AmBisome Induced Avascular Necrosis of the Alae of the Nose of a very young girl suffering from Kala-azar - a Case Report

The advantages of nanomedicine in the treatment of visceral leishmaniasis: between sound arguments and wishful thinking

Introduction: Although life-threatening if left untreated, visceral leishmaniasis (VL) is still a neglected endemic disease in 98 countries worldwide. The number of drugs available is low and few are in clinical trials. In the last decades, efforts have been made on the development of nanocarriers as drug delivery systems to treat VL. Given the preferential intracellular location of the parasite in the liver and spleen macrophages, the rationale is sturdy. In a clinical setting, liposomal amphotericin B displays astonishing cure rates.Areas covered: A literature search was performed through PubMed and Google Scholar. We critically reviewed the main literature highlighting the success of nanomedicine in VL. We also reviewed the hurdles and yet unfulfilled promises rising awareness of potential drawbacks of nanomedicine in VL.Expert opinion: VL is a disease where nanomedicines successes shine through. However, there are a lot of obstacles on the road to developing more efficient strategies such as targeting functionalization, oral formulations, or combined therapies. And those strategies raise many questions.

Using focused pharmacovigilance for ensuring patient safety against antileishmanial drugs in Bangladesh's National Kala-azar Elimination Programme

Background

Adverse effects of antileishmanial drugs can affect patients’ quality of life and adherence to therapy for visceral leishmaniasis (VL) and post-kala-azar dermal leishmaniasis (PKDL). In Bangladesh, there are 26 treatment centers that manage leishmaniasis cases coming from 100 endemic upazilas (subdistricts) of 26 districts (these include VL, PKDL, treatment failure, and relapse VL and cutaneous leishmaniasis cases). This study aimed to investigate the feasibility of using focused pharmacovigilance for VL (VLPV) in Bangladesh’s National Kala-azar Elimination Programme for the early detection and prevention of expected and unexpected adverse drug reactions (ADRs).

Methods

This activity has been going on since December 2014. Activity area includes secondary public hospital or Upazila health complex (UHC) in hundred sub districts and Surya Kanta Kala-azar Research Center (SKKRC) in Mymensingh District, a specialized center for management of complicated VL and PKDL cases. Communicable Disease Control (CDC) of the Directorate General of Health Services (DGHS) assigned twenty five of hundred UHCs and SKKRC (total 26) as treatment centers depending on their suitable geographical location. This was implemented for better management of VL cases with Liposomal Amphotericin B (AmBisome®) to ensure patient convenience and proper utilization of this expensive donated drug. A VLPV expert committee and a UHC VLPV team were established, an operational manual and pharmacovigilance report forms were developed, training and refresher training of health personnel took place at UHCs and at the central level, collected information such as patient data including demographics, treatment history and response, adverse events were analyzed. This report includes information for the period from December 2014 to December 2016.

Results

From December 2014 to December 2016, 1327 leishmaniasis patients were treated and 1066 (80%) were available for VLPV. Out of these, 57, 33, 9, and 1% were new VL, PKDL, VL relapse, and other cases, respectively. Liposomal amphotericin B was mostly used (82%) for case management, followed by miltefosine (20%) and paromomycin (3%). Out of the 1066 patients, 26% experienced ADRs. The most frequent ADR was fever (17%, 176/1066), followed by vomiting (5%, 51/1066). Thirteen serious adverse events (SAEs) (eight deaths and five unexpected SAEs) were observed. The expert committee assessed that three of the deaths and all unexpected SAEs were possibly related to treatment. Out of the five unexpected SAEs, four were miltefosine-induced ophthalmic complications and the other was an AmBisome®-induced avascular necrosis of the nasal alae. The Directorate General of the Drug Administration entered the ADRs into the World Health Organization Uppsala Monitoring Centre (WHO-UMC) VigiFlow database.

Conclusions

This study found that VLPV through NKEP is feasible and should be continued as a routine activity into the public health system of Bangladesh to ensure patient safety against anti-leishmanial drugs.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0461-0) contains supplementary material, which is available to authorized users.

AmBisome Induced Avascular Necrosis of the Alae of the Nose of a very young girl suffering from Kala-azar - a Case Report

Although liposomal amphotericin B (AmBisome) is considered as the first-line treatment for New Kala-azar, there is not enough evidence on the dosage formulation in children and its effect on them. Being considered as the safest drug for treatment of Kala-azar, this case of AmBisome-induced avascular necrosis now gives rise to the question; whether it is actually safe enough and if a dosage modification is needed in case of children. This so far, to the best of our knowledge, is the first instance of such severe adverse event due to AmBisome administration.