Reviewer #1 (Public Review):
In this manuscript by Buchanan and colleagues, the authors set out to determine if mutations associated with resistance to the Plasmodium apicoplast inhibitor azithromycin (AZ) had a measurable impact on the fitness of Plasmodium berghei and P. falciparum parasites as they traverse both the mosquito host and vertebrate liver.
The Plasmodium endosymbiotic organelles - the mitochondrion and apicoplast - are attractive drug targets as they (1) possess essential functions across the multi-host multi-compartment life cycle of these parasites, and (2) are of bacterial origin and thus are vulnerable to inhibition both to extant antibiotics, and novel drugs with high parasite specificity.
Historically however the high resistance propensity of drug targets encoded in the organellar genomes (most notably atovaquone and doxycycline) has precluded the use of these drugs in an endemic setting, limiting these potent compounds to use in prophylaxis for travelers from non-endemic countries. Several studies in the last decade now fairly definitively show that mutations conferring resistance to atovaquone in the mitochondrial gene cytochrome b are, in a mutation-dependent manner, totally or near-totally compromised in their ability to infect, grow, and escape the mosquito host, leading to a reexamination of the potential utility of this extraordinarily potent drug in endemic settings. Symmetries exist between the Plasmodium mitochondrion and apicoplast, which both appear to have highly fexpanded roles in the mosquito and liver relative to the blood stages. Thus, the authors set out to explore whether mutations in essential apicoplast genes were, in a similar manner to mutations in cytochrome B, associated with fitness effects in the mosquito and/or liver.
Towards this, the authors selected for several AZ-resistant parasite populations, all of which acquired mutations in the apicoplast genome-encoded ribosomal protein Rpl4. Interestingly, the authors observed contrasting fitness effects caused by these mutations, both between mutants within Plasmodium species, and between species. In P. berghei, AZ mutants were compromised in their ability to form oocysts and sporozoites, and a large proportion of sporozoites lacked an intact apicoplast and displayed aberrant gliding behaviour. Similarly, in the liver, Rpl4 mutant P. berghei liver schizonts were smaller, had fewer nuclei, and appeared extremely limited in their ability to cause a patent infection - crucially in particular via mosquito bites. Surprisingly, a P. falciparum Rpl4 mutant (notably in a different position of the protein) had no impact on sporogony but appeared to have a strong impact on liver schizont development in a liver-humanized mouse model, suggesting that establishment of blood stage infection in a subsequent human host would be less likely for mutant parasites.
This is a well-executed study, that presents novel and noteworthy findings. The impact of drug-resistance-conferring mutations in Plasmodium outside of the blood stage is woefully understudied, primarily due to significant challenges associated with studying Plasmodium, especially P. falciparum, in both the mosquito and liver which the authors navigate commendably. The results presented in this manuscript leverage state-of-the-art techniques and clearly support the authors' conclusion that AZ-conferring resistance mutations have a strong negative effect on the ability of Plasmodium parasites to both reinfect and cause symptomatic infection in a subsequent vertebrate host. This could indicate that apicoplast-targeted inhibitors are more attractive as co-drugs for malaria treatment than previously thought, due to the reduced probability of the spread of resistance, which has been a perennial issue in malaria therapeutic care.