Covalent binding of the nitroso metabolite of sulfamethoxazole leads to toxicity and major histocompatibility complex-restricted antigen presentation
Abstract
Treatment with sulfamethoxazole (SMX) can lead to hypersensitivity reactions. T cells from hypersensitive patients recognize either the parent drug and/or the reactive nitroso (SMX-NO) metabolite. In this study, using a novel in vitro rat splenocyte assay, we have investigated the toxicological and immunological consequences of cell surface haptenation by SMX-NO. SMX-NO was found to be unstable in solution; spontaneous transformation yielded appreciable amounts of SMX-hydroxylamine, nitro-SMX, and the previously unknown azoxy and azo dimers within 15 min. Irreversible binding of SMX-NO to cellular protein was demonstrated by flow cytometry, with haptenation being greater on the surface of antigen-presenting cells than on T cells. The consequences of irreversible binding of SMX-NO were examined in two ways. First, haptenation above a threshold level led to a proportionate increase in cell death (both apoptosis and necrosis). Indeed, the cells that became haptenated were the same as those that underwent necrotic cell death. Second, sensitized splenocytes proliferated in the presence of major histocompatibility complex (MHC)-restricted antigen derived from both viable and dead cells haptenated with low and high levels of SMX-NO, respectively. However, direct modification of MHC by SMX-NO was not the mechanism of antigen presentation. The antigenic threshold of SMX-NO for T-cell proliferation and toxicity was estimated to be between 0.5 and 1 microM and 5 to 10 microM, respectively. The potential of SMX-NO to generate a potent antigen and cause cytotoxicity may in combination provide the signals necessary to induce a hypersensitivity reaction to SMX.
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SMX-HA can undergo further auto-oxidation to form the reactive metabolite SMX-NO, which has been linked to protein binding and hypersensitivity reactions.
“SMX-HA can then undergo further auto-oxidation to form the reactive metabolite, sulfamethoxazole-nitroso (SMX-NO), which has been linked to protein binding and hypersensitivity reactions.15–17”
From N-Acetyltransferase (NAT) 1 and NAT2 Enzyme Activities Drive Interindividual Variability in Sulfamethoxazole N-Acetylation (2025) · cites this paper as [16]
Sulfamethoxazole acts as a prohapten because it is transformed to sulfamethoxazole-hydroxylamine and further oxidized to sulfamethoxazole-nitroso.
“Sulfamethoxazole is a typical example of a drug that acts as prohapten, because it is transformed to sulfamethoxazole–hydroxylamine and further oxidized to sulfamethoxazole–nitroso [107–109].”
From The diagnosis of acute interstitial nephritis caused by infection versus antibiotic-induced interstitial nephritis: a narrative review (2024) · cites this paper as [109]
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“…metabolite which transforms this so-called pro-hapten to hapten [106 ], which may result in negative LTT. Sulfamethoxazole is a typical example of a drug that acts as prohapten, because it is transformed to sulfamethoxazole–hydroxylamine and further oxidized to sulfamethoxazole–nitroso [107 –109 ].”
BackgroundLanphier, R. M., Latham, B. D., Gerringer, A. J., Interrante, T., Jones, C. D., De Buysscher, T., Fallon, J. K., & Jackson, K. D. (2025) · Drug Metabolism and Disposition · doi:10.1016/j.dmd.2025.100195 · Cited by 1 · see citing works
- Authors
- Naisbitt, D. J., Farrell, J., Gordon, S. F., Maggs, J. L., Burkhart, C., Pichler, W. J., Pirmohamed, M., & Park, B. K.
- Affiliations
- University of Bern (CH)
- ORCID
- Venue
- Molecular Pharmacology
- Publisher
- Elsevier BV
- Published
- 2002-09
- Volume
- 62
- Issue
- 3
- Pages
- 628-637
- ISSN
- 0026-895X (ISSN-L)
- OpenAlex
- W2166901508
- Cited by
- 141
- References
- 43
- Citations by year
- 2026: 5 · 2025: 3 · 2024: 3 · 2023: 3 · 2022: 3 · 2021: 7 · 2020: 4 · 2019: 9 · 2018: 5 · 2017: 6 · 2016: 8 · 2015: 6 · 2014: 5 · 2013: 5 · 2012: 7
- FWCI
- 3.89
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Molecular Pharmacology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Wellcome Trust
- University of Liverpool
- Topics
- Health Sciences › Medicine › Pharmacology › Drug-Induced Adverse Reactions
- Life Sciences › Immunology and Microbiology › Immunology › Immunotoxicology and immune responses
- Health Sciences › Medicine › Dermatology › Contact Dermatitis and Allergies
- Keywords
- sulfamethoxazole, drug hypersensitivity, haptenation, covalent binding, T cell proliferation, necrosis, apoptosis, antigen-presenting cells, drug toxicity, immunotoxicity
- MeSH terms
- Animals, Anti-Infective Agents, Antigen-Presenting Cells, Cell Division, Major Histocompatibility Complex, Male, Nitroso Compounds, Rats, Inbred Lew, Sulfamethoxazole, T-Lymphocytes, Rats
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