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Ramisetty BS, Yang S, Dorlo TPC, Wang MZ. Determining tissue distribution of the oral antileishmanial agent miltefosine: a physiologically-based pharmacokinetic modeling approach. Antimicrob Agents Chemother 2024; 68:e0032824. [PMID: 38842325 PMCID: PMC11232387 DOI: 10.1128/aac.00328-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/15/2024] [Indexed: 06/07/2024] Open
Abstract
Miltefosine (MTS) is the only approved oral drug for treating leishmaniasis caused by intracellular Leishmania parasites that localize in macrophages of the liver, spleen, skin, bone marrow, and lymph nodes. MTS is extensively distributed in tissues and has prolonged elimination half-lives due to its high plasma protein binding, slow metabolic clearance, and minimal urinary excretion. Thus, understanding and predicting the tissue distribution of MTS help assess therapeutic and toxicologic outcomes of MTS, especially in special populations, e.g., pediatrics. In this study, a whole-body physiologically-based pharmacokinetic (PBPK) model of MTS was built on mice and extrapolated to rats and humans. MTS plasma and tissue concentration data obtained by intravenous and oral administration to mice were fitted simultaneously to estimate model parameters. The resulting high tissue-to-plasma partition coefficient values corroborate extensive distribution in all major organs except the bone marrow. Sensitivity analysis suggests that plasma exposure is most susceptible to changes in fraction unbound in plasma. The murine oral-PBPK model was further validated by assessing overlay of simulations with plasma and tissue profiles obtained from an independent study. Subsequently, the murine PBPK model was extrapolated to rats and humans based on species-specific physiological and drug-related parameters, as well as allometrically scaled parameters. Fold errors for pharmacokinetic parameters were within acceptable range in both extrapolated models, except for a slight underprediction in the human plasma exposure. These animal and human PBPK models are expected to provide reliable estimates of MTS tissue distribution and assist dose regimen optimization in special populations.
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Affiliation(s)
| | - Sihyung Yang
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas, USA
| | - Thomas P. C. Dorlo
- Pharmacometrics Research Group, Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Michael Zhuo Wang
- Department of Pharmaceutical Chemistry, The University of Kansas, Lawrence, Kansas, USA
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2
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Hargrove T, Lamb DC, Wawrzak Z, Hull M, Kelly SL, Guengerich FP, Lepesheva GI. Identification of Potent and Selective Inhibitors of Acanthamoeba: Structural Insights into Sterol 14α-Demethylase as a Key Drug Target. J Med Chem 2024; 67:7443-7457. [PMID: 38683753 PMCID: PMC11089504 DOI: 10.1021/acs.jmedchem.4c00303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/27/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
Acanthamoeba are free-living pathogenic protozoa that cause blinding keratitis, disseminated infection, and granulomatous amebic encephalitis, which is generally fatal. The development of efficient and safe drugs is a critical unmet need. Acanthamoeba sterol 14α-demethylase (CYP51) is an essential enzyme of the sterol biosynthetic pathway. Repurposing antifungal azoles for amoebic infections has been reported, but their inhibitory effects on Acanthamoeba CYP51 enzymatic activity have not been studied. Here, we report catalytic properties, inhibition, and structural characterization of CYP51 from Acanthamoeba castellanii. The enzyme displays a 100-fold substrate preference for obtusifoliol over lanosterol, supporting the plant-like cycloartenol-based pathway in the pathogen. The strongest inhibition was observed with voriconazole (1 h IC50 0.45 μM), VT1598 (0.25 μM), and VT1161 (0.20 μM). The crystal structures of A. castellanii CYP51 with bound VT1161 (2.24 Å) and without an inhibitor (1.95 Å), presented here, can be used in the development of azole-based scaffolds to achieve optimal amoebicidal effectiveness.
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Affiliation(s)
- Tatiana
Y. Hargrove
- Department
of Biochemistry, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - David C. Lamb
- Faculty
of Medicine, Health and Life Science, Swansea
University, Swansea SA2 8PP, U.K.
| | - Zdzislaw Wawrzak
- Synchrotron
Research Center, Life Science Collaborative Access Team, Northwestern University, Argonne, Illinois 60439, United States
| | - Marcus Hull
- Faculty
of Medicine, Health and Life Science, Swansea
University, Swansea SA2 8PP, U.K.
| | - Steven L. Kelly
- Faculty
of Medicine, Health and Life Science, Swansea
University, Swansea SA2 8PP, U.K.
| | - F. Peter Guengerich
- Department
of Biochemistry, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
| | - Galina I. Lepesheva
- Department
of Biochemistry, Vanderbilt University School
of Medicine, Nashville, Tennessee 37232, United States
- Vanderbilt
Institute of Chemical Biology, Nashville, Tennessee 37232, United States
- Center
for Structural Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
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3
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Spottiswoode N, Haston JC, Hanners NW, Gruenberg K, Kim A, DeRisi JL, Wilson MR. Challenges and advances in the medical treatment of granulomatous amebic encephalitis. Ther Adv Infect Dis 2024; 11:20499361241228340. [PMID: 38312848 PMCID: PMC10838035 DOI: 10.1177/20499361241228340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024] Open
Abstract
Granulomatous amebic encephalitis, caused by the free-living amebae Balamuthia mandrillaris or Acanthamoeba species, is a rare and deadly infectious syndrome with a current mortality rate of >90%. Much work remains to define the optimal treatment for these infections. Here, we provide a comprehensive overview of the supporting evidence behind antimicrobials currently recommended by the Centers for Disease Control and Prevention (CDC) with updated statistics on survival rates and medication usage from the CDC Free-Living Ameba Database. We also discuss promising treatments, especially the emerging therapeutic agent nitroxoline, and provide recommendations for the next steps in this area.
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Affiliation(s)
- Natasha Spottiswoode
- Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Julia C. Haston
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Natasha W. Hanners
- Division of Pediatric Infectious Diseases, University of Texas Southwestern, Dallas, TX, USA
| | - Katherine Gruenberg
- Department of Clinical Pharmacy, University of California San Francisco School of Pharmacy, San Francisco, CA, USA
| | - Annie Kim
- Department of Clinical Pharmacy, Zuckerberg San Francisco General, San Francisco, CA, USA
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub SF, San Francisco, CA, USA
| | - Michael R. Wilson
- Weill Institute for Neurosciences, Department of Neurology, University of California San Francisco, San Francisco, CA 94143, USA
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4
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Wang F, Shen F, Dai W, Zhao J, Chen X, Liu J. A primary amoebic meningoencephalitis case associated with swimming in seawater. Parasitol Res 2023; 122:2451-2452. [PMID: 37555856 DOI: 10.1007/s00436-023-07934-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/01/2023] [Indexed: 08/10/2023]
Abstract
This case report describes a 62-year-old male fisherman who presented with persistent vomiting, headache, and behavior changes. Despite initial antibiotic and corticosteroid treatment, his condition worsened, leading to coma and subsequent death. Macro-genome sequencing of cerebrospinal fluid (CSF) revealed the presence of Naegleria fowleri infection, which had been missed during initial laboratory tests. The patient's exposure history included sea-swimming near Zhoushan Island.
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Affiliation(s)
- Feng Wang
- Department of Laboratory Medicine, The First Affiliated Hospital of Ningbo University, Ningbo University, Ningbo, China
| | - Fuping Shen
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, 548 Binwen Road, Zhejiang, Hangzhou, China
| | - Wenchu Dai
- Department of Clinical Laboratory, Xian No. 1 Hospital, Xi'an, Shaanxi, China
| | - Jiwei Zhao
- Department of Laboratory Medicine, Nanjing Lishui District Hospital of Traditional Chinese Medicine, Nanjing, Jiangsu, China
| | - Xiaojuan Chen
- Department of Laboratory Medicine, The Second Affiliated Hospital of Hainan Medical University, Hainan, Haikou, 570311, China.
| | - Jinlin Liu
- Department of Clinical Laboratory, South China Hospital, Medical School, Shenzhen University, 1 Fuxin Road, Shenzhen, 518111, China.
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5
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Chen L, Kuang L, Ross AE, Farhat W, Boychev N, Sharfi S, Kanu LN, Liu L, Kohane DS, Ciolino JB. Topical Sustained Delivery of Miltefosine Via Drug-Eluting Contact Lenses to Treat Acanthamoeba Keratitis. Pharmaceutics 2022; 14:pharmaceutics14122750. [PMID: 36559244 PMCID: PMC9781349 DOI: 10.3390/pharmaceutics14122750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
This study aimed to develop a miltefosine-eluting contact lens (MLF-CL) device that would allow sustained and localized miltefosine release for the treatment of Acanthamoeba keratitis. MLF-CLs were produced in three different miltefosine doses by solvent-casting a thin miltefosine-polymer film around the periphery of a methafilcon hydrogel, which was then lathed into a contact lens. During seven days of in vitro testing, all three formulations demonstrated sustained release from the lens at theoretically therapeutic levels. Based on the physicochemical characterization of MLF-CLs, MLF-CL's physical properties are not significantly different from commercial contact lenses in terms of light transmittance, water content and wettability. MLF-CLs possessed a slight reduction in compression modulus that was attributed to the inclusion of polymer-drug films but still remain within the optimal range of soft contact lenses. In cytotoxicity studies, MLF-CL indicated up to 91% viability, which decreased proportionally as miltefosine loading increased. A three-day biocompatibility test on New Zealand White rabbits revealed no impact of MLF-CLs on the corneal tissue. The MLF-CLs provided sustained in vitro release of miltefosine for a week while maintaining comparable physical features to a commercial contact lens. MLF-CL has a promising potential to be used as a successful treatment method for Acanthamoeba keratitis.
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Affiliation(s)
- Lin Chen
- Department of Optometry and Visual Science, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Ophthalmology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Liangju Kuang
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
- Correspondence: (L.K.); (J.B.C.)
| | - Amy E. Ross
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Wissam Farhat
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Nikolay Boychev
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Sina Sharfi
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Levi N. Kanu
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
| | - Longqian Liu
- Department of Optometry and Visual Science, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Daniel S. Kohane
- Department of Anesthesia, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Joseph B. Ciolino
- Department of Ophthalmology, Schepens Eye Research Institute of Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA
- Correspondence: (L.K.); (J.B.C.)
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6
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Damhorst GL, Watts A, Hernandez-Romieu A, Mel N, Palmore M, Ali IKM, Neill SG, Kalapila A, Cope JR. Acanthamoeba castellanii encephalitis in a patient with AIDS: a case report and literature review. THE LANCET. INFECTIOUS DISEASES 2022; 22:e59-e65. [PMID: 34461057 PMCID: PMC10910629 DOI: 10.1016/s1473-3099(20)30933-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 11/17/2022]
Abstract
Amoebic encephalitis is a rare cause of CNS infection for which mortality exceeds 90%. We present the case of a 27-year-old man with AIDS who presented to a hospital in Atlanta (Georgia, USA) with tonic-clonic seizures and headache. His clinical condition deteriorated over several days. Brain biopsy revealed lymphohistiocytic inflammation and necrosis with trophozoites and encysted forms of amoebae. Immunohistochemical and PCR testing confirmed Acanthamoeba castellanii encephalitis, typically described as granulomatous amoebic encephalitis (GAE). No proven therapy for GAE is available, although both surgical and multiagent antimicrobial treatment strategies are often used. Most recently, these include the antileishmanial agent miltefosine. Here we review all cases of GAE due to Acanthamoeba spp in people with HIV/AIDS identified in the literature and reported to the Centers for Disease Control and Prevention. We describe this case as a reminder to the clinician to consider protozoal infections, especially free-living amoeba, in the immunocompromised host with a CNS infection refractory to traditional antimicrobial therapy.
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Affiliation(s)
- Gregory L Damhorst
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, USA.
| | - Abigail Watts
- Division of Pulmonary Critical Care & Sleep Medicine and Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | | | - Nonglin Mel
- Family Medicine, Broward Health, Fort Lauderdale, FL, USA
| | - Melody Palmore
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Ibne Karim M Ali
- Free-Living and Intestinal Amebas (FLIA) Laboratory, Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Stewart G Neill
- Department of Pathology & Laboratory Medicine, Emory University, Atlanta, GA, USA
| | - Aley Kalapila
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer R Cope
- Domestic Water, Sanitation, and Hygiene Epidemiology Team, Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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7
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Alli A, Ortiz JF, Morillo Cox Á, Armas M, Orellana VA. Miltefosine: A Miracle Drug for Meningoencephalitis Caused by Free-Living Amoebas. Cureus 2021; 13:e13698. [PMID: 33833918 PMCID: PMC8020194 DOI: 10.7759/cureus.13698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 11/05/2022] Open
Abstract
Meningoencephalitis caused by free-living amoebas (FLA) has a high mortality rate, and most treatments are ineffective. FLA includes Naegleria, Fowleri, Acanthamoeba, and Balamuthia mandrillaris (M). We explore the use of miltefosine in the treatment of one of these infections. The concerning mortality of the infection obligates us to look for more effective treatments for meningoencephalitis caused by FLA. During this review, we will consolidate the knowledge of using miltefosine in these three infections. We will investigate the mechanism by which the drug is effective in these infections as well. After this comprehensive review, we should assess if miltefosine improves the mortality and prognosis of the infection with the information collected. We used a Medical Subject Headings (MeSH) search on PubMed. Inclusion criteria included papers written in the English language and human subjects research for the past 25 years. Until today, there are no definitive guidelines to be followed when treating such patients. However, miltefosine has demonstrated promising results. Miltefosine decreases the usual mortality rate in the three infections; however, there are few reports due to the low frequency of these infections. Almost all cases we documented have survived. More information needs to be gathered for the use of miltefosine for these infections.
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Affiliation(s)
- Ammar Alli
- Internal Medicine, Tishreen University Faculty of Medicine, Lattakia, SYR
- Internal Medicine, Universitat de Barcelona, Barcelona, ESP
| | - Juan Fernando Ortiz
- Neurology, Universidad San Francisco de Quito, Quito, ECU
- Neurology, Larkin Community Hospital, Miami, USA
| | | | - Maria Armas
- Surgery, Pontificia Universidad Catolica del Ecuador, Quito, ECU
| | - Victor A Orellana
- Obstetrics and Gynecology, Pontifica Universidad Católica del Ecuador, Quito, ECU
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8
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Taravaud A, Fechtali-Moute Z, Loiseau PM, Pomel S. Drugs used for the treatment of cerebral and disseminated infections caused by free-living amoebae. Clin Transl Sci 2021; 14:791-805. [PMID: 33650319 PMCID: PMC8212752 DOI: 10.1111/cts.12955] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/25/2020] [Accepted: 11/25/2020] [Indexed: 01/29/2023] Open
Abstract
Free‐living amoebae (FLAs) are protozoa developing autonomously in diverse natural or artificial environments. The FLAs Acanthamoeba spp., Balamuthia mandrillaris, and Naegleria fowleri represent a risk for human health as they can become pathogenic and cause severe cerebral infections, named granulomatous amoebic encephalitis (GAE), Balamuthia amoebic encephalitis (BAE), and primary amoebic meningoencephalitis (PAM), respectively. Additionally, Acanthamoeba sp. can also rarely disseminate to diverse organs, such as the skin, sinuses, or bones, and cause extracerebral disseminated acanthamebiasis (EDA). No consensus treatment has been established for cerebral FLA infections or EDA. The therapy of cerebral and disseminated FLA infections often empirically associates a large diversity of drugs, all exhibiting a high toxicity. Nevertheless, these pathologies lead to a high mortality, above 90% of the cases, even in the presence of a treatment. In the present work, a total of 474 clinical cases of FLA infections gathered from the literature allowed to determine the frequency of usage, as well as the efficacy of the main drugs and drug combinations used in the treatment of these pathologies. The efficacy of drug usage was determined based on the survival rate after drug administration. The most efficient drugs, drug combinations, and their mechanism of action were discussed in regard to the present recommendations for the treatment of GAE, EDA, BAE, and PAM. At the end, this review aims to provide a useful tool for physicians in their choice to optimize the treatment of FLA infections.
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Affiliation(s)
- Alexandre Taravaud
- BioCIS, Université Paris-Sud, CNRS, Université Paris-Saclay, Châtenay-Malabry, France
| | - Zineb Fechtali-Moute
- BioCIS, Université Paris-Sud, CNRS, Université Paris-Saclay, Châtenay-Malabry, France
| | - Philippe M Loiseau
- BioCIS, Université Paris-Sud, CNRS, Université Paris-Saclay, Châtenay-Malabry, France
| | - Sébastien Pomel
- BioCIS, Université Paris-Sud, CNRS, Université Paris-Saclay, Châtenay-Malabry, France
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9
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Inhibition of Fatty Acid Oxidation as a New Target To Treat Primary Amoebic Meningoencephalitis. Antimicrob Agents Chemother 2020; 64:AAC.00344-20. [PMID: 32513800 PMCID: PMC7526813 DOI: 10.1128/aac.00344-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022] Open
Abstract
Primary amoebic meningoencephalitis (PAM) is a rapidly fatal infection caused by the free-living amoeba Naegleria fowleri. The amoeba migrates along the olfactory nerve to the brain, resulting in seizures, coma, and, eventually, death. Previous research has shown that Naegleria gruberi, a close relative of N. fowleri, prefers lipids over glucose as an energy source. Therefore, we tested several already-approved inhibitors of fatty acid oxidation alongside the currently used drugs amphotericin B and miltefosine. Primary amoebic meningoencephalitis (PAM) is a rapidly fatal infection caused by the free-living amoeba Naegleria fowleri. The amoeba migrates along the olfactory nerve to the brain, resulting in seizures, coma, and, eventually, death. Previous research has shown that Naegleria gruberi, a close relative of N. fowleri, prefers lipids over glucose as an energy source. Therefore, we tested several already-approved inhibitors of fatty acid oxidation alongside the currently used drugs amphotericin B and miltefosine. Our data demonstrate that etomoxir, orlistat, perhexiline, thioridazine, and valproic acid inhibited growth of N. gruberi. We then tested these compounds on N. fowleri and found etomoxir, perhexiline, and thioridazine to be effective growth inhibitors. Hence, not only are lipids the preferred food source for N. gruberi, but also oxidation of fatty acids seems to be essential for growth of N. fowleri. Inhibition of fatty acid oxidation could result in new treatment options, as thioridazine inhibits N. fowleri growth in concentrations that can be reached at the site of infection. It could also potentiate currently used therapy, as checkerboard assays revealed synergy between miltefosine and etomoxir. Animal testing should be performed to confirm the added value of these inhibitors. Although the development of new drugs and randomized controlled trials for this rare disease are nearly impossible, inhibition of fatty acid oxidation seems a promising strategy as we showed effectivity of several drugs that are or have been in use and that thus could be repurposed to treat PAM in the future.
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