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Kumar A, Singh VK, Tiwari R, Madhukar P, Rajneesh, Kumar S, Gautam V, Engwerda C, Sundar S, Kumar R. Post kala-azar dermal leishmaniasis in the Indian sub-continent: challenges and strategies for elimination. Front Immunol 2023; 14:1236952. [PMID: 37638047 PMCID: PMC10451093 DOI: 10.3389/fimmu.2023.1236952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/24/2023] [Indexed: 08/29/2023] Open
Abstract
Visceral leishmaniasis (VL) is a severe and often fatal form of leishmaniasis caused by Leishmania donovani in the Indian sub-continent. Post Kala-azar Dermal Leishmaniasis (PKDL) is a late cutaneous manifestation of VL, typically occurring after apparent cure of VL, but sometimes even without a prior history of VL in India. PKDL serves as a significant yet neglected reservoir of infection and plays a crucial role in the transmission of the disease, posing a serious threat to the VL elimination program in the Indian sub-continent. Therefore, the eradication of PKDL should be a priority within the current VL elimination program aimed at achieving a goal of less than 1 case per 10,000 in the population at the district or sub-district levels of VL endemic areas. To accomplish this, a comprehensive understanding of the pathogenesis of PKDL is essential, as well as developing strategies for disease management. This review provides an overview of the current status of diagnosis and treatment options for PKDL, highlighting our current knowledge of the immune responses underlying disease development and progression. Additionally, the review discusses the impact of PKDL on elimination programs and propose strategies to overcome this challenge and achieve the goal of elimination. By addressing the diagnostic and therapeutic gaps, optimizing surveillance and control measures, and implementing effective intervention strategies, it is possible to mitigate the burden of PKDL and facilitate the successful elimination of VL in the Indian sub-continent.
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Affiliation(s)
- Awnish Kumar
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Vishal Kumar Singh
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rahul Tiwari
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Prasoon Madhukar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rajneesh
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shashi Kumar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Vibhav Gautam
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Christian Engwerda
- Immunology and Infection Laboratory, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Rajiv Kumar
- Centre of Experimental Medicine and Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Long-term incidence of relapse and post-kala-azar dermal leishmaniasis after three different visceral leishmaniasis treatment regimens in Bihar, India. PLoS Negl Trop Dis 2020; 14:e0008429. [PMID: 32687498 PMCID: PMC7392342 DOI: 10.1371/journal.pntd.0008429] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/30/2020] [Accepted: 05/28/2020] [Indexed: 11/19/2022] Open
Abstract
Background Few prospective data exist on incidence of post kala-azar dermal leishmaniasis (PKDL) and visceral leishmaniasis (VL) relapse after different treatment regimens. Methodology/Principal findings A Phase IV trial included 1761 VL patients treated between 2012–2014 with single dose AmBisome (SDA; N = 891), miltefosine-paromomycin (Milt-PM; n = 512), or AmBisome-miltefosine (AmB-Milt; n = 358). Follow-up for PKDL and VL relapse was scheduled for 6, 12 and 24 months after treatment, lasting until 2017. Patients with lesions consistent with PKDL were tested by rK39 rapid test, and if positive, underwent skin-snip sampling, smear microscopy and PCR. Probable PKDL was defined by consistent lesions and positive rK39; confirmed PKDL required additional positive microscopy or PCR. PKDL and relapse incidence density were calculated by VL treatment and risk factors evaluated in Cox proportional hazards models. Among 1,750 patients who completed treatment, 79 had relapse and 104 PKDL. Relapse incidence density was 1.58, 2.08 and 0.40 per 1000 person-months for SDA, AmB-Milt and Milt-PM, respectively. PKDL incidence density was 1.29, 1.45 and 2.65 per 1000 person-months for SDA, AmB-Milt and Milt-PM. In multivariable models, patients treated with Milt-PM had lower relapse but higher PKDL incidence than those treated with SDA; AmB-Milt rates were not significantly different from those for SDA. Children <12 years were at higher risk for both outcomes; females had a higher risk of PKDL but not relapse. Conclusions/Significance Active surveillance for PKDL and relapse, followed by timely treatment, is essential to sustain the achievements of VL elimination programs in the Indian sub-continent. Efforts to eliminate visceral leishmaniasis (VL) in the Indian subcontinent have had an unprecedented impact on the number of cases over the past decade, however, the disease is known to be cyclical and previous periods of low incidence have been followed by a major resurgence. The disease is thought to be maintained between epidemics as post-kala-azar dermal leishmaniasis (PKDL), a skin disease affecting 5 to 15% of apparently cured VL patients in the Indian subcontinent. PKDL is difficult to cure and since PKDL patients are not systemically ill, they seldom seek treatment, meaning that PKDL is likely to be a major obstacle to elimination. A key question is how different VL treatment regimens affect the risk of subsequent PKDL. We followed-up a cohort of more than 1700 patients treated with three different drug regimens in an effectiveness trial in Bihar and found that patients treated with miltefosine-paromomycin had a lower risk of relapse but higher PKDL incidence, while AmBisome treated patients had the reverse pattern. In order to sustain the gains already made, active surveillance for PKDL and relapse is essential, along with timely treatment, and new VL treatment regimens that avoid future PKDL are needed.
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Gedda MR, Singh B, Kumar D, Singh AK, Madhukar P, Upadhyay S, Singh OP, Sundar S. Post kala-azar dermal leishmaniasis: A threat to elimination program. PLoS Negl Trop Dis 2020; 14:e0008221. [PMID: 32614818 PMCID: PMC7332242 DOI: 10.1371/journal.pntd.0008221] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Leishmaniasis remains a public health concern around the world that primarily affects poor folks of the developing world spanning across 98 countries with mortality of 0.2 million to 0.4 million annually. Post kala-azar dermal leishmaniasis (PKDL) is the late skin manifestation of visceral leishmaniasis (VL). It has been reported that about 2.5% to 20% of patients recovered from VL develop PKDL having stilted macular or nodular lesions with parasites. In the Indian subcontinent (ISC), it manifests a few months after recovery from VL, though in Africa it can occur simultaneously with VL or a little later. New cases of PKDL are also observed without prior VL in the ISC. These individuals with PKDL represent an important but largely neglected reservoir of infection that perpetuates anthroponotic Leishmania donovani transmission in the ISC and can jeopardize the VL elimination program as these cases can infect the sand flies and spread the endemic. Therefore, it becomes imperative to eradicate PKDL as a part of the VL elimination program. With the limited treatment options besides little knowledge on PKDL, this review stands out in focusing on different aspects that should be dealt for sustained VL elimination.
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Affiliation(s)
- Mallikarjuna Rao Gedda
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Center for Cellular Engineering, NIH Clinical Center, Bethesda, Maryland, United States of America
| | - Bhawana Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Dhiraj Kumar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Department of Zoology, Rameshwar College, BRA Bihar University, Muzaffarpur, India
| | - Abhishek Kumar Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Prasoon Madhukar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shreya Upadhyay
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Om Prakash Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Das VNR, Siddiqui NA, Pandey K, Lal CS, Sinha SK, Bimal S, Topno RK, Singh SK, Kumar S, Das P. The usefulness of trained field workers in diagnosis of post-kala-azar dermal leishmaniasis (PKDL) and clinico-epidemiological profile in highly endemic areas of Bihar. Trans R Soc Trop Med Hyg 2020; 113:332-340. [PMID: 30920625 DOI: 10.1093/trstmh/trz007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/29/2018] [Accepted: 12/02/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Surveillance of post-kala-azar dermal leishmaniasis (PKDL) is critical to the elimination of visceral leishmaniasis (VL). In this study we assessed the feasibility of using trained field workers for detecting suspected PKDL cases. METHODS A cross-sectional study using a multistage sampling technique was conducted in the Araria district of Bihar. Trained field workers were utilized for identification of suspected PKDL case. RESULTS We investigated 57 099 individuals from 11 300 households. The trained field workers were useful in identifying 107 (18%) probable PKDL cases. The calculated PKDL prevalences were 18.7/10 000 and 9.7/10 000 for probable and confirmed PKDL cases, respectively. The median duration of onset of PKDL was 23 months (interquartile range 16.5-56.5). The younger age group developed PKDL significantly more often compared with the older age group (p=0.007). Of the 107 patients, 25 (55.5%) were positive by microscopy of slit skin smear and 42 (93.3%) by polymerase chain reaction. Of 45 patients, 33 (73%) PKDL cases were cured after full treatment. The risk of not being cured with incomplete treatment was three times higher than with complete treatment (relative risk 3.12 [95% confidence interval 1.23 to 8.67], p=0.004). CONCLUSIONS We conclude that the prevalence of PKDL is high and the use of trained field workers may be feasible to actively detect PKDL cases in VL-endemic areas of Bihar, India.
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Affiliation(s)
- Vidya N R Das
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | | | - Krishna Pandey
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | - Chandra S Lal
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | - Sanjay K Sinha
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | - Sanjiva Bimal
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | - Roshan K Topno
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
| | | | - Sunil Kumar
- Department of Pathology, Nalanda Medical College and Hospital, Patna, India
| | - Pradeep Das
- Rajendra Memorial Research Institute of Medical Sciences, Patna, India
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Sengupta R, Chaudhuri SJ, Moulik S, Ghosh MK, Saha B, Das NK, Chatterjee M. Active surveillance identified a neglected burden of macular cases of Post Kala-azar Dermal Leishmaniasis in West Bengal. PLoS Negl Trop Dis 2019; 13:e0007249. [PMID: 30856178 PMCID: PMC6428339 DOI: 10.1371/journal.pntd.0007249] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 03/21/2019] [Accepted: 02/18/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Post Kala-azar Dermal Leishmaniasis (PKDL) develops in patients apparently cured of Visceral Leishmaniasis (VL), and is the strongest contender for being the disease reservoir. Therefore, existence of a few cases is sufficient to trigger an epidemic of VL in a given community, emphasizing the need for its active detection and in turn ensuring success of the current elimination program. This study explored the impact of active surveillance on the demographic profile of PKDL patients in West Bengal. METHODOLOGY/PRINCIPAL FINDINGS Patients with PKDL were recruited through passive (2003-date, n = 100) and active surveillance (2015-date, n = 202), the former from outpatient departments of dermatology in medical colleges in West Bengal and the latter through an active door-to-door survey in four VL hyper-endemic districts of West Bengal. Passive surveillance indicated a male preponderance and a predominance of polymorphic lesions, whereas active surveillance indicated absence of any gender bias and more importantly, macular PKDL constituted almost 50% of the population burden. In terms of polymorphic vs. macular PKDL, the former appeared at a later age, their disease duration was longer and had a higher parasite burden. In the polymorphic variant, the lesional distribution was asymmetrical, comprised of papules/nodules/macules that were present mainly in sun-exposed areas whereas in macular cases, the hypopigmented patches were diffusely present all over the body. CONCLUSIONS/SIGNIFICANCE Active surveillance unraveled a disease component whose demographic profile showed important differences with PKDL cases who sought treatment in government hospitals. Detection of a higher proportion of macular cases indicates that this variant is not an uncommon presentation as conventionally stated in text books, and should be studied in greater detail to ensure success of the ongoing Leishmaniasis elimination programme.
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Affiliation(s)
- Ritika Sengupta
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | | | - Srija Moulik
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Manab Kumar Ghosh
- Department of Tropical Medicine, School of Tropical Medicine, Kolkata, West Bengal, India
| | - Bibhuti Saha
- Department of Tropical Medicine, School of Tropical Medicine, Kolkata, West Bengal, India
| | - Nilay Kanti Das
- Department of Dermatology, Bankura Sammilani Medical College, Bankura, West Bengal, India
| | - Mitali Chatterjee
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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Saleem MD, Oussedik E, Picardo M, Schoch JJ. Acquired disorders with hypopigmentation: A clinical approach to diagnosis and treatment. J Am Acad Dermatol 2018; 80:1233-1250.e10. [PMID: 30236514 DOI: 10.1016/j.jaad.2018.07.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/09/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
Acquired hypopigmented skin changes are commonly encountered by dermatologists. Although hypopigmentation is often asymptomatic and benign, occasional serious and disabling conditions present with cutaneous hypopigmentation. A thorough history and physical examination, centered on disease distribution and morphologic findings, can aid in delineating the causes of acquired hypopigmented disorders. The second article in this 2-part continuing medical education series focuses on conditions with a hypopigmented phenotype. Early diagnosis and appropriate management of these disorders can improve a patient's quality of life, halt disease progression, and prevent irreversible disability.
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Affiliation(s)
- Mohammed D Saleem
- Department of Internal Medicine, University of Florida College of Medicine and University of Florida Health, Gainesville, Florida.
| | | | - Mauro Picardo
- Department of Dermatology and Pediatric Dermatology, Cutaneous Physiopathology and Integrated Center of Metabolomics Research, San Gallicano Dermatologic Institute, IRCCS, Rome, Italy
| | - Jennifer J Schoch
- Department of Dermatology, University of Florida, Gainesville, Florida; Department of Pediatrics, University of Florida, Gainesville, Florida
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Zijlstra EE, Alves F, Rijal S, Arana B, Alvar J. Post-kala-azar dermal leishmaniasis in the Indian subcontinent: A threat to the South-East Asia Region Kala-azar Elimination Programme. PLoS Negl Trop Dis 2017; 11:e0005877. [PMID: 29145397 PMCID: PMC5689828 DOI: 10.1371/journal.pntd.0005877] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The South-East Asia Region Kala-azar Elimination Programme (KAEP) is expected to enter the consolidation phase in 2017, which focuses on case detection, vector control, and identifying potential sources of infection. Post-kala-azar dermal leishmaniasis (PKDL) is thought to play a role in the recurrence of visceral leishmaniasis (VL)/kala-azar outbreaks, and control of PKDL is among the priorities of the KAEP. Methodology and principal finding We reviewed the literature with regard to PKDL in Asia and interpreted the findings in relation to current intervention methods in the KAEP in order to make recommendations. There is a considerable knowledge gap regarding the pathophysiology of VL and PKDL, especially the underlying immune responses. Risk factors (of which previous VL treatments may be most important) are poorly understood and need to be better defined. The role of PKDL patients in transmission is largely unknown, and there is insufficient information about the importance of duration, distribution and severity of the rash, time of onset, and self-healing. Current intervention methods focus on active case detection and treatment of all PKDL cases with miltefosine while there is increasing drug resistance. The prevention of PKDL by improved VL treatment currently receives insufficient attention. Conclusion and significance PKDL is a heterogeneous and dynamic condition, and patients differ with regard to time of onset after VL, chronicity, and distribution and appearance of the rash, as well as immune responses (including tendency to self-heal), all of which may vary over time. It is essential to fully describe the pathophysiology in order to make informed decisions on the most cost-effective approach. Emphasis should be on early detection of those who contribute to transmission and those who are in need of treatment, for whom short-course, effective, and safe drug regimens should be available. The prevention of PKDL should be emphasised by innovative and improved treatment for VL, which may include immunomodulation.
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Affiliation(s)
- Eduard E. Zijlstra
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
- Rotterdam Centre for Tropical Medicine, Rotterdam, the Netherlands
- * E-mail:
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Suman Rijal
- Drugs for Neglected Diseases initiative, India Office, New Delhi, India
| | - Byron Arana
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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Ramesh V, Kaushal H, Mishra AK, Singh R, Salotra P. Clinico-epidemiological analysis of Post kala-azar dermal leishmaniasis (PKDL) cases in India over last two decades: a hospital based retrospective study. BMC Public Health 2015; 15:1092. [PMID: 26503551 PMCID: PMC4621871 DOI: 10.1186/s12889-015-2424-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 10/16/2015] [Indexed: 12/20/2022] Open
Abstract
Background Patients with Post kala-azar dermal leishmaniasis (PKDL) are considered a reservoir of Leishmania donovani. It is imperative to identify and treat them early for control of visceral leishmaniasis (VL), a current priority in the Indian subcontinent. We explored trends in clinico-epidemiological features of PKDL cases over last two decades, for improving management of the disease. Methods Clinically suspected cases were diagnosed with rK39 strip test followed by parasitological confirmation by microscopy and/or PCR/qPCR in skin tissue/slit aspirates. Patients were treated with antimonials till 2008 and subsequently with miltefosine. Results The study indicated higher incidence of PKDL cases in areas of high endemicity for VL, with 20 % cases reporting no history of VL. Approximately 26 % cases of PKDL were initially misdiagnosed at primary health centers. Duration between onset of PKDL and diagnosis was above 12 months in 80 % cases. Diagnostic sensitivity was 32-36 % with microscopy and 96–100 % with PCR/qPCR. Compliance to treatment was over 85 % with miltefosine while 15 % with antimonials. Relapse rate with miltefosine was up to 13.2 %. Conclusions PKDL patients tend to delay reporting and are often misdiagnosed. Confirmatory diagnosis using minimally invasive skin slit aspirate samples would help overcome such issues. There was a paradigm shift in compliance with miltefosine; however, increasing relapse rate indicated the need for newer therapies with oral formulations.
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Affiliation(s)
- V Ramesh
- Department of Dermatology, VMMC & Safdarjung Hospital, New Delhi, 110029, India
| | - Himanshu Kaushal
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, 110029, India
| | | | - Ruchi Singh
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, 110029, India
| | - Poonam Salotra
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, 110029, India.
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Abstract
Protozoan parasites Leishmania donovani (family: Trypanosomatidae) cause fatal visceral leishmaniasis (VL) and the infection relapses in apparently cured population as post kala-azar dermal leishmaniasis (PKDL) in the Indian subcontinent. In recent years co-infection of another Trypanosomatid parasite Leptomonas with L. donovani during VL/PKDL in this region has become prominent. The observation of clinically lesser-known insect parasite, Leptomonas in leishmaniasis is intriguing to researchers. The presence of Leishmania look alike Leptomonas in the cultures of clinical isolates of Leishmania has been worrisome to those, who prefer to work with pure Leishmania cultures for drug and vaccine development or immune response studies. The exact implications of such a co-habitation, which might lead to a delay in the diagnostics of VL and elevate mortality, need a thorough investigation. Also whether Leptomonas is involved in leishmaniasis manifestation needs to be ascertained. Thus we are currently witnessing a new paradigm of a parasitic co-infection in VL/PKDL cases in India and this review outlines various opportunities for further research in understanding such emerging co-infection.
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Ganguly S, Saha P, Chatterjee M, Roy S, Ghosh TK, Guha SK, Kundu PK, Bera DK, Basu N, Maji AK. PKDL--A Silent Parasite Pool for Transmission of Leishmaniasis in Kala-azar Endemic Areas of Malda District, West Bengal, India. PLoS Negl Trop Dis 2015; 9:e0004138. [PMID: 26485704 PMCID: PMC4613818 DOI: 10.1371/journal.pntd.0004138] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 09/14/2015] [Indexed: 11/19/2022] Open
Abstract
Post Kala-azar Dermal Leishmaniasis (PKDL) is a chronic but not life-threatening disease; patients generally do not demand treatment, deserve much more attention because PKDL is highly relevant in the context of Visceral Leishmaniasis (VL) elimination. There is no standard guideline for diagnosis and treatment for PKDL. A species-specific PCR on slit skin smear demonstrated a sensitivity of 93.8%, but it has not been applied for routine diagnostic purpose. The study was conducted to determine the actual disease burden in an endemic area of Malda district, West Bengal, comparison of the three diagnostic tools for PKDL case detection and pattern of lesion regression after treatment. The prevalence of PKDL was determined by active surveillance and confirmed by PCR based diagnosis. Patients were treated with either sodium stibogluconate (SSG) or oral miltefosine and followed up for two years to observe lesion regression period. Twenty six PKDL cases were detected with a prevalence rate of 27.5% among the antileishmanial antibody positive cases. Among three diagnostic methods used, PCR is highly sensitive (88.46%) for case confirmation. In majority of the cases skin lesions persisted after treatment completion which gradually disappeared during 6–12 months post treatment period. Reappearance of lesions noted in two cases after 1.5 years of miltefosine treatment. A significant number of PKDL patients would remain undiagnosed without active mass surveys. Such surveys are required in other endemic areas to attain the ultimate goal of eliminating Kala-azar. PCR-based method is helpful in confirming diagnosis of PKDL, referral laboratory at district or state level can achieve it. So a well-designed study with higher number of samples is essential to establish when/whether PKDL patients are free from parasite after treatment and to determine which PKDL patients need treatment for longer period. A significant number of PKDL patients have been detected in the endemic areas of Malda who would remain undiagnosed without active mass surveys. Such active survey is required in other endemic areas of the country to attain the ultimate goal of eliminating Kala-azar from this part of the world by reducing the source of infection. PCR-based method is helpful in confirming diagnosis of PKDL, which is not applicable at field level. A referral laboratory at district or state level can be a solution to the problem. Since PKDL cases do not have a fatal outcome, treatment administration of these cases can be deferred until confirmed results are obtained, which requires about 7 days’ time. The detection of leishmanial DNA in skin lesions during successive treatment courses is essential to establish whether/ when PKDL patients are parasite free during/after treatment and to determine which PKDL patients need treatment for a longer period.
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Affiliation(s)
- Swagata Ganguly
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
- Department of Microbiology, NRS Medical College & Hospital, Kolkata, West Bengal, India
- * E-mail:
| | - Pabitra Saha
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
- Department of Zoology, A. P. C. Roy Govt. College, Himachal Bihar, Matigara, Siliguri, West Bengal, India
| | - Moytrey Chatterjee
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Surajit Roy
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | | | - Subhasish K. Guha
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Pratip K. Kundu
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Dilip K. Bera
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Nandita Basu
- Department of Pathology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
| | - Ardhendu K. Maji
- Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
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Ahuja K, Arora G, Khare P, Selvapandiyan A. Selective elimination of Leptomonas from the in vitro co-culture with Leishmania. Parasitol Int 2015; 64:1-5. [PMID: 25582929 DOI: 10.1016/j.parint.2015.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 12/30/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022]
Abstract
Leishmania and Leptomonas are protozoan parasites of the family Trypanosomatidae. Leishmania donovani causes the fatal visceral leishmaniasis (VL; kala-azar) in mammals and is transmitted by sand fly vector. Certain VL-cured human populations in India and Sudan develop post kala-azar dermal leishmaniasis (PKDL) due to the same parasite. Although Leptomonas is parasitic mainly in insects, several recent reports on the clinical isolates of L. donovani from VL and PKDL patients in India confirm co-infection of Leptomonas seymouri, probably due to immune suppression in those individuals. Detection of L. seymouri in the in vitro cultures of L. donovani from clinical origin is difficult due to many similarities between L. seymouri and L. donovani. We describe here ways to detect L. seymouri and L. donovani in co-culture. In addition, based on our observation regarding the growth of L. seymouri in different culture conditions, we report here a novel procedure, which can selectively eliminate L. seymouri from the in vitro co-culture with L. donovani. This would be beneficial to researchers who prefer to deal with pure populations of Leishmania parasites for various downstream immunological and genetic studies.
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Affiliation(s)
- Kavita Ahuja
- Institute of Molecular Medicine, New Delhi India; Department of Research, Sir Gangaram Hospital, New Delhi, India
| | - Ginni Arora
- Institute of Molecular Medicine, New Delhi India
| | | | - Angamuthu Selvapandiyan
- Institute of Molecular Medicine, New Delhi India; Department of Research, Sir Gangaram Hospital, New Delhi, India.
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Hartley MA, Drexler S, Ronet C, Beverley SM, Fasel N. The immunological, environmental, and phylogenetic perpetrators of metastatic leishmaniasis. Trends Parasitol 2014; 30:412-22. [PMID: 24954794 DOI: 10.1016/j.pt.2014.05.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 05/23/2014] [Accepted: 05/24/2014] [Indexed: 02/07/2023]
Abstract
Cutaneous leishmaniases have persisted for centuries as chronically disfiguring parasitic infections affecting millions of people across the subtropics. Symptoms range from the more prevalent single, self-healing cutaneous lesion to a persistent, metastatic disease, where ulcerations and granulomatous nodules can affect multiple secondary sites of the skin and delicate facial mucosa, even sometimes diffusing throughout the cutaneous system as a papular rash. The basis for such diverse pathologies is multifactorial, ranging from parasite phylogeny to host immunocompetence and various environmental factors. Although complex, these pathologies often prey on weaknesses in the innate immune system and its pattern recognition receptors. This review explores the observed and potential associations among the multifactorial perpetrators of infectious metastasis and components of the innate immune system.
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Affiliation(s)
- Mary-Anne Hartley
- Department of Biochemistry, University of Lausanne, 1066 Epalinges, Switzerland
| | - Stefan Drexler
- Department of Biochemistry, University of Lausanne, 1066 Epalinges, Switzerland
| | - Catherine Ronet
- Department of Biochemistry, University of Lausanne, 1066 Epalinges, Switzerland
| | - Stephen M Beverley
- Department of Molecular Microbiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Nicolas Fasel
- Department of Biochemistry, University of Lausanne, 1066 Epalinges, Switzerland.
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Mukhopadhyay D, Dalton JE, Kaye PM, Chatterjee M. Post kala-azar dermal leishmaniasis: an unresolved mystery. Trends Parasitol 2014; 30:65-74. [PMID: 24388776 PMCID: PMC3919212 DOI: 10.1016/j.pt.2013.12.004] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 11/29/2013] [Accepted: 12/05/2013] [Indexed: 12/31/2022]
Abstract
Sodium antimony gluconate contributes towards the pathogenesis of PKDL. UV light plays a pivotal role in the development of PKDL. Development of PKDL can be viewed as a reinfection or activation of latent Leishmania parasites. PKDL can be resolved by mounting an effective tissue-specific memory T cell response. Host genetic factors play a contributory role.
Post kala-azar dermal leishmaniasis (PKDL), a cutaneous sequela of visceral leishmaniasis (VL), develops in some patients alongside but more commonly after apparent cure from VL. In view of the pivotal role of PKDL patients in the transmission of VL, here we review clinical, epidemiological, parasitological, and immunological perspectives of this disease, focusing on five hypotheses to explain the development of PKDL: (i) the role of antimonial drugs; (ii) UV-induced skin damage; (iii) reinfection; (iv) organ specific failure of memory T cell responses; and (v) genetic susceptibility of the host. This review will enable researchers and clinicians to explore the unresolved mystery of PKDL and provide a framework for future application of ‘omic’ approaches for the control and eventual elimination of VL.
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Affiliation(s)
- Debanjan Mukhopadhyay
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, 244 B, Acharya JC Bose Road, Kolkata 700 020, India
| | - Jane E Dalton
- Centre for Immunology and Infection, Hull York Medical School and Department of Biology, University of York, Wentworth Way, York, YO10 5DD, UK
| | - Paul M Kaye
- Centre for Immunology and Infection, Hull York Medical School and Department of Biology, University of York, Wentworth Way, York, YO10 5DD, UK.
| | - Mitali Chatterjee
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, 244 B, Acharya JC Bose Road, Kolkata 700 020, India.
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Islam S, Kenah E, Bhuiyan MAA, Rahman KM, Goodhew B, Ghalib CM, Zahid MM, Ozaki M, Rahman MW, Haque R, Luby SP, Maguire JH, Martin D, Bern C. Clinical and immunological aspects of post-kala-azar dermal leishmaniasis in Bangladesh. Am J Trop Med Hyg 2013; 89:345-53. [PMID: 23817330 DOI: 10.4269/ajtmh.12-0711] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We conducted active surveillance for kala-azar and post-kala-azar dermal leishmaniasis (PKDL) in a population of 24,814 individuals. Between 2002 and 2010, 1,002 kala-azar and 185 PKDL cases occurred. Median PKDL patient age was 12 years; 9% had no antecedent kala-azar. Cases per 10,000 person-years peaked at 90 for kala-azar (2005) and 28 for PKDL (2007). Cumulative PKDL incidence among kala-azar patients was 17% by 5 years. Kala-azar patients younger than 15 years were more likely than older patients to develop PKDL; no other risk factors were identified. The most common lesions were hypopigmented macules. Of 98 untreated PKDL patients, 48 (49%) patients had resolution, with median time of 19 months. Kala-azar patients showed elevated interferon-γ (IFNγ), tumor necrosis factor-α (TNFα), and interleukin 10 (IL-10). Matrix metalloproteinase 9 (MMP9) and MMP9/tissue inhibitor of matrix metalloproteinase-1 (TIMP1) ratio were significantly higher in PKDL patients than in other groups. PKDL is frequent in Bangladesh and poses a challenge to the current visceral leishmaniasis elimination initiative in the Indian subcontinent.
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Affiliation(s)
- Shamim Islam
- Children's Hospital and Research Center, Oakland, California, USA.
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Singh RP, Picado A, Alam S, Hasker E, Singh SP, Ostyn B, Chappuis F, Sundar S, Boelaert M. Post-kala-azar dermal leishmaniasis (PKDL) in visceral leishmaniasis-endemic communities in Bihar, India. Trop Med Int Health 2012:n/a-n/a. [PMID: 23279744 DOI: 10.1111/tmi.12044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE: To assess the prevalence of Post-kala-azar dermal leishmaniasis (PKDL) in 16 visceral leishmaniasis-endemic communities in Bihar, India. METHODS: Three-stage house-to-house survey of 2020 households to identify and confirm PKDL cases. RESULTS: The prevalence of confirmed PKDL cases was 4.4 per 10 000 individuals and 7.8 if probable cases were also considered. The clinical history and treatment of the PKDL cases are discussed in detail. CONCLUSION: PKDL can develop in visceral leishmaniasis patients treated with different anti-leishmanial drugs. Migration of PKDL cases to other villages may expand visceral leishmaniasis-affected areas.
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Singh RP, Picado A, Alam S, Hasker E, Singh SP, Ostyn B, Chappuis F, Sundar S, Boelaert M. Post-kala-azar dermal leishmaniasis in visceral leishmaniasis-endemic communities in Bihar, India. Trop Med Int Health 2012; 17:1345-8. [PMID: 22882665 DOI: 10.1111/j.1365-3156.2012.03067.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We assessed the prevalence of post-kala-azar dermal leishmaniasis (PKDL), a late cutaneous manifestation of visceral leishmaniasis (VL), in 16 VL-endemic communities in Bihar, India. The prevalence of confirmed PKDL cases was 4.4 per 10 000 individuals and 7.8 if probable cases were also considered. The clinical history and treatment of the post-kala-azar dermal leishmaniasis cases are discussed.
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Affiliation(s)
- Rudra Pratap Singh
- Banaras Hindu University, Varanasi, India Institute of Tropical Medicine, Antwerp, Belgium Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain Geneva University Hospitals, Geneva, Switzerland
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Katara GK, Ansari NA, Singh A, Ramesh V, Salotra P. Evidence for involvement of Th17 type responses in post kala azar dermal leishmaniasis (PKDL). PLoS Negl Trop Dis 2012; 6:e1703. [PMID: 22724038 PMCID: PMC3378621 DOI: 10.1371/journal.pntd.0001703] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 05/04/2012] [Indexed: 12/05/2022] Open
Abstract
Background Post kala-azar dermal leishmaniasis (PKDL), a dermal sequel of visceral leishmaniasis, caused by Leishmania donovani, constitutes an important reservoir for the parasite. Parallel functioning of counter acting immune responses (Th1/Th2) reflects a complex immunological scenario, suggesting the involvement of additional regulatory molecules in the disease pathogenesis. Methodology/Principal Findings In the present study, human cytokine/chemokine/receptor specific cDNA array technique was employed to identify modulations in gene expression of host immuno-determinants during PKDL, followed by evaluation of Th17 type responses by analyzing mRNA and protein expression of Th17 markers (IL-23, IL-17, RORγt) and performing functional assays using Leishmania antigen (TSLA) or recombinant (rec)IL-17. Array analysis identified key immuno-regulatory molecules including cytokines (TNF-α, IFN-γ, IL-10, IL-17), chemokines (MCP-1, MIP-1α), apoptotic molecules (FasL, TRAIL, IRF-1) and receptors (CD40, Fas). Up regulation in lesional expression of Th17 markers was observed during PKDL compared to control (IL-17 and IL-23, P = 0.0008; RORγt, P = 0.02). In follow-up samples, chemotherapy significantly down regulated expression of all markers. In addition, lesional expression of IL-17 was confirmed at protein level by Immuno-histochemistry. Further, systemic presence of Th17 responses (IL-17 and IL-23) was observed in plasma samples from PKDL patients. In functional assays, TSLA stimulated the secretion of IL-17 and IL-23 from PBMCs of PKDL patients, while recIL-17 enhanced the production of TNF-α as well as nitric oxide (NO) in PKDL compared to control (TNF-α, P = 0.0002; NO, P = 0.0013). Further, a positive correlation was evident between lesional mRNA expression of IL-17 and TNF-α during PKDL. Conclusion/Significance The results highlight key immune modulators in PKDL and provide evidence for the involvement of Th17 type responses in the disease pathogenesis. Post kala azar dermal leishamniasis (PKDL), an unusual dermatosis, develops in 5–15% of apparently cured visceral leishmaniasis cases in India and in about 60% of cases in Sudan. PKDL cases assume importance since they constitute an important human reservoir for the parasite. Host immunological responses, considered as major factors in PKDL development, are poorly understood. Limited studies have been performed to explore the host immune responses and that too, restricted to a few immune parameters. The present study employed cDNA array technique that identified various host immuno-determinants including cytokines, chemokines, apoptotic and signaling molecules which were not reported previously in PKDL. In addition, we showed for the first time that Th17 responses are present during L. donovani infection in PKDL which possibly contributes significantly to disease pathogenesis by inducing TNF-α and nitric oxide production. Our findings lead to improved understanding of the host parasite interaction in terms of immune responses and pathology in tissue lesions of PKDL.
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Affiliation(s)
- Gajendra Kumar Katara
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Nasim Akhtar Ansari
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - Avninder Singh
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
| | - V. Ramesh
- Department of Dermatology, Safdarjung Hospital, New Delhi, India
| | - Poonam Salotra
- National Institute of Pathology (ICMR), Safdarjung Hospital Campus, New Delhi, India
- * E-mail:
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Abstract
PURPOSE OF REVIEW Post-kala-azar dermal leishmaniasis (PKDL) is a challenge for clinicians and researchers, because its burden is poorly investigated and pathogenesis is disputable. However, recent studies contributed to understanding of the pathogenesis of PKDL especially its association with host immunological factors, and also how to improve its diagnosis and treatment. This review focuses on recent advances in diagnosis, new insights into pathogenesis and case management. RECENT FINDINGS Information regarding the burden of PKDL, especially in Bangladesh, is now available. Association between skin parasite burden and different clinical forms of PKDL has been explored. The diagnostic importance of detection of Leishmania donovani DNA in the peripheral blood buffy coat and in skin specimens by PCR has been studied. Variable effects of different antileishmanial drugs on immune response have been observed. Finally, high efficacy of miltefosine for treatment of PKDL has been demonstrated. SUMMARY The incidence of PKDL is reducing in India after introduction of miltefosine and amphotericin B for treatment of visceral leishmaniasis. It remains higher in Bangladesh and in Sudan. Parasite burden is higher in nodular and papular forms of PKDL compared to the macular form of the disease. The demonstration of Leishmania DNA in peripheral blood buffy coat and in skin specimens can help to diagnose 40-75% clinically suspected PKDL individuals. An initial cure rate of 95% has been achieved with miltefosine for treatment of PKDL. However, the efficacy of combination therapy should be explored to reduce the treatment duration and hence to improve treatment compliance.
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Affiliation(s)
- Dinesh Mondal
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
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Abstract
A substantial number of patients who recover from kala-azar will develop dermatosis [commonly known as post-kala-azar dermal leishmaniasis (PKDL)]. It usually occurs in the Indian subcontinent and East Africa. As many as 10-20% of Indian cases and 50-60% of Sudanese cases develop PKDL after successful treatment of visceral leishmaniasis. Most cases occur after infection with Leishmania donovani and less commonly after Leishmania infantum. However, the PKDL is extremely rare in patients infected with Leishmania chagasi. Though exact pathology is not yet fully known, here we review various evidence, which suggest that the pathogenesis is largely immunologically mediated. Our group has been of the opinion that PKDL disease manifestation is a result of in-vivo generation of quasi-species either as in-vivo hybridization of various circulating and latent populations of the causative species within the host cells or due to external reinfection. We, and other scientists, have recently demonstrated that strains of Leishmania that cause visceral diseases differ genetically from those that cause PKDL. We feel that this review will incite interest in several parasitologists and molecular biologists in the pathogenesis of this important manifestation of the infection, often blamed as the source of outbreaks of leishmaniasis.
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Affiliation(s)
- Sarman Singh
- Division of Clinical Microbiology, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India.
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