Anti-Wolbachia therapy for onchocerciasis & lymphatic filariasis: Current perspectives.

Onchocerciasis and lymphatic filariasis (LF) are human filarial diseases belonging to the group of neglected tropical diseases, leading to permanent and long-term disability in infected individuals in the endemic countries such as Africa and India. Microfilaricidal drugs such as ivermectin and albendazole have been used as the standard therapy in filariasis, although their efficacy in eliminating the diseases is not fully established. Anti-Wolbachia therapy employs antibiotics and is a promising approach showing potent macrofilaricidal activity and also prevents embryogenesis. This has translated to clinical benefits resulting in successful eradication of microfilarial burden, thus averting the risk of adverse events from target species as well as those due to co-infection with loiasis. Doxycycline shows potential as an anti-Wolbachia treatment, leading to the death of adult parasitic worms. It is readily available, cheap and safe to use in adult non-pregnant patients. Besides doxycycline, several other potential antibiotics are also being investigated for the treatment of LF and onchocerciasis. This review aims to discuss and summarise recent developments in the use of anti-Wolbachia drugs to treat onchocerciasis and LF.

Preclinical development of an oral anti-Wolbachia macrolide drug for the treatment of lymphatic filariasis and onchocerciasis.

There is an urgent global need for a safe macrofilaricide drug to accelerate elimination of the neglected tropical diseases onchocerciasis and lymphatic filariasis. From an anti-infective compound library, the macrolide veterinary antibiotic, tylosin A, was identified as a hit against Wolbachia This bacterial endosymbiont is required for filarial worm viability and fertility and is a validated target for macrofilaricidal drugs. Medicinal chemistry was undertaken to develop tylosin A analogs with improved oral bioavailability. Two analogs, A-1535469 and A-1574083, were selected. Their efficacy was tested against the gold-standard second-generation tetracycline antibiotics, doxycycline and minocycline, in mouse and gerbil infection models of lymphatic filariasis (Brugia malayi and Litomosoides sigmodontis) and onchocerciasis (Onchocerca ochengi). A 1- or 2-week course of oral A-1535469 or A-1574083 provided >90% Wolbachia depletion from nematodes in infected animals, resulting in a block in embryogenesis and depletion of microfilarial worm loads. The two analogs delivered comparative or superior efficacy compared to a 3- to 4-week course of doxycycline or minocycline. A-1574083 (now called ABBV-4083) was selected for further preclinical testing. Cardiovascular studies in dogs and toxicology studies in rats and dogs revealed no adverse effects at doses (50 mg/kg) that achieved plasma concentrations >10-fold above the efficacious concentration. A-1574083 (ABBV-4083) shows potential as an anti-Wolbachia macrolide with an efficacy, pharmacology, and safety profile that is compatible with a short-term oral drug course for treating lymphatic filariasis and onchocerciasis.

AWZ1066S, a highly specific anti-Wolbachia drug candidate for a short-course treatment of filariasis.

Onchocerciasis and lymphatic filariasis are two neglected tropical diseases that together affect ∼157 million people and inflict severe disability. Both diseases are caused by parasitic filarial nematodes with elimination efforts constrained by the lack of a safe drug that can kill the adult filaria (macrofilaricide). Previous proof-of-concept human trials have demonstrated that depleting >90% of the essential nematode endosymbiont bacterium, Wolbachia, using antibiotics, can lead to permanent sterilization of adult female parasites and a safe macrofilaricidal outcome. AWZ1066S is a highly specific anti-Wolbachia candidate selected through a lead optimization program focused on balancing efficacy, safety and drug metabolism/pharmacokinetic (DMPK) features of a thienopyrimidine/quinazoline scaffold derived from phenotypic screening. AWZ1066S shows superior efficacy to existing anti-Wolbachia therapies in validated preclinical models of infection and has DMPK characteristics that are compatible with a short therapeutic regimen of 7 days or less. This candidate molecule is well-positioned for onward development and has the potential to make a significant impact on communities affected by filariasis.

Serum antibody responses to Wolbachia surface protein in patients with human lymphatic filariasis.

Wolbachia surface protein (WSP), which is the most abundantly expressed protein of Wolbachia from the human filarial parasite Brugia malayi, was chosen for the present study. B-cell epitope prediction of the WSP protein sequence indicates a high antigenicity, surface probability and hydrophilicity by DNA STAR software analysis. ProPred analysis suggests the presence of HLA class II binding regions in the WSP protein that contribute to T-cell responses and isotype reactivity. In order to validate these findings, the gene coding for endosymbiont WSP was PCR-amplified from the genomic DNA of the human filarial parasite Brugia malayi and cloned in T-7 expression vector pRSET-A. Western blot and ELISA at the total IgG level with recombiant WSP indicated a significantly elevated reactivity in CP compared to MF, EN and NEN individuals. Isotype ELISA also suggested an elevated reactivity in CP patients at the IgG1 level. In contrast, WSP-specific IgG4 levels were found to be elevated in MF patients compared to CP and EN. Besides this, WSP-specific IgE levels indicated an elevated reactivity in CP and MF patients compared to normals. Observations from ELISA supported the in silico predictions that indicate the presence of B- and T-cell epitopes. Hence, a combinatorial approach of in silico predictions and wet-lab studies provides interesting insights into the role of Wolbachia proteins in filarial pathogenesis.

[Paradigm shift in bancroftian filariasis]. / Mudanças de paradigmas na filariose bancroftiana.

The way a particular subject is understood changes over time as a result of scientific research. In most cases, these changes are minor, with limited effect on the overall knowledge on the subject. Sometimes, however, revolutionary changes occur and not only modify the understanding of the subject but open perspectives that can trigger new interpretations and new ways for expansion of scientific knowledge. The studies of Gregor Johann Mendel were a good example. They led to discovery of the laws of inheritance which, in turn, have revolutionized biology and provided the foundation for genetics. In certain situations, changes not only alter ways of thinking, but have practical implications, also improving the quality of life for many people. In his book The Structure of Scientific Revolutions, Thomas Kuhn refers to discontinuities in scientific development as a 'change of paradigm', a term now used in a generic manner to describe a profound changes in our reference points. For lymphatic filariasis the old paradigm stated that Wuchereria bancrofti at the adult stage causes lymphatic vessel obstruction, triggering an inevitable immune response in predisposed individuals and leading to elephantiasis. This has been replaced by a new paradigm, which offers hope that W. bancrofti infection does not necessarily predispose to the disfiguring outward manifestation of lymphatic dysfunction. Repeated secondary bacterial infections (erysipela-like) are now recognized as the most important factor for initiation and progression of chronic lymphedema in individuals living in filariasis-endemic areas. Most inhabitants of endemic communities can prevent and minimize the acute bacterial episodes by regular use of soap and water, the simplest form of hygiene already well known to human beings.

Mudanças de paradigmas na filariose bancroftiana / Paradigm shift in bancroftian filariasis

Ao longo do tempo, a maneira como se entende um determinado assunto passa por modificações através da pesquisa científica. Na maioria das vezes, essas mudanças causam pequenas diferenças na estrutura total do tópico em questão. Outras vezes, entretanto, ocorrem mudanças revolucionárias que não só alteram a compreensão do assunto em si, mas promovem a abertura de diferentes perspectivas que podem desencadear o início de novas etapas de interpretações e de novos caminhos de conhecimento. Exemplo disso foram os estudos de Gregor Johann Mendel que levaram à descoberta de leis da hereditariedade que, por sua vez, revolucionaram a biologia e traçaram as bases da genética. Em algumas situações, as mudanças não só modificam a forma de pensar, mas também têm implicações práticas ao melhorar a qualidade de vida de muitos seres humanos. No seu livro A Estrutura de Revoluções Científicas, Thomas Kuhn se refere às ruturas nessa evolução científica como "mudanças de paradigma", um termo que hoje é usado de uma forma genérica para descrever uma modificação profunda em nossos pontos de referência. O paradigma de que o estágio adulto da Wuchereria bancrofti causava a obstrução do vaso linfático e desencadeava uma reação imunológica inevitável em indivíduos predispostos, provocando a elefantíase, foi substituído pela esperança de que ser infectado não mais significa, necessariamente, ser um potencial portador da forma mais deformante da disfunção linfática. A infecção bacteriana secundária de repetição (semelhante clinicamente à erisipela) é hoje reconhecida como o fator mais importante para a instalação e a progressão do linfedema crônico, nos indivíduos que vivem em áreas endêmicas de filariose linfática. Evitar ou minimizar os episódios agudos bacterianos é um processo factível para a maioria dos habitantes das comunidades endêmicas, através do uso regular de água e sabão: a forma mais simples de higiene já conhecida pelo ser humano.

The way a particular subject is understood changes over time as a result of scientific research. In most cases, these changes are minor, with limited effect on the overall knowledge on the subject. Sometimes, however, revolutionary changes occur and not only modify the understanding of the subject but open perspectives that can trigger new interpretations and new ways for expansion of scientific knowledge. The studies of Gregor Johann Mendel were a good example. They led to discovery of the laws of inheritance which, in turn, have revolutionized biology and provided the foundation for genetics. In certain situations, changes not only alter ways of thinking, but have practical implications, also improving the quality of life for many people. In his book The Structure of Scientific Revolutions, Thomas Kuhn refers to discontinuities in scientific development as a "change of paradigm", a term now used in a generic manner to describe a profound changes in our reference points. For lymphatic filariasis the old paradigm stated that Wuchereria bancrofti at the adult stage causes lymphatic vessel obstruction, triggering an inevitable immune response in predisposed individuals and leading to elephantiasis. This has been replaced by a new paradigm, which offers hope that W. bancrofti infection does not necessarily predispose to the disfiguring outward manifestation of lymphatic dysfunction. Repeated secondary bacterial infections (erysipela-like) are now recognized as the most important factor for initiation and progression of chronic lymphedema in individuals living in filariasis-endemic areas. Most inhabitants of endemic communities can prevent and minimize the acute bacterial episodes by regular use of soap and water, the simplest form of hygiene already well known to human beings.

Cytodiagnosis of filarial infections from an endemic area.

OBJECTIVE: To throw light on cytologic findings as a possible mode of diagnosis of lymphatic filariasis. STUDY DESIGN: Filariasis has worldwide distribution, but lymphatic filariasis predominantly affects tropical and subtropical regions. Demonstration of microfilaremia, the specific test for diagnosis of lymphatic filariasis, often shows false negative results in endemic areas. The present study, done in an endemic area, showed the presence of microfilariae or adult worms of Wuchereria bancrofti in fine needle aspirates collected from amicrofilariaemic cases. In a few cases the discovery was incidental. A total 4,534 cases undergoing cytologic evaluation were carefully screened for the presence of adult worms or larvae, irrespective of clinical diagnosis. Microfilariae were demonstrated in both clinically suspected cases of filariasis and asymptomatic cases. RESULTS: A total of 1 positive cases were found; in 4 cases the clinical diagnosis was lymphatic filariasis, and 7 cases were asymptomatic. All 11 cases were amicrofilariaemic. CONCLUSION: Various sophisticated investigations are used for diagnosis of lymphatic filariasis without microfilaremia. Fine needle aspiration cytology, being a cheap, simple and easy procedure, may have some role in this field, but further detailed studies are needed before any final claim.

Brugia malayi Wolbachia hsp60 IgG antibody and isotype reactivity in different clinical groups infected or exposed to human bancroftian lymphatic filariasis.

Wolbachia, an endosymbiotic bacterium in filarial parasites, comes into contact with the host immune system upon parasite death. Here, we analyzed, total IgG and isotype antibody responses to Wolbachia hsp60 in individuals from an area endemic for Wuchereria bancrofti. Wolbachia derived hsp60 gene was cloned and the recombinant protein was used to determine the IgG and isotype reactivity by Western blotting and ELISA. All individuals from the endemic area generated antibody responses to Brugia malayi Wolbachia hsp60, which were elevated in the group with chronic pathology. Isotype analysis showed that, all clinical groups mounted IgG1-IgG4 responses with higher levels of B. malayi Wolbachia hsp60 specific IgG1 observed in the sera of patients with chronic pathology compared to microfilaraemics and endemic normals. These findings suggests that Wolbachia-derived hsp60 generates antibody responses in individuals infected or exposed to W. bancrofti and an elevated IgG and IgG1 reactivity is observed in people with filarial pathology.

Characterization of antibody responses to Wolbachia surface protein in humans with lymphatic filariasis.

Symbiotic Wolbachia organisms of filarial nematodes have received much attention as possible chemotherapy targets and disease-causing organisms. In order to further investigate the association between anti-Wolbachia immune responses and chronic filarial disease in humans, antibody responses to Wolbachia surface protein (WSP) were assayed in serum samples collected from 232 individuals living in Leogane, Haiti, an area where Wuchereria bancrofti infection is endemic, and from 67 North Americans with no history of lymphatic filariasis. As opposed to antifilarial antibody responses, which were largely influenced by the patient's infection status, the prevalence and levels of anti-WSP immunoglobulin G (IgG) antibodies among individuals with lymphedema or hydrocele were significantly greater than those in gender- and infection-matched individuals without disease. In at least one case, the anti-WSP IgG response was coincident with the onset of lymphedema development, and among anti-WSP-positive women with lymphedema, anti-WSP IgG levels were negatively correlated with the duration of lymphedema. The presence of anti-WSP IgG was also associated with the severity of inguinal adenopathy among men with hydrocele. In addition to the presence of anti-WSP antibodies among Haitians, 15 of 67 (22%) serum samples collected from individuals from North America, where filariasis is not endemic, were also positive for anti-WSP antibodies. In comparison to those from Haitians, anti-WSP antibodies from North Americans primarily recognized a distinct region of WSP located within the highly conserved second transmembrane domain. The results of this study demonstrate that anti-WSP antibody responses are associated with the presence of chronic filarial morbidity and not filarial infection status in humans and suggest that WSP should be further studied as a potential trigger for the development of filarial disease.

Quantification of PCR amplification products of Brugia HhaI repeat DNA using a semiautomated Q-PCR system.

The sensitive, rapid and species-specific diagnosis of Brugia infections in humans or animal models is important in determining the level of parasitemia and the efficacy of chemotherapy or vaccinations. The HhaI family of highly repeated DNA sequences from Brugia have been useful in polymerase chain reaction (PCR)-based diagnosis of brugian filarial infections in blood samples and in mosquitoes. A PCR assay was developed using a biotinylated primer, a non-biotinylated primer and a species-specific chemiluminescent probe [tris[2,2'bipyridine] ruthenium (II) chelate, TBR] to detect PCR amplified Hhal family repeats. Individual blood samples from jirds infected with Brugia malayi or B. pahangi and with different levels of microfilaremia were tested in this assay. Known concentrations of Brugia DNA and DNA from the blood of uninfected control jirds were used as positive and negative controls, respectively. The PCR products generated by this method were analyzed using a semi-automated quantitative (Q)-PCR system. The levels of parasite DNA can be calculated from the luminosity units generated. Significant amounts of parasite DNA were detected in blood samples from infected jirds, and these values were correlated with the levels of microfilaremia. In contrast, reductions in circulating microfilaria following treatment with ivermectin correlated with low levels of measurable DNA. Using this system, we were also able to detect HhaI repeat DNA in the spleens of B. pahangi- infected jirds at 56 days post-infection when circulating microfilariae were not readily detectable. The results indicate that the species-specific Hhal Q-PCR detection and quantification method is rapid and sensitive, is useful in the detection of Brugia DNA in blood and other tissues and is suited for use in clinical settings because it does not require radioactive isotopes and gel-based protocols.

Bacteriological studies of blood, tissue fluid, lymph and lymph nodes in patients with acute dermatolymphangioadenitis (DLA) in course of 'filarial' lymphedema.

Filarial lymphedema is complicated by frequent episodes of dermatolymphangioadenitis (DLA). Severe systemic symptoms during attacks of DLA resemble those of septicemia. The question we asked was whether bacterial isolates can be found in the peripheral blood of patients during the episodes of DLA. Out of 100 patients referred to us with 'filarial' lymphedema 14 displayed acute and five subacute symptoms of DLA. All were on admission blood microfilariae negative but had a positive test in the past. Blood bacterial isolates were found in nine cases, four acute (21%) and five subacute (26%). In 10 acute cases blood cultures were found negative. Six blood isolates belonged to Bacilli, four to Cocci and one was Sarcina. To identify the sites of origin of bacterial dissemination, swabs taken from the calf skin biopsy wounds and tissue fluid, lymph and lymph node specimens were cultured. Swabs from the calf skin biopsy wound contained isolates in nine (47%) cases. They were Bacilli in nine, Cocci in three, Acinetobacter and Erwinia in two cases. Tissue fluid was collected from 10 patients and contained Bacilli in four (40%) and Staphylococci in three (30%). Lymph was drained in four patients and contained isolates in all samples (100%). They were Staphylococcus epidermis, xylosus and aureus, Acinetobacter, Bacillus subtilis and Sarcina. Three lymph nodes were biopsied and contained Staphylococcus chromogenes, xylosus, Enterococcus and Bacillus cereus. In six cases the same phenotypically defined species of bacteria were found in blood and limb tissues or fluids. In the 'control' group of patients with lymphedema without acute or subacute changes all blood cultures were negative. Interestingly, swabs from biopsy wound of these patients contained isolates in 80%, tissue fluid in 68%, lymph in 70% and lymph nodes in 58% of cases. In healthy controls, tissue fluid did not contain bacteria, and lymph isolates were found only in 12% of cases. This study demonstrates that patients with acute episodes of DLA reveal bacteremia in a high percentage of cases. Diversity of blood and tissue bacterial isolates in these patients points to a breakdown of the skin immune barrier in lymphedema and subsequently indiscriminate bacterial colonization of deep tissues and spread to an blood circulation.

Bacteriologic studies of skin, tissue fluid, lymph, and lymph nodes in patients with filarial lymphedema.

Filarial lymphedema is complicated by frequent episodes of dermatolymphangioadenitis (DLA). It is not certain whether DLA is of filarial or bacterial etiology. The frequency of episodic DLA does not depend on the presence or absence of microfilariae. Antibiotic therapy is effective in prevention and treatment of DLA. These observations point to the bacterial rather than filarial etiology of DLA. Skin and lymph node biopsies, tissue fluid, lymph, and blood from patients with chronic filarial lymphedema, and during acute episodes of DLA, were cultured for detection of bacteria. A high prevalence of bacterial isolates from the tissue fluid (64%), lymph (75%), and inguinal lymph nodes (66%) of limbs with filarial lymphedema was found. Bacillus cereus, Staphylococcus epidermidis, S. hominis, S. capitis, S. xylosus, and Micrococcus spp. were the most common isolates. Bacteria were also isolated from the blood of patients with recent episodes of DLA, with strains of the same phenotype and antibiotic sensitivity in all specimens from patients with DLA. Bacterial strains of the same phenotype and antibiotic sensitivity were documented on the toe web surface and in tissue fluid (25%), lymph (26%), or lymph nodes (41%). Increasing prevalence of bacterial isolates in tissue fluid, lymph, and lymph nodes was observed in advanced stages of lymphedema. Bacilli and cocci were sensitive to gentamicin, tetracyline, rifampicin, vancomycin, kanamycin and cotrimoxazole, and least sensitive to penicillin. Blood cultures of patients in the periods between DLA attacks were negative. In healthy controls without edema and episodes of DLA, tissue fluid did not contain bacteria. In lymph, only single colonies of Micrococcus and Acinetobacter were cultured in 12% of the cases. Impaired lymph drainage and lack of elimination of penetrating bacteria may be responsible for progression of lymphedema and recurrent attacks of DLA.

Microscopical and serological diagnosis of wuchereria bancrofti

Venous blood from 292 patients attending a Filaria Clinic in Georgetown, Guyana, was assayed by ELISA for IgG and IgM antibodies and by Indirect Haemagglutination Antibody Assay (IHA) against filaria parasites. They were also assayed by microscopic methods before and after concentration procedures for microfilaraemia. Of the 41 blood samples microscopically positive for Wuchereria bancrofti microfilfariae, 87.8//(ELISA IgG), 65.9//(ELISA IgM) and 73.2//(IHA) occurred in samples with subdiagnostic serological threshold titres of<1:32 (IgG and IgM) and <1:128(IHA). But indicators of value based on the standards of the presence of chronic and acute symptoms, the IgG and IgM diagnostic data gave 79.9//sensitivity, 96.4//specificity, 97.1//positive predictable value and 44.3//negative predictive value. A membrane filtration system (92.7//) was slightly better than a centrifugation technique (90.2//), but more efficient than a thick smear preparation (75.6//) for the detection of microfilariae. The filtration system was vastly superior for yields of microfilariae. However, the Knott's concentration (sedimentation) was the most economical in terms of technical time and materials. Most microscopically confirmed filaria cases were in the 20 - 29-year age group (25//), followed by the broad 30--69-year age groups (10-12//). Males were significantly more commonly affected by the ratio 24.2:6.0. It is recommended that skills and materials for concentration of microfilariae from peripheral blood be maintained in all Caribbean countries. In known filaria endemic countries, it is recommended that the serological tool be used as an aid in diagnosis for patients with acute and chronic symptoms