Disseminated cutaneous leishmaniasis in a field clinic in Bahia, Brazil: a report of eight cases

Eight Bahian patients with cutaneous leishmaniasis who had 20 or more ulcerative lesions of short duration are described. Of five identifications of isolated parasites, four were Leishmania braziliensis braziliensis and one was L. mexicana amazonensis. All but one had positive Montenegro tests initially, and all did after treatment. All had circulating anti-leishmanial antibodies and five responded well to glucantime therapy suggesting a functioning immune response. This is quite different to the anergic hansenoid leishmaniasis seen with L. mexicana amazonensis infections in Brazil. Possible reasons for the occurrence of this type of leishmaniasis are briefly discussed.

New perspectives on a subclinical form of visceral leishmaniasis

During an epidemiological study of visceral leishmaniasis in an endemic region of Brazil, new perspectives emerged on a subclinical form of the disease. A group of 86 children with antibody to Leishmania were identified. None of these children had a history of leishmaniasis. The children were segregated into four groups: One group remained asymptomatic (n = 20), whereas another developed classic kala-azar within weeks of the index serology (n = 15). The remaining 51 patients initially had subclinical disease; 13 (25%) of these patients progressed to classic kala-azar (mean, five months). The others (75%) resolved their illness after a prolonged period (mean, 35 months). The initial illness in the subclinical group was characterized by hepatomegaly, frequent splenomegaly, intermittent cough, diarrhea, and low-grade fever. Malaise and poor weight gain were common. Giemsa-stained smears and cultures of bone marrow aspirates were usually negative for Leishmania in the absence of symptoms of classic kala-azar.

A prospective study of visceral leishmaniasis in an endemic area of Brazil

The epidemiology, clinical patterns, and risk factors for visceral leishmaniasis were prospectively studied in an endemic area of Brazil. The prevalence of disease was 3.1% for children less than 15 years of age, and the annual incidence was 4.3 cases per 1,000 children. The number of children with disease fluctuated yearly and seasonally, and distribution of the disease varied within the endemic area. Risk factors included young age (median, three years) and malnutrition before the onset of disease. Intestinal parasitism, recent migration into the area, and house location within the area did not influence the progression of infection to disease. Serological testing indicated that 7.5% of children were infected with Leishmania each year and that the ratio of disease to infection was 1:18.5 for the whole area and 1:6.5 for the section with the highest prevalence of disease. Early diagnosis and therapy altered clinical patterns of the disease.

Suppression of lymphocyte proliferative responses by sera from patients with American visceral leishmaniasis

We examined the effect of sera from 11 patients with American visceral leishmaniasis on mitogen-driven lymphocyte proliferative capacity. All sera inhibited lymphocyte proliferation of patients' peripheral blood mononuclear cells (PBMC) when stimulated by either phytohemagglutinin, Concanavalin A or pokeweed mitogen. Serum was also strongly inhibitory for Concanavalin A-pulsed normal volunteers' PMBC. The effect of the serum was not due to cytotoxicity, inadequate nutritional support or altered kinetics of DNA synthesis. High levels of IgM or IgG (both total and antiparasite) and high levels of triglycerides were found in patients' sera.

Isolation of Leishmania mexicana amazonensis from the bone marrow in a case of American visceral leishmaniasis

The first documented human case of visceral leishmaniasis caused by L. mexicana amazonensis is reported. Leishmania were isolated from bone marrow aspirate material from a typical visceral leishmaniasis patient. Further characterization by isoenzyme electrophoresis and by a panel of species- and subspecies-specific monoclonal antibodies established its classification as L. m. amazonensis.

Nature and incidence of erythrocyte-bound IgG and some aspects of the physiopathogenesis of anaemia in American visceral leishmaniasis

IgG molecules were found associated with erythrocyte membranes in all patients with American visceral leishmaniasis. They were detected by two different immunoradiometric assays and by one enzyme-linked immunosorbent assay. Although autoimmune phenomena seem to be constant features of American visceral leishmaniasis, the erythrocyte-bound IgG are not erythrocyte-specific autoantibodies. Moreover, anti-Leishmania activity was found associated with the erythrocyte-bound IgG, indicating that the IgG may be a component of Leishmania antigens-anti-Leishmania immune complexes. No associations were found between the amounts of erythrocyte-bound IgG and the degree of anaemia or between spleen dimensions and the degree of anaemia. These findings suggest that the pathogenesis of anaemia in American visceral leishmaniasis is multifactorial.

Leishmania donovani: an opportunistic microbe associated with progressive disease in three immunocompromised patients

Three cases are described showing that Leishmania donovani can cause progressive disease in immunocompromised hosts. The first patient was receiving corticosteroid therapy for ulcerative colitis and the second corticosteroids and cyclophosphamide for proliferative glomerulonephritis; in the third patient, leishmaniasis occurred after a long episode of hepatosplenic schistosomiasis and salmonella bacteraemia which was treated with chloramphenicol. In two cases, the patients had moved away from areas of L donovani transmission many years before the progressive disease occurred, consistent with long-term survival of the organism in normal hosts. L donovani should be added to the growing list of opportunistic microbial infections.

Selection of a skin test antigen for American visceral leishmaniasis

Studies were designed to examine skin test responses to leishmanial antigens in American visceral leishmaniasis (AVL) in Brazil. We found that after recovery from AVL, patients had positive delayed hypersensitivity reactions to Leishmania. Different amounts of a soluble extract obtained from Leishmania donovani chagasi promastigotes were compared with whole L. d. chagasi promastigotes in persons with past AVL. The most effective soluble preparations tested contained 25 and 50 micrograms leishmanial protein. These produced positive responses in 95%-100% of the individuals with past AVL. The 25 micrograms protein dose was used in further studies. This preparation produced no positive responses in either normal controls, tuberculosis patients, or schistosomiasis patients, and less than 5% positive responses in persons with Chagas' disease. The same amount of soluble extract prepared from L. mexicana amazonensis produced 82% positive skin test responses in persons with past AVL. When persons living in an area endemic for AVL were skin tested with the 25 micrograms preparation of L. d. chagasi extract, 34.1% yielded positive tests with a low number of positive responses in young children and 48% positive in adults. Only 3.1% of the population studied had a history of AVL. We have found that positive delayed hypersensitivity response to a soluble Leishmania extract is a sensitive and specific indicator of previous infection with AVL.

Absence of gamma interferon and interleukin 2 production during active visceral leishmaniasis

The lymphocytes from eight patients with active visceral leishmaniasis (VL), a disease associated with marked immunologic dysfunction, were examined for ability to produce interleukin 2 (IL-2) and gamma interferon during in vitro cultivation. It was found that both IL-2 and gamma interferon production, in response to leishmania antigen, was absent during the active disease, but was restored after successful chemotherapy. Untreated VL patients produced IL-2 and gamma interferon when stimulated with phytohemagglutinin (PHA). Six patients with either active cutaneous or mucosal leishmaniasis, a disease not associated with immunosuppression, showed high levels of gamma interferon in response to leishmania antigen and PHA. Since IL-2 and gamma interferon have been shown to have important roles in the immune response and in the killing of leishmania, their absence may represent a key defect in the immune response in VL.

Cell mediated immunity in American cutaneous and mucosal leishmaniasis

Cellular immune responses were studied in 35 Brazilian patients with either active cutaneous leishmaniasis (CL), active mucosal leishmaniasis (ML), or healed cutaneous leishmaniasis. The mean age and duration of illness in the two groups were as follows: 14 CL patients, age 28 +/- 13 yr, disease 5 +/- mo; and 16 ML patients, age 34 +/- 15 yr, disease 86 +/- 117 mo. Patients with CL and ML responded well to leishmania antigen in blastogenesis assays. However, the response of ML patients was over three times greater than the response of CL patients. There was a significant correlation between the magnitude of the lymphoproliferative response and the duration of disease activity. There were no significant differences between CL and ML patients in terms of the following parameters: lymphoproliferative responsiveness to mitogens (phytohemagglutinin, concanavalin A, and pokeweed mitogen) and peripheral blood lymphocyte subpopulations (T and B cells, oKT8+ and OKT4+ cells, OKT4:OKT8 ratio). Peripheral blood mononuclear cells from ML patients also generated interferon-gamma containing lymphokine in response to stimulation with leishmania antigen. This lymphokine was capable of inducing macrophages from ML patients to inhibit the intracellular multiplication of leishmania in vitro. These studies have determined that the parameters of lymphocyte and macrophage functions evaluated in ML and CL patients are comparable, except for an enhanced lymphoproliferative response, with leishmania antigen in ML patients. This later finding may be a function of the long duration of active disease in this population and unrelated to the pathogenesis of their mucosal lesions.

Cell mediated immunity in American cutaneous and mucosal leishmaniasis

Cellular immune responses were studied in 35 Brazilian patients with either active cutaneous leishmaniasis (CL), active mucosal leishmaniasis (ML), or healed cutaneous leishmaniasis. The mean age and duration of illness in the two groups were as follows: 14 CL patients, age 28 +/- 13 yr, disease 5 +/- mo; and 16 ML patients, age 34 +/- 15 yr, disease 86 +/- 117 mo. Patients with CL and ML responded well to leishmania antigen in blastogenesis assays. However, the response of ML patients was over three times greater than the response of CL patients. There was a significant correlation between the magnitude of the lymphoproliferative response and the duration of disease activity. There were no significant differences between CL and ML patients in terms of the following parameters: lymphoproliferative responsiveness to mitogens (phytohemagglutinin, concanavalin A, and pokeweed mitogen) and peripheral blood lymphocyte subpopulations (T and B cells, oKT8+ and OKT4+ cells, OKT4:OKT8 ratio). Peripheral blood mononuclear cells from ML patients also generated interferon-gamma containing lymphokine in response to stimulation with leishmania antigen. This lymphokine was capable of inducing macrophages from ML patients to inhibit the intracellular multiplication of leishmania in vitro. These studies have determined that the parameters of lymphocyte and macrophage functions evaluated in ML and CL patients are comparable, except for an enhanced lymphoproliferative response, with leishmania antigen in ML patients. This later finding may be a function of the long duration of active disease in this population and unrelated to the pathogenesis of their mucosal lesions.

[Bacterial infection in patients with visceral leishmaniasis]

In an analysis of 63 hospitalized cases with visceral leishmaniasis, the clinical or post-mortem diagnosis of bacterial infection was performed in 33; 13 (39.3%) patients had respiratory infection, 4 (12.1%) had skin infection, 4 had urinary tract infection, 3 (9.0%) showed ear infection and 2 (6.6%) had infection of the oral cavity. It is worth mentioning that in 7 (21%) cases there was infection in multiple sites. Gram positive and/or Gram negative organisms were isolated from 10 patients. In only two (autopsied) cases, infection with less common organisms was recorded, one with disseminated candidiasis and another with disseminated tuberculosis. Death occurred in 9 of the 63 cases, and in 8 of these, concomitant bacterial infection of importance was documented. Patients who had serum globulins lower than 4 g% had significantly more infection (p less than 0.05) than patients with globulin levels higher than 4 g%; there was no significant difference when the number of leucocytes and neutrophils in patients with associated infection was compared with those in patients without bacterial infection. The present study demonstrates that bacterial infection frequently occurs in patients with visceral leishmaniasis, and indicates an unfavourable prognosis. Even though the mechanism of increased susceptibility to infection in this condition was unclear, the widespread range of infections and of infective agents, suggests a multifactorial process.

High continuous antimony therapy in two patients with unresponsive mucosal leishmaniasis

The treatment of two patients with severe mucosal leishmaniasis due to Leishmania braziliensis braziliensis is described. Both patients had received much prior antimonial therapy and one had relapsed after a total dose of 2.5 g of Amphotericin B. Both patients responded to prolonged continuous Pentostam therapy at a daily dose of 20 mg Sbv/kg/day for 62 days in one case and for 85 days in the other. Pentavalent antimonials can be curative in such protracted courses in selected patients unresponsive to standard chemotherapy.

Modulation of eosinophil cytotoxicity by blood mononuclear cells from healthy subjects and patients with chronic schistosomiasis mansoni

Human blood mononuclear cells in culture release a factor(s) that markedly enhances eosinophil cytotoxicity. This factor(s) stimulates eosinophils to kill Schistosoma mansoni larvae at low antibody concentrations and cell/target ratios. A study of the mononuclear cells of 78 subjects with chronic schistosomiasis mansoni and 33 controls suggests that the production of eosinophil cytotoxicity enhancing activity (ECEA) is suppressed in most patients with S. mansoni infections. Suppression of ECEA production was not observed, however, with cells from many patients with heavy infections, including patients with hepatosplenomegaly. The possible role of ECEA in the development of pathology is discussed.

Immunofluorescent antibody test in American visceral leishmaniasis: sensitivity and specificity of different morphological forms of two Leishmania species

This study was designed to determine which morphologic form and species of Leishmania is most suitable for detection of antibody in sera from American visceral leishmaniasis (AVL) patients by the indirect fluorescent antibody test (IFAT). Promastigotes and amastigotes of Leishmania mexicana or Leishmania donovani chagasi were used as sources of antigen. A total of 70 sera, including 30 from AVL patients, 30 from healthy subjects and 10 from Chagas' disease patients, were used in the study. Titers of antibody up to a dilution of 1:64 were found with all four antigens. At a titer of 1:128, the sensitivity of the IFAT using L. d. chagasi promastigotes as a source of antigen was 100% and the specificity at a titer of 1:32 was 98%. Although the sensitivity of the amastigote forms was close to 100% at a similar titer, the specificity at a titer of 32 using the L. d. chagasi amastigotes was 91% and using L. mexicana amastigotes was only 80%. The L. d. chagasi promastigote antigen was also the one that showed less cross reaction with sera from Chagas' disease patients. Since cross reactivity between Trypanosoma cruzi and Leishmania species is well known in serological tests, and minimizing of such cross reactivity is of critical importance for diagnosis, we suggest that L. d. chagasi promastigotes should be the antigen of choice for diagnosis of visceral leishmaniasis by IFAT in areas also endemic for trypanosomiasis.

Lymphocyte reactivity to mitogens in American visceral leishmaniasis

In vitro lymphocyte reactivity to phytohemagglutinin (PHA), concanavalin A (Con A) and pokeweed mitogen (PWM) was evaluated in 11 patients with American visceral leishmaniasis (AVL) and 11 control subjects. The diagnosis of AVL was established by the demonstration of leishmania in bone marrow aspirates. Thymidine incorporation (cpm +/- SEM) of PHA-stimulated cultures was 27, 520 +/- 4,488 in the AVL patients and 56,531 +/- 8,787 in the controls (P less than 0.01). No significant difference was observed in the response to Con A and PWM between AVL and control patients. The restoration of the PHA response to levels similar to normal was observed when cells from five AVL patients were cultured in medium supplemented with standard AB serum rather than autologous serum. In this group of experiments the average suppressor activity of the PHA response present in sera from AVL patients was 46%. Lymphocyte reactivity of normal subjects to PHA was also suppressed by the AVL serum: PHA-stimulated lymphocytes cultured in standard AB serum were 49,122 +/- 9,345 vs 23,115 +/- 4,935 cpm in cultures supplemented with AVL serum. The demonstration that AVL serum suppressed the PHA response indicates that some of the cellular immunological abnormalities in AVL patients may be dependent on inhibitor factory present in AVl serum.

Immunological features in different clinical forms of strongyloidiasis

Serum immunoglobulin levels, skin test response to PPD, lymphocyte surface markers and eosinophil count in peripheral blood were studied in 35 patients with strongyloidiasis diagnosed by stool examination. The patients were divided into three groups based on clinical history, physical examination and laboratory examination: an asymptomatic group (14 patients), a symptomatic group (14 patients) and a group with severe parasitic infection (seven patients). In three of the seven patients with severe strongyloidiasis, massive infection caused by Strongyloides stercoralis had been diagnosed at least once before this study. The IgG levels were significantly lower (p less than 0.05) in patients with severe strongyloidiasis (1180 +/- 529 mg/dl) than in the asymptomatic group (2347 +/- 1224). IgA and IgM levels were also lower in the patients with massive infection when compared to the asymptomatic and symptomatic groups. No decrease of T cells or B cells was found in patients with severe strongyloidiasis. However, the eosinophil count was significantly lower in patients with severe strongyloidiasis than in asymptomatic or symptomatic patients (p less than 0.05). The authors suggest that eosinophils and antibodies may play an important role in the defence mechanism against S. stercoralis larvae.

Circulating immune complexes and rheumatoid factor in schistosomiasis and visceral leishmaniasis

Circulating immune complexes, measured by the C1q binding and Raji cell radioimmunoassays, were detected in 16 of 25 (64%) patients with schistosomiasis alone, in all 13 patients (100%) with schistosomiasis infection associated with prolonged bacteremia by salmonella organisms, and in 15 of 18 (83%) patients with visceral leishmaniasis. The C3 levels in the serum of patients with schistosomiasis, with and without prolonged salmonella bacteremia, were significantly lower in those with renal disease. Further, in patients with schistosomiasis alone, the absence of renal involvement was positively associated with C1q binding within the normal range (P = 0.015) and the presence of IgM rheumatoid factor in serum (P = 0.04). In six of eight patients with visceral leishmaniasis treated with a pentavalent antimonial, there was a fall in Raji cell binding, suggesting indirectly that the parasitic antigen may be involved in the pathogenic immune complexes in serum.

Conversion of a wideband frequency-modulated signal to amplitude modulation through dispersion in an optical fiber

Our calculation shows that, by means of group-velocity dispersion of an optical fiber, a cw frequency-modulated signal evolves into an intense and sharp pulse. The results compare favorably with an earlier analysis of a narrowband FM system. In particular, the minimum fiber length needed for maximum FM-AM conversion may be considerably reduced.

Regulation of antigen-induced lymphoproliferation by BSA gradient-separated T cell fractions

Human T cells from 6 volunteers immunized with keyhole limpet hemocyanin (KLH) or tetanus toxoid were fractionated on bovine serum albumin (BSA) gradients. These T cell fractions were then recombined with autologous unseparated mononuclear cells or unseparated T cells to determine the effect of each fraction on the proliferative (DNA synthetic) response to the immunizing antigen. Using this separation technique, we were able to define 2 fractions of T cells of widely different densities that had a suppressive effect on the proliferative response to KLH of unfractionated T cells. The demonstration of suppressive activity was possible only if cells were tested within 8 wk of immunization with KLH. These suppressive T cell fractions differed not only in density but also in surface characteristics. Fraction 1 cells had a high proportion of Ia+ cells but no Fc receptors for IgG (FcRG-) were seen, whereas cells from fraction 4 (of higher density) were Ia- and were composed of 12.1 +/- 1.2% FcRG+ cells. this suppression was shown to be specific for the immunizing antigen. One individual who had been immunized with KLH for more than 1 yr in which suppression of KLH-induced proliferation was no longer demonstrable was given primary immunization to tetanus toxoid. Suppression could be demonstrated in fractions 1 and 4 specific for tetanus toxoid; there was no demonstrable effect of these T cell fractions on the response to KLH. We postulate that these are different functional populations of suppressor T cells that regulate antigen specific lymphoproliferation.

Regulation of antigen-induced lymphoproliferation by BSA gradient-separated T cell fractions

Human T cells from 6 volunteers immunized with keyhole limpet hemocyanin (KLH) or tetanus toxoid were fractionated on bovine serum albumin (BSA) gradients. These T cell fractions were then recombined with autologous unseparated mononuclear cells or unseparated T cells to determine the effect of each fraction on the proliferative (DNA synthetic) response to the immunizing antigen. Using this separation technique, we were able to define 2 fractions of T cells of widely different densities that had a suppressive effect on the proliferative response to KLH of unfractionated T cells. The demonstration of suppressive activity was possible only if cells were tested within 8 wk of immunization with KLH. These suppressive T cell fractions differed not only in density but also in surface characteristics. Fraction 1 cells had a high proportion of Ia+ cells but no Fc receptors for IgG (FcRG-) were seen, whereas cells from fraction 4 (of higher density) were Ia- and were composed of 12.1 +/- 1.2% FcRG+ cells. this suppression was shown to be specific for the immunizing antigen. One individual who had been immunized with KLH for more than 1 yr in which suppression of KLH-induced proliferation was no longer demonstrable was given primary immunization to tetanus toxoid. Suppression could be demonstrated in fractions 1 and 4 specific for tetanus toxoid; there was no demonstrable effect of these T cell fractions on the response to KLH. We postulate that these are different functional populations of suppressor T cells that regulate antigen specific lymphoproliferation.

Cell-mediated immunity in American visceral leishmaniasis: reversible immunosuppression during acute infection

Cell-mediated immunity was assessed in 14 Brazilian patients with acute untreated American visceral leishmaniasis (AVL) and in 11 healthy patients successfully treated 1 to 14 years previously. The diagnosis of AVL was established by demonstration of leishmania in bone marrow aspirates. The responsiveness of peripheral blood mononuclear cells to Leishmania chagasi antigens and phytohemagglutinin was studied in vitro. Soluble preparations of L. chagasi antigens were obtained from frozen-thawed promastigote cultures. L. chagasi antigen-stimulated lymphocytes from untreated AVL patients were unresponsiveness and incorporated a mean of 1.2 +/- 0.5 X 10(-3) cpm after a [3H]thymidine pulse. The cured AVL patients had 19.1 +/- 7.2 cpm, and 15 normal control subjects had 0.8 +/- 0.1 cpm. There were no differences in the response of controls and either untreated or cured AVL patients to phytohemagglutinin stimulation. Three of four untreated AVL patients responded to L. chagasi antigens when studied 2 to 4 weeks after therapy. The impaired response of lymphocytes from untreated AVL patients could not be attributed to either reduced numbers of circulating T cells or the inhibitory effect of monocytes or serum factors.

Enhanced helminthotoxic capacity of eosinophils from patients with eosinophilia

To determine whether eosinophils from patients with eosinophilia have an enhanced capacity to kill parasites, we compared purified eosinophils (mean purity, 89 per cent) from 30 patients with various degrees of eosinophilia and with or without infection with Schistosoma mansoni for the capacity to kill schistosomula, the larval stage of S. mansoni, in vitro. There was a significant correlation between peripheral eosinophil count and antibody-dependent, eosinophil-mediated death of parasites after 40 hours of culture (P < 0.0001). Antibody-dependent adherence of eosinophils, measured after two hours of incubation, also correlated with the capacity of the eosinophils to kill the parasites. The correlation between the killing capacity of eosinophils and their peripheral-blood count was observed in patients both with and without S. mansoni infection. We suggest that eosinophilia involves not only a quantitative change in eosinophil numbers but also a qualitative change in functional capacity that renders circulating eosinophils more effective in resisting parasitic infections.