[Miltefosine: a new remedy for leishmaniasis]. / Miltefosine: een nieuw geneesmiddel voor leishmaniasis.

There is a need for a safe and effective oral treatment for cutaneous and visceral leishmaniasis. Miltefosine is the first oral drug that is efficacious against different forms ofleishmaniasis, however it is not equally effective against all Leishmania species. Miltefosine is an alkylphosphocholine, originally developed for the treatment of cancer. The mechanism of action is probably based on interference with the synthesis and degradation of parasitic membrane lipids. Little is known about the pharmacokinetics ofmiltefosine; an important characteristic is its long elimination half-life of seven days or longer. The most frequent adverse effects are of gastrointestinal origin. Miltefosine should not be used during pregnancy. Over thirty leishmaniasis patients have already been treated with miltefosine in the Netherlands.

Phthalonic acid, an inhibitor of alpha-oxoglutarate transport in mitochondria.

Phthalonic acid is a powerful inhibitor of alpha-oxoglutarate transport in mitochondria. This conclusion is based on the following observations: 1. Phthalonic acid inhibits the oxidation of alpha-oxoglutarate but has no effect on the oxidation of glutamate or cis-aconitate. 2. With arsenite present, phthalonic acid inhibits the oxidation of glutamate plus malate and of cis-aconitate plus malate. Under these conditions alpha-oxoglutarate accumulates inside the mitochondria. With glutamate plus malate as substrates the inhibition is competitive with malate with a Ki value of 20 muM. 3. Phthalonic acid inhibits the oxidation of intramitochondrial NAD(P)H by alpha-oxoglutarate plus ammonia. The inhibition is competitive with respect to alpha-oxoglutarate with a Ki of 30 muM. 4. Phthalonic acid inhibits the exchange between extramitochondrial alpha-oxoglutarate and intramitochondrial malate.

Urocanic acid isomers are good hydroxyl radical scavengers: a comparative study with structural analogues and with uric acid.

UV-exposure of the epidermis leads to the isomerisation of trans-UCA into cis-UCA as well as to the generation of hydroxyl radicals. This study shows by means of the deoxyribose degradation test that UCA isomers are more powerful hydroxyl radical scavengers than the other 4-(5-)substituted imidazole derivatives, such as histidine, though less powerful than uric acid. UCA, present in relatively high concentrations in the epidermis, may well be a major natural hydroxyl radical scavenger.

Oxidative breakdown and conversion of urocanic acid isomers by hydroxyl radical generating systems.

cis-Urocanic acid (cis-UCA), formed from trans-urocanic acid (trans-UCA) by photoisomerization, has been shown to mimic suppressive effects of UV on the immune system. It is our hypothesis that UCA oxidation products in the skin play a role in the process of immunosuppression. Recently, both UCA isomers were found to be good hydroxyl radical scavengers and in this context we investigated the formation of products resulting from the interaction of hydroxyl radicals with UCA. Hydroxyl radicals were generated by (1) UV/H(2)O(2) (photooxidation), (2) ferrous ions/H(2)O(2) (Fenton oxidation) and (3) cupric ions/ascorbic acid. Oxidation products were identified by spectrometric methods and assessed by reversed-phase HPLC analysis. The photooxidation of UCA was induced by UV-B and UV-C, but not by UV-A radiation. Photooxidation and Fenton oxidation of trans-UCA, as well as of cis-UCA yielded comparable chromatographic patterns of UCA oxidation products. Several of the formed products were identified. The formation of three identified imidazoles was shown in UV-B exposed corneal layer samples, derived from human skin.

Artemisinin drugs in the treatment of malaria: from medicinal herb to registered medication.

Registration in Europe of several artemisinin drugs for the treatment of malaria can soon be expected. Artemisinin is isolated from the herb Artemisia annua, in use in China more than 2000 years as a herbal tea against fever. Artemisinin drugs are being used extensively in South-East Asia and increasingly in Africa. Active derivatives have been synthesized - artemether, arteether and artesunate - which are used for oral, intramuscular, rectal and intravenous administration. The origin, mechanism of action, efficacy and safety in patients, the pharmacokinetics and the position of this group of compounds among existing antimalarials are discussed in this review.

Measurement of antigen specific lymphocyte proliferation using 5-bromo-deoxyuridine incorporation. An easy and low cost alternative to radioactive thymidine incorporation.

The classical in vitro assay for the determination of cell mediated immune responses is the lymphocyte transformation test (LTT) in which cell proliferation is measured by incorporation of radioactive labeled thymidine (3H-TdR). The LTT assay using 3H-TdR is less suited for modestly equipped laboratories as it is costly, laborious and involves the need to handle radioactive isotopes and specialized equipment. Here we describe an improved alternative LTT method which is capable of detecting specific cellular immune reactions (CMI) against (mycobacterial) antigens in vitro. This assay, the bromodeoxyuridine-ELISA LTT test, is simple, less expensive, reproducible and is as sensitive as the 3H-TdR test. The specific advantages of the test are a simple denaturation step and the fact that no radioactive isotopes are needed. The test is specifically suited for research laboratories in tropical countries which study CMI in those human infectious diseases where this arm of the immune response plays a pivotal role in the generation of immunity, e.g., in tuberculosis, leprosy and leishmaniasis.

Plasmodium falciparum dihydrofolate reductase alleles and pyrimethamine use in pregnant Ghanaian women.

Drug resistance in Plasmodium falciparum affects prevention of malaria in pregnancy. In a cross-sectional study of 530 pregnant Ghanaian women, P. falciparum dihydrofolate reductase (DHFR) gene mutations linked with pyrimethamine resistance were assessed and associations with pyrimethamine intake were analyzed. P. falciparum infected 69% of women without pyrimethamine use, 59% of those who had a history of pyrimethamine consumption but a negative urine test, and 53% of individuals with a positive urine test. Eighty-one percent, 43%, and 74% of the isolates contained the mutations Asn-108, Ile-51, and Arg-59, respectively. Thr-108 occurred in 8%. Pyrimethamine use was associated with increased frequencies of Asn-108 and Arg-59 but not of Ile-51 or Thr-108. In women with prophylaxis, wild-type parasites were absent and anemia tended to be more common with an increasing number of DHFR gene mutations. Pyrimethamine appears to be not adequately effective in this part of Ghana, most likely due to the predominance of resistant parasites. Selection for resistance following insufficient prophylaxis could possibly affect the efficacy of future intermittent sulfadoxine-pyrimethamine treatment.

Multiplicity of Plasmodium falciparum infection in pregnancy.

Little is known about the distribution and disease association of multiple Plasmodium falciparum infections in pregnant women. Genotyping of the merozoite surface protein-1 region was performed in 332 P. falciparum infected pregnant women in Ghana, and clinical and epidemiologic data were obtained. Overall, 68% of the women were infected with more than one strain (mean number of strains per carrier = 2.9). The multiplicity of infection decreased significantly with an increasing number of pregnancies, and infection with multiple P. falciparum strains was significantly associated with anemia. In logistic regression, women infected with four or more strains were 2.3 times more likely to be anemic than women harboring fewer strains. This association, however, was only observed in women with up to three pregnancies. The results suggest that with increasing gravidity and subsequent infections with multiple strains effective immune mechanisms against more and more strains develop. In pregnant women, the multiplicity of infection may be an important factor for the acquisition and maintenance of immunity against malaria.

The development of an immunoassay for the detection of artemisinin compounds in urine.

We have produced monoclonal antibodies against artelinic acid and investigated the reactivity with artemisinin drugs and metabolites. Antibody F170-10 is fairly specific for artelinic acid but does bind artemisinin and artemether (3-5% cross-reactivity). Dihydroartemisinin, artesunate, and metabolites of artemisinin showed less reactivity. With this antibody, an inhibition ELISA has been set up to detect artemisinin compounds in urine. In healthy subjects who received a single oral dose of artemisinin, artemether, artesunate or dihydroartemisinin, ELISA reactivity in urine was found. This reactivity in urine paralleled the plasma concentrations of artemether and dihydroartemisinin. The results show that this immunoassay for artelinic acid can be used to detect artemisinin compounds in urine for about 8 hr after intake. With a more sensitive test, this simple method as a urine dipstick may be become useful for drug use and compliance studies in malaria-endemic areas where the artemisinin derivatives are increasingly used.

Efficacy and tolerance of artemisinin in short combination regimens for the treatment of uncomplicated falciparum malaria.

Two oral regimens comprising a single dose of 20 mg/kg of artemisinin followed by three days of quinine, 10 mg/kg three times a day (AQ), or doxycycline, 4 mg/kg once a day (AD), were compared with a standard seven-day course of oral quinine, 10 mg/kg three times a day (Q), in the treatment of uncomplicated falciparum malaria. Of 161 treated patients, 157 could be included in the analysis. The mean +/- SD parasite clearance time was 43 +/- 14 hr for AQ and 41 +/- 19 hr for AD, and significantly longer for quinine: 66 +/- 24 hr (P = 0.0001). Treatment failure occurred in one Q and in 3 AD patients. The recrudescence rate was 16% for Q, 28% for AQ, and significantly worse for AD: 67% (P = 0.0001). Adverse effects were mainly limited to cinchonism. The conclusion is that a seven-day course of quinine is still effective in the initial treatment of uncomplicated falciparum malaria in Vietnam, but one should pay attention to possible recrudescence. The addition of a single 20 mg/kg per os dose of artemisinin allows for shortening the duration of treatment, with faster parasite clearance, comparable efficacy, and better tolerance, but with no reduction of recrudescence. The combination of artemisinin with three days of doxycycline is also not effective in preventing recrudescence.

Anti-malarial drug use among preschool children in an area of seasonal malaria transmission in Kenya.

The aims of this study were to estimate the proportion of asymptomatic Kenyan preschool children using anti-malarial drugs, to identify factors associated with chloroquine use, and to assess the validity of frequency of febrile episodes and drug use reported by mothers or carers. Of 318 children studied, 38% (95% confidence interval [CI] = 30-47%]) tested positive for chloroquine or sulfadoxine. Of chloroquine-positive children, 15% had concentrations exceeding the estimated minimum therapeutically effective values. Among those testing negative for sulfadoxine, chloroquine-positive children were more frequently parasitemic (odds ratio = 2.6, 95% CI = 1.3-5.2), and had lower mean hemoglobin concentrations (6.1 g/L, 95% CI = 2.1-10.1) than chloroquine-negative children. Mothers over-reported the frequency of malaria or fever episodes as usually defined in medical studies, and underreported anti-malarial drug use. We conclude that anti-malarials are frequently given for treatment of malaria or malaria-associated illness, rather than prophylactically or for symptoms unrelated to malaria. Questionnaire surveys cannot replace biochemical markers to obtain information on anti-malarial drug use.

Short report: high prevalence and imbalanced age distribution of the Plasmodium falciparum dihydrofolate reductase gene Asn108 mutation in an area of low pyrimethamine usage in Nigeria.

Resistance of Plasmodium falciparum to pyrimethamine is associated with a non-silent point mutation of the parasite dihydrofolate reductase (DHFR) gene (Ser108 --> Asn108). Wide-scale use of antimalarials is thought to contribute to the emergence of drug resistance. In 131 P. falciparum-infected children in rural Nigeria, the frequency of the resistant Asn108 genotype was assessed by enzymatic restriction digestion of polymerase chain reaction-amplified DHFR sequences and compared with residual pyrimethamine blood levels. The prevalence of the Asn108 variant was 41.2%. In 18.3% of the isolates, both the Asn108 and the wild-type alleles were present. In contrast to the high prevalence of resistant genotypes, residual pyrimethamine blood levels were detected in only 4%. Furthermore, age was found to be a determinant of the parasite genotype since the proportion of Asn108 variants decreased with age (P < 0.05). These findings indicate that additional, unidentified factors, rather than selection by residual drug levels alone, might be responsible for the emergence of pyrimethamine-resistant parasite genotypes.

An ELISA test for detecting chloroquine in urine.

Two ELISA tests for detecting chloroquine in urine have been developed using polyclonal and monoclonal antibodies which react with the 7-chloro-4-amino-quinoline part of the chloroquine molecule and thus recognize chloroquine, its metabolites, and amodiaquine. The ELISAs were sensitive and specific and did not cross-react with other commonly used antimalarials. In a field trial the chloroquine ELISA performed better than the Dill Glazko or Haskins colorimetric tests. A small proportion of urines gave an apparently false positive reaction when tested at a dilution of 1:10, but not when tested at higher dilution.

Field evaluation of the use of an ELISA to detect chloroquine and its metabolites in blood, urine and breast-milk.

The evaluation of an enzyme-linked immunosorbent assay (ELISA) for chloroquine and its metabolites in blood, urine and breast-milk is reported. ELISA blood levels, following standard treatment with chloroquine of pregnant and non-pregnant women, showed mean values comparable to other analytical methods. Blood chloroquine concentrations were estimated at day 0, 350-400 ng/ml; day 2, 1000-1500 ng/ml; day 14, 350-400 ng/ml; day 28, 180-350 ng/ml. In a separate sample a significant association was observed between history of chloroquine use in the previous 2 weeks and blood ELISA values (P less than 0.01). Mean ELISA values in breast-milk were higher than in corresponding whole blood samples. High concentrations of chloroquine in urine were observed. There was a weak association of the ELISA of urine and blood samples collected at the same time (P = 0.076). This study confirms the low sensitivity (less than 55%) of the Dill-Glazko test in urine, which is 100-1000 times less sensitive than the ELISA; the latter can detect 10-20 ng chloroquine per ml. A cut-off value for blood positivity 2 weeks following therapeutic drug ingestion was determined (40% ELISA inhibition), which can be used to make decisions about subject selection in drug sensitivity tests or population surveys. There are several advantages with the ELISA under field conditions. These include direct measurement of whole blood concentration; avoidance of problems of urine collection; suitability of finger-prick samples, especially with young children; application to population surveys to monitor drug use; and selection of subjects for drug sensitivity tests and monitoring of blood levels during in vivo tests.

Age-related accumulation of phytanic acid in plasma from patients with the cerebro-hepato-renal (Zellweger) syndrome.

Plasma samples from several Zellweger patients were found to contain elevated phytanic acid levels. It was subsequently found that the level of phytanic acid in plasma from Zellweger patients depends upon the age of the patients at the time of sampling. In patients 17 weeks of age or younger, plasma phytanic acid levels were found to be normal, whereas in patients 40 weeks of age or older plasma phytanic acid levels were found to be elevated. The relationship between the age of the patients at sampling and the level of phytanic acid in the patients' plasma is probably the resultant of dietary intake of phytanic acid combined with a defective catabolism of this compound.

The epidemiology of malaria in southern Sierra Leone.

The epidemiology of malaria was investigated in a high rainfall, forested area of southern Sierra Leone. The prevalence rates of P. falciparum, P. malariae and P. ovale in 0-7 year old children, during two surveys conducted over a 12-month period, averaged 61%, 12% and 1% respectively. Groups of febrile children had higher prevalence rates than afebrile groups. Overall, gametocyte rates were approximately one fifth of the trophozoite rates. Malaria accounted for 27% of deaths, as did malnutrition, although no malaria associated deaths occurred in 0-12 month olds. Spleen rates were similar to P. falciparum prevalence rates, and the size did not appear to be related to parasite load at the time of the surveys. Packed cell volumes had normal distributions, with a lower mode after the peak prevalence period. Chloroquine usage increased during the post-rains period compared to the pre-rains period.