Abstract
BackgroundThe resistance of Plasmodium falciparum to artemisinin has been identified in Asia and some parts of Africa. The drug resistance of P. falciparum will be an obstacle to the successful elimination of malaria by 2025. Whole-genome sequencing of the artemisinin-resistant parasite line revealed mutations on the k13 gene associated with drug resistance in P. falciparum. To understand the artemisinin resistance of the imported P. falciparum cases from Africa, the mutations in the k13 gene in parasites from imported malaria cases in Guangxi Province were detected and the treatment efficiency of artesunate monotherapy was observed.MethodsDNA was extracted from 319 blood samples from migrant workers with P. falciparum infection who returned to their hometown in Guangxi Province from Africa between 2014 and 2017. The k13-propeller gene was amplified by nested PCR, and sequencing, gene mutation frequency and geographic difference of imported P. falciparum cases were analysed by comparison with the wild-type strain. Of 319 patients, 158 were P. falciparum-infected and were treated with intravenous injection of artesunate and were observed, including the time of asexual stage clearance and the dose of artesunate used.ResultsOf the 319 P. falciparum samples, 12 samples had the k13-propeller mutation, and 11 point mutations were detected; 5 were non-synonymous mutations (T474I, A481T, A578S, V603E, G665S) and were not associated with artemisinin resistance. The clinical treatment observation showed that the median (IQR) dose of artesunate for peripheral blood parasite asexual stage clearance was 407.55 (360–510) mg, and the D3 parasite clearance rate was 70.25%, including the five k13-propeller mutations of P. falciparum. After 7 days of treatment, 98.73% of cases were cleared. Two cases were treated with artemisinin for 8 days with a 960-mg dose to completely clear the asexual parasite, but they did not have a mutation in the k13 gene.ConclusionsFive mutations of the k13-propeller gene in 319 P. falciparum samples from patients returning from Africa were identified. The frequency of the k13-propeller mutants was low, and the mutations were not strongly associated with artemisinin resistance. The median (IQR) dose of artesunate monotherapy in actual clinical treatment to remove asexual parasite stages was 407.55 (360–510) mg, equivalent to D3–D4. Some P. falciparum cases without a k13-propeller mutation showed obvious delayed clearance of the parasite from peripheral blood.Trial registration The diagnosis of malaria and the treatment of malaria-infected patients are the routine work of Centres for Disease Control and Prevention. Information on the patients was conveyed with the patient’s approval, and the research aim, methods, risks and benefits of the study were explained in detail to the patients
Highlights
The resistance of Plasmodium falciparum to artemisinin has been identified in Asia and some parts of Africa
Studies found that the C580Y, R539T, Y493H, M476I, and F446I mutations of the k13 gene are closely related to the resistance of artemisinin [9, 10]
There is not sufficient evidence to suggest that resistance to artemisinin derivatives of P. falciparum originating in the Mekong River Basin has spread to Africa, South America, Oceania and East and Central Asia [14,15,16], the decrease in sensitivity to artemisinin in several cases recorded in Africa is not related to the mutation of k13 but to the severe infection in children [17,18,19]
Summary
The resistance of Plasmodium falciparum to artemisinin has been identified in Asia and some parts of Africa. To understand the artemisinin resistance of the imported P. falciparum cases from Africa, the mutations in the k13 gene in parasites from imported malaria cases in Guangxi Province were detected and the treatment efficiency of artesunate monotherapy was observed. There is not sufficient evidence to suggest that resistance to artemisinin derivatives of P. falciparum originating in the Mekong River Basin has spread to Africa, South America, Oceania and East and Central Asia [14,15,16], the decrease in sensitivity to artemisinin in several cases recorded in Africa is not related to the mutation of k13 but to the severe infection in children [17,18,19]. P. falciparum imported into China from Equatorial Guinea in Africa has been found to be resistant to artemisinin [20] in vitro
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