Multi-drug tolerance in Leishmania persister-like cells.

Leishmaniasis is caused by parasitic protozoa of the genus Leishmania and is found widely across the tropics and sub-tropics, afflicting hundreds of thousands of people. The disease is notoriously difficult to treat. Here, we present evidence of the existence of persister-like cells in cultured Leishmania populations, induced upon exposure to normally lethal doses of antimony, a still used anti-leishmanial. Persisters are a small fraction of non-proliferative cells with reduced metabolism that are adapted to withstand a variety of environmental assaults, including lethal doses of antimicrobials. We show that Leishmania persister-like cells survive lethal doses of antimonials by adopting a quiescence phenotype characterised by reduced proliferation, constrained metabolism, diminished mitochondrial membrane potential and downregulated transcription of core metabolic pathways. What is more, these cells demonstrate cross-tolerance to other anti-leishmanial drugs. Wild-type persister-like cells reverted to similar levels of drug susceptibility once the antimony-induced pressure was removed. Surprisingly, cells from strains with genetic changes causing resistance to antimony acquired a level of hyper-resistance after transient passage through the quiescent state, without further genetic change. Our results demonstrate the extreme versatility of this eukaryotic pathogen in adaptation to drug pressure and highlight the need for the development of new anti-leishmanials targeting non-proliferative forms.