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Miltefosine and Nifuratel Combination: A Promising Therapy for the Treatment of Leishmania donovani Visceral Leishmaniasis. Int J Mol Sci 2023; 24:ijms24021635. [PMID: 36675150 PMCID: PMC9865052 DOI: 10.3390/ijms24021635] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Visceral leishmaniasis is a neglected vector-borne tropical disease caused by Leishmania donovani and Leishmania infantum that is endemic not only in East African countries, but also in Asia, regions of South America and the Mediterranean Basin. For the pharmacological control of this disease, there is a limited number of old and, in general, poorly adherent drugs, with a multitude of adverse effects and low oral bioavailability, which favor the emergence of resistant pathogens. Pentavalent antimonials are the first-line drugs, but due to their misuse, resistant Leishmania strains have emerged worldwide. Although these drugs have saved many lives, it is recommended to reduce their use as much as possible and replace them with novel and more friendly drugs. From a commercial collection of anti-infective drugs, we have recently identified nifuratel-a nitrofurantoin used against vaginal infections-as a promising repurposing drug against a mouse model of visceral leishmaniasis. In the present work, we have tested combinations of miltefosine-the only oral drug currently used against leishmaniasis-with nifuratel in different proportions, both in axenic amastigotes from bone marrow and in intracellular amastigotes from infected Balb/c mouse spleen macrophages, finding a potent synergy in both cases. In vivo evaluation of oral miltefosine/nifuratel combinations using a bioimaging platform has revealed the potential of these combinations for the treatment of this disease.
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Ribeiro Antinarelli LM, Glanzmann N, Mendonça DVC, Lage DP, Oliveira-da-Silva JA, Tavares GSV, Carvalho AMRS, Freitas CS, Martins VT, Duarte MC, Menezes-Souza D, da Silva AD, Coelho EAF, Soares Coimbra E. Parasitological and immunological evaluation of a quinoline derivative salt incorporated into a polymeric micelle formulation against Leishmania infantum infection. Parasitol Res 2022; 121:2129-2140. [PMID: 35614147 PMCID: PMC9132674 DOI: 10.1007/s00436-022-07544-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 05/06/2022] [Indexed: 11/28/2022]
Abstract
Leishmaniasis is a parasitic disease caused by Leishmania protozoa, which presents a large spectrum of clinical manifestations. In the present study, a quinoline derivative salt named N-(2-((7-chloroquinolin-4-yl)amino)ethyl)-N-(prop-2-yn-1-yl)prop-2-yn-1-aminium chloride or QDS3 was in vitro and in vivo tested against L. infantum by means of its incorporation in Poloxamer 407-based polymeric micelles (QDS3/M). The in vitro antileishmanial activity of QDS3 and QDS3/M was investigated in L. infantum promastigotes, axenic amastigotes and infected macrophages. BALB/c mice were infected with L. infantum, and parasitological parameters were evaluated 1 and 15 days post-treatment by determining the parasite load by a limiting dilution assay, besides a quantitative PCR (qPCR) method. Immunological response was assessed based on production of cellular cytokines, as well as by quantification of nitrite levels and specific antibodies. In vitro results showed that QDS3 free or in micelles presented effective antileishmanial action against both parasite stages, being more effective in amastigotes. In vivo data showed that treatment using QDS3 or QDS3/M reduced the parasite load in the livers, spleens, draining lymph nodes (dLN) and bone marrows of the treated animals, 1 and 15 days after treatment, when compared to values found in the control groups. Additionally, treated mice developed a polarized Th1-type immune response, with higher levels of IL-12, IFN-γ, GM-CSF and nitrite, besides high production of specific IgG2a antibodies, when compared to the controls. Parasitological and immunological data obtained using the micellar composition were better than the others. In conclusion, QDS3, mainly when applied in a delivery adjuvant system, could be considered for future studies as therapeutic candidate against VL.
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Affiliation(s)
- Luciana M Ribeiro Antinarelli
- Departamento de Parasitologia, Microbiologia E Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, Campus Universitário, Juiz de Fora, Minas Gerais, 36036-900, Brazil.,Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Nícolas Glanzmann
- Departamento de Química, Instituto de Ciências Exatas, Universidade Federal de Juiz de Fora, Campus Universitário, Juiz de Fora, Minas Gerais, 36036-900, Brazil
| | - Débora V C Mendonça
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Daniela P Lage
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - João A Oliveira-da-Silva
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Grasiele S V Tavares
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Ana Maria R S Carvalho
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Camila S Freitas
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Vívian T Martins
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil
| | - Mariana C Duarte
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 31270-901, Brazil
| | - Daniel Menezes-Souza
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 31270-901, Brazil
| | - Adilson David da Silva
- Departamento de Química, Instituto de Ciências Exatas, Universidade Federal de Juiz de Fora, Campus Universitário, Juiz de Fora, Minas Gerais, 36036-900, Brazil
| | - Eduardo Antônio Ferraz Coelho
- Programa de Pós-Graduação Em Ciências da Saúde: Infectologia E Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 30130-100, Brazil.,Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, 31270-901, Brazil
| | - Elaine Soares Coimbra
- Departamento de Parasitologia, Microbiologia E Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Juiz de Fora, Campus Universitário, Juiz de Fora, Minas Gerais, 36036-900, Brazil.
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Drug associations as alternative and complementary therapy for neglected tropical diseases. Acta Trop 2022; 225:106210. [PMID: 34687644 DOI: 10.1016/j.actatropica.2021.106210] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/02/2021] [Accepted: 10/15/2021] [Indexed: 12/23/2022]
Abstract
The present paper aims to establish different treatments for neglected tropical disease by a survey on drug conjugations and possible fixed-dose combinations (FDC) used to obtain alternative, safer and more effective treatments. The source databases used were Science Direct and PubMed/Medline, in the intervals between 2015 and 2021 with the drugs key-words or diseases, like "schistosomiasis", "praziquantel", "malaria", "artesunate", "Chagas' disease", "benznidazole", "filariasis", diethylcarbamazine", "ivermectin", " albendazole". 118 works were the object of intense analysis, other articles and documents were used to increase the quality of the studies, such as consensuses for harmonizing therapeutics and historical articles. As a result, an effective NTD control can be achieved when different public health approaches are combined with interventions guided by the epidemiology of each location and the availability of appropriate measures to detect, prevent and control disease. It was also possible to verify that the FDCs promote a simplification of the therapeutic regimen, which promotes better patient compliance and enables a reduction in the development of parasitic resistance, requiring further studies aimed at resistant strains, since the combined APIs usually act by different mechanisms or at different target sites. In addition to eliminating the process of developing a new drug based on the identification and validation of active compounds, which is a complex, long process and requires a strong long-term investment, other advantages that FDCs have are related to productive gain and gain from the industrial plant, which can favor and encourage the R&D of new FDCs not only for NTDs but also for other diseases that require the use of more than one drug.
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Kar A, Charan Raja MR, Jayaraman A, Srinivasan S, Debnath J, Kar Mahapatra S. Oral combination of eugenol oleate and miltefosine induce immune response during experimental visceral leishmaniasis through nitric oxide generation with advanced cytokine demand. Cytokine 2021; 146:155623. [PMID: 34144446 DOI: 10.1016/j.cyto.2021.155623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/01/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022]
Abstract
Conventional therapy of visceral leishmaniasis (VL) remains challenging with the pitfall of toxicity, drug resistance, and expensive. Hence, urgent need for an alternative approach is essential. In this study, we evaluated the potential of combination therapy with eugenol oleate and miltefosine in Leishmania donovani infected macrophages and in the BALB/c mouse model. The interactions between eugenol oleate and miltefosine were found to be additive against promastigotes and amastigotes with xΣFIC 1.13 and 0.68, respectively. Significantly (p < 0.001) decreased arginase activity, increased nitrite generation, improved pro-inflammatory cytokines, and phosphorylated p38MAPK were observed after combination therapy with eugenol oleate and miltefosine. >80% parasite clearance in splenic and hepatic tissue with concomitant nitrite generation, and anti-VL cytokines productions were observed after orally administered miltefosine (5 mg/kg body weight) and eugenol oleate (15 mg/kg body weight) in L. donovani-infected BALB/c mice. Altogether, this study suggested the possibility of an oral combination of miltefosine with eugenol oleate against visceral leishmaniasis.
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Affiliation(s)
- Amrita Kar
- Department of Biotechnology, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India
| | - Mamilla R Charan Raja
- Department of Biotechnology, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India; Department of Biotechnology, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Chennai 600077, India
| | - Adithyan Jayaraman
- Department of Biotechnology, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India
| | - Sujatha Srinivasan
- Department of Biotechnology, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India
| | - Joy Debnath
- Department of Chemistry, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India
| | - Santanu Kar Mahapatra
- Department of Biotechnology, School of Chemical and Biotechnology, SASTRA Deemed to be University, Thanjavur, India; Department of Paramedical and Allied Health Sciences, Midnapore City College, Midnapore 721129, West Bengal, India.
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Kar A, Jayaraman A, Charan Raja MR, Srinivasan S, Debnath J, Mahapatra SK. Synergic effect of eugenol oleate with amphotericin B augments anti-leishmanial immune response in experimental visceral leishmaniasis in vitro and in vivo. Int Immunopharmacol 2021; 91:107291. [PMID: 33360084 DOI: 10.1016/j.intimp.2020.107291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 12/29/2022]
Abstract
Present treatment regimen on visceral leishmaniasis has multiple limitations including severe side effects, toxicity, and resistance of Leishmania strains. Amphotericin B is a well-established pharmacologically approved drug; however, mainly toxicity is a foremost issue with that drug. Recently, our group identified eugenol oleate as an anti-leishmanial immunomodulatory compound. The important objectives of this present study was to evaluate the possible synergistic effect of eugenol oleate with amphotericin B to reduce the toxicity of this approved drug. Results obtained from this study signified that combination of eugenol oleate and amphotericin B showed indifferent combinatorial effect against promastigotes with xΣFIC 1.015, while, moderate synergistic activity with xΣFIC 0.456 against amastigotes. It was also notable that eugenol oleate (2.5 μM) with low concentrations of amphotericin B (0.3125 μM) showed 96.45% parasite reduction within L. donovani-infected murine macrophages. Furthermore, eugenol oleate and amphotericin B significantly (p < 0.01) enhanced the nitrite generation, and pro-inflammatory cytokines (IL-12, IFN-γ and TNF-α) in infected macrophages in vitro and in BALB/c mice in vivo. Eugenol oleate (10 mg/Kg b. wt.) with amphotericin B (1 mg/Kg b.wt.) significantly (p < 0.01) controlled the parasite burden in liver by 96.2% and in spleen by 93.12%. Hence, this study strongly suggested the synergic potential of eugenol oleate with low concentration of amphotericin B in experimental visceral leishmaniasis through anti-leishmanial immune response.
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MESH Headings
- Amphotericin B/pharmacology
- Animals
- Cells, Cultured
- Cytokines/metabolism
- Disease Models, Animal
- Drug Synergism
- Drug Therapy, Combination
- Female
- Host-Parasite Interactions
- Inflammation Mediators/metabolism
- Leishmania donovani/drug effects
- Leishmania donovani/immunology
- Leishmania donovani/pathogenicity
- Leishmaniasis, Visceral/drug therapy
- Leishmaniasis, Visceral/immunology
- Leishmaniasis, Visceral/metabolism
- Leishmaniasis, Visceral/parasitology
- Liver/drug effects
- Liver/immunology
- Liver/metabolism
- Liver/parasitology
- Macrophages, Peritoneal/drug effects
- Macrophages, Peritoneal/immunology
- Macrophages, Peritoneal/metabolism
- Macrophages, Peritoneal/parasitology
- Mice, Inbred BALB C
- Nitrites/metabolism
- Parasite Load
- Spleen/drug effects
- Spleen/immunology
- Spleen/metabolism
- Spleen/parasitology
- Th1 Cells/drug effects
- Th1 Cells/immunology
- Th1 Cells/metabolism
- Th1 Cells/parasitology
- Th1-Th2 Balance
- Th2 Cells/drug effects
- Th2 Cells/immunology
- Th2 Cells/metabolism
- Th2 Cells/parasitology
- Trypanocidal Agents/pharmacology
- Mice
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Affiliation(s)
- Amrita Kar
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India
| | - Adithyan Jayaraman
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India
| | - Mamilla R Charan Raja
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India
| | - Sujatha Srinivasan
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India
| | - Joy Debnath
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India.
| | - Santanu Kar Mahapatra
- Department of Biotechnology, Centre for Research in Infectious Diseases, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India; Department of Chemistry, School of Chemical and Biotechnology, SASTRA University, Thanjavur, India.
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Ham RE, Temesvari LA. Joining forces: Leveraging novel combination therapies to combat infections with eukaryotic pathogens. PLoS Pathog 2021; 16:e1009081. [PMID: 33382854 PMCID: PMC7774843 DOI: 10.1371/journal.ppat.1009081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Rachel E. Ham
- Department of Biological Sciences, Clemson University, Clemson, South Carolina, Unites States of America
- Eukaryotic Pathogens Innovation Center (EPIC), Clemson University, Clemson, South Carolina, Unites States of America
| | - Lesly A. Temesvari
- Department of Biological Sciences, Clemson University, Clemson, South Carolina, Unites States of America
- Eukaryotic Pathogens Innovation Center (EPIC), Clemson University, Clemson, South Carolina, Unites States of America
- * E-mail:
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Rebello KM, Andrade-Neto VV, Gomes CRB, de Souza MVN, Branquinha MH, Santos ALS, Torres-Santos EC, d'Avila-Levy CM. Miltefosine-Lopinavir Combination Therapy Against Leishmania infantum Infection: In vitro and in vivo Approaches. Front Cell Infect Microbiol 2019; 9:229. [PMID: 31316919 PMCID: PMC6611157 DOI: 10.3389/fcimb.2019.00229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/11/2019] [Indexed: 12/19/2022] Open
Abstract
Concurrently, leishmaniasis and AIDS are global public health issues and the overlap between these diseases adds additional treats to the management of co-infected patients. Lopinavir (LPV) has a well characterized anti-HIV and leishmanicidal action, and to analyze its combined action with miltefosine (MFS) could help to envisage strategies to the management of co-infected patients. Here, we evaluate the interaction between LPV and MFS against Leishmania infantum infection by in vitro and in vivo approaches. The effect of the compounds alone or in association was assessed for 72 h in mouse peritoneal macrophages infected with L. infantum by the determination of the IC50s and FICIs. Subsequently, mice were orally treated twice daily during 5 days with the compounds alone or in association and evaluated after 30 days. The in vitro assays revealed an IC50 of 0.24 μM and 9.89 μM of MFS and LPV, respectively, and an additive effect of the compounds (FICI 1.28). The in vivo assays revealed that LPV alone reduced the parasite load in the spleen and liver by 52 and 40%, respectively. The combined treatment of infected BALB/c mice revealed that the compounds alone required at least two times higher doses than when administered in association to virtually eliminate the parasite. Mice plasma biochemical parameters assessed revealed that the combined therapy did not present any relevant hepatotoxicity. In conclusion, the association of MFS with LPV allowed a reduction in each compound concentration to achieve the same outcome in the treatment of visceral leishmaniasis. Although a pronounced synergistic effect was not evidenced, it does not discard that such combination could be useful in humans co-infected with HIV and Leishmania parasites.
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Affiliation(s)
- Karina M Rebello
- Laboratório de Estudos Integrados em Protozoologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Valter V Andrade-Neto
- Laboratório de Bioquímica de Tripanosomatídeos, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
| | - Claudia Regina B Gomes
- Laboratório de Síntese de Substâncias no Combate a Doenças Tropicais, Farmanguinhos, FIOCRUZ, Rio de Janeiro, Brazil
| | - Marcos Vinícius N de Souza
- Laboratório de Síntese de Substâncias no Combate a Doenças Tropicais, Farmanguinhos, FIOCRUZ, Rio de Janeiro, Brazil
| | - Marta H Branquinha
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Instituto de Microbiologia Paulo de Góes, UFRJ, Rio de Janeiro, Brazil
| | - André L S Santos
- Laboratório de Estudos Avançados de Microrganismos Emergentes e Resistentes, Instituto de Microbiologia Paulo de Góes, UFRJ, Rio de Janeiro, Brazil
| | | | - Claudia M d'Avila-Levy
- Laboratório de Estudos Integrados em Protozoologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
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Mastroianni A, Gaibani P, Rossini G, Vocale C, Re MC, Ravaglia G, Sambri V, Varani S. Two cases of relapsed HIV-associated visceral leishmaniasis successfully treated with combination therapy. AIDS Res Ther 2018; 15:27. [PMID: 30572924 PMCID: PMC6300903 DOI: 10.1186/s12981-018-0215-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022] Open
Abstract
Background The management of visceral leishmaniasis (VL) in HIV-infected patients is often complex with patients experiencing higher mortality rates, more toxic side effects and a higher possibility of treatment failure and relapse than HIV-negative individuals with VL. Case presentation We report on successful salvage therapy in two HIV-infected patients suffering with disseminated cutaneous and visceral leishmaniasis, recalcitrant to therapy with liposomal amphotericin B. After the employment of combination anti-leishmanial treatment, parasite genomes were not detectable up to the last follow up visit, 57 and 78 weeks after treatment onset, respectively. CD4+ lymphocyte counts fluctuated over time, but were generally higher than counts detected at treatment onset, which likely contributed to protection against VL relapse. Conclusions Results achieved with the anti-leishmanial combination treatment were promising, but are based on only two patients. Future investigation is necessary to confirm the efficacy of this salvage therapy in sustaining the immunological response and control of VL.
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