Waverly Hills Tuberculosis Sanatorium' Louisville KT 1926

1
Despite Kochs discovery, for 60 years the only
treatment was isolation, fresh air, and sunshine
www.umdnj.edu/librweb
Waverly Hills Tuberculosis Sanatorium. Louisville
KT 1926 Built in 1911, expanded in 1926, closed
in 1961
2
So it was time for another Nobel laureate!
Selman Waksman 1888-1973
3
He was working on bugs that live in dirt!
Selman Waksman 1888-1973
4
He was working on bugs that live in dirt!
A childhood immigrant from the Ukraine, through
hard work He became a professor Of microbiology
and biochemistry at Rutgers
Selman Waksman 1888-1973
5
He was working on bugs that live in dirt!
A childhood immigrant from the Ukraine, through
hard work He became a professor Of microbiology
and biochemistry at Rutgers He coined the term
antibiotic and Discovered more than
20 Antibiotics, including two which Are widely
used today. Neomycin--check your medicine cabinet
Selman Waksman 1888-1973
6
He was working on bugs that live in dirt!
Streptomycin
Streptomyces griseus.
7
He was working on bugs that live in dirt!
Streptomycin
Streptomyces griseus.
Isolated on October 19, 1943 by Albert Schatz, a
graduate student in Waksmans lab
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He was working on bugs that live in dirt!
the-scientist.com
Streptomycin
Isolated on October 19, 1943 by Albert Schatz, a
graduate student in Waksmans lab
9
Bugs fight bugs
Streptomycin kills many bacteria, including
Mycobacterium Tuberculosis!
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Bugs fight bugs
Streptomycin kills many bacteria, including
Mycobacterium Tuberculosis!
But how?
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The central dogma-- anybody remember that?
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The central dogma-- anybody remember that?
DNA -gt RNA -gt Proteins
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The central dogma-- anybody remember that?
DNA -gt RNA -gt Proteins
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And we call that step?
DNA -gt RNA -gt Proteins
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Translation!
DNA -gt RNA -gt Proteins
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Bacteria do it too, and like us they use
RIBOSOMES
www.palaeos.com
17
Lets zoom in on the action
Lovely picture from Harry Noller
18
The ribosome is an amazing machine That unlike
most in the cell runs on RNA!
Lovely picture from Harry Noller
19
The ribosome is an amazing machine That unlike
most in the cell runs on RNA!
16S rRNA proteins 30S or small subunit
Lovely picture from Harry Noller
20
If we zoom in further
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Luckily, our ribosomes are slightly different and
thus streptomycin affects them less
16S rRNA proteins 30S subunit
Lovely picture from Harry Noller
22
Streptomycin cannot be given orally, but must be
administered by regular intramuscular injection.
An adverse effect of this drug is ototoxicity,
i.e. It can result in temporary hearing loss.
23
Streptomycin cannot be given orally, but must be
administered by regular intramuscular injection.
An adverse effect of this drug is ototoxicity,
i.e. It can result in temporary hearing loss.
Cool fact--this may be due to effect on
Mitochondrial ribosomes!!!
24
OK. So streptomycin kills bugs in a flask in the
lab. What about inside a patient?
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First we have to make a lot of it. In steps
George Merck of Merck and Co.
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First we have to make a lot of it. In steps
George Merck of Merck and Co.
And we got the patent
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First we have to make a lot of it. In steps
George Merck of Merck and Co.
But we gave it back to Rutgers!
28
Now we need to try it on animals.
Enter Dr. William H. Feldman and Dr. H. Corwin
Hinshaw at the Mayo Clinic
29
Now we need to try it on animals.
Enter Dr. William H. Feldman and Dr. H. Corwin
Hinshaw at the Mayo Clinic
In two months they reported to Waksman that four
tubercular guinea pigs receiving streptomycin
"look exceedingly well."
We do, dont we!
30
OK, but how about people?
Next Feldman and Hinshaw invent clinical trials
www.jameslindlibrary.org
31
OK, but how about people?
Next Feldman and Hinshaw invent clinical trials
32
OK, but how about people?
Next Feldman and Hinshaw invent clinical trials
This is really important!!
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OK, but how about people?
In August 1945 Hinshaw reported that
thirty-three patients had been treated "and
we continue to be quite optimistic."
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Initially streptomycin appeared to be a miracle
cure
Patients, including the first, Patricia T, Were
returned to health from deaths door
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Now the problem was scaling up
(Remember 5 million people a year Were still
dying of TB!)
By 1948 8 companies were making streptomycin But
their 80,000 pounds Would only treat 1000
patients
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Initially streptomycin appeared to be a miracle
cure
BUT..
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A second, much worse Problem was now on the
horizon
By 1948 patients began to relapse!
For example the author George Orwell
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But a second, much worse problem was now on the
horizon
In an MRC clinical trial, patients improved
rapidly But within five years the death rate was
the Same as the untreated controls
Professor Hill of the MRC
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But a second, much worse problem was now on the
horizon
In an MRC clinical trial, patients improved
rapidly But within five years the death rate was
the Same as the untreated controls
Uh, oh.
Professor Hill of the MRC
40
What was going wrong??
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What was going wrong??
Streptomycin resistant bacteria could be cultured
from these patients!
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What was going wrong??
Streptomycin resistant bacteria could be cultured
from these patients!
How could That happen?
43
What was going wrong??
Streptomycin resistant bacteria could be cultured
from these patients!
How could That happen?
44
Have you heard The one about Natural selection?
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What was going wrong??
evolution.berkeley.edu
46
And how did this happen?
evolution.berkeley.edu
47
And how did this happen?
evolution.berkeley.edu
48
And how did this happen?
evolution.berkeley.edu
49
And how did this happen?
evolution.berkeley.edu
50
And how did this happen?
Remember me?
16S rRNA proteins 30S subunit
Lovely picture from Harry Noller
51
Occasional bacteria had variants in 16sRNA or the
ribosomal protein S12
16S rRNA proteins 30S subunit
Lovely picture from Harry Noller
52
These blocked binding of streptomycin to the
ribosome and thus these bacteria were resistant!
16S rRNA proteins 30S subunit
Lovely picture from Harry Noller
53
Thanks and kudos to Gary Trudeau for hitting the
nail on the head
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(No Transcript)
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(No Transcript)
56
So what now?
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So what now?
Luckily, help was on the way from
para-aminosalycilic acid (PAS)
AND
Jörgen Lehmann
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Lehmann started with a strange published fact The
TB bug loves to eat aspirin (salicylic acid)
59
Lehmann started with a strange published fact The
TB bug loves to eat aspirin (salicylic acid)
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Lehmann started with a strange published fact The
TB bug loves to eat aspirin (salicylic acid)
His hypothesis Alter aspirin slightly And the
bugs will die trying to eat it
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Lehmann moved quickly, from bacterial trials in
December 1943 To Guinea pig trials in January
1944 To the first patient in March 1944 (before
streptomycin!!)
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Lehmann J. Para-aminosalicylic acid in the
treatment of tuberculosis. Lancet. 1946 115-6.
Chest 194916684-703
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So how does PAS work?
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So how does PAS work?
50 years later we still dont know for sure
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So how does PAS work?
It is likely to act somewhere in the pathway For
making nucleotides to make DNA
http//themedicalbiochemistrypage.org
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So which is better Streptomycin or PAS?
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So which is better Streptomycin or PAS?
BOTH!
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Remember this?
I fear no streptomycin
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Remember this?
I fear no streptomycin
and PAS doesnt touch me
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But if the same patient is given both drugs
I fear no streptomycin
and PAS doesnt touch me
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But if the same patient is given both drugs
Ahhhh
No
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After this trial..
The two drug combination became The new standard
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But the story is not over yet-- we needed Another
Nobel laureate
74
But the story is not over yet-- we needed Another
Nobel laureate
I was already the 1939 Nobel laureate For
discovering sulphanilamide The first
antibacterial drug
Gerhard Domagk
Nobelprize.org
75
But the story is not over yet-- we needed Another
Nobel laureate
I was already the 1939 Nobel laureate For
discovering sulphanilamide The first
antibacterial drug
(though I was not allowed by the Nazis to accept
the prize and I was held by the Gestapo for a
week because of this honor)
Gerhard Domagk
Nobelprize.org
76
But the story is not over yet-- we needed Another
Nobel laureate
I spent World War II in a bomb- damaged hospital
lab pursuing new chemical relatives
of sulphanilamide that might be effective against
TB
Gerhard Domagk
Nobelprize.org
77
Heres what I discovered
Isoniazid
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Heres what I discovered
First we need to know more About mycobacteria
Isoniazid
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All living cells Have a plasma membrane
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All living cells Have a plasma membrane
Gram positive Bacteria also Have a cell wall
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Mycobacteria have a Very complex cell
wall Serving as a barrier
All living cells Have a plasma membrane
Gram positive Bacteria also Have a cell wall
http//web.uct.ac.za/depts/mmi/lsteyn/cellwall.htm
l
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1. outer lipids 2. mycolic acid 3.
polysaccharides (arabinogalactan) 4.
peptideglycan 5. plasma membrane 6.
lipoarabinomannan (LAM) 7. phosphatidylinositol
mannoside 8. cell wall skeleton
Just look at the parts list
Wikipeda/mycobacterium
83
1. outer lipids 2. mycolic acid 3.
polysaccharides (arabinogalactan) 4.
peptideglycan 5. plasma membrane 6.
lipoarabinomannan (LAM) 7. phosphatidylinositol
mannoside 8. cell wall skeleton
Just look at the parts list
Wikipeda/mycobacterium
84
Isoniazid is metabolized by the bacterium To
isonicotinic acyl anion or radical and inhibits
the enzyme that makes
85
Isoniazid was added to the combination
therapy and remains there today!
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Isoniazid was added to the combination
therapy and remains there today! Streptomycin
and PAS were removed from frontline therapy as
new drugs that were more effective or had fewer
side effects came into the clinic
87
Current first-line TB drugs and their dates of
discovery
National Institute of Allergy and Infectious
Diseases (NIAID) 2007
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NIAID (2007)
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First-line TB drugs
Left to right isoniazid, rifampin, pyrazinamide,
ethambutol Streptomycin (not shown) is given
by injection
CDC
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First-line TB drugs
4 drugs, 130 doses Over 6-9 months!
TBAlliance
91
First-line TB drugs
4 drugs, 130 doses!
Daily dose!
http//www.mcvay.com/tb_treatment_in_the_western.h
tml
TBAlliance
92
First-line TB drugs
Are also not compatible with Antiretroviral HIV
therapy (problem for 1/3 of HIV patients!)
Rifampin induces cytochrome p450s, Increasing
metabolism of anti-HIV drugs
TBAlliance
93
Remember the difference in TB rates world-wide
but
CDC
94
The other major challenge Is multi-drug resistant
TB
CDC
95
Remember this story???
96
In other word MDR TB says
I fear none of the First line drugs!
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What drives drug resistance?
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Incorrect, unsupervised, or incomplete treatment
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The answer in the developed world
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The answer in the developed world MORE DRUGS!
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NIAID (2007)
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NIAID (2007)
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New TB drugs under development
NIAID (2007)
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And the future beckons
Nature 393, 537-544(11 June 1998)
105
In 1998 the Sanger centre and the Pasteur
Institute Determined the complete genome
sequence Of M. tuberculosis
Nature 393, 537-544(11 June 1998)
106
4.4 million base pairs
About 4000 genes
Remarkable diversity Of genes involved in fatty
acid Synthesis and metabolism (gt250 genes)
Nature 393, 537-544(11 June 1998)
107
Remarkable diversity Of genes involved in fatty
acid Synthesis and metabolism (gt250 genes)
Nature 393, 537-544(11 June 1998)
108
The genome provides new targets for drugs and
vaccines
Nature 393, 537-544(11 June 1998)
109
But in the developing world..
Stats from WHO slide from TBAlliance