Advances in the treatment of Chagas disease: Promising new drugs, plants and targets.

Chagas disease, caused by Trypanosoma cruzi, is treated with only two drugs; benznidazole and nifurtimox. These drugs have some disadvantages, including their efficacy only in the acute or early infection phases, adverse effects during their use, and the resistance that the parasite has developed to their activity. Therefore, it is necessary to identify new, safe and effective therapeutic alternatives to treat Chagas disease, though governments and the pharmaceutical industry have shown a lack of interest in contributing to this solution. Institutions and research groups on the other hand have worked on some strategies that can help to address the problem. Some of these include the modification of conventional drug dosages, drug repurposing, and combined therapy. Plants and derived compounds with antiparasitic effects have also been studied, taking advantage of traditional medicinal knowledge. Others have studied the parasite to identify essential genes that can be used as therapeutic targets to design new, targeted drugs. Some of these studies have generated promising results, but few reach clinical phase studies. Institutions and research groups should be encouraged to unify efforts and cover all aspects of drug development according to resources and knowledge availability. In the end, this exchange of knowledge would lead to the development of new therapeutic alternatives to treat Chagas disease and benefit the populations it affects.

Role of nucleic acid amplification assays in monitoring treatment response in chagas disease: Usefulness in clinical trials.

Chagas disease has become a global health problem due to migration of infected people out of Latin America to non-endemic countries. For more than 40 years, only the nitroimidazole compounds Benznidazole and Nifurtimox, have been used for specific treatment of Trypanosoma cruzi infection with disappointing results, specially due to the long duration of treatment and adverse events in the chronic phase. In the last years, ergosterol inhibitors have been also proposed for specific treatment. Different randomized clinical trials were performed for evaluating their treatment efficacy and safety. One of the greatest concerns in clinical trials is to provide an early surrogate biomarker of response to trypanocidal chemotherapy. Serological response is slow and the classical parasitological tests have poor sensitivity and are time-consuming. Nowadays, PCR is the most helpful tool for assessing treatment response in a short period of time. Different protocols of PCR have been developed, being quantitative real time PCR based on amplification of repetitive satellite or minicircle DNA sequences plus an internal amplification standard, the mostly employed strategies in clinical trials. Standardized protocols and the use of an external quality assessment ensure adequate technical procedures and reliable data. Clinical trials have shown a significant reduction in parasite loads, reaching undetectable DNA levels in bloodstream after specific treatment, however events of treatment failure have also been reported. Treatment failure could be due to inadequate penetrance of the drugs into the affected tissues, to the presence of primary or secondary drug resistance of the infecting strains as well as to the existence of dormant parasite variants reluctant to drug action. The early diagnosis of drug resistance would improve clinical management of Chagas disease patients, allowing dictating alternative therapies with a combination of existing drugs or new anti-T. cruzi agents. The aim of this review was to describe the usefulness of detecting T.cruzi DNA by means of real time PCR assays, as surrogate biomarker in clinical trials for evaluating new drugs for CD or new regimens of available drugs and the possibility to detect treatment failure.

Effects of astaxanthin in mice acutely infected with Trypanosoma cruzi.

During Trypanosoma cruzi infection, oxidative stress is considered a contributing factor for dilated cardiomyopathy development. In this study, the effects of astaxanthin (ASTX) were evaluated as an alternative drug treatment for Chagas disease in a mouse model during the acute infection phase, given its anti-inflammatory, immunomodulating, and anti-oxidative properties. ASTX was tested in vitro in parasites grown axenically and in co-culture with Vero cells. In vivo tests were performed in BALB/c mice (4-6 weeks old) infected with Trypanosoma cruzi and supplemented with ASTX (10 mg/kg/day) and/or nifurtimox (NFMX; 100 mg/kg/day). Results show that ASTX has some detrimental effects on axenically cultured parasites, but not when cultured with mammalian cell monolayers. In vivo, ASTX did not have any therapeutic value against acute Trypanosoma cruzi infection, used either alone or in combination with NFMX. Infected animals treated with NFMX or ASTX/NFMX survived the experimental period (60 days), while infected animals treated only with ASTX died before day 30 post-infection. ASTX did not show any effect on the control of parasitemia; however, it was associated with an increment in focal heart lymphoplasmacytic infiltration, a reduced number of amastigote nests in cardiac tissue, and less hyperplasic spleen follicles when compared to control groups. Unexpectedly, ASTX showed a negative effect in infected animals co-treated with NFMX. An increment in parasitemia duration was observed, possibly due to ASTX blocking of free radicals, an anti-parasitic mechanism of NFMX. In conclusion, astaxanthin is not recommended during the acute phase of Chagas disease, either alone or in combination with nifurtimox.

Current drug therapy and pharmaceutical challenges for Chagas disease.

One of the most significant health problems in the American continent in terms of human health, and socioeconomic impact is Chagas disease, caused by the protozoan parasite Trypanosoma cruzi. Infection was originally transmitted by reduviid insects, congenitally from mother to fetus, and by oral ingestion in sylvatic/rural environments, but blood transfusions, organ transplants, laboratory accidents, and sharing of contaminated syringes also contribute to modern day transmission. Likewise, Chagas disease used to be endemic from Northern Mexico to Argentina, but migrations have earned it global. The parasite has a complex life cycle, infecting different species, and invading a variety of cells - including muscle and nerve cells of the heart and gastrointestinal tract - in the mammalian host. Human infection outcome is a potentially fatal cardiomyopathy, and gastrointestinal tract lesions. In absence of a vaccine, vector control and treatment of patients are the only tools to control the disease. Unfortunately, the only drugs now available for Chagas' disease, Nifurtimox and Benznidazole, are relatively toxic for adult patients, and require prolonged administration. Benznidazole is the first choice for Chagas disease treatment due to its lower side effects than Nifurtimox. However, different strategies are being sought to overcome Benznidazole's toxicity including shorter or intermittent administration schedules-either alone or in combination with other drugs. In addition, a long list of compounds has shown trypanocidal activity, ranging from natural products to specially designed molecules, re-purposing drugs commercialized to treat other maladies, and homeopathy. In the present review, we will briefly summarize the upturns of current treatment of Chagas disease, discuss the increment on research and scientific publications about this topic, and give an overview of the state-of-the-art research aiming to produce an alternative medication to treat T. cruzi infection.

Profile of Trypanosoma cruzi infection in a tropical medicine reference center, Northern Italy.

BACKGROUND: Chagas disease (CD) is endemic in Central and South America, Mexico and even in some areas of the United States. However, cases have been increasingly recorded also in non-endemic countries. The estimated number of infected people in Europe is in a wide range of 14000 to 181000 subjects, mostly resident in Spain, Italy and the United Kingdom. METHODOLOGY/PRINCIPAL FINDINGS: Retrospective, observational study describing the characteristics of patients with CD who attended the Centre for Tropical Diseases (Negrar, Verona, Italy) between 2005 and 2013. All the patients affected by CD underwent chest X-ray, ECG, echocardiography, barium X-ray of the oesophagus and colonic enema. They were classified in the indeterminate, cardiac, digestive or mixed category according to the results of the screening tests. Treatment with benznidazole (or nifurtimox in case of intolerance to the first line therapy) was offered to all patients, excluding the ones with advanced cardiomiopathy, pregnant and lactating women. Patients included were 332 (73.9% women). We classified 68.1% of patients as having Indeterminate Chagas, 11.1% Cardiac Chagas, 18.7% as Digestive Chagas and 2.1% as Mixed Form. Three hundred and twenty-one patients (96.7%) were treated with benznidazole, and most of them (83.2%) completed the treatment. At least one adverse effect was reported by 27.7% of patients, but they were mostly mild. Only a couple of patients received nifurtimox as second line treatment. CONCLUSIONS/SIGNIFICANCE: Our case series represents the largest cohort of T. cruzi infected patients diagnosed and treated in Italy. An improvement of the access to diagnosis and cure is still needed, considering that about 9200 infected people are estimated to live in Italy. In general, there is an urgent need of common guidelines to better classify and manage patients with CD in non-endemic countries.

Towards a paradigm shift in the treatment of chronic Chagas disease.

Treatment for Chagas disease with currently available medications is recommended universally only for acute cases (all ages) and for children up to 14 years old. The World Health Organization, however, also recommends specific antiparasite treatment for all chronic-phase Trypanosoma cruzi-infected individuals, even though in current medical practice this remains controversial, and most physicians only prescribe palliative treatment for adult Chagas patients with dilated cardiomyopathy. The present opinion, prepared by members of the NHEPACHA network (Nuevas Herramientas para el Diagnóstico y la Evaluación del Paciente con Enfermedad de Chagas/New Tools for the Diagnosis and Evaluation of Chagas Disease Patients), reviews the paradigm shift based on clinical and immunological evidence and argues in favor of antiparasitic treatment for all chronic patients. We review the tools needed to monitor therapeutic efficacy and the potential criteria for evaluation of treatment efficacy beyond parasitological cure. Etiological treatment should now be mandatory for all adult chronic Chagas disease patients.

[Indications and current development of new targeted therapies in pediatric oncology]. / Indications et développement actuels des nouvelles thérapeutiques ciblées en pédiatrie.

Progresses performed in pediatric oncology during the last 30 years allowed to obtain about 70 to 80% healing rates. These progresses are the result of the optimization of the cytotoxic chemotherapies protocols used at standard and high doses, as well as the improvement of the local treatment. Most of the new anticancer treatments currently in developmental stage are based on targeted therapies, acting against numerous tumor cell abnormalities, like growth factors et their receptors, cell proliferation-inducing factors, molecules involved in DNA repair, cell death inducers, tumor invasion and angiogenesis. They are widely used in adult patients since 10 years and they are being more and more employed in children with cancer. The aim of this article is to review the main indications of these new targeted drugs in pediatric oncology and the new developments of these drugs.

Avaliaçäo do tratamento especifíco para Trypanosoma cruzi em crianças, na evoluçäo da fase indeterminada / Specific treatment evaluation for Trypanosoma cruzi in children, in the evolution of the indeterminate phase

Doze pacientes com idades entre 7 a 12 anos, na forma indeterminada da doença de Chagas, com sorologia e xenodiagnóstico positivos, receberam tratamento específico. Dois pacientes tomaram 7mg/kg de nifurtimox durante 60 e 90 dias e 10 usaram 5-7mg/kg de benznidazol durante 60 dias. A evoluçäo clínica foi verificada através de exame clínico, eletrocardiograma, exame radiológico contrastado do esôfago. Após o tratamento somente uma (8,3 por cento) paciente apresentou todos os exames negativos. Oito deles foram avaliados após oito anos do tratamento e 4 acompanhados durante 20 anos. Sete (58,4 por cento) permaneceram na forma indeterminada e 4 (33,3 por cento) chagásicos progrediram clinicamente para cardiopatia grau II e/ou esofagopatia, apesar do tratamento precoce. Säo necessários estudos com maior número de crianças na fase indeterminada e acompanhamento a longo prazo para se estabelecer a influência do tratamento específico na evoluçäo da doença de Chagas

Activity of anticancer compounds against Trypanosoma cruzi-infected mice.

Chagas' disease, which is caused by Trypanosoma cruzi, remains essentially incurable. Due principally to a lack of profit incentive, the pharmaceutical industry has had limited interest in developing new antichagasic drugs. Thus, a search for agents that exhibit activity against T. cruzi, although medicaments have been developed for the treatment of other diseases, seems justifiable. Responding to evidence that the principal biochemical differences between mammalian cells and African trypanosomes apply equally to T. cruzi, our evaluations were conducted. Previous work showed the effectiveness of anticancer agents against T. rhodesiense. In the present studies, 76 anticancer compounds were assessed for their ability to suppress the trypomastigotes of T. cruzi- infected mice. Five compounds were found to be active. The most effective was cycloheximide, which was more than six times as effective as the standard, nifurtimox.

Actividad de diterpenoides de azorella compacta, llareta, sobre amastigotes de trypanosoma cruzi / Activity of dipernoids isolated from azorella compacta, llareta, on trypanosoma cruzi amastigotes

The trypanocidad activity against amastigote forms of SPA-14, Tulahuen and G strains and CL Brener clone of Trypanosoma cruzi of diterpenoids isolated from Azorella compacta. Phil. (Llareta), a plant with ethnomedicinal prestige from prespanish age, was investigated. Amastigocidal activity was shown in azorellanol (2), diterpene isolated by first time, with an inhitory concentration 50 (IC) that varied between 60 M (CL Brener clone) and 84 M (SPA-14 strain), and in mulin -11,13 -dien-20-oico acid (5) with IC between 41 µM (G strain) and 87 mM (CL Brener clone). The cytotoxicity levels of both compounds against Hela and Vero cells and macrophages J144 are lower than nifurtimox and similar to gentian violet

Chagas' disease: a search for treatment and a question--should the disease be of military concern?

If military forces are required to operate in areas that are endemic for Chagas' disease, the occupation should be of critical concern. These areas, located in Central and South America, are many. The matter is of particular importance because no suitable drug exists to treat individuals who contract the disease. We examined 60 compounds of a chemical class, thiosemicarbazones, known to have some activity against the disease. The work was carried out using Trypanosoma cruzi-infected mice. Of the 60 potential drugs evaluated, 12 showed significant suppressive activity. One of these compounds was almost 50% greater than the reference drug used in the test system.

Evidence that certain 8-aminoquinolines are potentially effective drugs against Chagas disease.

Forty 8-aminoquinolines (a chemical class with members having some activity against Trypanosoma cruzi infections) were evaluated for their effectiveness in reducing the 14-day parasitaemias of 4-6 week-old, female, albino mice infected with a Brazilian strain of T. cruzi. Six of the compounds were more active or as active as the reference drug, nifurtimox, and one was > 13-fold as efficacious. Certain members of the series tested warrant further evaluation.

Phase-contrast study of the efficacy of Lampit (BAY 2502, Nifurtimox) on experimental infection with Trypanosoma rhodesiense.

Lampit (BAY 2502, Nifurtimox) was tested in experimental Wistar strain white rats with acute infection induced by Trypanosoma rhodesiense strain (180 TS1A1), which normally contains cytoplasmic granules of both Type (I) & (II). Lampit injected subcutaneously in low doses of 25, 50, 100, and 250 mg/kg b-w as one-time application, gave no effect. When repeated higher doses (500 mg/kg b-w) was given a reasonable effect was achieved and formation of additional granules in T. rhodesiense was noticed. In experimental animals, some what higher initial doses appear to be particularly advantageous.

Terapêutica da fase crônica da infecçäo experimental pelo Trypanosoma cruzi com o benzonidazol e o nifurtimox / Therapy of the chronic phase of the experimental infection by Trupanosoma cruzi with benzonidazole and nifurtimox

Foram submetidos à quimioterapia com Nifurtimox (Bay 2502) ou com o Benzonidazol (Ro7-1051) cinqüenta e oito camundongos cronicamente infectados com diferentes cepas do Trypanosoma cruzi (Tipos II e III) por períodos de 90 a 100 dias. Vinte e um camundongos cronicamente infectados foram utilizado como controles näo tratados. Os inóculos variaram ente 1 x 10***4 e 5 x 10***4 tripomastigotas sanguícolas. O tratamento foi feito durante 90 dias, nas doses de 200 mg/Kg/dia durante 4 dias, seguidas de doses de 50 mg/Kg/dia, para o Nifurtimox e de 100 mg/Kg/dia, para o Benzonidazol. Os resultados dos testes parasitológicos (xenodiagnóstico, subnoculaçäo do sangue e hemocultura), nos camundongos tratados com Benzonidazol, mostraram 85,3% de negativaçäo nos animais infectados com as cepas de Tipo II e 43% com as cepas de Tipo III. Nos camundongos tratados com o Nifurtimox observou-se 71,4% de cura parasitológica nos infectados com as cepas de Tipo II e 66% nos infectados com as cepas de Tipo III. Os testes de IFI permaneceram positivos em 90% dos animais tratados e curados. Houve regressäo total ou parcial das lesöes miocárdicas e de músculo esquelético nos animais tratados e curados. Em 50% dos animais em que os testes de cura permaneceram positivos, houve persistência de lesöes histopatológicas discretas. Conclui-se que o tratamento na fase crônica pode determinar negativaçäo parasitológica em percentagem elevada de casos, compáravel ao obtido na fase aguda, com as cepas de Tipo II e mais elevadas com as cepas de Tipo III, com persistência da positividade da IFI

[Therapy of the chronic phase of the experimental infection by Trypanosoma cruzi with benzonidazole and nifurtimox]. / Terapêutica da fase crônica da infeccao experimental pelo Trypanosoma cruzi com o benzonidazol e o nifurtimox.

Fifty-eight mice, chronically infected with different T. cruzi strains (Types II and III) were submitted to chemotherapy either with Nifurtimox (Bay 2502) or Benznidazole (Ro 7-1051). Twenty one mice were not treated and were used as infected controls. The duration of infection was from 90 to 400 days. Inocula varied from 1 x 10(4) to 5 x 10(4) blood forms. Treatment lasted for 90 days, doses being 200mg/kg/day during 4 days, followed by 50mg/kg/day for Nifurtimox and 100mg/kg/day for Benznidazole. Parasitological tests (xenodiagnosis, inoculations into baby mice and hemoculture) showed 85.3% negativation for Type II strains and 43% for Type III in animals treated with Benznidazole. As for Nifurtimox, there were 71.4% of parasitological negativation for the animals infected with Type II strains and 66% for those infected with Type III. IFA tests remained positive in 90% of treated and cured animals. Disappearance or marked regression of myocardial and skeletal muscle lesions was seen in the treated and parasitologically negative animals. The conclusion is that the treatment in the chronic phase of T. cruzi infection can result in parasitological cure in a high percentage of cases with regression of histopathological lesions, although with persistence of positivity of the IFA tests.

Padräo isoenzimático da cepa y do Trypanosoma cruzi após quimioterapia específica / Isoenzymatic pattern of Trypanosoma cruzi y strain following specific chemoterapy

Foi estudado o perfil isoenzimático da cepa Y do Trypanosoma cruzi isolada de camundongos tratados e näo curados com o Nufurtimox (Bay 25.2) ou com o Benzonidazol (Ro 7.1051), submetida a passagens em camundongos recém-nascidos e a seguir inoculada nos seguintes grupos experimentais: I - camundongos inoculados com a cepa Y resistente ao Nifurtimox e tratados com esta mesma droga; II - camundongos inoculdado com a cepa Y resistente ao Nifurtimox e tratados com o Benzonidazol e III - camundognos resistentes ao tratamento com o Benzonidazol e tratados com esta mesma droga. Os inóculos foram de 15 x 10**4 tripomastigotas sanguícolas. Houve aumento de resistência em relaçäo a cepa original com a mesma droga e resistência cruzada. A cepa Y isolada dos animais näo curados foi passada em cultura em meio Warren e preparados os extratos enzimáticos para a eletroforese das seguintes enzimas: GPI, PGM, ALAT e ASAT. Como controle isoenzimático foram utilizadas as cepas Peruana (Tipo I), 21 SF (Tipo II) e Colombiana (Tipo III) e duas amostras da cepa Y mantidas por diferentes período em cultura e em criopreservaçäo dos extraidos enzimáticos. Näo houve modificaçöes do perfil isoenzimático da cepa Y, que Tipo I (Peruana) e ao padräo das amostras da cepa Y com diferentes períodos de manutençäo

[Isoenzymatic pattern of Trypanosoma cruzi Y strain after specific chemotherapy]. / Padrao isoenzimático da cepa Y do Trypanosoma cruzi após quimioterapia especifica.

The isoenzyme pattern of the Trypanosoma cruzi Y strain recovered from mice inoculated with 15 x 10(4) blood trypomastigotes and previously treated with either Bay 2502 (Nifurtimox) or Ro 7-1051 (Benzonidazol) was analyzed in the following situations: a) strain resistant to Bay 2502 and again treated with the same drug; b) strain resistant to Bay 2502 and treated with Ro 7-1051; c) strain resistant to Ro 7-1051 and treated with that same drug. Although marked drug resistance was noted in all cases, the isoenzyme pattern of the Y strain for GPI, PGM, ALAT and ASAT remained throughout the same. The pattern was similar to that of the Peruvian strain, which also belongs to the same strain Type of the Y strain, but differed from those of the 21 SF (Type II) and Colombian (Type III) strains. Thus, the appearance of drug resistance in T. cruzi strain was not associated with a change in its isoenzymatic pattern.