New drug discovery strategies for the treatment of benznidazole-resistance in Trypanosoma cruzi, the causative agent of Chagas disease.

INTRODUCTION: Benznidazole, the drug of choice for treating Chagas Disease (CD), has significant limitations, such as poor cure efficacy, mainly in the chronic phase of CD, association with side effects, and parasite resistance. Understanding parasite resistance to benznidazole is crucial for developing new drugs to treat CD. AREAS COVERED: Here, the authors review the current understanding of the molecular basis of benznidazole resistance. Furthermore, they discuss the state-of-the-art methods and critical outcomes employed to evaluate the efficacy of potential drugs against T. cruzi, aiming to select better compounds likely to succeed in the clinic. Finally, the authors describe the different strategies employed to overcome resistance to benznidazole and find effective new treatments for CD. EXPERT OPINION: Resistance to benznidazole is a complex phenomenon that occurs naturally among T. cruzi strains. The combination of compounds that inhibit different metabolic pathways of the parasite is an important strategy for developing a new chemotherapeutic protocol.

Transcriptomic analysis of benznidazole-resistant and susceptible Trypanosoma cruzi populations.

BACKGROUND: Chagas disease (CD), caused by the parasite Trypanosoma cruzi, is a serious public health concern in Latin America. Nifurtimox and benznidazole (BZ), the only two drugs currently approved for the treatment of CD, have very low efficacies in the chronic phase of the disease and several toxic side effects. Trypanosoma cruzi strains that are naturally resistant to both drugs have been reported. We performed a comparative transcriptomic analysis of wild-type and BZ-resistant T. cruzi populations using high-throughput RNA sequencing to elucidate the metabolic pathways related to clinical drug resistance and identify promising molecular targets for the development of new drugs for treating CD. METHODS: All complementary DNA (cDNA) libraries were constructed from the epimastigote forms of each line, sequenced and analysed using the Prinseq and Trimmomatic tools for the quality analysis, STAR as the aligner for mapping the reads against the reference genome (T. cruzi Dm28c-2018), the Bioconductor package EdgeR for statistical analysis of differential expression and the Python-based library GOATools for the functional enrichment analysis. RESULTS: The analytical pipeline with an adjusted P-value of < 0.05 and fold-change > 1.5 identified 1819 transcripts that were differentially expressed (DE) between wild-type and BZ-resistant T. cruzi populations. Of these, 1522 (83.7%) presented functional annotations and 297 (16.2%) were assigned as hypothetical proteins. In total, 1067 transcripts were upregulated and 752 were downregulated in the BZ-resistant T. cruzi population. Functional enrichment analysis of the DE transcripts identified 10 and 111 functional categories enriched for the up- and downregulated transcripts, respectively. Through functional analysis we identified several biological processes potentially associated with the BZ-resistant phenotype: cellular amino acid metabolic processes, translation, proteolysis, protein phosphorylation, RNA modification, DNA repair, generation of precursor metabolites and energy, oxidation-reduction processes, protein folding, purine nucleotide metabolic processes and lipid biosynthetic processes. CONCLUSIONS: The transcriptomic profile of T. cruzi revealed a robust set of genes from different metabolic pathways associated with the BZ-resistant phenotype, proving that T. cruzi resistance mechanisms are multifactorial and complex. Biological processes associated with parasite drug resistance include antioxidant defenses and RNA processing. The identified transcripts, such as ascorbate peroxidase (APX) and iron superoxide dismutase (Fe-SOD), provide important information on the resistant phenotype. These DE transcripts can be further evaluated as molecular targets for new drugs against CD.

Comparative transcriptomic analysis of antimony resistant and susceptible Leishmania infantum lines.

BACKGROUND: One of the major challenges to leishmaniasis treatment is the emergence of parasites resistant to antimony. To study differentially expressed genes associated with drug resistance, we performed a comparative transcriptomic analysis between wild-type and potassium antimonyl tartrate (SbIII)-resistant Leishmania infantum lines using high-throughput RNA sequencing. METHODS: All the cDNA libraries were constructed from promastigote forms of each line, sequenced and analyzed using STAR for mapping the reads against the reference genome (L. infantum JPCM5) and DESeq2 for differential expression statistical analyses. All the genes were functionally annotated using sequence similarity search. RESULTS: The analytical pipeline considering an adjusted p-value < 0.05 and fold change > 2.0 identified 933 transcripts differentially expressed (DE) between wild-type and SbIII-resistant L. infantum lines. Out of 933 DE transcripts, 504 presented functional annotation and 429 were assigned as hypothetical proteins. A total of 837 transcripts were upregulated and 96 were downregulated in the SbIII-resistant L. infantum line. Using this DE dataset, the proteins were further grouped in functional classes according to the gene ontology database. The functional enrichment analysis for biological processes showed that the upregulated transcripts in the SbIII-resistant line are associated with protein phosphorylation, microtubule-based movement, ubiquitination, host-parasite interaction, cellular process and other categories. The downregulated transcripts in the SbIII-resistant line are assigned in the GO categories: ribonucleoprotein complex, ribosome biogenesis, rRNA processing, nucleosome assembly and translation. CONCLUSIONS: The transcriptomic profile of L. infantum showed a robust set of genes from different metabolic pathways associated with the antimony resistance phenotype in this parasite. Our results address the complex and multifactorial antimony resistance mechanisms in Leishmania, identifying several candidate genes that may be further evaluated as molecular targets for chemotherapy of leishmaniasis.

[Prevalence of pain among patients admitted to a clinical hospital]. / Prevalencia de dolor en la internación en un hospital de alta complejidad de Argentina.

BACKGROUND: Pain prevalence during hospital admission is variable, with estimates ranging from 32 to 77%. AIM: To determine pain prevalence during admission to a clinical hospital. MATERIAL AND METHODS: Patients admitted to medical and surgical wards were interrogated about the presence of pain within 48 to 72 hours after admission. Subjective pain was analyzed using a scale ranging from 0 to 10. Data was analyzed separately for medical, surgical, and obstetrical patients. RESULTS: A total of 736 patients aged 18 to 94 years (416 women) were recruited. Pain prevalence at 48 hours after admission was 56% (95% confidence intervals (CI (52.7 to 60.1). Pain prevalence in medical, surgical and obstetric patients was 37% (95% CI 31.4 to 42.1), 70% (95% CI 64.5 to 75.5) and 77% (95% CI 68.6 to 84), respectively. The median pain intensities in medical, surgical, and obstetrical patients were 7 (interquartile range (IQR) 6-8), 7 (IQR 5-8) y 7 (IQR 5-8), respectively. CONCLUSIONS: The prevalence of pain among patients admitted to the hospital is high, especially in obstetric and surgical units.

Prevalencia de dolor en la internación en un hospital de alta complejidad de Argentina / Prevalence of pain among patients admitted to a clinical hospital

Background: Pain prevalence during hospital admission is variable, with estimates ranging from 32 to 77%. Aim: To determine pain prevalence during admission to a clinical hospital. Material and Methods: Patients admitted to medical and surgical wards were interrogated about the presence of pain within 48 to 72 hours after admission. Subjective pain was analyzed using a scale ranging from 0 to 10. Data was analyzed separately for medical, surgical, and obstetrical patients. Results: A total of 736 patients aged 18 to 94 years (416 women) were recruited. Pain prevalence at 48 hours after admission was 56% (95% confidence intervals (CI (52.7 to 60.1). Pain prevalence in medical, surgical and obstetric patients was 37% (95% CI 31.4 to 42.1), 70% (95% CI 64.5 to 75.5) and 77% (95% CI 68.6 to 84), respectively. The median pain intensities in medical, surgical, and obstetrical patients were 7 (interquartile range (IQR) 6-8), 7 (IQR 5-8) y 7 (IQR 5-8), respectively. Conclusions: The prevalence of pain among patients admitted to the hospital is high, especially in obstetric and surgical units.

Molecular characterization of Cyclophilin (TcCyP19) in Trypanosoma cruzi populations susceptible and resistant to benznidazole.

Cyclophilin (CyP), a peptidyl-prolyl cis/trans isomerase, is a key molecule with diverse biological functions that include roles in molecular chaperoning, stress response, immune modulation, and signal transduction. In this respect, CyP could serve as a potential drug target in disease-causing parasites. Previous studies employing proteomics techniques have shown that the TcCyP19 isoform was more abundant in a benznidazole (BZ)-resistant Trypanosoma cruzi population than in its susceptible counterpart. In this study, TcCyP19 has been characterized in BZ-susceptible and BZ-resistant T. cruzi populations. Phylogenetic analysis revealed a clear dichotomy between Cyphophilin A (CyPA) sequences from trypanosomatids and mammals. Sequencing analysis revealed that the amino acid sequences of TcCyP19 were identical among the T. cruzi samples analyzed. Southern blot analysis showed that TcCyP19 is a single-copy gene, located in chromosomal bands varying in size from 0.68 to 2.2 Mb, depending on the strain of T. cruzi. Northern blot and qPCR indicated that the levels of TcCyP19 mRNA were twofold higher in drug-resistant T. cruzi populations than in their drug-susceptible counterparts. Similarly, as determined by two-dimensional gel electrophoresis immunoblot, the expression of TcCyP19 protein was increased to the same degree in BZ-resistant T. cruzi populations. No differences in TcCyP19 mRNA and protein expression levels were observed between the susceptible and the naturally resistant T. cruzi strains analyzed. Taken together, these data indicate that cyclophilin TcCyP19 expression is up-regulated at both transcriptional and translational levels in T. cruzi populations that were in vitro-induced and in vivo-selected for resistance to BZ.

Comparative proteomic analysis of antimony-resistant and -susceptible Leishmania braziliensis and Leishmania infantum chagasi lines.

The emergence of drug-resistant Leishmania species is a significant problem in several countries. A comparative proteomic analysis of antimony-susceptible and antimony-resistant Leishmania braziliensis (LbSbR) and Leishmania infantum chagasi (LcSbR) lines was carried out using two-dimensional gel electrophoresis (2-DE) followed by mass spectrometry (LC/MS/MS) for protein identification. Out of 132 protein spots exclusive or up-regulated submitted to MS, we identified 80 proteins that corresponded to 57 distinct proteins. Comparative analysis of data showed that most of the protein spots with differential abundance in both species are involved in antioxidant defense, general stress response, glucose and amino acid metabolism, and cytoskeleton organization. Five proteins were commonly more abundant in both SbIII-resistant Leishmania lines: tryparedoxin peroxidase, alpha-tubulin, HSP70, HSP83, and HSP60. Analysis of the protein abundance by Western blotting assays confirmed our proteomic data. These assays revealed that cyclophilin-A is less expressed in both LbSbR and LcSbR lines. On the other hand, the expression of pteridine reductase is higher in the LbSbR line, whereas tryparedoxin peroxidase is overexpressed in both LbSbR and LcSbR lines. Together, these results show that the mechanism of antimony-resistance in Leishmania spp. is complex and multifactorial.

Selection and phenotype characterization of potassium antimony tartrate-resistant populations of four New World Leishmania species.

In the present study, we selected in vitro populations of Leishmania Viannia guyanensis, L.V. braziliensis, L. Leishmania amazonensis and L.L. infantum chagasi that were resistant to potassium antimony tartrate (SbIII). The resistance index of these populations varied from 4- to 20-fold higher than that of their wild-type counterparts. To evaluate the stability of the resistance phenotype, these four resistant populations were passaged 37 to 47 times in a culture medium without SbIII. No change was observed in the resistance indexes of L.V. guyanensis (19-fold) and L.L. infantum chagasi (4-fold). In contrast, a decrease in the resistance index was observed for L.V. braziliensis (from 20- to 10-fold) and L.L. amazonensis (from 6- to 3-fold). None of the antimony-resistant populations exhibited cross-resistance to amphotericin B and miltefosine. However, the resistant populations of L.V. braziliensis, L.L. amazonensis and L.L. infantum chagasi were also resistant to paromomycin. A drastic reduction was observed in the infectivity in mice for the resistant L.V. guyanensis, L.L. amazonensis and L.V. braziliensis populations. The SbIII-resistant phenotype of L.V. braziliensis was stable after one passage in mice. Although the protocol of induction was the same, the SbIII-resistant populations showed different degrees of tolerance, stability, infectivity in mice and cross-resistance to antileishmanial drugs, depending on the Leishmania species.

Characterization of a gene encoding alcohol dehydrogenase in benznidazole-susceptible and -resistant populations of Trypanosoma cruzi.

Alcohol dehydrogenases (ADH) are a class of oxidoreductases that catalyse the reversible oxidation of ethanol to acetaldehyde. In the human parasite Trypanosoma cruzi the TcADH gene was identified through microarray analysis as having reduced transcription in an in vitro induced benznidazole (BZ)-resistant population. In the present study, we have extended these results by characterizing the TcADH gene from 11 strains of T. cruzi that were either susceptible or naturally resistant to benznidazole and nifurtimox or had in vivo selected or in vitro induced resistance to BZ. Sequence comparisons showed that TcADH was more similar to prokaryotic ADHs than to orthologs identified Leishmania spp. Immunolocalisation using confocal microscopy revealed that TcADH is present in the kinetoplast region and along the parasite body, consistent with the mitochondrial localization predicted by sequence analysis. Northern blots showed a 1.9kb transcript with similar signal intensity in all T. cruzi samples analysed, except for the in vitro selected resistant population, where transcript levels were 2-fold lower. These findings were confirmed by quantitative real-time PCR. In Western blot analysis, anti-TcADH polyclonal antisera recognised a 42kDa protein in all T. cruzi strains tested. The level of expression of this polypeptide was approximately 2-fold lower in the in vitro induced benznidazole-resistant strain, than in the susceptible parental strain. The chromosomal location of the TcADH gene was variable, but was not associated with the zymodeme or with the drug resistance phenotype. The data presented here show that the TcADH enzyme has a decreased level of expression in the in vitro induced BZ-resistant T. cruzi population, a situation that has not been observed in the in vivo selected BZ-resistant and naturally resistant strains.

Trypanosoma cruzi: multiplex PCR to detect and classify strains according to groups I and II.

A multiplex PCR was developed for simultaneous detection of Trypanosoma cruzi DNA and classification of the parasite strain into groups I and II. As little as 10fg of T. cruzi DNA could be detected by multiplex PCR. The technique was shown to be specific for T. cruzi DNA, since no PCR amplification products were obtained with DNA from other tripanosomatid species. Multiplex PCR was validated by assaying genomic DNA from 34 strains of T. cruzi that had been previously characterized; 24 blood samples from experimentally-infected mice and non-infected controls; 20 buffy coat samples from patients in the acute phase of Chagas disease and non-infected individuals, and 15 samples of feces from naturally-infected Triatoma infestans. T. cruzi samples from patients and from Y strain-infected mice were classified by multiplex PCR as T. cruzi II and samples from T. infestans and Colombiana strain-infected mice as T. cruzi I.

Differential gene expression in Trypanosoma cruzi populations susceptible and resistant to benznidazole.

Differential gene expression in three pairs of Trypanosoma cruzi populations or clones susceptible or resistant to benznidazole (BZ) was investigated by differential display (DD) and representation of differential expression (RDE). GenBank searches of 14 genes selected by DD showed that four sequences corresponded to different hypothetical proteins and the others were very similar to T. cruzi genes encoding mucin (TcMUC), dihydrolipoamide dehydrogenase (TcLipDH), the hexose transporter (TcHT), or a ribosomal protein. Sequence analysis was performed on 34 clones obtained by RDE; approximately half of these clones encoded 14 different hypothetical proteins and the other half encoded proteins involved with stress response, antioxidant defence, metabolism, transporter proteins, surface proteins, ribosomal proteins and others. The mRNA levels of eight T. cruzi genes obtained by RDE and DD were analysed by northern blotting to confirm the differential expression of these sequences. For six of the eight genes, TcLipDH, TcHT, TcFeSOD-A (iron superoxide dismutase-A), TcHSP70, TcHSP100 (heat shock protein) and Tc52 (thiol-transferase), mRNA levels in the drug-resistant T. cruzi population were at least twice those in the susceptible population. Further analysis of TcHSP70 showed that although the levels of TcHSP70 mRNA were four-fold higher in T. cruzi BZ-resistant population, no corresponding increase was observed in the levels of TcHSP70 protein expression. The results suggest that TcHSP70 is not directly associated with the T. cruzi drug resistance phenotype.

Arylfurans as potential trypanosoma cruzi trypanothione reductase inhibitors.

The natural lignans veraguensin and grandisin have been reported to be active against Trypanosoma cruzi bloodstream forms. Aiming at the total synthesis of these and related compounds, we prepared three 2-arylfurans and eight 2,5-diarylfurans. They were evaluated for their potential as T. cruzi trypanothione reductase (TR) inhibitors as well against the parasite's intracellular (amastigote) and bloodstream (trypomastigote) forms. Compound 12 was the most effective against TR with an IC50 of 48.5 microM while 7 and 14 were active against amastigotes, inhibiting the parasite development by 60% at 20 microg/ml (59 and 90 microM, respectively). On the other hand, none of the compounds was significantly active against the parasite bloodstream forms even at 250 microg/ml (0.6-1.5 mM).

Arylfurans as potential Trypanosoma cruzi trypanothione reductase inhibitors

The natural lignans veraguensin and grandisin have been reported to be active against Trypanosoma cruzi bloodstream forms. Aiming at the total synthesis of these and related compounds, we prepared three 2-arylfurans and eight 2,5-diarylfurans. They were evaluated for their potential as T. cruzi trypanothione reductase (TR) inhibitors as well against the parasite's intracellular (amastigote) and bloodstream (trypomastigote) forms. Compound 12 was the most effective against TR with an IC50 of 48.5 æM while 7 and 14 were active against amastigotes, inhibiting the parasite development by 60 percent at 20 æg/ml (59 and 90 æM, respectively). On the other hand, none of the compounds was significantly active against the parasite bloodstream forms even at 250 æg/ml (0.6-1.5 mM).

Desenvolvimento de uma PCR multiplex capaz de detectar e classificar cepas de Trypanosoma cruzi em amostras clínicas e de campo

Nesse trabalho, descrevemos a busca por marcadores moleculares que permitam simultaneamente o diagnóstico da doença de Chagas e a classificação das cepas segundo o fenótipo de susceptibilidade a drogas, zimodema e/ou grupos I e II do T. cruzi. [...], selecionamos seqüências repetitivas do DNA do T. cruzi e iniciadores descritos para o diagnóstico da doença de Chagas. Analisamos as seqüências do elemento repetitivo E13, kDNA e o DNA satélite (195 pb). Os resultados com o elemento repetitivo E13 e seqüências do kDNA, mostraram uma grandevariabilidade dessas seqüências, inviabilizando a busca de marcadores. Analisamos 160 seqüências do DNA satélite de 195 pb de 12 cepas do T. cruzi previamente caracterizadas segundo o fenótipo de susceptibilidade a drogas e zimodema. Estudos de filogenia mostraram a existência de dois grupos distintos, associados com os grupos I e II do T. cruzi. Observamos a presença de 8 polimorfismos exclusivos das cepas do grupo I do T. cruzi. [...] . Umsistema de PCR multiplex constituído pelos iniciadores TcSat 4 e Diaz 7 e 8 permitiram a classificação das cepas de T. cruzi nos grupos I e II. A sensibilidade foi de 10 fg, o que corresponde a 1/30 do DNA de um parasito. Amostras de DNA de outros tripanosomatídeos não produziram produto amplificado. Comparamos o perfil de amplificação do DNA satélite de 30 cepas de T. cruzi e 24 amostras de sangue de camundongos experimentalmente infectados com as cepas Colombiana (grupo I) e Y(grupo II) em papel de filtro. Em todas as amostras positivas foi possível a identificação dos grupos I e II. Para validarmos a técnica com amostras de campo, utilizamos 7 amostras de DNA do creme leucocitário de pacientes na fase aguda da doença deChagas e 15 amostras de fezes de Triatoma infestans em papel de filtro. As amostras de pacientes foram grupo II e as amostras de T. infestans grupo I. Esses resultadosestão de acordo com os dados descritos na literatura que mostram uma associação entre cepas do grupo I do T.

Desenvolvimento de uma PCR multiplex capaz de detectar e classificar cepas de Trypanosoma cruzi em amostras clínicas e de campo / Development of a PCR multiplex capable to detect and to classify cepas of Trypanosoma cruzi in clinical samples and field

Nesse trabalho, descrevemos a busca por marcadores moleculares que permitam simultaneamente o diagnóstico da doença de Chagas e a classificação das cepas segundo o fenótipo de susceptibilidade a drogas, zimodema e/ou grupos I e II do T. cruzi. [...], selecionamos seqüências repetitivas do DNA do T. cruzi e iniciadores descritos para o diagnóstico da doença de Chagas. Analisamos as seqüências do elemento repetitivo E13, kDNA e o DNA satélite (195 pb). Os resultados com o elemento repetitivo E13 e seqüências do kDNA, mostraram uma grandevariabilidade dessas seqüências, inviabilizando a busca de marcadores. Analisamos 160 seqüências do DNA satélite de 195 pb de 12 cepas do T. cruzi previamente caracterizadas segundo o fenótipo de susceptibilidade a drogas e zimodema. Estudos de filogenia mostraram a existência de dois grupos distintos, associados com os grupos I e II do T. cruzi. Observamos a presença de 8 polimorfismos exclusivos das cepas do grupo I do T. cruzi. [...] . Umsistema de PCR multiplex constituído pelos iniciadores TcSat 4 e Diaz 7 e 8 permitiram a classificação das cepas de T. cruzi nos grupos I e II. A sensibilidade foi de 10 fg, o que corresponde a 1/30 do DNA de um parasito. Amostras de DNA de outros tripanosomatídeos não produziram produto amplificado. Comparamos o perfil de amplificação do DNA satélite de 30 cepas de T. cruzi e 24 amostras de sangue de camundongos experimentalmente infectados com as cepas Colombiana (grupo I) e Y(grupo II) em papel de filtro. Em todas as amostras positivas foi possível a identificação dos grupos I e II. Para validarmos a técnica com amostras de campo, utilizamos 7 amostras de DNA do creme leucocitário de pacientes na fase aguda da doença deChagas e 15 amostras de fezes de Triatoma infestans em papel de filtro. As amostras de pacientes foram grupo II e as amostras de T. infestans grupo I. Esses resultadosestão de acordo com os dados descritos na literatura que mostram uma associação entre cepas do grupo I do T.