Successful liposomal amphotericin B treatment of Leishmania braziliensis cutaneous leishmaniasis

Review of Leishmaniasis Treatment: Can We See the Forest through the Trees?

There are three known clinical syndromes of leishmaniasis: cutaneous (CL), mucocutaneous (MCL), and visceral disease (VL). In MCL and VL, treatment must be systemic (either oral or intravenous), while CL treatment options vary and include observation-only localized/topical treatment, oral medications, or parenteral drugs. Leishmaniasis treatment is difficult, with several factors to be considered. First, the efficacy of treatments varies among different species of parasites prevalent in different areas on the globe, with each species having a unique clinical presentation and resistance profile. Furthermore, leishmaniasis is a neglected tropical disease (NTD), resulting in a lack of evidence-based knowledge regarding treatment. Therefore, physicians often rely on case reports or case series studies, in the absence of randomized controlled trials (RCT), to assess treatment efficacy. Second, defining cure, especially in CL and MCL, may be difficult, as death of the parasite can be achieved in most cases, while the aesthetic result (e.g., scars) is hard to predict. This is a result of the biological nature of the disease, often diagnosed late in the course of disease (with possible keloid formation, etc.). Third, physicians must consider treatment ease of use and the safety profile of possible treatments. Thus, topical or oral treatments (for CL) are desirable and promote adherence. Fourth, the cost of the treatment is an important consideration. In this review, we aim to describe the diverse treatment options for different clinical manifestations of leishmaniasis. For each currently available treatment, we will discuss the various considerations mentioned above (efficacy, ease of use, safety, and cost).

Treatment of Pediatric Cutaneous Leishmaniasis with Liposomal Amphotericin B

BACKGROUND

The use of liposomal amphotericin B (L-AmB) in the treatment of cutaneous leishmaniasis (CL) is increasing. However, few data are available regarding the efficacy and safety of L-AmB in pediatric CL patients.

AIMS

Our aim in this study is to evaluate the efficacy and safety of L-AmB in pediatric CL patients.

METHODS

Pediatric patients admitted to a tertiary training and research hospital in a hyperendemic region for CL between January 2019 and May 2021 and receiving L-AmB therapy for CL were included in this retrospective study. L-AmB treatment was administered as 3 mg/kg for 5 consecutive days and on the 10th day, in a total of 6 doses (18 mg/kg total dose).

RESULT

Fifty-two pediatric patients who received L-AmB therapy for CL were included in the study. In the follow-up 3 months after L-AmB treatment, 16 (31%) patients showed complete clinical recovery, while treatment failure was detected in 36 (69%) patients.

CONCLUSION

In conclusion, considering the low treatment success rate in our study, we think that the L-AmB dose used in our study is not an appropriate treatment option for the treatment of pediatric CL patients. However, we think that prospective studies with a large number of patients treated with higher doses of L-AmB and in whom the causative agents of CL were determined are needed. This article is protected by copyright. All rights reserved.

The antimicrobial and immunomodulatory effects of Ionophores for the treatment of human infection

Ionophores are a diverse class of synthetic and naturally occurring ion transporter compounds which demonstrate both direct and in-direct antimicrobial properties against a broad panel of bacterial, fungal, viral and parasitic pathogens. In addition, ionophores can regulate the host-immune response during communicable and non-communicable disease states. Although the clinical use of ionophores such as Amphotericin B, Bedaquiline and Ivermectin highlight the utility of ionophores in modern medicine, for many other ionophore compounds issues surrounding toxicity, bioavailability or lack of in vivo efficacy studies have hindered clinical development. The antimicrobial and immunomodulating properties of a range of compounds with characteristics of ionophores remain largely unexplored. As such, ionophores remain a latent therapeutic avenue to address both the global burden of antimicrobial resistance, and the unmet clinical need for new antimicrobial therapies. This review will provide an overview of the broad-spectrum antimicrobial and immunomodulatory properties of ionophores, and their potential uses in clinical medicine for combatting infection.

Applications of Nanomaterials in Leishmaniasis: A Focus on Recent Advances and Challenges

Leishmaniasis is a widely distributed protozoan vector-born disease affecting almost 350 million people. Initially, chemotherapeutic drugs were employed for leishmania treatment but they had toxic side effects. Various nanotechnology-based techniques and products have emerged as anti-leishmanial drugs, including liposomes, lipid nano-capsules, metal and metallic oxide nanoparticles, polymeric nanoparticles, nanotubes and nanovaccines, due to their unique properties, such as bioavailability, lowered toxicity, targeted drug delivery, and biodegradability. Many new studies have emerged with nanoparticles serving as promising therapeutic agent for anti-leishmanial disease treatment. Liposomal Amphotericin B (AmB) is one of the successful nano-based drugs with high efficacy and negligible toxicity. A new nanovaccine concept has been studied as a carrier for targeted delivery. This review discusses different nanotechnology-based techniques, materials, and their efficacies in leishmaniasis treatment and their futuristic improvements.

Comparison of Efficacy of Two Different Concentrations of Intralesional Amphotericin B in the Treatment of Cutaneous Leishmaniasis; A Randomized Controlled Trial

Introduction:

Cutaneous leishmaniasis is a vector borne disease caused by Leishmania major and Leishmania tropica. Bikaner is an endemic pocket for cutaneous leishmaniasis caused by Leishmania tropica.

Materials and Methods:

A prospective study was done to evaluate the efficacy of different concentrations of intralesional amphotericin B as a treatment modality for cutaneous leishmaniasis in Bikaner, Rajasthan, India from January 2016 to June 2017. Fifty patients were randomized into two groups, A and B. Twenty-five patients from group A, received intralesionl amphotericin B (2.5 mg/ml) 0.5 ml/cm², weekly for 8 weeks. Another group of 25 patients were treated by intralesional amphotericin B (5.0 mg/ml) weekly for same period. The cases were followed-up for response, side effects, and recurrence of disease.

Results:

The results at the end of 8 weeks, showed complete response in 18 (72%) patients, partial response in 5 (20%) and 2 (8%) patients were non responders in group A. In group B, complete response was observed in 14 (56%), partial response in 7 (28%) patients and 4 (16%) patients did not show response. The difference was statistically insignificant (P > 0.05). No side effects were observed in both groups.

Conclusion:

The difference between the efficacy of 5 mg/ml and 2.5 mg/ml concentrations of Amphotericin B injections was found to be statistically insignificant. So, weekly injections of amphotericin B looks promising, however, larger sample size is required to assess the efficacy of both concentrations in the treatment of cutaneous leishmaniasis.

Lipsosomal amphotericin B: a review of its properties, function, and use for treatment of cutaneous leishmaniasis

The genus Leishmania includes a number of protozoan parasites that cause a wide range of infections named leishmaniasis. Leishmaniasis may be appear in three clinical forms — cutaneous (CL), visceral, and mucocutaneous (MCL) — with variation in their presentation and severity: diffuse CL and post–kala-azar dermal leishmaniasis). The prevalent signs of CL are nonhealing ulcers on exposed skin, but infected patients may have other dermatologic symptoms. In the 1960s, amphotericin B deoxycholate was introduced as a second-line therapy for CL and MCL. However, widespread administration of the agent was prevented, due to its renal and systemic toxicity, high price, and obstacles to intravenous use in leishmaniasis-endemic regions. Amphotericin B binds to ergosterol in the photogenic cell membranes and causes changes in membrane permeability, leakage of ions, and finally cell death. Compared to amphotericin B deoxycholate, a higher dose of liposomal amphotericin B should be administered to show the treatment effect. A high percentage of liposomal amphotericin B is “fastened” in the liposome and not biologically effective. Amphotericin B deoxycholate has some toxic effects, and liposomal amphotericin B is meaningfully less toxic compared to it. Treatment options for CL are limited, due to variation in species causing CL and pharmacokinetic issues. Amphotericin B is effective against some particular forms of CL.

In Vitro Sensitivity of Cutaneous Leishmania Promastigote Isolates Circulating in French Guiana to a Set of Drugs

AbstractAnti-leishmaniasis drug resistance is a common problem worldwide. The aim of this study was to inventory the general in vitro level of sensitivity of Leishmania isolates circulating in French Guiana and to highlight potential in vitro pentamidine-resistant isolates. This sensitivity study was conducted on 36 patient-promastigote isolates for seven drugs (amphotericin B, azithromycin, fluconazole, meglumine antimoniate, miltefosine, paromomycin, and pentamidine) using the Cell Counting Kit-8 viability test. The IC₅₀ values obtained were heterogeneous. One isolate exhibited high IC₅₀ values for almost all drugs tested. Pentamidine, which is the first-line treatment in French Guiana, showed efficacy at very low doses (mean of 0.0038 μg/mL). The concordance of the in vitro pentamidine results with the patients' clinical outcomes was 94% (K = 0.82).

Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Therapeutic options and vaccine development in the treatment of leishmaniasis

Early treatment of leishmaniasis is critical to achieve cure, prevent psychological and social distress, and prevent transmission of disease. Untreated Leishmaniasis-cutaneous leishmaniasis, mucocutaneous leishmaniasis and visceral leishmaniasis - results in disfiguring scars and high rates of morbidity and mortality in highly endemic regions of the world. However, cure rates with available therapeutics are limited due to cost, therapeutic toxicity and the growing rate of resistance. New therapeutic targets for medications and vaccine development are under investigation to provide improved healing and efficacy for the treatment of Leishmania spp.

Therapeutic options for old world cutaneous leishmaniasis and new world cutaneous and mucocutaneous leishmaniasis

Estimated worldwide incidence of tegumentary leishmaniasis (cutaneous leishmaniasis [CL] and mucocutaneous leishmaniasis [MCL]) is over 1.5 million cases per year in 82 countries, with 90 % of cases occurring in Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria. Current treatments of CL are poorly justified and have sub-optimal effectiveness. Treatment can be based on topical or systemic regimens. These different options must be based on Leishmania species, geographic regions, and clinical presentations. In certain cases of Old World CL (OWCL), lesions can spontaneously heal without any need for therapeutic intervention. Local therapies (thermotherapy, cryotherapy, paromomycin ointment, local infiltration with antimonials) are good options with less systemic toxicity, reserving systemic treatments (azole drugs, miltefosine, antimonials, amphotericin B formulations) mainly for complex cases. The majority of New World CL (NWCL) types require systemic treatment (mainly with pentavalent antimonials), either to speed the healing or to prevent dissemination to oral-nasal mucosa as MCL (NWMCL). These types of lesions are potentially serious and always require systemic-based regimens, mainly antimonials and pentamidine; however, the associated immunotherapy is promising. This paper is an exhaustive review of the published literature on the treatment of OWCL, NWCL and NWMCL, and provides treatment recommendations stratified according to their level of evidence regarding the species of Leishmania implicated and the geographical location of the infection.

Cutaneous leishmaniasis in Cuban immigrants to Texas who traveled through the Darién Jungle, Panama

Cutaneous leishmaniasis is rarely seen in the United States. Four Cuban immigrants traveled along the same route at different times from Cuba to Ecuador, then northward, including through the Darién Jungle in Panama. These patients had chronic ulcerative non-healing skin lesions and were given a diagnosis of leishmaniasis.

Review of the current treatments for leishmaniases

Leishmaniases are vector-borne zoonotic diseases that are prevalent in tropical and subtropical areas in the world, with two million new cases occurring yearly. Visceral and tegumentary forms of leishmaniasis are known. The latter form may present as localized cutaneous or mucosal forms, disseminated, diffuse forms, or leishmaniasis recidiva cutis. Visceral leishmaniasis is caused by parasites of the species Leishmania (Leishmania) donovani and L. (L.) infantum, and tegumentary leishmaniasis is caused by 15 other species, with distinct distributions in the Old and New World. The varied clinical manifestations, the multitude of Leishmania species, and the increasing incidence of HIV coinfection make the diagnosis and treatment of leishmaniases complex. Since there are no solid data relating clinical manifestations, treatment outcomes and Leishmania species the decision regarding the best therapeutic option is almost entirely based on clinical manifestations. Because most of the literature is focused on leishmaniasis in the Old World, in this review we present data on the treatment of New World leishmaniasis in more detail. Ranked therapeutic options, clinical trials, and also observations, even with a restricted number of subjects, on treatment outcome of visceral and different forms of tegumentary leishmaniasis, are presented. Treatment for leishmaniasis in HIV-coinfected patients is addressed as well. Some of these data strongly suggest that the differences in the outcome of the treatment are related to the Leishmania species. Therefore, although it is not possible at most points of care to identify the species causing the infection - a process that requires a well equipped laboratory - the infecting species should be identified whenever possible. More recent approaches, such as the use of immunomodulators and immunotherapy, and the lines for development of new candidate drugs are mentioned.

Treatment of imported New World cutaneous leishmaniasis in Germany

BACKGROUND

Cutaneous leishmaniasis (CL), a parasitic disease which represents a public health problem, particularly in Central and South America, has become a leading condition in travelers who return from tropical countries with skin disorders. Cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis, the most common causative agent, requires systemic treatment because it is potentially able to disseminate and to cause mucosal or mucocutaneous disease. Although several drugs are available for the systemic treatment of leishmaniases, a definitive treatment regimen for infection caused by species of the Viannia subgenus has yet to be established in many countries, including Germany.

METHODS

We analyzed treatment outcomes in 23 returnees from Central and South America who were diagnosed with L. (V.) braziliensis CL by polymerase chain reaction.

RESULTS

Complete cure within one month following treatment was observed in 18 patients (78%). Cure was achieved with liposomal amphotericin B in 11 of 13 patients, miltefosine in five of eight patients, and meglumine antimoniate in two (of two) patients. Of the five patients (22%) who failed to respond to initial therapy, four were cured with meglumine antimoniate and one with liposomal amphotericin B.

CONCLUSIONS

In this outcome evaluation of treatment of imported L. (V.) braziliensis infections, liposomal amphotericin B, miltefosine, and meglumine antimoniate proved to be effective. Conventional meglumine antimoniate showed high efficacy as a first-line treatment and cured lesions that failed to respond to the other two drugs. A multi-country study using standardized treatment protocols is needed to establish a definitive regimen.

Acute New World cutaneous leishmaniasis presenting as tuberculoid granulomatous dermatitis

Acute primary cutaneous leishmaniasis typically presents microscopically with a lymphohistiocytic infiltrate containing admixed plasma cells, parasitized macrophages and abundant organisms. Tuberculoid granulomatous changes may occur in the later phases of primary infection. A 23-year-old male presented 1 month after visiting Peru with classic clinical findings of acute primary cutaneous leishmaniasis, while histopathology showed a tuberculoid granulomatous process that lacked any organisms in hematoxylin-eosin and fungal stains. Polymerase chain reaction (PCR) analysis and tissue cultures confirmed the diagnosis of cutaneous leishmaniasis with Leishmania (Viannia) panamensis infection. A pauci-organism tuberculoid granulomatous process may uncommonly be the presenting histopathology in the acute infectious phase of cutaneous leishmaniasis. Clinicians and dermatopathologists should be aware of this atypical presentation, which may cause diagnostic confusion and delay proper treatment. PCR testing should be employed in cases with high clinical suspicion when histopathology is not definitive.

Old world Leishmania infantum cutaneous leishmaniasis unresponsive to liposomal amphotericin B treated with topical imiquimod

We present a case of a child with Leishmania infantum cutaneous leishmaniasis unresponsive to 2 courses of intravenous liposomal amphotericin B, a treatment failure that has not been reported in this Leishmania species. The patient responded to topical imiquimod and had no relapse. We review the literature on the treatment failure of liposomal amphotericin B for cutaneous leishmaniasis.

Efficacy of Topical Liposomal Amphotericin B versus Intralesional Meglumine Antimoniate (Glucantime) in the Treatment of Cutaneous Leishmaniasis

Background. Topical treatment of cutaneous leishmaniasis is an attractive alternative avoiding toxicities of parenteral therapy while being administered through a simple painless route. Recently liposomal formulations of amphotericin B have been increasingly used in the treatment of several types of leishmaniasis. Aims. The efficacy of a topical liposomal amphotericin B formulation was compared with intralesional glucantime in the treatment of cutaneous leishmaniasis. Methods. From 110 patients, the randomly selected 50 received a topical liposomal formulation of amphotericin B into each lesion, 3–7 drops twice daily, according to the lesion's size and for 8 weeks. The other group of 60 patients received intralesional glucantime injection of 1-2 mL once a week for the same period. The clinical responses and side effects of both groups were evaluated weekly during the treatment course. Results. Per-protocol analysis showed no statistically significant difference between the two groups (P = 0.317, 95% confidence interval (CI) = 1.610 (0.632–4.101)). Moreover, after intention-to-treat analysis, the same results were seen (P = 0.650, 95% CI = 0.1.91 (0.560–2.530)). Serious post treatment side effects were not observed in either group. Conclusions. Topical liposomal amphotericin B has the same efficacy as intralesional glucantime in the treatment of cutaneous leishmaniasis.

Leishmaniasis

Leishmaniasis is an uncommon infectious disease in the UK with a variety of clinical presentations. Physicians should remember to consider this diagnosis in patients with an appropriate travel history (including the Mediterranean basin) and seek help with diagnostics from a specialised parasitology laboratory. Treatment regimens may be unfamiliar to the general physician, and thus should also be discussed with an expert.

Cutaneous leishmaniasis in a Japanese returnee from West Africa successfully treated with liposomal amphotericin B

Leishmaniasis has been occasionally reported in returnees from endemic areas. Here, we report a case of cutaneous leishmaniasis in a 33-year-old Japanese man who presented with a skin nodule after returning from an 8-year stay in West Africa including Burkina Faso. He was successfully treated with liposomal amphotericin B with no significant adverse effects. This is the first Japanese case of cutaneous leishmaniasis treated successfully with liposomal amphotericin B.

A cluster of cutaneous leishmaniasis associated with human smuggling

Cutaneous leishmaniasis (CL) is rarely seen in the United States, and the social and geographic context of the infection can be a key to its diagnosis and management. Four Somali and one Ethiopian, in U.S. Border Patrol custody, came to the United States by the same human trafficking route: Djibouti to Dubai to Moscow to Havana to Quito; and then by ground by Columbia/Panama to the United States-Mexico border where they were detained. Although traveling at different times, all five patients simultaneously presented to our institution with chronic ulcerative skin lesions at different sites and stages of evolution. Culture of biopsy specimens grew Leishmania panamensis. Soon thereafter, three individuals from East Africa traveling the identical route presented with L. panamensis CL to physicians in Tacoma, WA. We document here the association of a human trafficking route and new world CL. Clinicians and public health officials should be aware of this emerging infectious disease risk.

Central nervous system toxicity associated with liposomal amphotericin B therapy for cutaneous leishmaniasis

AmBisome (liposomal amphotericin B) is used for prophylaxis and treatment of fungal infections, treatment of visceral leishmaniasis, and more recently, treatment of cutaneous leishmaniasis. Although the package insert cites neurologic toxicities in up to 20% of cases, review of the literature did not reveal any specific cases describing this side effect, particularly in a patient without comorbidities. We describe a healthy 38-year-old male treated with liposomal amphotericin B for cutaneous leishmaniasis acquired during military duties in Iraq. Shortly after completion of his treatment course, he reported memory difficulties and confusion. Further evaluation revealed no other source, and his cognitive issues were attributed to liposomal amphotericin B toxicity. These issues resolved over a few weeks, which is consistent with data about the drug's tissue penetration and metabolism available in the literature. This is a potential side effect of liposomal amphotericin B that can be observed in otherwise healthy patients.

A pilot study comparing low-dose liposomal amphotericin B with N-methyl glucamine for the treatment of American cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis is an infectious re-emerging disease that has increased in incidence worldwide. Antimony, a highly toxic drug, remains the first choice therapy to treat it. Liposomal amphotericin B is active against Leishmania and is less toxic than antimony.

OBJECTIVE

To compare low-dose liposomal amphotericin B with N-methyl glucamine for the treatment of American cutaneous leishmaniasis.

PATIENTS/METHODS

In a controlled open-label trial 35 patients with a localized form of American cutaneous leishmaniasis were included. They were allocated to a first group treated with 1.5 mg/kg/day of liposomal amphotericin B for 5 days, or to a second one treated with 20 mgSbV/kg/day of N-methyl glucamine for 20 days.

RESULTS

In the first group, 50% and 81% of patients experienced a clinical cure and clinical improvement respectively. There was a 100% clinical cure in the second group.

CONCLUSION

Liposomal amphotericin B seems to be promising and safe for the treatment of American cutaneous leishmaniasis.

A species-specific approach to the use of non-antimony treatments for cutaneous leishmaniasis

We used a species-specific approach to treat 10 patients with cutaneous leishmaniasis diagnosed using polymerase chain reaction. Non-antimony treatments (oral miltefosine, ketoconazole, and liposomal amphotericin B) were chosen as an alternative to pentavalent antimony drugs based on likely or proven drug efficacy against the infecting species. Leishmania Viannia panamensis was diagnosed in three patients and treated successfully with oral ketoconazole. Miltefosine treatment cured two patients with L. infantum chagasi. A wide variety of Leishmania responded to liposomal amphotericin B administered for 5-7 days. Three patients with L. V. braziliensis, one patient with L. tropica, and two patients with L. infantum chagasi were treated successfully. One person with L. V. braziliensis healed slowly because of a resistant bacterial superinfection, and a second patient with L. infantum chagasi relapsed and was retreated with miltefosine. These drugs were reasonably well-tolerated. In this limited case series, alternative non-antimony-based regimens were convenient, safe, and effective.

Lipsosomal amphotericin B for treatment of cutaneous leishmaniasis

Treatment options for cutaneous leishmaniasis in the United States are problematic because the available products are either investigational, toxic, and/or of questionable effectiveness. A retrospective review of patients receiving liposomal amphotericin B through the Walter Reed Army Medical Center for the treatment of cutaneous leishmaniasis during 2007-2009 was conducted. Twenty patients who acquired disease in five countries and with five different strains of Leishmania were treated, of whom 19 received a full course of treatment. Sixteen (84%) of 19 experienced a cure with the initial treatment regimen. Three patients did not fully heal after an initial treatment course, but were cured with additional dosing. Acute infusion-related reactions occurred in 25% and mild renal toxicity occurred in 45% of patients. Although the optimum dosing regimen is undefined and the cost and toxicity may limit widespread use, liposomal amphotericin B is a viable treatment alternative for cutaneous leishmaniasis.

[Therapy of leishmaniasis in France: consensus on proposed guidelines]

Because it relies on potentially toxic, difficult-to-handle, or expensive compounds the therapy of leishmaniasis is still a complex issue in 2010, especially for visceral leishmaniasis in immuno-suppressed subjects, or in patients with cutaneous and mucosal involvement. This induces a wide diversity of observed therapeutic practices, some being sub-optimal. The Société de Pathologie Exotique organised a meeting dedicated to the therapy of leishmaniasis in France that led to the first consensus on therapeutic guidelines. Liposomal amphotericin B is the first-line option for visceral leishmaniasis both in immunocompetent, and immunosuppressed patients (cumulated doses of 20 mg/kg and 30-40 mg/kg, respectively). Secondary prophylaxis with either liposomal amphotericin B, pentamidine or meglumine antimoniate is proposed to patients with heavy immunosuppression until immunity has been restored for at least 6 months. While the efficacy of new topical formulations of paromomycin is being tested, patients with Old World cutaneous leishmaniasis may be left untreated, or be administered a combination of superficial cryotherapy plus intralesional antimony, or even--in complex situations--receive systemic therapy. The efficacy of a short course of pentamidine (L. guyanensis/L. panamensis) and a 20-day schedule of meglumine antimoniate (L. braziliensis) is solidly established. However, in well-defined situations, local therapy of New World cutaneous leishmaniasis is now considered acceptable.

A chronic mutilating rhinopathy with a delayed diagnosis of mucocutaneous leishmaniasis

BACKGROUND

Mucocutaneous leishmaniasis is a granulomatous disease clinically characterized by ulcerated skin and mucosal lesions. Mucocutaneous leishmaniasis is very rare in India and to our knowledge, only two cases have been reported, and this is the first case of mucocutaneous leishmaniasis presenting with mutilating rhinopathy reported from the Indian subcontinent.

CASE REPORT

A 64-year-old man presented with a destructive ulceration of the central face of 23 years' duration, who was diagnosed to have mucocutaneous leishmaniasis, and showed dramatic response to intramuscular injections of sodium stibogluconate.

RESULTS

Histopathologic examination of skin biopsy revealed a granulomatous infiltrate with the presence of leishmania donovani (LD) bodies. The clinical picture, plus the pathologic findings, and the response to sodium stibogluconate confirmed mucocutaneous leishmaniasis.

CONCLUSION

Mucocutaneous leishmaniasis is a rare disease in the Indian subcontinent, and clinicians from this region should have a high index of suspicion on encountering mucocutaneous ulcerative lesions.

Successful treatment of childhood cutaneous leishmaniasis with liposomal amphotericin B: report of two cases

Treatment of cutaneous leishmaniasis is sometimes difficult. No single ideal therapy has yet been identified and some of the drugs that are currently used are associated with significant toxicity. We present two cases of cutaneous leishmaniasis in children, one caused by Leishmania infantum and the other by Leishmania braziliensis. Both of them were successfully treated with intravenous liposomal amphotericin B.

New World cutaneous leishmaniasis: updated review of current and future diagnosis and treatment

BACKGROUND

Cutaneous leishmaniasis (CL) has traditionally been underrecognized and underreported. Improved awareness is warranted as the number of cases has increased as a result of increased travel to endemic countries, the HIV/AIDS pandemic, and the larger number of military and contract workers deployed overseas.

OBJECTIVE

We sought to present a systematic review of evidence from a gamut of research trials on the treatment efficacy of different regimens and aggregate this knowledge for use as a guide for clinical practice decisions.

METHODS

We performed a comprehensive search of print and electronic sources to identify the accumulated research information on New World CL.

RESULTS

Topical treatment of New World CL lesions is generally not recommended. Findings support the systemic administration of pentavalent antimonials as first-line treatment. Exception to this is infection with L guyanensis in French Guiana where systemic pentamidine is suggested as first-line treatment.

LIMITATIONS

The reliability of the findings of this review of research evidence is dependent on the individual quality and potential bias in its component principal trials. There was a conscious attempt to only include evidence derived from randomized controlled studies, with adequate randomization, adequate patient numbers, and complete follow-up information. However, because of the relatively small number of such studies on New World CL, evidence from nonrandomized studies and case series studies was also considered.

CONCLUSIONS

The pentavalent antimony compounds remain the first-line treatment choice for the treatment of New World CL. Concerns with cost, availability, poor compliance, and systemic toxicity, however, may compel clinicians to opt for alternative treatment modalities. Some advances in the development of an antileishmanial vaccine have been made but none is yet available for clinic use. The increase, over recent years, in the incidence of CL warrants an enhanced effort to increase awareness of the disease, assure timely diagnosis, and implement effective management and treatment strategies.

Mucosal leishmaniasis . Current scenario and prospects for treatment

Leishmaniasis causes significant morbidity and mortality and thus constitutes a serious public health problem. Even though it has long been endemic in developing countries, in recent years the economic globalization and the increased volume of international travel have extended its prevalence in developed countries. In addition, native populations may be exposed to the infection through blood transfusion and the use of blood products produced from infected asymptomatic individuals. Mucosal leishmaniasis (ML) is a chronic form of this infection, which attacks the mucosa. In most cases this form of leishmaniasis results from the metastatic spread of Leishmania (Viannia) braziliensis from cutaneous lesions. It is a healthcare issue because of its wide demographic distribution, its association with significant morbidity levels, and because of the pressing concern that tourists who travel to endemic areas might present the disease even years later. The treatment currently available for ML is based on drugs such as pentavalent antimony-containing compounds, amphotericin B deoxycholate and pentamidine and often guarantees a satisfactory clinical response. Nevertheless, it also frequently provokes serious side effects. This review offers a critical analysis of the drugs now available for the treatment of ML as also of the future prospects for the treatment of the disease.

Cutaneous leishmaniasis treatment

The causative species of cutaneous leishmaniasis determines the clinical features and courses, and treatments. Intralesional or systemic antimonials are the gold standard for the treatment of these diseases. However, as for visceral leishmaniasis, other therapeutic options appear promising. Paromomycin ointments are effective in Leishmania major, L. tropica, L. mexicana, and L. panamensis lesions. In L. braziliensis localized leishmaniasis, both paromomycin and imiquimod may be topically applied. Oral fluconazole and zinc sulfate are useful in L. major. Oral azithromycin, effective in vitro and in mice, needs further investigation in human leishmaniasis. On the contrary, data with oral itraconazole are disappointing. Oral miltefosine, which is very effective in visceral leishmaniasis caused by L. donovani, appears ineffective in L. major and L. braziliensis infections. Intramuscular pentamidine is required for L. guyanensis cutaneous leishmaniasis, for which systemic antimony is not effective. Liposomal amphotericin B could be an alternative to antimony in south American cutaneous leishmaniasis with mucosal involvement (especially L. braziliensis and L. guyanensis infections).

Leishmaniasis

Epidemiology, disease patterns, immunology, diagnosis, treatment and control measures of leishmaniasis are described. Various issues relating to leishmaniasis are highlighted: the relative lack of importance given to this disease compared with other infections, climate change and its possible impact on extension of endemicity of this infection, and new diagnostic tests which are improving diagnosis, especially in resource poor areas. Other important aspects discussed include the potential for newer oral therapy to change the way this disease is managed; Leishmania-HIV coinfection and groups at risk; and development of an effective vaccine.

Action of sodium deoxycholate on subcutaneous human tissue: local and systemic effects

BACKGROUND

Phosphatidylcholine injections have been used as a nonsurgical alternative to the surgical removal of undesired fat. Studies in cell culture suggest that sodium deoxycholate (SD) has a detergent action in fat reduction.

OBJECTIVE

The objective was to study SD in subcutaneous human tissue.

METHODS AND MATERIALS

Thirty volunteers underwent four sessions of subcutaneous abdominal injections of diluted 2.5 or 1% SD stock solutions or placebo. Clinical, hematologic, and ultrasonographic evaluations were performed for 3 months and histology at 3 and 6 months.

RESULTS

Both concentrations of SD induced an inflammatory response at the injection site, with dose-dependent adipocyte lysis. Patients reported mild, localized heat, erythema, swelling, and intense pain. Microscopic evaluation revealed necrosis of adipose tissue with adipocyte lysis, fat dissolution, acute lymphomononuclear inflammatory reaction, and intense phagocytosis of fat cells by macrophages. Fibrosis was observed only at the 6-month biopsy. Nodules at the injection sites, compatible with areas of inflammation, were detected by ultrasonography 2 weeks after the first injection. Placebo injections induced no histologic changes.

CONCLUSIONS

SD induces an inflammatory reaction in subcutaneous human fat and dose-dependent adipocyte lysis with acute pain and fibrosis. No systemic effects were detected. Further studies will establish the best dose-result ratio, frequency of application, and long-term safety.

Cutaneous leishmaniasis

Cutaneous leishmaniasis is a widespread tropical infection caused by numerous different species of Leishmania protozoa that are transmitted by sandflies. Its clinical presentations are extremely diverse and dependent on a variety of parasite and host factors that are poorly understood. Diagnosis should aim to identify the exact species involved, but this requires laboratory investigations that are not widely available. No single ideal treatment has been identified, and those available are limited by variable success rates and toxicity. Clinical guidelines are needed to make better use of the investigations and treatments that do exist. Prevention is currently limited to bite prevention measures.

Liposomal amphotericin B in comparison to sodium stibogluconate for cutaneous infection due to Leishmania braziliensis

BACKGROUND

New World cutaneous leishmaniasis among Israeli travelers is mostly acquired in the Amazon Basin of Bolivia where Leishmania viannia (V.) braziliensis is endemic. Treatment with systemic pentavalent antimonial compounds is effective in achieving clinical cure in only 75% of cases. In this study, we assessed liposomal amphotericin B (AmBisome) as an alternative treatment for cutaneous L (V.) braziliensis infection.

METHODS

A prospective evaluation was performed for cutaneous leishmaniasis due to L (V.) braziliensis, proven by polymerase chain reaction. A 3-mg/kg AmBisome dose was given for 5 consecutive days, and a sixth dose on day 10, all in an outpatient setting. This therapy was compared with a series of historical patients who were treated with sodium stibogluconate (SSG).

RESULTS

Seven consecutive patients, 5 males and 2 females, received AmBisome treatment. All were returned travelers infected in Bolivia; their mean age was 23.1 years; 5 had failed to respond to a full course of SSG; two had a primary lesion; none had mucosal lesions. All achieved complete clinical cure within less than 1 month. Mean follow-up of 12 months revealed no relapses. Side effects were mild, and none had to terminate treatment prematurely. Comparison of AmBisome to SSG treatment shows that the former is safer, with fewer recurrence rates. Additionally, the expense of the total care with AmBisome is less than with SSG: 45% less if SSG was given in an inpatient setting; 15% less when SSG was given in an outpatient setting.

LIMITATIONS

This was a nonrandomized study, with relatively few patients.

CONCLUSION

AmBisome treatment for L (V.) braziliensis appears to be effective, better tolerated, and to have more cost benefit in countries where hospital-care costs are significant.