An analysis of the development of resistance to metachloridine in clones of Plasmodium gallinaceum

An analysis of the development of resistance to proguanil and pyrimethamine in Plasmodium gallinaceum

1. The development of resistance to proguanil and pyrimethamine was studied in a clone of Plasmodium gallinaceum (strain A) derived from a single erythrocytic parasite and maintained by a standard method of serial inoculations in young chicks.

2. The rate of the development of resistance to 0·05 mg./20 g. doses of proguanil was compared in strains maintained by inocula of 5 × 107, 108 and 109 parasites. Some evidence was obtained that the rate of the development of resistance to the drug was related to the numbers of parasites in the inocula.

3. No correlation was observed between the rate of the development of resistance to pyrimethamine and the size of the population of parasites exposed to its action in strains treated with 0·001 g./20 g. doses of the drug and maintained by inocula of 5 × 107 parasites or 109 parasites; but a greater variability was observed in the rate in the strains maintained by the small inocula than in the strains maintained by the large inocula. Resistance appeared to develop sporadically.

4. Some evidence was obtained that strains treated with a high dose of pyrimethamine (0·05 mg./20 g.) might become more sensitive to the drug as a result of treatment. In three experiments the infections were eradicated by the second or third course of treatment with the drug. However, strains which withstood this dose, developed resistance as rapidly, or more rapidly than those treated with 0·001 mg./20 g. doses. There was therefore no evidence from these experiments with pyrimethamine that resistance to the drug could be produced more readily with small than with large doses of the drug.

5. Except for slight variations, resistance to proguanil developed concurrently with resistance to pyrimethamine in strains treated with that drug.

6. In many of the strains, whether treated with proguanil or with pyrimethamine, resistance appeared to develop quite suddenly, but in others it developed more gradually. The pattern of the development of resistance in strains treated with either of these drugs could be explained by the selection of spontaneously occurring mutants, though some of the data suggested that the mutants differed in degree of resistance to the drug.

7. The rate of development of resistance to pyrimethamine was studied in strains derived from primary inocula composed of known numbers of pyrimethamine resistant parasites and 5 × 107 parasites of the untreated strain A. The addition of at least 106 resistant parasites to the inoculum was required to produce an increase in parasitaemia during the subsequent course of treatment with the drug, but the addition of 102 resistant parasites or, in some experiments, fewer than 102 resistant parasites to the primary inoculum was sufficient to produce a heavy parasitaemia during the second serial course of treatment if the strain was maintained by the standard method (p. 496). When these results are compared with the pattern of the development of resistance to pyrimethamine in the strains treated with that drug, it can be concluded that only in one strain was there any evidence that resistant parasites were present in the primary inoculum when it consisted only of parasites of the untreated parent strain. The rate of development of resistance in many of the strains treated with either proguanil or pyrimethamine suggested a mutation rate of a low frequency.

Resistance to diamino-diphenylsulphone in Plasmodium gallinaceum

A fourfold enhancement of resistance to diamino-diphenylsulphone has been produced over a period of 15 months in strain A of P. gallinaceum by subjecting the strain, maintained in a state of patent infection, to increasing doses of the drug.

The DDS-resistant strain was cross-resistant to the minimum effective dose of sulphadiazine and slightly resistant to twice this dose, but it showed only a slight enhancement of resistance to pyrimethamine and proguanil.

The antimalarial action of DDS was antagonized by p–A.B. in the ratio of 100 to 1. DDS, in the minimum effective dose, was antagonized completely by folic acid if given in equal doses, but not by smaller doses of the antagonist; the antagonism was not competitive.

The relationship of cross-resistance between p–A.B.-inhibited sulphonamides and proguanil and pyrimethamine is discussed.

Mechanisms of resistance of malaria parasites to antifolates

Antifolate antimalarial drugs interfere with folate metabolism, a pathway essential to malaria parasite survival. This class of drugs includes effective causal prophylactic and therapeutic agents, some of which act synergistically when used in combination. Unfortunately, the antifolates have proven susceptible to resistance in the malaria parasite. Resistance is caused by point mutations in dihydrofolate reductase and dihydropteroate synthase, the two key enzymes in the folate biosynthetic pathway that are targeted by the antifolates. Resistance to these drugs arises relatively rapidly in response to drug pressure and is now common worldwide. Nevertheless, antifolate drugs remain first-line agents in several sub-Saharan African countries where chloroquine resistance is widespread, at least partially because they remain the only affordable, effective alternative. New antifolate combinations that are more effective against resistant parasites are being developed and in one case, recently introduced into use. Combining these antifolates with drugs that act on different targets in the parasite should greatly enhance their effectiveness as well as deter the development of resistance. Molecular epidemiological techniques for monitoring parasite drug resistance may contribute to development of strategies for prolonging the useful therapeutic life of this important class of drugs.

Mutation rates in the dihydrofolate reductase gene of Plasmodium falciparum

A new method has been established to define the limits on a spontaneous mutation rate for a gene in Plasmodium falciparum. The method combines mathematical modelling and large-scale in vitro culturing and calculates the difference in mutant frequencies at 2 separate time-points. We measured the mutation rate at 2 positions in the dihydrofolate reductase (DHFR) gene of 3D7, a pyrimethamine-sensitive line of P. falciparum. This line was re-cloned and an effectively large population was treated with a selective pyrimethamine concentration of 40 nM. We detected point mutations at codon-46 (TTA to TCA) and codon-108 (AGC to AAC), resulting in serine replacing leucine and asparagine replacing serine respectively in the corresponding gene product. The substitutions caused a decrease in pyrimethamine sensitivity. By mathematical modelling we determined that the mutation rate at a given position in DHFR was low and occurred at less than 2.5 x 10(-9) mutations/DHFR gene/replication. This result has important implications for Plasmodium genetic diversity and antimalarial drug therapy by demonstrating that even with low mutation rates anti-malarial resistance will inevitably arise when mutant alleles are selected under drug pressure.

Implications of genetic exchange in the study of protozoan infections

Genetic exchange is now known to occur during the life-cycle of many parasitic protozoa, including malaria parasites, coccidia and trypanosomes. The process is studied by making deliberate crosses between cloned organisms differing in clearly defined markers. In malaria parasites, crosses have been made between parasites differing in characters such as isoenzymes, antigens and other proteins, drug sensitivity, and chromosome and other DNA polymorphisms. Crosses are made by transmitting a mixture of gametes of each clone through mosquitoes to allow cross-fertilization to take place, and examining the resulting progeny by cloning for organisms exhibiting non-parental combinations of characters. The inheritance of many characters, such as antigen and protein variants, is in accordance with Mendelian expectations for a haploid organism. Recombination occurs at a higher than expected frequency. Studies on chromosomes have show that crossing-over events commonly occur following meiosis of hybrid zygotes. Repetitive DNA and subtelomeric regions of chromosomes appear to be particularly susceptible to such recombination events. In trypanosomes, crosses between clones of Trypanosoma brucei have shown that hybrids are formed during tsetse fly transmission. The organism appears to be mainly diploid, but some characters including certain chromosomes seem to be inherited in a non-Mendelian manner.

Sex determination and sex differentiation in coccidia: gametogony and oocyst production after monoclonal infection of cats with free-living and intermediate host stages of Isospora (Toxoplasma) gondii

Clones of single oocysts, single sporocysts, single sporozoites, single proliferative parasites, single cysts and single cystozoites of Isospora (Toxoplasma) gondii (KB-strain) were made under visual control using a de Fonbrune micromanipulator. Cloning was successful in 28, 32, 21, 8, 54 and 7% of the trials, respectively. All clones were used for monoclonal infection in non-immune conventionally reared (CV) or specified pathogen-free (SPF) cats. Pre-patent and patent periods, sporulation percentages of excreted oocysts, mouse infectivity of sporulated oocysts, antibody response and immunity to reinfection of CV cats were determined. For these parameters almost no differences were observed between monoclonal infections and infections described with the non-cloned KB-strain. In all cats autopsied during the patent period, 5-8 days post-infection, macrogametes, microgametes and oocysts were found. Since meiosis occurs during sporulation and since all free-living and intermediate host stages proved to be bisexual, it is concluded that sex differentiation in I. (T) gondii is not determined by segregation of sex chromosomes or sex genes but is caused by some final host factor(s) that induce(s) differential gene expression in genetically identical cells.

The genetic basis of diversity in malaria parasites

The principal findings of the P. falciparum surveys are given below. Considerable diversity of enzymes, antigens, drug sensitivity and other characters is seen among P. falciparum isolates. Cloning studies show that certain isolates contain mixtures of parasites which may be diverse in one or more of these characters. No obvious regional distribution is seen in the enzymic and antigenic characters examined, although differences in the frequencies of certain enzymes appear to exist. Variations in drug sensitivity are seen among parasites from different regions, the occurrence of resistant forms usually being correlated with the extent of use of the drug concerned.

Resistance to primaquine in Plasmodium gallinaceum, and the problem of resistance to quinoline compounds in malaria parasites

A tenfold enhancement of resistance to primaquine was obtained by maintaining a strain of Plasmodium gallinaceum in a state of acute infection by serial passage of infected blood through young chicks treated with gradually increasing doses of the drug.

No loss in resistance to primaquine was observed when the resistant strain was transmitted through mosquitoes, though there was some loss in resistance to the maximum tolerated dose, but not to lower doses, when the strain was maintained in a state of acute infection through untreated chicks for 41 weeks.

The primaquine-resistant strain was cross-resistant to lower effective doses of pamaquin, and slightly less sensitive to quinine than the parent strain but the loss in sensitivity to chloroquine was only marginal. Sensitivity to proguanil, dihydrotriazine and pyrimethamine was normal.

Attempts were made to produce a chloroquine-resistant strain of P. gallinaceum using different doses of the drug but no change in sensitivity was observed though the experiments were continued for more than a year. An attempt to produce a chloroquine-resistant strain by treatment of a proguanil-resistant strain with chloroquine also failed.

The problem of resistance to quinoline compounds in different species of Plasmodium is discussed.

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.