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Kast RE, Alfieri A, Assi HI, Burns TC, Elyamany AM, Gonzalez-Cao M, Karpel-Massler G, Marosi C, Salacz ME, Sardi I, Van Vlierberghe P, Zaghloul MS, Halatsch ME. MDACT: A New Principle of Adjunctive Cancer Treatment Using Combinations of Multiple Repurposed Drugs, with an Example Regimen. Cancers (Basel) 2022; 14:2563. [PMID: 35626167 PMCID: PMC9140192 DOI: 10.3390/cancers14102563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/11/2022] [Accepted: 05/17/2022] [Indexed: 12/12/2022] Open
Abstract
In part one of this two-part paper, we present eight principles that we believe must be considered for more effective treatment of the currently incurable cancers. These are addressed by multidrug adjunctive cancer treatment (MDACT), which uses multiple repurposed non-oncology drugs, not primarily to kill malignant cells, but rather to reduce the malignant cells' growth drives. Previous multidrug regimens have used MDACT principles, e.g., the CUSP9v3 glioblastoma treatment. MDACT is an amalgam of (1) the principle that to be effective in stopping a chain of events leading to an undesired outcome, one must break more than one link; (2) the principle of Palmer et al. of achieving fractional cancer cell killing via multiple drugs with independent mechanisms of action; (3) the principle of shaping versus decisive operations, both being required for successful cancer treatment; (4) an idea adapted from Chow et al., of using multiple cytotoxic medicines at low doses; (5) the idea behind CUSP9v3, using many non-oncology CNS-penetrant drugs from general medical practice, repurposed to block tumor survival paths; (6) the concept from chess that every move creates weaknesses and strengths; (7) the principle of mass-by adding force to a given effort, the chances of achieving the goal increase; and (8) the principle of blocking parallel signaling pathways. Part two gives an example MDACT regimen, gMDACT, which uses six repurposed drugs-celecoxib, dapsone, disulfiram, itraconazole, pyrimethamine, and telmisartan-to interfere with growth-driving elements common to cholangiocarcinoma, colon adenocarcinoma, glioblastoma, and non-small-cell lung cancer. gMDACT is another example of-not a replacement for-previous multidrug regimens already in clinical use, such as CUSP9v3. MDACT regimens are designed as adjuvants to be used with cytotoxic drugs.
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Affiliation(s)
| | - Alex Alfieri
- Department of Neurosurgery, Cantonal Hospital of Winterthur, 8400 Winterthur, Switzerland; (A.A.); (M.-E.H.)
| | - Hazem I. Assi
- Naef K. Basile Cancer Center, American University of Beirut, Beirut 1100, Lebanon;
| | - Terry C. Burns
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Ashraf M. Elyamany
- Oncology Unit, Hemato-Oncology Department, SECI Assiut University Egypt/King Saud Medical City, Riyadh 7790, Saudi Arabia;
| | - Maria Gonzalez-Cao
- Translational Cancer Research Unit, Dexeus University Hospital, 08028 Barcelona, Spain;
| | | | - Christine Marosi
- Clinical Division of Medical Oncology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria;
| | - Michael E. Salacz
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA;
| | - Iacopo Sardi
- Department of Pediatric Oncology, Meyer Children’s Hospital, Viale Pieraccini 24, 50139 Florence, Italy;
| | - Pieter Van Vlierberghe
- Department of Biomolecular Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium;
| | - Mohamed S. Zaghloul
- Children’s Cancer Hospital & National Cancer Institute, Cairo University, Cairo 11796, Egypt;
| | - Marc-Eric Halatsch
- Department of Neurosurgery, Cantonal Hospital of Winterthur, 8400 Winterthur, Switzerland; (A.A.); (M.-E.H.)
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Xu N, Fu Y, Zhang X, Liu Y, Yang Y, Zhou S, Dong J, Yang Q, Ai X. The pharmacokinetic characteristics of sulfadiazine in channel catfish (Ictalurus punctatus) following oral and intravenous administrations. J Vet Pharmacol Ther 2021; 45:16-22. [PMID: 34779521 DOI: 10.1111/jvp.13032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022]
Abstract
This study aimed to determine the bioavailability and pharmacokinetic parameters of sulfadiazine (SDZ) in channel catfish (Ictalurus punctatus) following oral gavage and intravenous injection. The healthy channel catfish were orally and intravenously administrated with SDZ solution at doses of 50 and 5 mg/kg, respectively. Plasma samples were determined by ultra-performance liquid chromatography with an ultraviolet detector. The results demonstrated that the concentration-time profile of SDZ after oral dosing was best described by a one-compartmental open model with first-order absorption. The absorption half-life (t1/2Kα ), the elimination half-life (t1/2Ke ), and the area under concentration-time profile (AUC0-∞ ) were estimated to be 0.87 h, 29.04 h, and 1311.72 mg.h/L, respectively. After intravenous administration, the concentration-time curve of SDZ conformed to a two-compartmental open model without absorption. The distribution half-life (t1/2α ), the elimination half-life (t1/2β ), the apparent distribution volume (Vss ), the total clearance (CL), and AUC0-∞ were calculated to be 0.19 h, 14.24 h, 0.36 L/kg, 0.018 L/h/kg, and 277.12 mg.h/L, respectively. Finally, the bioavailability was estimated to be 47.33%. This study will provide some useful information for the modification of the dosage form of SDZ in aquaculture, and is partly beneficial for appropriate use of SDZ in the future.
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Affiliation(s)
- Ning Xu
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China
| | - Yu Fu
- Hunan University of Arts and Science, Changde, China
| | | | - Yongtao Liu
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China.,Key Laboratory of Control of Quality and Safety for Aquatic Products, Ministry of Agriculture, Beijing, China
| | - Yibin Yang
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China
| | - Shun Zhou
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China
| | - Jing Dong
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China
| | - Qiuhong Yang
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China
| | - Xiaohui Ai
- Yangtze River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Wuhan, China.,Hu Bei Province Engineering and Technology Research Center of Aquatic Product Quality and Safety, Wuhan, China.,Key Laboratory of Control of Quality and Safety for Aquatic Products, Ministry of Agriculture, Beijing, China
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OPALS: A New Osimertinib Adjunctive Treatment of Lung Adenocarcinoma or Glioblastoma Using Five Repurposed Drugs. Cells 2021; 10:cells10051148. [PMID: 34068720 PMCID: PMC8151869 DOI: 10.3390/cells10051148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/30/2021] [Accepted: 05/07/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Pharmacological targeting aberrant activation of epidermal growth factor receptor tyrosine kinase signaling is an established approach to treating lung adenocarcinoma. Osimertinib is a tyrosine kinase approved and effective in treating lung adenocarcinomas that have one of several common activating mutations in epidermal growth factor receptor. The emergence of resistance to osimertinib after a year or two is the rule. We developed a five-drug adjuvant regimen designed to increase osimertinib’s growth inhibition and thereby delay the development of resistance. Areas of Uncertainty: Although the assembled preclinical data is strong, preclinical data and the following clinical trial results can be discrepant. The safety of OPALS drugs when used individually is excellent. We have no data from humans on their tolerability when used as an ensemble. That there is no data from the individual drugs to suspect problematic interaction does not exclude the possibility. Data Sources: All relevant PubMed.org articles on the OPALS drugs and corresponding pathophysiology of lung adenocarcinoma and glioblastoma were reviewed. Therapeutic Opinion: The five drugs of OPALS are in wide use in general medicine for non-oncology indications. OPALS uses the anti-protozoal drug pyrimethamine, the antihistamine cyproheptadine, the antibiotic azithromycin, the antihistamine loratadine, and the potassium sparing diuretic spironolactone. We show how these inexpensive and generically available drugs intersect with and inhibit lung adenocarcinoma growth drive. We also review data showing that both OPALS adjuvant drugs and osimertinib have data showing they may be active in suppressing glioblastoma growth.
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Reiter-Owona I, Hlobil H, Enders M, Klarmann-Schulz U, Gruetzmacher B, Rilling V, Hoerauf A, Garweg JG. Sulfadiazine plasma concentrations in women with pregnancy-acquired compared to ocular toxoplasmosis under pyrimethamine and sulfadiazine therapy: a case-control study. Eur J Med Res 2020; 25:59. [PMID: 33228795 PMCID: PMC7686675 DOI: 10.1186/s40001-020-00458-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Dosing recommendations for the treatment of pregnancy-acquired toxoplasmosis are empirical and widely based on experimental data. There are no pharmacological data on pregnant women with acute Toxoplasma gondii infection under treatment with pyrimethamine (PY) and sulfadiazine (SA) and our study intends to tighten this gap. Methods In this retrospective case–control study, we included 89 pregnant women with primary Toxoplasma infection (PT) treated with PY (50 mg first dose, then 25 mg/day), SA (50 mg/kg of body weight/day), and folinic acid (10–15 mg per week). These were compared to a group of 17 women with acute ocular toxoplasmosis (OT) treated with an initial PY dose of 75 mg, thereafter 25 mg twice a day but on the same SA and folinic acid regimen. The exact interval between drug intake and blood sampling and co-medication had not been recorded. Plasma levels of PY and SA were determined 14 ± 4 days after treatment initiation using liquid chromatography–mass spectrometry and compared using the Mann–Whitney U test at a p < 0.05 level. Results In 23 PT patients (26%), SA levels were below 20 mg/l. Fifteen of these 23 patients (17% of all patients) in parallel presented with PY levels below 700 µg/l. Both drug concentrations differed remarkably between individuals and groups (PY: PT median 810 µg/l, 95% CI for the median [745; 917] vs. OT 1230 µg/l [780; 1890], p = 0.006; SA: PT 46.2 mg/l [39.9; 54.4] vs. OT 70.4 mg/l [52.4; 89], p = 0.015) despite an identical SA dosing scheme. Conclusions SA plasma concentrations were found in the median 34% lower in pregnant women with PT compared to OT patients and fell below a lower reference value of 50 mg/l in a substantial portion of PT patients. The interindividual variability of plasma concentrations in combination with systematically lower drug levels and possibly a lower compliance in pregnant women may thus account for a still not yet supportable transmission risk. Systematic drug-level testing in PT under PY/SA treatment deserves to be considered.
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Affiliation(s)
- Ingrid Reiter-Owona
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital of Bonn, Bonn, Germany
| | | | - Martin Enders
- Labor Prof. Gisela Enders Und Kollegen, Stuttgart, Germany
| | - Ute Klarmann-Schulz
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital of Bonn, Bonn, Germany.,Institute for Medical Biometry, Informatics and Epidemiology, University Hospital of Bonn, Bonn, Germany.,Deutsches Zentrum Für Infektionsforschung (DZIF) E. V., Braunschweig, Germany
| | - Barbara Gruetzmacher
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital of Bonn, Bonn, Germany
| | | | - Achim Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital of Bonn, Bonn, Germany.,Deutsches Zentrum Für Infektionsforschung (DZIF) E. V., Braunschweig, Germany
| | - Justus G Garweg
- Swiss Eye Institute, Berner Augenklinik am Lindenhofspital, Bremgartenstrasse 119, CH-3012, Bern, Switzerland. .,Department of Ophthalmology, Inselspital, University of Bern, Bern, Switzerland.
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Picone O, Fuchs F, Benoist G, Binquet C, Kieffer F, Wallon M, Wehbe K, Mandelbrot L, Villena I. Toxoplasmosis screening during pregnancy in France: Opinion of an expert panel for the CNGOF. J Gynecol Obstet Hum Reprod 2020; 49:101814. [PMID: 32428782 DOI: 10.1016/j.jogoh.2020.101814] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/12/2020] [Indexed: 11/15/2022]
Abstract
Prenatal screening to prevent congenital toxoplasmosis as performed in France for several decades has been questioned in view of the decreasing incidence of this infection and the cost of testing. The French College of Obstetrics and Gynecology mandated a multidisciplinary panel of experts to perform a reassessment of the screening program in accordance with international good practice. In France, about 70% of pregnant women are not immune to T. gondii, and 0.2-0.25% become infected during pregnancy. The risk of maternal-fetal transmission of infection is on average 25-29% and depends greatly on the gestational age at seroconversion. In case of fetal transmission, the outcome is livebirth in 95% of cases, with latent congenital toxoplasmosis in 90% of cases and symptomatic forms in 10% of cases, of which 1/3 are severe and 2/3 moderate. Biological techniques have satisfactory performance regarding serologies for the diagnosis of maternal infections and PCR on amniotic fluid for the prenatal diagnosis of congenital toxoplasmosis. Primary prevention of toxoplasmosis is based on hygiene measures that are relatively simple, but poorly implemented. In case of maternal seroconversion, there is a strong case for prenatal prophylactic treatment as soon as possible (ideally within 3 weeks of seroconversion), spiramycin before 14 weeks of gestation (WG), and with a tendency to superiority of the pyrimethamine/sulfadiazine association over spiramycin beyond 14 W G, in order to reduce the risk of symptomatic congenital toxoplasmosis. In case of congenital toxoplasmosis, prompt initiation of treatment reduces the occurrence of cerebral signs and symptoms, as well as retinal lesions. Several medico-economic evaluations of the French toxoplasmosis screening program have been conducted including an individual cost-effectiveness approach with decision analysis which concluded on the profitability of prenatal screening as carried out in France (monthly surveillance of seronegative women, prenatal treatment in case of seroconversion, termination of pregnancy in severe forms). Though most international societies do not recommend systematic screening for mainly financial reasons, if congenital toxoplasmosis appears benign in France today, it is probably thanks to screening and the possibility of early treatment of fetuses and/or newborns. Thus, the panel recommends continuing for now the program in France for prevention of congenital toxoplasmosis.
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Affiliation(s)
- Olivier Picone
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris; Inserm IAME-U1137, Paris, France; FHU PREMA; Groupe de Recherche sur les Infections pendant la grossesse (GRIG)
| | - Florent Fuchs
- Service de Gynécologie Obstétrique CHU de Montpellier, Hopital Arnaud de Villeneuve, Montpellier, France; Inserm, CESP Centre de recherche en Epidémiologie et Santé des Populations, U1018, Reproduction et Développement de l'enfant, 94807 Villejuif, France; EA2415: Aide à la décision médicale Personnalisée, Axe B: Méthode en épidémiologie Clinique, Université de Montpellier
| | | | - Christine Binquet
- Inserm, CIC1432, module Epidémiologie Clinique, Dijon, France; CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, Dijon, France
| | - François Kieffer
- Assistance Publique-Hôpitaux de Paris, Service de néonatologie, Hôpital Armand Trousseau, Paris, France
| | - Martine Wallon
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service de Parasitologie - Mycologie Médicale, Lyon, France; Université Lyon-1, Equipe Waking, Physiologie Intégrée du Système d'éveil, Centre de Recherche en Neurosciences de Lyon (INSERM U1028 - CNRS UMR 5292), Bron, France
| | - Karl Wehbe
- Centre Hospitalier Universitaire de Strasbourg, Service de Gynécologie-Obstétrique, Strasbourg, France
| | - Laurent Mandelbrot
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Louis Mourier, Colombes, France; Université de Paris; Inserm IAME-U1137, Paris, France; FHU PREMA; Groupe de Recherche sur les Infections pendant la grossesse (GRIG)
| | - Isabelle Villena
- Université Reims Champagne -Ardenne, EA7510 et Centre National de Référence de la Toxoplasmose, Centre de Ressources Biologiques Toxoplasma, Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Reims, Reims, France
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Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice. Clin Microbiol Rev 2018; 31:31/4/e00057-17. [PMID: 30209035 DOI: 10.1128/cmr.00057-17] [Citation(s) in RCA: 238] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary Toxoplasma gondii infection is usually subclinical, but cervical lymphadenopathy or ocular disease can be present in some patients. Active infection is characterized by tachyzoites, while tissue cysts characterize latent disease. Infection in the fetus and in immunocompromised patients can cause devastating disease. The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection, is the current gold standard for treating toxoplasmosis, but failure rates remain significant. Although other regimens are available, including pyrimethamine in combination with clindamycin, atovaquone, clarithromycin, or azithromycin or monotherapy with trimethoprim-sulfamethoxazole (TMP-SMX) or atovaquone, none have been found to be superior to pyr-sulf, and no regimen is active against the latent stage of the infection. Furthermore, the efficacy of these regimens against ocular disease remains uncertain. In multiple studies, systematic screening for Toxoplasma infection during gestation, followed by treatment with spiramycin for acute maternal infections and with pyr-sulf for those with established fetal infection, has been shown to be effective at preventing vertical transmission and minimizing the severity of congenital toxoplasmosis (CT). Despite significant progress in treating human disease, there is a strong impetus to develop novel therapeutics for both the acute and latent forms of the infection. Here we present an overview of toxoplasmosis treatment in humans and in animal models. Additional research is needed to identify novel drugs by use of innovative high-throughput screening technologies and to improve experimental models to reflect human disease. Such advances will pave the way for lead candidates to be tested in thoroughly designed clinical trials in defined patient populations.
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Belal US, Norose K, Aosai F, Mun HS, Ahmed AK, Chen M, Mohamed RM, Piao LX, Iwakura Y, Yano A. Evaluation of the Effects of Sulfamethoxazole onToxoplasma gondiiLoads and Stage Conversion in IFN-γ Knockout Mice Using QC-PCR. Microbiol Immunol 2013; 48:185-93. [PMID: 15031531 DOI: 10.1111/j.1348-0421.2004.tb03504.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Toxoplasma gondii abundance with or without sulfamethoxazole treatment was evaluated by quantitative competitive polymerase chain reaction (QC-PCR) assay in various organs of IFN-gamma knockout BALB/c (B/c) mice after peroral infection with the cyst-forming Fukaya strain. T. gondii infection was observed in the brain, skin, tongue, heart, and skeletal muscle of the mice treated with sulfamethoxazole, although the parasite was not observed during the treatment in the mesenteric lymph node, spleen, small intestine or kidney. After discontinuing the therapy, T. gondii reappeared within five days in all organs. Reverse transcriptase (RT)-PCR showed that sulfamethoxazole treatment accelerated the stage conversion of T. gondii from tachyzoites into bradyzoites in the brain, lung, and heart. In contrast, after discontinuing sulfamethoxazole treatment, T. gondii underwent stage conversion from bradyzoites into tachyzoites in these organs. These results indicate that we successfully established an animal model for evaluating chemotherapy regimens in immunocompromised hosts infected with T. gondii.
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Affiliation(s)
- Usama S Belal
- Department of Infection & Host Defense, Graduate School of Medicine, Chiba University, Japan
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Immunopathogenesis of toxoplasmosis in pregnancy. Infect Dis Obstet Gynecol 2012; 5:121-7. [PMID: 18476164 PMCID: PMC2364566 DOI: 10.1155/s1064744997000197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/1997] [Accepted: 10/21/1997] [Indexed: 11/24/2022] Open
Abstract
The immunopathogenesis of toxoplasmosis during pregnancy is not completely understood. This paper will try to discuss the most frequently asked questions about the immunopathogeny of congenital toxoplasmosis: differential virulence of Toxoplasma isolates, genetic susceptibility to infection, facilitation of placental transfer, models of congenital toxoplasmosis, and transmission in seropositive hosts. Most published data suggest a role of the genetic background of the host and of the parasite. Models of congenital toxoplasmosis have been evaluated, but it appears that the conclusion drawn would be barely appropriate to understand the pathogenesis in pregnant women.
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Robert-Gangneux F, Murat JB, Fricker-Hidalgo H, Brenier-Pinchart MP, Gangneux JP, Pelloux H. The placenta: a main role in congenital toxoplasmosis? Trends Parasitol 2011; 27:530-6. [PMID: 22079164 DOI: 10.1016/j.pt.2011.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 09/09/2011] [Accepted: 09/21/2011] [Indexed: 02/08/2023]
Abstract
Systemic infections, such as toxoplasmosis, acquired during pregnancy can lead to placental infection and have profound effects on the mother-to-child relationship and the success of pregnancy. Placental permeability to Toxoplasma gondii is a main parameter that determines parasite transmission to the foetus, and the use of antibiotics to decrease placental parasite load and prevent congenital toxoplasmosis has been suggested for decades. Although parasitological examination of the placenta at birth is commonly used to diagnose neonatal congenital toxoplasmosis, this approach can be controversial. Here we argue in favour of placental examination for both diagnostic and epidemiological purposes.
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Affiliation(s)
- Florence Robert-Gangneux
- Laboratoire de Parasitologie-Mycologie, Centre Hospitalier et Universitaire de Rennes, Rennes, France.
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McLeod R, Kieffer F, Sautter M, Hosten T, Pelloux H. Why prevent, diagnose and treat congenital toxoplasmosis? Mem Inst Oswaldo Cruz 2009; 104:320-44. [PMID: 19430661 PMCID: PMC2735102 DOI: 10.1590/s0074-02762009000200029] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 10/20/2008] [Indexed: 11/21/2022] Open
Abstract
Evidence that prevention, diagnosis and treatment of toxoplasmosis is beneficial developed as follows: anti-parasitic agents abrogate Toxoplasma gondii tachyzoite growth, preventing destruction of infected, cultured, mammalian cells and cure active infections in experimental animals, including primates. They treat active infections in persons who are immune-compromised, limit destruction of retina by replicating parasites and thereby treat ocular toxoplasmosis and treat active infection in the fetus and infant. Outcomes of untreated congenital toxoplasmosis include adverse ocular and neurologic sequelae described in different countries and decades. Better outcomes are associated with treatment of infected infants throughout their first year of life. Shorter intervals between diagnosis and treatment in utero improve outcomes. A French approach for diagnosis and treatment of congenital toxoplasmosis in the fetus and infant can prevent toxoplasmosis and limit adverse sequelae. In addition, new data demonstrate that this French approach results in favorable outcomes with some early gestation infections. A standardized approach to diagnosis and treatment during gestation has not yet been applied generally in the USA. Nonetheless, a small, similar experience confirms that this French approach is feasible, safe, and results in favorable outcomes in the National Collaborative Chicago-based Congenital Toxoplasmosis Study cohort. Prompt diagnosis, prevention and treatment reduce adverse sequelae of congenital toxoplasmosis.
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Affiliation(s)
- Rima McLeod
- Department of Ophthalmology and Visual Sciences, Committees on Immunology, Genetics, Molecular Medicine, The College, University of Chicago, Chicago, IL 60637, USA.
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Thalib L, Gras L, Romand S, Prusa A, Bessieres MH, Petersen E, Gilbert RE. Prediction of congenital toxoplasmosis by polymerase chain reaction analysis of amniotic fluid. BJOG 2005; 112:567-74. [PMID: 15842278 DOI: 10.1111/j.1471-0528.2005.00486.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the accuracy of polymerase chain reaction (PCR) analysis of amniotic fluid for fetal toxoplasmosis according to clinical predictors of outcome and study centre. DESIGN Prospective cohort study. SETTING Nine European centres. POPULATION Women with suspected toxoplasma infection identified by prenatal screening. METHODS Logistic regression was used to examine the effects of gestational age at maternal seroconversion, treatment and timing of amniocentesis, on PCR accuracy, and to calculate the post-test probability of congenital toxoplasmosis. MAIN OUTCOME MEASURES Infants had congenital toxoplasmosis if specific IgG persisted beyond 11.5 months. Uninfected infants had undetectable IgG in the absence of anti-toxoplasma treatment. RESULTS Of 593 PCR results, 64 were positive (57 confirmed infected), and 529 were negative (23 confirmed infected). The likelihood ratio for a positive PCR result decreased significantly with trimester at seroconversion, but did not change significantly for a negative result. Weak associations were detected between sensitivity and, inversely, with specificity, and gestational age at maternal seroconversion. There was no significant association between sensitivity and centre, type or duration of treatment, or timing of amniocentesis. Specificity differed significantly between centres (P < 0.001). The change in pre- to post-test probability of infection was maximal for a positive PCR after first trimester seroconversion, affecting 1% of women tested, and a negative PCR after third trimester seroconversion, affecting half the women tested. CONCLUSIONS Prediction of the risk of congenital toxoplasmosis should combine estimates of test accuracy and maternal-fetal transmission, which take account of the gestational age at which the mother seroconverted. Local laboratory standards will affect the generalisability of these results.
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Affiliation(s)
- L Thalib
- Department of Community Medicine and Behavioural Sciences, Faculty of Medicine, Kuwait University, Kuwait
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Antsaklis A, Daskalakis G, Papantoniou N, Mentis A, Michalas S. Prenatal diagnosis of congenital toxoplasmosis. Prenat Diagn 2002; 22:1107-11. [PMID: 12454967 DOI: 10.1002/pd.476] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ninety-three pregnant women with Toxoplasma gondii seroconversion during pregnancy underwent prenatal diagnosis of fetal toxoplasmosis. The following tests were used: (1). amniocentesis for mouse inoculation (93 subjects), (2). amplification of T. gondii DNA by polymerase chain reaction (PCR) (79 subjects), and (3). cordocentesis for the detection of T. gondii-specific IgM antibodies (13 subjects). All patients had serial ultrasonographic scans to detect those fetuses with abnormalities that could be associated with congenital toxoplasmosis. Eighteen pregnancies (19.4%) had evidence of vertical transmission. A total of 11/18 (61.1%) had positive amniotic mouse inoculation test, while 10/12 (83.3%) had positive PCR results. The combination of both tests allowed the prenatal diagnosis in 17/18 infected fetuses (94.4%). All patients who underwent cordocentesis for the detection of T. gondii-specific IgM antibodies had negative results. However, in two of the above cases fetal toxoplasmosis was detected by amniotic fluid studies. In five of the infected fetuses there were abnormal ultrasonographic findings. All pregnancies with evidence of vertical transmission were terminated, whereas the remaining pregnancies proceeded normally to term. The present data showed that amniotic fluid studies, preferably PCR amplification of T. gondii DNA, are the best diagnostic tools for the detection of vertical transmission in pregnancies with seroconversion during pregnancy.
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Affiliation(s)
- Aris Antsaklis
- First Department of Obstetrics and Gynaecology, Fetal Medicine Unit, Alexandra Hospital, University of Athens, Athens, Greece
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Gilbert RE, Gras L, Wallon M, Peyron F, Ades AE, Dunn DT. Effect of prenatal treatment on mother to child transmission of Toxoplasma gondii: retrospective cohort study of 554 mother-child pairs in Lyon, France. Int J Epidemiol 2001; 30:1303-8. [PMID: 11821334 DOI: 10.1093/ije/30.6.1303] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of prenatal serological screening for toxoplasmosis is to identify and treat maternal infection as soon as possible in order to prevent transmission of the parasite to the fetus. However, despite widespread provision of prenatal toxoplasma screening across Europe, the effectiveness of prenatal treatment is uncertain. The study aimed to determine the effect of the timing and type of prenatal treatment on mother to child transmission of Toxoplasma gondii. METHOD A cohort of 554 infected pregnant women were identified in Lyon, France between 1987 and 1995 and their children were followed to determine congenital infection status. We determined the effect of prenatal treatment on transmission by examining the effect of the delay between maternal seroconversion and start of treatment. We also compared the effect of the type of treatment and no treatment on the risk of mother to child transmission. Analyses were adjusted for gestation at maternal seroconversion. RESULTS Compared to treatment within 4 weeks from seroconversion, the adjusted odds ratios (OR) for mother to child transmission after a treatment delay of 4-7 weeks was 1.29 (95% CI : 0.61, 2.73) and after more than 8 weeks, 1.44 (95% CI : 0.60, 3.31). The adjusted OR associated with spiramycin alone compared with pyrimethamine-sulfadiazine treatment was 0.91 (95% CI : 0.45, 1.84) and the OR for no treatment compared with pyrimethamine-sulfadiazine treatment was 1.06 (95% CI : 0.37, 3.03). CONCLUSIONS The authors hypothesize that the absence of an effect of prenatal treatment is due to transmission before the start of treatment.
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Affiliation(s)
- R E Gilbert
- Centre for Paediatric Epidemiology and Biostatistics, Institute of Child Health, London, UK
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ROMAND STÉPHANE, WALLON MARTINE, FRANCK JACQUELINE, THULLIEZ PHILIPPE, PEYRON FRANCOIS, DUMON HENRI. Prenatal Diagnosis Using Polymerase Chain Reaction on Amniotic Fluid for Congenital Toxoplasmosis. Obstet Gynecol 2001. [DOI: 10.1097/00006250-200102000-00024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tjalma W, Vanderheyden T, Naessens A, Vanderheyden J, Foulon W. Discordant prenatal diagnosis of congenital toxoplasmosis in a dizygotic pregnancy. Eur J Obstet Gynecol Reprod Biol 1998; 79:107-8. [PMID: 9643415 DOI: 10.1016/s0301-2115(98)00047-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Prenatal diagnosis of toxoplasmosis gondii in twin pregnancies has been described twice. In both cases they were accomplished by prenatal blood sampling of the foetuses. We report the first prenatal diagnosis with a discordant result in a dizygotic pregnancy. One of the foetuses died in utero and the other was born unaffected at term.
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Affiliation(s)
- W Tjalma
- Department of Obstetrics and Gynecology, General Hospital Saint Camillus-Saint Augustinus, Antwerp, Belgium.
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16
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Vergani P, Ghidini A, Ceruti P, Strobelt N, Spelta A, Zapparoli B, Rescaldani R. Congenital toxoplasmosis: efficacy of maternal treatment with spiramycin alone. Am J Reprod Immunol 1998; 39:335-40. [PMID: 9602252 DOI: 10.1111/j.1600-0897.1998.tb00527.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
PROBLEM The evidence supporting an additional benefit of a combined regimen of pyrimethamine-sulfonamides compared with spiramycin alone in the secondary prevention of congenital toxoplasmosis was critically evaluated. METHOD OF STUDY We reviewed the series of cases published in the English literature on antiparasitic treatment of acute toxoplasmosis infection in pregnancy, using spiramycin until fetal infection is documented, then using cycles of spiramycin alternated with combined pyrimethamine-sulfonamide therapy. We then compared the occurrence of overt disease among infected offspring (both severe, represented by ophthalmologic or cerebral abnormalities, and mild occurrences, represented by asymptomatic intracranial calcifications and retinal scars without visual impairment) between the published case series and our consecutive series of cases treated during a 10-year period (January 1986-December 1995) with spiramycin alone. RESULTS The prevalence of fetal infection in our series was 7.8% (12/154), similar to that reported after alternated regimens (7.0%). The rate of overt disease among infected fetuses is not different after treatment with alternated regimens than after continuous antibiotic spiramycin therapy [23% (19/82) vs. 10% (1/10); relative risk, 2.3; 95% confidence interval, 0.4, 47.0]. The pharmacokinetics of the drugs used may account for this finding. CONCLUSION The treatment of acute toxoplasmosis in pregnancy with an alternated antibiotic regimen of pyrimethamine-sulfonamide is not more efficacious at preventing overt neonatal disease than treatment with continuous spiramycin alone.
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Affiliation(s)
- P Vergani
- Division of Obstetrics and Gynecology, University of Milan, Italy
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17
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Schoondermark-van de Ven EM, Melchers WJ, Galama JM, Meuwissen JH, Eskes TK. Prenatal diagnosis and treatment of congenital Toxoplasma gondii infections: an experimental study in rhesus monkeys. Eur J Obstet Gynecol Reprod Biol 1997; 74:183-8. [PMID: 9306115 DOI: 10.1016/s0301-2115(97)00119-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The efficacy of treatment in fetuses in whom congenital Toxoplasma gondii infection has ben established has been investigated using rhesus monkeys as a model for humans. A polymerase chain reaction has been developed for the detection of Toxoplasma gondii. Using this polymerase chain reaction congenital infection can be established within 2 days of receiving an amniotic fluid sample. The polymerase chain reaction has subsequently been used to monitor the effect of treatment on fetal infection. The results show that early treatment with the combination of pyrimethamine and sulfadiazine was clearly effective in reducing the number of parasites in the infected fetus. The parasite was no longer detectable in the amniotic fluid 10 to 13 days after treatment was started. Spiramycin, on the other hand, has to be administered for at least 3 weeks to achieve the same effect. Moreover, pharmacokinetic studies revealed that spiramycin does not reach the brain. Pyrimethamine and sulfadiazine are able to pass the blood-brain barrier. Pyrimethamine appears to accumulate in the brain tissue and reaches concentrations which are also effective in vitro.
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MESH Headings
- Amniotic Fluid/parasitology
- Animals
- Anti-Infective Agents/administration & dosage
- Anti-Infective Agents/therapeutic use
- DNA, Protozoan/analysis
- DNA, Protozoan/genetics
- DNA, Ribosomal/analysis
- DNA, Ribosomal/genetics
- Disease Models, Animal
- Drug Therapy, Combination
- Female
- Fetal Diseases/diagnosis
- Fetal Diseases/drug therapy
- Fetal Diseases/parasitology
- Macaca mulatta
- Polymerase Chain Reaction
- Pregnancy
- Pregnancy Complications, Parasitic/diagnosis
- Pregnancy Complications, Parasitic/drug therapy
- Prenatal Diagnosis
- Prospective Studies
- Pyrimethamine/administration & dosage
- Pyrimethamine/therapeutic use
- Sulfadiazine/administration & dosage
- Sulfadiazine/therapeutic use
- Toxoplasma/genetics
- Toxoplasma/isolation & purification
- Toxoplasmosis, Animal/congenital
- Toxoplasmosis, Animal/diagnosis
- Toxoplasmosis, Animal/drug therapy
- Toxoplasmosis, Animal/embryology
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van der Wel AM, Tomás AM, Kocken CH, Malhotra P, Janse CJ, Waters AP, Thomas AW. Transfection of the primate malaria parasite Plasmodium knowlesi using entirely heterologous constructs. J Exp Med 1997; 185:1499-503. [PMID: 9126931 PMCID: PMC2196274 DOI: 10.1084/jem.185.8.1499] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The recently developed transfection systems for Plasmodium berghei and Plasmodium falciparum offer important new tools enabling further insight into the biology of malaria parasites. These systems rely upon artificial parasite-host combinations which do not allow investigation into the complex interactions between parasites and their natural hosts. Here we report on stable transfection of Plasmodium knowlesi (a primate malaria parasite that clusters phylogenetically with P. vivax) for which both natural and artificial experimental hosts are available. Transfection of this parasite offers the opportunity to further analyze the biology of antigens not only in a natural host but also in hosts that are closely related to humans. To facilitate future development of integration-dependent transfection in P. knowlesi, completely heterologous plasmids that would reduce homologous recombination at unwanted sites in the genome were constructed. These plasmids contained the pyrimethamine-resistant form of dihydrofolate reductase-thymidylate synthase (dhfr-ts) from Toxoplasma gondii or P. berghei, under control of either (a) P. berghei or (b) P. falciparum promoters. Plasmids were electroporated into mature P. knowlesi schizonts and these cells were injected into rhesus monkeys (Macaca mulatta). After pyrimethamine treatment of these monkeys, resistant parasites were obtained that contained the plasmids. Promoter regions of both P. berghei and P. falciparum controlling dhfr-ts expression were effective in conferring pyrimethamine resistance in P. knowlesi, indicating that common signals control gene expression in phylogenetically distant Plasmodium species.
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Affiliation(s)
- A M van der Wel
- Department of Parasitology, Biomedical Primate Research Centre, Rijswijk, The Netherlands
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Gross U, Pohl F. Influence of antimicrobial agents on replication and stage conversion of Toxoplasma gondii. Curr Top Microbiol Immunol 1996; 219:235-45. [PMID: 8791704 DOI: 10.1007/978-3-642-51014-4_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- U Gross
- Institute of Hygiene and Microbiology, University of Würzburg, Germany
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Schoondermark-van de Ven E, Vree T, Melchers W, Camps W, Galama J. In vitro effects of sulfadiazine and its metabolites alone and in combination with pyrimethamine on Toxoplasma gondii. Antimicrob Agents Chemother 1995; 39:763-5. [PMID: 7793889 PMCID: PMC162621 DOI: 10.1128/aac.39.3.763] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Sulfadiazine and the metabolites N4-acetyl-sulfadiazine, 4-OH-sulfadiazine, 5-OH-sulfadiazine, 5-OH-glucuronide-sulfadiazine, and 5-OH-sulfate-sulfadiazine were tested separately and in combination with pyrimethamine for the inhibitory activity on Toxoplasma gondii growth in vitro. Except for N4-acetyl-sulfadiazine, all sulfa compounds possessed anti-Toxoplasma activity. The addition of 0.05 micrograms of pyrimethamine per ml, a concentration which in itself is not inhibitory, potentiated the microbial activity of sulfadiazine and its metabolites 100 fold.
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