a summarised form. On the other hand, emphasis was made about the speculation done by several authors about the intriguing findings regarding its efficacy reported in the literature. Latter, it was brought the new advances about the disease, as for example, the visualization by ultrasound of living Wuchereria bancrofti adult worm on its natural host--the human being. This made possible the comprehension of several paradoxical issues reported, focusing the treatment of infection using diethylcarbamazine. So far, because of the lack of ideal drug with micro and macrofilaricidal properties, together with the new understand about the disease and the new parameters for monitoring the efficacy of the drug, diethylcarbamazine has back its importance conquered at the begin of its discovery, almost fifth years ago.

Neutrophil granule proteins: evidence for the participation in the host reaction to skin microfilariae of Onchocerca volvulus after diethylcarbamazine administration

The participation of neutrophil granulocytes in the cellular reaction to skin microfilariae of Onchocerca volvulus was studied by immunohistochemistry. Skin biopsies were obtained from adult Liberian and Ugandan patients with generalized onchocerciasis after exposure to topically applied diethylcarbamazine (DEC) and from untreated patients. After DEC many damaged microfilariae were observed either in dermal infiltrates or in epidermal microabscesses consisting both of neutrophils and eosinophils. Infiltrates and microabscesses contained some intact granulocytes and many neutrophils releasing myeloperoxidase, elastase, lactoferrin, defensin, lysozyme, alpha 1-antitrypsin and alpha 1-antichymotrypsin. Eosinophils discharged peroxidase and cationic proteins. Released granule proteins and remnants of disrupted granulocytes were found on the surface and in close proximity of damaged microfilariae in dermal infiltrates and epidermal microabscesses. In larger microabscesses neutrophils were predominant. These observations show that neutrophils and not only eosinophils recruit, accumulate, localize around and release their helminthotoxic granule proteins such as myeloperoxidase onto or closely around skin microfilariae of O. volvulus after topical DEC administration. The association between these processes and the damage of the microfilariae indicated that neutrophils together with eosinophils attack and damage microfilariae of O. volvulus after DEC treatment in the skin.

Setaria digitata microfilaraemia in Mastomys coucha: an animal model for chemotherapeutic and immunobiological studies

Intraperitoneal implantation of adult gravid females of the bovine filarial parasite, Setaria digitata in Mastomys coucha was found to induce microfilaraemia lasting for about 125 days. The microfilariae (mf) could be detected as early as 4 days post-implantation (p.i.) and peak levels of about 30 mf in 20 microliters of blood were observed by 21 days. A significant positive correlation was found between mf density and the body weight of recipients pre-implantation. The implanted adult worms were generally viable only for less than 1 week. Implantation resulted in a significant decrease in total leucocytes and erythrocytes, induction of eosinophilia, splenomegaly and anti-erythrocyte autoantibodies. The microfilariae in circulation developed into 3rd-stage infective larvae (L3) when fed onto Aedes aegypti (refm, Liverpool strain). The mf in circulation were found to be eliminated by oral administration of diethylcarbamazine citrate, indicating the usefulness of this model for screening potential anti-microfilarial drugs. During the microfilaraemic phase, priming with tetanus toxoid (TT) resulted in significantly decreased production of anti-toxin levels indicating a state of generalized immunosuppression. Induction of antibodies to various fractionated antigenic components of adult parasites could be demonstrated by enzyme immunoassay (EIA) in M. coucha implanted with live or cold-stunned adult worms. The S. digitata-M. coucha model thus is found amenable to perform chemotherapeutic and immunobiological investigations in experimental filariasis.

Histological evidence for adulticidal effect of low doses of diethylcarbamazine in bancroftian filariasis

The ability of diethylcarbamazine (DEC) to kill adult Wuchereria bancrofti worms was evaluated by examining lymphatic nodules formed after treatment with 4 different treatment schedules of 193 males living in the endemic area of Greater Recife, Brazil. Lymphatic nodules appeared in the spermatic cord or upper extremities in 43 of 138 microfilaraemic individuals, in 3 of 30 amicrofilaraemic patients with filarial disease manifestations, and in 1 of 25 asymptomatic amicrofilaraemic residents of the endemic area treated with DEC. Fourteen of these nodules were surgically removed 10-150 d after the start of treatment. Regardless of the DEC dosage and schedule used, all nodules contained damaged and degenerating adult worms. An exuberant granulomatous process with large numbers of eosinophils and progressive fibrosis gradually developed around the dead parasites. The mechanism(s) by which DEC killed adult W. bancrofti could not be determined.

Purification and characterization of prostaglandin-H E-isomerase, a sigma-class glutathione S-transferase, from Ascaridia galli

Comparison of partial primary sequences of sigma-class glutathione S-transferases (GSH) of parasitic helminths and a GSH-dependent prostaglandin (PG)-H D-isomerase of rat immune accessory cells suggested that some of the helminth enzymes may also be involved in PG biosynthesis [Meyer and Thomas (1995) Biochem. J. 311, 739-742]. A soluble GSH transferase of the parasitic nematode Ascaridia galli has now been purified which shows high activity and specificity in the GSH-dependent isomerization of PGH to PGE, comparable to that of the rat spleen enzyme in its isomerization of PGH to PGD, and similarly stimulates the activity of prostaglandin H synthase. The enzyme subunit is structurally related to the rat spleen enzyme and sigma-class GSH transferases of helminths according to the partial primary sequence. The data support the hypothesis that some sigma-class GSH transferases of helminth parasites are involved in PG biosynthesis which, in the case of PGE, is likely to be associated with the subversion or suppression of host immunity. A PG-H E-isomerase of comparable specificity and activity has not previously been isolated.

Characterization of rat spleen prostaglandin H D-isomerase as a sigma-class GSH transferase

The prostaglandin H D-isomerase of rat immune accessory cells has been purified from spleen by a simple procedure, and its high specificity and activity [Urade, Fujimoto, Ujihara and Hayaishi (1987) J. Biol. Chem. 262, 3820-3825] have been confirmed in an assay coupled to prostaglandin H synthase. The enzyme also decreases the formation of 12[S]-hydroxy-5,8,10-heptadecatrienoic acid formed by the synthase in the presence of GSH and increases the overall rate of arachidonate oxidation. A partial amino acid sequence shows a strong relationship to GSH transferases of parasitic helminths and molluscs, indicating that it is the first example of a vertebrate sigma-class GSH transferase, and suggesting that certain helminth GSH transferases may be involved in prostaglandin synthesis.

Light and electron microscopy studies on Onchocerca jakutensis and O. flexuosa of red deer show different host-parasite interactions

Adult filariae of two intranodular Onchocerca species of red deer (Cervus elaphus) were examined at the ultrastructural level. In all, 90 nodules of O. flexuosa and 20 nodules of O. jakutensis were studied by histology. O. jakutensis caused cystic and pus-filled nodules in which the female and male worms were motile. Female worms possessed a thick cuticle and a well-developed somatic musculature. The basal lamina of the muscular syncytia was connected with the transhypodermal fibers through long protrusions. The epicuticle had only few protuberances and no visible surface coat. Female O. flexuosa showed morphological features similar to those of other intranodular filariae. A surface coat could not be detected. In 24% of 33 nodules with young live female worms and 40% of 38 nodules with older live female O. flexuosa the worms were surrounded by giant cells apparently attacking a cuticle. This was found even in nodules obtained from animals no older than 9 months. It is probable that the lack of a surface coat protecting the female worm and the inability to move due to the reduced somatic muscles lead to an early elimination of O. flexuosa by the host's immune system.

Preface: positive interactions between anti-infection drugs and the immune response: an emerging paradigm

In the third and fourth decades of this century chemotherapy began to be established as one of the greatest success stories in medicine. Now unfortunately severe problems compromise the efficacy of drugs used to treat infectious diseases, two of the most serious handicaps being the rapidity with which target pathogens can develop drug-resistance and the slow rate at which replacement products are appearing on the market. Increased understanding of the ways in which existing drugs act may help both to prolong their usefulness and to generate novel therapeutic strategies.