waverly hills tuberculosis sanatorium. louisville kt 1926

“Wars and elections are both too big and too small to matter in the long run. The daily work—that goes on, it adds up. It goes into the ground, into crops, into children’s bellies and their bright eyes. Good things don’t get lost.

Here's what I've decided: the very least you can do in your life is to figure out what you hope for. And the most you can do is live inside that hope. Not admire it from a distance but live right inside it, under its roof. What I want is so simple I almost can't say it: elementary kindness. Enough to eat, enough to go around. The possibility that kids might one day grow up to be neither the destroyers nor the destroyed. That's about it. Right now I'm living in that hope, running down its hallway and touching the walls on both sides. I can't tell you how good it feels”

From Barbara Kingsolver, “Animal Dreams”

Waverly Hills Tuberculosis Sanatorium. Louisville KT 1926

Built in 1911, expanded in 1926, closed in 1961

www.umdnj.edu/librweb

Despite Koch’s discovery, for 60 years the only treatment was isolation, “fresh air, and sunshine”

So it was time for another Nobel laureate!

Selman Waksman1888-1973

He was working on bugs that live in dirt!

A childhood immigrant from theUkraine, through hard workHe became a professorOf microbiology and biochemistry at Rutgers

He coined the term antibiotic andDiscovered more than 20Antibiotics, including two whichAre widely used today.

Neomycin--check your medicine cabinet

StreptomycinStreptomyces griseus.

Isolated on October 19, 1943 by Albert Schatz, a graduate student in Waksman’s lab

Streptomycin

Isolated on October 19, 1943 by Albert Schatz, a graduate student in Waksman’s lab

the-scientist.com

Streptomycin kills many bacteria, including

Mycobacterium Tuberculosis!

Bugs fight bugs

Streptomycin kills many bacteria, including

Mycobacterium Tuberculosis!

Bugs fight bugs

But how?

The central dogma--anybody remember that?

DNA -> RNA -> Proteins

The central dogma--anybody remember that?

And we call that step?

Translation!

www.palaeos.com

Bacteria do it too, and like us they use RIBOSOMES

Lovely picture from Harry Noller

Let’s zoom in on the action

The ribosome is an amazing machineThat unlike most in the cell runs on RNA!

16S rRNA + proteins =30S or small subunit

If we zoom in further…

Luckily, our ribosomes are slightly differentand thus streptomycin affects them less

16S rRNA + proteins =30S subunit

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.

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!!!

OK. So streptomycin kills bugs ina flask in the lab. What about inside a patient?

First we have to make a lot of it.

In steps George Merck

of Merck and Co.

And we got the patent…

of Merck and Co.

But we gave it back to Rutgers!

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, don’t we!

OK, but how about people?Next Feldman and Hinshaw invent clinical trials

www.jameslindlibrary.org

OK, but how about people?Next Feldman and Hinshaw invent clinical trials

This is really important!!

OK, but how about people?

In August 1945 Hinshaw reported that thirty-three patients had been treated "and [we] continue to be quite optimistic."

Initially streptomycin appeared to be a miracle cure

Patients, including the first, “Patricia T”,Were returned to health from death’s door

Now the problem was scaling up

(Remember 5 million people a yearWere still dying of TB!)

By 1948 8 companies were making streptomycinBut their 80,000 pounds

Would only treat 1000 patients

Initially streptomycin appeared to be a miracle cure

BUT…..

A second, much worse Problem was now on the horizon

By 1948 patients began to relapse!

For example the author George Orwell

But a second, much worse problem was now on the horizon

In an MRC clinical trial, patients improved rapidlyBut within five years the death rate was the

Same as the untreated controls

Professor Hill of the MRC

But a second, much worse problem was now on the horizon

In an MRC clinical trial, patients improved rapidlyBut within five years the death rate was the

Same as the untreated controls

Professor Hill of the MRC

Uh, oh.

What was going wrong??

Streptomycin resistant bacteriacould be cultured from these patients!

How couldThat happen?

Have you heardThe one aboutNatural selection?

evolution.berkeley.edu

And how did this happen?

Remember me?

Occasional bacteria had variants in16sRNA or the ribosomal protein S12

These blocked binding of streptomycin to the ribosome and thus these bacteria

were resistant!

Thanks and kudos to Gary Trudeau for hitting the nail on the head

So what now?

Luckily, help was on the wayfrom

para-aminosalycilic acid (PAS)

Jörgen Lehmann

Lehmann started with a strange published factThe TB bug loves to eat aspirin (salicylic acid)

His hypothesis: Alter aspirin slightlyAnd the bugs will die trying to eat it

Lehmann moved quickly, from bacterial trials in December 1943To Guinea pig trials in January 1944To the first patient in March 1944 (before streptomycin!!)

Chest 1949;16;684-703

Lehmann J. Para-aminosalicylic acid in the treatment of tuberculosis. Lancet. 1946; 1:15-6.

So how does PAS work?

50 years later we still don’t know for sure

So how does PAS work?

It is likely to act somewhere in the pathwayFor making nucleotides to make DNA

http://themedicalbiochemistrypage.org

So which is better:Streptomycin or PAS?

Remember this?

I fear no streptomycin

Remember this?

and PAS doesn’t touch me

But if the same patient is given both drugs…

Ahhhh……

No………

But if the same patient is given both drugs…

The two drug combination becameThe new standard

After this trial…..

But the story is not over yet-- we neededAnother Nobel laureate

Nobelprize.org

I was already the 1939 Nobel laureateFor discovering sulphanilamideThe first antibacterial drug

Gerhard Domagk

Nobelprize.org

I was already the 1939 Nobel laureateFor discovering sulphanilamideThe first antibacterial drug

Gerhard Domagk

(though I was not allowed by the Nazisto accept the prize and I was held by the Gestapo for a week because of this honor)

Nobelprize.org

Gerhard Domagk

I spent World War II in a bomb-damaged hospital labpursuing new chemical relatives ofsulphanilamide thatmight be effective against TB

Here’s what I discovered

Isoniazid

Here’s what I discovered

Isoniazid

First we need to know moreAbout mycobacteria

All living cellsHave a plasma membrane

Gram positiveBacteria alsoHave a cell wall

All living cellsHave a plasma membrane

Gram positiveBacteria alsoHave a cell wall

Mycobacteria have aVery complex cell wallServing as a barrier

http://web.uct.ac.za/depts/mmi/lsteyn/cellwall.html

1. outer lipids2. mycolic acid3. polysaccharides (arabinogalactan)4. peptideglycan5. plasma membrane6. lipoarabinomannan (LAM)7. phosphatidylinositol mannoside8. cell wall skeleton

Wikipeda/mycobacterium

Just look at the parts list

1. outer lipids2. mycolic acid3. polysaccharides (arabinogalactan)4. peptideglycan5. plasma membrane6. lipoarabinomannan (LAM)7. phosphatidylinositol mannoside8. cell wall skeleton

Wikipeda/mycobacterium

Just look at the parts list

Isoniazid is metabolized by the bacteriumTo isonicotinic acyl anion or radical

and inhibits the enzymethat makes

Isoniazid was added to the combination therapyand remains there today!

Streptomycin and PAS were removed fromfrontline therapy as new drugs

that were more effective orhad fewer side effects

came into the clinic

National Institute of Allergy and Infectious Diseases (NIAID) 2007

Current first-line TB drugs and their dates of discovery

NIAID (2007)

Let’s look at one of the new drugs in detail

rifampicin

It binds the ß subunit of RNA polymerase

rifampicin

Check out a cool video view athttp://www.pingrysmartteam.com/rifampicin/rifampicin.htm

Cell. 2001 Mar 23;104(6):901-12

Binding does not block recruitment to the promotorBut inhibits transcription elongation after 2-3 nucleotides are madeby sterically blocking transcript elongation

Cell. 2001 Mar 23;104(6):901-12

Let’s take a closer look

Cell. 2001 Mar 23;104(6):901-12

Most mutations that confer rifampicin resistance changeResidues in the binding pocket

Our RNA polymerase is different enough that it is notinhibited by rifampicin

Cell. 2001 Mar 23;104(6):901-12

First-line TB drugs

Left to right isoniazid, rifampin, pyrazinamide, & ethambutol Streptomycin (not shown) is given by injection

First-line TB drugs

TBAlliance

4 drugs, 130 doses

Over 6-9 months!

First-line TB drugs

TBAlliance

4 drugs, 130 doses!

http://www.mcvay.com/tb_treatment_in_the_western.html

Daily dose!

First-line TB drugs

TBAlliance

Are also not compatible withAntiretroviral HIV therapy

(problem for 1/3 of HIV patients!)

Rifampin induces cytochrome p450s, Increasing metabolism of anti-HIV drugs

Remember the difference in TB rates world-wide but

The other major challengeIs multi-drug resistant TB

Remember this story???

In other word MDR TB says

I fear none of theFirst line drugs!

What drives drug resistance?

Incorrect, unsupervised, or incomplete treatment

The answer in the developed world:

MORE DRUGS!

NIAID (2007)

New TB drugs under development

NIAID (2007)