Volume 74, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Sulfadoxine-pyrimethamine (SP) is the second-line treatment for malaria in Sri Lanka. Resistance to SP is caused by point mutations in the dihydrofolate reductase () and dihydropteroate synthase (-) genes of . We determined the genotype of and and the clinical response to SP in 30 field isolates of from Sri Lanka. All patients treated with SP had an adequate clinical response. Eighty-five percent (23 of 27) of pure field isolates carried parasites with double mutant alleles of (C59R + S108N) and showed about 200-fold higher levels of resistance to pyrimethamine than the wild type in a yeast system. None of the isolates had either known or novel mutations at other positions in the domain. In contrast, 67% (20 of 30) of the isolates carried parasites that were wild type for . In Sri Lanka, detection of the triple mutant allele of will require tracking mutations at codon 51.


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  1. Ratnapala R, Subramaniam K, Yapabandara MG, Fernando WP, 1984. Chloroquine resistant Plasmodium falciparum in Sri Lanka. Ceylon Med J 29 : 135–145. [Google Scholar]
  2. Handunnetti SM, Gunewardena DM, Pathirana PP, Ekanayake K, Weerasinghe S, Mendis KN, 1996. Features of recrudescent chloroquine-resistant Plasmodium falciparum infections confer a survival advantage on parasites and have implications for disease control. Trans R Soc Trop Med Hyg 90 : 563–567. [Google Scholar]
  3. Hapuarachchi HA, Dayanath MY, Abeysundara S, Bandara KB, Abeyewickreme W, de Silva NR, 2004. Chloroquine resistant falciparum malaria among security forces personnel in the northern province of Sri Lanka. Ceylon Med J 49 : 47–51. [Google Scholar]
  4. Gunasekare D, Perera D, 1996. Multidrug resistant malaria in Sri Lanka. Ceyon Med J 41 : 170–171. [Google Scholar]
  5. Sarukkali C, de Silva S, 1994. Falciparum malaria resistant to sulfadoxine-pyrimethamine and associated with eosinophilia. Ceylon J Child Health 23 : 18–20. [Google Scholar]
  6. Handunnetti SM, Jayasinghe S, Pathirana PP, Fernando R, Sheriff MH, Mendis KN, 1994. Sulphadoxine-pyrimethamine and chloroquine resistant Plasmodium falciparum infection in Sri Lanka. Ceylon Med J 39 : 45–46. [Google Scholar]
  7. Triglia T, Menting JG, Wilson C, Cowman AF, 1997. Mutations in dihydropteroate synthase are responsible for sulfone and sulfonamide resistance in Plasmodium falciparum. Proc Natl Acad Sci USA 94 : 13944–13949. [Google Scholar]
  8. Triglia T, Wang P, Sims PF, Hyde JE, Cowman AF, 1998. Allelic exchange at the endogenous genomic locus in Plasmodium falciparum proves the role of dihydropteroate synthase in sulfadoxine-resistant malaria. EMBO J 17 : 3807–3815. [Google Scholar]
  9. Basco LK, 2003. Molecular epidemiology of malaria in Cameroon. XVI. Longitudinal surveillance of in vitro pyrimethamine resistance in Plasmodium falciparum. Am J Trop Med Hyg 69 : 174–178. [Google Scholar]
  10. Nzila-Mounda A, Mberu EK, Sibley CH, Plowe CV, Winstanley PA, Watkins WM, 1998. Kenyan Plasmodium falciparum field isolates: correlation between pyrimethamine and chlorcycloguanil activity in vitro and point mutations in the dihydrofolate reductase domain. Antimicrob Agents Chemother 42 : 164–169. [Google Scholar]
  11. Zolg JW, Plitt JR, Chen G-X, Palmer S, 1989. Point mutations in the dihydrofolate reductase-thymidylate synthase gene as the molecular basis for pyrimethamine resistance in Plasmodium falciparum. Mol Biochem Parasitol 36 : 253–262. [Google Scholar]
  12. Wang P, Read M, Sims PFG, Hyde JE, 1997. Sulfadoxine resistance in the human malaria parasite Plasmodium falciparum is determined by mutations in dihydropteroate synthetase and an additional factor associated with folate utilization. Mol Microbiol 23 : 979–986. [Google Scholar]
  13. Sirawaraporn W, Sathitkul T, Sirawaraporn R, Yuthavong Y, Santi DV, 1997. Antifolate-resistant mutants of Plasmodium falciparum dihydrofolate reductase. Proc Natl Acad Sci USA 94 : 1124–1129. [Google Scholar]
  14. Gregson A, Plowe CV, 2005. Mechanisms of resistance of malaria parasites to antifolates. Pharmacol Rev 57 : 117–145. [Google Scholar]
  15. Cowman AF, Morry MJ, Biggs BA, Cross GA, Foote SJ, 1988. Amino acid changes linked to pyrimethamine resistance in the dihydrofolate reductase-thymidylate synthase gene of Plasmodium falciparum. Proc Natl Acad Sci USA 85 : 9109–9113. [Google Scholar]
  16. Peterson DS, Walliker D, Wellems TE, 1988. Evidence that a point mutation in dihydrofolate reductase-thymidylate synthase confers resistance to pyrimethamine in falciparum malaria. Proc Natl Acad Sci USA 85 : 9114–9118. [Google Scholar]
  17. Wang P, Lee CS, Bayoumi R, Djimde A, Doumbo O, Swedberg G, Dao LD, Mshinda H, Tanner M, Watkins WM, Sims PFG, Hyde JE, 1997. Resistance to antifolates in Plasmodium falciparum monitored by sequence analysis of dihydropteroate synthetase and dihydrofolate reductase alleles in a large number of field samples of diverse origins. Mol Biochemi Parasitol 89 : 161–177. [Google Scholar]
  18. Brooks DR, Wang P, Read M, Watkins WM, Sims PF, Hyde JE, 1994. Sequence variation of the hydroxymethyldihydropterin pyrophosphokinase: dihydropteroate synthase gene in lines of the human malaria parasite, Plasmodium falciparum, with differing resistance to sulfadoxine. Eur J Biochem 224 : 397–405. [Google Scholar]
  19. Triglia T, Cowman AF, 1994. Primary structure and expression of the dihydropteroate synthetase gene of Plasmodium falciparum. Proc Natl Acad Sci USA 91 : 7149–7153. [Google Scholar]
  20. Talisuna AO, Nalunkuma-Kazibwe A, Langi P, Mutabingwa TK, Watkins WW, Marck EV, Egwang TG, D’Alessandro U, 2004. Two mutations in dihydrofolate reductase combined with one in the dihydropteroate synthase gene predict sulphadoxine-pyrimethamine parasitological failure in Ugandan children with uncomplicated falciparum malaria. Infect Genet Evol 4 : 321–327. [Google Scholar]
  21. Talisuna AO, Langi P, Mutabingwa TK, Watkins W, Van Marck E, Egwang TG, D’Alessandro U, 2003. Population-based validation of dihydrofolate reductase gene mutations for the prediction of sulfadoxine-pyrimethamine resistance in Uganda. Trans R Soc Trop Med Hyg 97 : 338–342. [Google Scholar]
  22. Nzila AM, Mberu EK, Sulo J, Dayo H, Winstanley PA, Sibley CH, Watkins WM, 2000. Towards an Understanding of the mechanism of pyrimethamine-sulfadoxine resistance in Plasmodium falciparum: genotyping of dihydrofolate reductase and dihydropteroate synthase of Kenyan parasites. Antimicrob Agents Chemother 44 : 991–996. [Google Scholar]
  23. Ministry of Health, Sri Lanka. 1999. Annual Health Bulletin.
  24. Ministry of Health, Sri Lanka, 2000. Annual Health Bulletin.
  25. Ministry of Health, Sri Lanka. 2001. Annual Health Bulletin.
  26. Doumbo OK, Kayentao K, Djimde A, Cortese JF, Diourte Y, Konare A, Kublin JG, Plowe CV, 2000. Rapid selection of Plasmodium falciparum dihydrofolate reductase mutants by pyrimethamine prophylaxis. J Infect Dis 182 : 993–996. [Google Scholar]
  27. Nzila AM, Nduati E, Mberu EK, Sibley CH, Monks SA, Winstanley PA, Watkins WM, 2000. Molecular evidence of greater selective pressure for drug resistance exerted by the long-acting antifolate pyrimethamine/sulfadoxine compared with the shorter-acting chlorproguanil/dapsone on Kenyan Plasmodium falciparum. J Infect Dis 181 : 2023–2028. [Google Scholar]
  28. World Health Organization, 2003. Monitoring Antimalarial Drug Resistance: A Report of a Consultation. Geneva: World Health Organization.
  29. Karunaweera N, Carter R, Grau G, Mendis K, 1998. Demonstration of anti-disease immunity to Plasmodium vivax malaria in Sri Lanka using a quantitative method to assess clinical disease. Am J Trop Med Hyg 58 : 204–210. [Google Scholar]
  30. Duraisingh MT, Curtis J, Warhurst DC, 1998. Plasmodium falciparum: detection of polymorphisms in the dihydrofolate reductase and dihydropteroate synthetase genes by PCR and restriction digestion. Exp Parasitol 89 : 1–8. [Google Scholar]
  31. Sibley CH, Brophy VH, Cheesman S, Hamilton KL, Hankins EG, Wooden JM, Kilbey B, 1997. Yeast as a model system to study drugs effective against apicomplexan proteins. Methods 13 : 190–207. [Google Scholar]
  32. Sikorski RS, Hieter P, 1989. A system of shuttle vectors and yeast host strains designed for efficient manipulation of DNA in Saccharomyces cerevisiae. Genetics 122 : 19–27. [Google Scholar]
  33. Cortese JF, Plowe CV, 1998. Antifolate resistance due to new and known Plasmodium falciparum dihydrofolate reductase mutations expressed in yeast. Mol Biochem Parasitol 94 : 205–214. [Google Scholar]
  34. Huang T, Barclay BJ, Kalman TI, von Borstel RC, Hastings PJ, 1992. The phenotype of a dihydrofolate reductase mutant of Saccharomyces cerevisiae. Gene 121 : 167–171. [Google Scholar]
  35. Wooden JM, Hartwell LH, Vasquez B, Sibley CH, 1997. Analysis in yeast of antimalaria drugs that target the dihydrofolate reductase of Plasmodium falciparum. Mol Biochem Parasitol 85 : 25–40. [Google Scholar]
  36. Ito H, Fukuda Y, Murata K, Kimura A, 1983. Transformation of intact yeast cells treated with alkali cations. J Bacteriol 153 : 163–168. [Google Scholar]
  37. Desjardins RE, Canfield CJ, Haynes JH, Chulay JD, 1979. Quantitative assessment of antimalarial activity in vitro by a semiautomated microdilution technique. Antimicrob Agents Chemother 16 : 710–718. [Google Scholar]
  38. Plowe CV, Cortese JF, Djimde A, Nwanyanwu OC, Watkins WM, Winstanley PA, Estrada-Franco JG, Mollinedo RE, Avila JC, Cespedes JL, Carter D, Doumbo OK, 1997. Mutations in Plasmodium falciparum dihydrofolate reductase and dihydropteroate synthase and epidemiologic patterns of pyrimethamine-sulfadoxine use and resistance. J Infect Dis 176 : 1590–1596. [Google Scholar]
  39. Jelinek T, Ronn AM, Curtis J, Duraisingh MT, Lemnge MM, Mhina J, Bygbjerg IC, Warhurst DC, 1997. High prevalence of mutations in the dihydrofolate reductase gene of Plasmodium falciparum in isolates from Tanzania without evidence of an association to clinical sulfadoxine/pyrimethamine resistance. Trop Med Int Health 2 : 1075–1079. [Google Scholar]
  40. Mutabingwa TK, Maxwell CA, Sia IG, Msuya FH, Mkongewa S, Vannithone S, Curtis J, Curtis CF, 2001. A trial of proguanil-dapsone in comparison with sulfadoxine-pyrimethamine for the clearance of Plasmodium falciparum infections in Tanzania. Trans R Soc Trop Med Hyg 95 : 433–438. [Google Scholar]
  41. Roper C, Pearce R, Bredenkamp B, Gumede J, Drakeley C, Mosha F, Chandramohan D, Sharp B, 2003. Antifolate anti-malarial resistance in southeast Africa: a population-based analysis. Lancet 361 : 1174–1181. [Google Scholar]
  42. EANMAT, 2001. Monitoring antimalarial drug resistance within National Malaria Control Programmes: the EANMAT experience. Trop Med Int Health 6 : 891–898. [Google Scholar]
  43. Plowe CV, Kublin JG, Dzinjalamala FK, Kamwendo DS, Mukadam RA, Chimpeni P, Molyneux ME, Taylor TE, 2004. Sustained clinical efficacy of sulfadoxine-pyrimethamine for uncomplicated falciparum malaria in Malawi after 10 years as first line treatment: five year prospective study. BMJ 328 : 545. [Google Scholar]
  44. Bates SJ, Winstanley PA, Watkins WM, Alloueche A, Bwika J, Happi TC, Kremsner PG, Kublin JG, Premji Z, Sibley CH, 2004. Rare, highly pyrimethamine-resistant alleles of the Plasmodium falciparum dihydrofolate reductase gene from 5 African sites. J Infect Dis 190 : 1783–1792. [Google Scholar]
  45. Sibley CH, Hyde JE, Sims PFG, Plowe CV, Kublin JG, Mberu EK, Cowman AF, Winstanley PA, Watkins WM, Nzila AM, 2001. Pyrimethamine/sulfadoxine resistance in Plasmodium falciparum: What next? Trends Parasitol 17 : 582–588. [Google Scholar]
  46. Kublin JG, Dzinjalamala FK, Kamwendo DD, Malkin EM, Cortese JF, Martino LM, Mukadam RA, Rogerson SJ, Lescano AG, Molyneux ME, Winstanley PA, Chimpeni P, Taylor TE, Plowe CV, 2002. Molecular markers for failure of sulfadoxine-pyrimethamine and chlorproguanil-dapsone treatment of Plasmodium falciparum malaria. J Infect Dis 185 : 380–388. [Google Scholar]
  47. Ahmed A, Bararia D, Vinayak S, Yameen M, Biswas S, Dev V, Kumar A, Ansari MA, Sharma YD, 2004. Plasmodium falciparum isolates in India exhibit a progressive increase in mutations associated with Sulfadoxine-Pyrimethamine resistance. Antimicrob Agents Chemother 48 : 879–889. [Google Scholar]
  48. Nair S, Williams JT, Brockman A, Paiphun L, Mayxay M, Newton PN, Guthmann JP, Smithuis FM, Hien TT, White NJ, Nosten F, Anderson TJ, 2003. A selective sweep driven by pyrimethamine treatment in Southeast Asian malaria parasites. Mol Biol Evol 20 : 1526–1536. [Google Scholar]
  49. Roper C, Pearce R, Nair S, Sharp B, Nosten F, Anderson T, 2004. Intercontinental spread of pyrimethamine-resistant malaria. Science 305 : 1124. [Google Scholar]
  50. Biswas S, Escalante A, Chaiyaroj S, Angkasekwinai P, Lal AA, 2000. Prevalence of point mutations in the dihydrofolate reductase and dihydropteroate synthetase genes of Plasmodium falciparum isolates from India and Thailand: a molecular epidemiologic study. Trop Med Int Health 5 : 737–743. [Google Scholar]

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  • Received : 24 Mar 2005
  • Accepted : 06 Oct 2005

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