In vitro antileishmanial and cytotoxicity activities of essential oils from Haplophyllum tuberculatum A. Juss leaves, stems and aerial parts

Pharmacological activities of chemically characterized essential oils from Haplophyllum tuberculatum (Forssk.)

The present work aimed at characterizing the phytochemical composition of Haplophyllum tuberculatum essential oil (HTEO), assessing its antifungal activity against various fungal strains, evaluating its insecticidal and repulsive properties against Callosobruchus maculatus, and determine its antioxidant capacity. To this end, Gas chromatography-mass spectrometry analysis detected 34 compounds in HTEO, with β-Caryophyllene being the major constituent (36.94%). HTEO demonstrated predominantly modest antifungal effects, however, it sustains notable activity, particularly against Aspergillus flavus, with an inhibition rate of 76.50% ± 0.60%. Minimum inhibitory concentrations ranged from 20.53 ± 5.08 to 76.26 ± 5.08 mg/mL, effectively inhibiting fungal growth. Furthermore, the antifungal, and antioxidant activities of HTEO were evaluated in silico against the proteins Aspergillus flavus FAD glucose dehydrogenase, and beta-1,4-endoglucanase from Aspergillus niger, NAD(P)H Oxidase. Moreover, HTEO displayed strong insecticidal activity against C. maculatus, with contact and inhalation tests yielding LC50 values of 30.66 and 40.28 μL/100g, respectively, after 24 h of exposure. A dose of 5 μL/100g significantly reduced oviposition (48.85%) and inhibited emergence (45.15%) compared to the control group. Additionally, HTEO exhibited a high total antioxidant capacity of 758.34 mg AAE/g EO, highlighting its antioxidant potential. Insilico results showed that the antifungal activity of HTEO is mostly attributed to γ-Cadinene and p-Cymen-7-ol, while antioxidant is attributed to α-Terpinyl isobutyrate displayed. Overall, HTEO offers a sustainable and environmentally friendly alternative to synthetic products used to manage diseases.

Synthetic hydrazones: In silico studies and in vitro evaluation of the antileishmania potential

Bioprospecting and synthesis of strategically designed molecules have been used in the search for drugs that can be in leishmaniasis. Hydrazones (HDZ) are promising compounds with extensive biological activities. The objective of this work was to perform in silico studies of hydrazones 1-5 and to evaluate their antileishmanial, cytotoxic and macrophage immunomodulatory potential in vitro. Hydrazones were subjected to prediction and molecular docking studies. Antileishmanial protocols on promastigotes and amastigotes of Leishmania amazonensis, cytotoxicity and macrophage immunomodulatory activity were performed. Hydrazones showed a good pharmacokinetic profile and hydrazone 3 and hydrazone 5 were classified as non-carcinogenic. Hydrazone 5 obtained the best conformation with trypanothione reductase. Hydrazone 1 and hydrazone 3 obtained the best mean inhibitory concentration (IC₅₀) values for promastigotes, 4.4-61.96 μM and 8.0-58.75 μM, respectively. It also showed good activity on intramacrophagic amastigotes, with hydrazone 1 being the most active (IC₅₀ = 6.79 μM) with selectivity index of 56. In cytotoxicity to macrophages hydrazone 3 was the most cytotoxic (CC₅₀ = 256.3 ± 0,04 μM), while hydrazone 4 the least (CC₅₀ = 1055.9 ± 0.03 μM). It can be concluded that the hydrazones revealed important pharmacokinetic and toxicological properties, in addition to antileishmania potential in reducing infection and infectivity in parasitized macrophages.

Leishmaniasis: Recent epidemiological studies in the Middle East

Leishmaniasis, one of the most neglected tropical diseases (NTDs), is the third most important vector-borne disease worldwide. This disease has a global impact and severity of the infection and is greatest in the Middle East. The agent of infection is a protozoan parasite of the genus, Leishmania, and is generally transmitted by blood-sucking female sandflies. In humans, there are three clinical forms of infection: (1) cutaneous (CL), (2) mucocutaneous (ML), and (3) visceral leishmaniasis (VL). This review aims to discuss the current epidemiological status of leishmaniasis in Saudi Arabia, Iraq, Syria, and Yemen with a consideration of treatment options. The elevated risk of leishmaniasis is influenced by the transmission of the disease across endemic countries into neighboring non-infected regions.

How the volatile organic compounds emitted by corpse plant change through flowering

The corpse plant (Amorphophallus titanum) is so named because it produces a pungent, foul odor when flowering. Little is known about how the emitted volatiles change throughout the two-day flowering period. In this study, the comprehensive monitoring of the presence and change in volatile molecules during the female and the male flowering phases of A. titanum was conducted, and the plant temperature was monitored. A total of 422 volatile features were detected over the entire sampling period, of which 118 features were statistically significantly different between the pre-flowering and both flowering phases, and an additional 304 features were found present throughout the flowering period. A total of 45 molecules could be assigned putative names. The volatile profile of A. titanum changes over the two-day flowering period, with the S-containing molecules and aldehydes dominant in the female flowering phase, and the alcohols and hydrocarbons dominant in the male flowering phase. The two-dimensional gas chromatography time-of-flight mass spectrometry (GC × GC-TOFMS) enabled us to identify 32 new molecules produced by A. titanum. Each of these molecules alone, and in combination, likely contribute to the different odors emitted during the flowering phase of A. titanum.

Chemical Composition and Insecticidal, Antiplasmodial, and Anti-Leishmanial Activity of Capparis spinosa Essential Oil and Its Main Constituents

Background

This investigation was designed to evaluate the insecticidal, antiplasmodial, anti-leishmanial, and cytotoxic effects of Capparis spinosa essential oil (CSEO) and its main components, methyl isothiocyanate, hexadecanoic acid, and limonene.

Methods

Insecticidal activity of CSEO and its main components, methyl isothiocyanate, hexadecanoic acid, and limonene, was determined against Aedes aegypti 4th-instar larvae at 25 ± 2°C. Antiplasmodial and anti-leishmanial effects of CSEO and its main components were carried out against chloroquine-resistant Plasmodium falciparum K1 strain and Leishmania major amastigotes based on the Malstat method and the macrophage model, respectively. We also performed the cytotoxic activity of CZEO and its main components against J774A1 macrophage cells using the colorimetric MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay. In addition, the plasma membrane permeability and caspase-3-like activity CSEO and its main components were evaluated against L. major.

Results

CSEO and its main components showed considerable (p < 0.001) larvicidal activity against Ae. aegypti larva. The 50% lethal concentration values for CSEO, methyl isothiocyanate, hexadecanoic acid, and limonene were 21.6, 30.9, 41.6, and 35.3 μg/mL, respectively. By antiplasmodial effects, the 50% inhibitory concentration (IC₅₀) values for CSEO, methyl isothiocyanate, hexadecanoic acid, and limonene were 7.4, 14.5, 19.6, and 21.3 μg/mL, respectively, while these values for their anti-leishmanial effects were 9.1, 20.7, 23.3, and 18.6 μg/mL, respectively. The 50% cytotoxic concentration values for CSEO, methyl isothiocyanate, hexadecanoic acid, and limonene were 93.7, 216.2, 199.4, and 221.3 μg/mL, respectively. Different concentrations of CSEO and its main components significantly (p < 0.05) increased the plasma membrane permeability and caspase-3-like activity against L. major promastigote level as dose-dependent response.

Conclusion

Based on the obtained results, C. spinosa essential oil and its main components, methyl isothiocyanate, hexadecanoic acid, and limonene, displayed insecticidal, antiplasmodial, and anti-leishmanial activity against healthy 4th-instar larvae of A. aegypti, chloroquine-resistant P. falciparum K1 strain, and L. major amastigotes, respectively. However, further surveys are required to display the mechanisms of action mode of tested drugs and their efficacy in animal model and clinical settings.

The effects of medicinal herbs and marine natural products on wound healing of cutaneous leishmaniasis: A systematic review

This study aimed to investigate the effects of medicinal herbs and marine natural products on wound healing of cutaneous leishmaniasis. To carry out this literature review, the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) instructions were used. Articles on the potential of medicinal plants and natural substances of marine origin against wound healing of cutaneous leishmaniasis were explored. The scientific databases considered were PubMed, Science Direct, Google Scholar, Web of Science, Scopus, and SpringerLink. The scientific documents collected were mainly scientific articles, books, book chapters, and doctoral thesis. The research considered 73 manuscripts published in the period from 1990 to 2020. From all the data collected, it appears that the scientific literature is rich in medicinal herbs and marine products to be valorized in the wound healing of cutaneous leishmaniasis. We have identified 15 medicinal plants traditionally used in the management of healing or ulcer of cutaneous leishmaniasis, 32 medicinal plants whose efficacy has been demonstrated in vitro or in vivo against cutaneous leishmaniasis, 5 marine products active against cutaneous leishmaniasis. It is also clear that the option of medicinal herbs/marine products in the management of cutaneous leishmaniasis is less expensive and allows to avoid the side effects of conventional products. It is necessary to encourage the development of dermatological topicals for the management of cutaneous leishmaniasis based on the data collected. In vivo research should be intensified on medicinal herbs traditionally used in wound healing of cutaneous leishmaniasis.

In-vitro Cytotoxicity and In-silico Insights of the Multi-target Anticancer Candidates from Haplophyllum tuberculatum

This study aimed to investigate the anticancer activity of Haplophyllum tuberculatum(Forsk.) aerial parts ethanol extract and fractions and reveal the potential anticancer targets, binding modes, pharmacokinetics, and toxicity properties of its phytoconstituents. MTT assay was used to investigate the anticancer activity. TargetNet, ChemProt version 2.0, and CLC-Pred web servers were used for virtual screening, and Cresset Flare software was used for molecular docking with the 26 predicted targets. Moreover, pkCSM, swiss ADME, and eMolTox web servers were used to predict pharmacokinetics and safety. Ethanolic extracts of H. tuberculatum on HepG2 and HeLa cell lines showed promising activities with IC50 values 54.12 and 48.1 µg/mL, respectively. Further, ethyl acetate fraction showed the highest cytotoxicity on HepG2 and HeLa cell lines with IC50 values 41.7 and 52.31 µg/mL. Of 70 compounds screened virtually, polygamain, justicidin A, justicidin B, haplotubine, kusunokinin, and flindersine were predicted as safe anticancer drugs candidates. They showed the highest binding scores with targets involved in cell growth, proliferation, survival, migration, tumor suppression, induction of apoptosis, metastasis, and drug resistance. Our findings revealed the potency of H. tuberculatum as a source of anticancer candidates that further studies should support.

Cytotoxicity and Antiviral Activities of Haplophyllum tuberculatum Essential Oils, Pure Compounds, and Their Combinations against Coxsackievirus B3 and B4

Haplophyllum tuberculatum is a plant commonly used in folk medicine to treat several diseases including vomiting, nausea, infections, rheumatism, and gastric pains. In the current study, H. tuberculatum essential oils, hydrosols, the pure compounds R-(+)-limonene, S-(-)-limonene, and 1-octanol, as well as their combinations R-(+)-limonene/1-octanol and S-(-)-limonene/1-octanol, were screened for their cytotoxicity on HEp-2 cells after 24, 48, and 72 h, and then tested for their activity against Coxsackievirus B3 and B4 (CV-B3 and CV-B4) at 3 different moments: addition of the plant compounds before, after, or together with virus inoculation. Results showed that the samples were more cytotoxic after 72 h than after 24 h or 48 h cell contact. However, the combinations R-(+)-limonene/1-octanol and S-(-)-limonene/1-octanol showed less effect on HEp-2 cells than pure R-(+)-limonene and S-(-)-limonene after 24 h, 48 h, and 72 h. 1-octanol exhibited the highest concentration causing 50% cytotoxicity (CC₅₀) on HEp-2 cells after 24 h (CC₅₀ = 93 µg/mL) and 48 h (CC₅₀ = 83 µg/mL). The antiviral assays showed that the tested samples exhibited potent inhibition of CV-B. IC₅₀ values ranged from 0.66 µg/mL to 28.4 µg/mL. In addition, CV-B3 was more sensitive than CV-B4. Both CV-B strains are more inhibited when cells were pretreated with the plant compounds. The hydrosols have no effect, neither on HEp-2 cells nor on the virus. 1-octanol, S-(-), and R-(+)-limonene/1-octanol had important selectivity indexes over time. Although essential oils had potent antiviral activity, they can be considered for application in the pretreatment of cells. However, 1-octanol and the combinations are within the safety limits, and thus, they can be used as an active natural antiviral agent for CV-B3 and CV-B4 inhibition.

Essential Oil of Deverra tortuosa Aerial Parts: Detailed Chemical Profile, Allelopathic, Antimicrobial, and Antioxidant Activities

Essential oils (EOs) are a promising group of natural products of the aromatic plants due to their various biological effects such as allelopathic, antioxidant, antimicrobial activities. The present study aimed to construct the detailed chemical profile of the EO derived from Deverra tortuosa aerial parts along with assessing its allelopathic, antimicrobial, and antioxidant potentialities. The EO was extracted by hydrodistillation and analyzed via gas chromatography-mass spectrometry (GC/MS). The allelopathic activity of the EO was assessed against the germination and seedling growth of the weed Chenopodium murale. Also, the EO was tested against five microbes. The antioxidant activity was determined using the free radical 2,2-diphenyl-1-picrylhydrazyl (DPPH) and 2,2'-azinobis(3-ethylbenzothiazoline-6-sulfonic acid) (ABTS). The GC/MS analysis of EO revealed the presence of 86 compounds with a preponderance of oxygenated sesquiterpenes and monoterpene hydrocarbons. Widdrol, β-phellandrene, piperitol, cubedol, α-terpinene, (E)-10-heptadecen-8-ynoic acid methyl ester, citronellyl tiglate, and m-cymene were the major compounds. A comparative profile was established between the EOs constituents of our study with the documented EOs of D. tortuosa and the other Deverra species around the world via agglomerative hierarchical clustering (AHC) and principal components analysis (PCA). The EO showed a substantial allelopathic activity against C. murale, as well as it showed considerable antimicrobial and antioxidant activities. Thereby, the EO of D. tortuosa could be considered as a promising environmental-friendly bioherbicide against weeds. Also, it could be integrated into food preservation due to its potent antimicrobial and antioxidant activities. However, further study is recommended for more characterization of the major compounds and evaluation of their activities, either singular or synergistic, and assess their efficiency and biosafety.

Leishmanicidal and trypanocidal potential of the essential oil of Psidium myrsinites DC

Neglected tropical diseases (NTDs) are a group of pathologies caused by infectious agents or parasites, including the protozoa Leishmania sp. and Trypanosoma cruzi, which cause leishmaniasis and Chagas disease, respectively. The complications of the treatment regimen indicate the urgent need to search for new strategies and therapeutic agents. Among these is the essential oil of Psidium myrsinites DC. The essential oil of the leaves (PMEO) was evaluated in vitro, and cytotoxic activity was analysed against promastigotes of Leishmania braziliensis and Leishmania infantum and epimastigotes of Trypanosoma cruzi, as well as mammalian cells. The results showed that the PMEO had relevant activity against L. braziliensis, low cytotoxicity and a high selectivity index SI = 6.6. These results suggest that PMEO has antiparasitic potential against L. braziliensis, making this species is a possible alternative therapeutic source, given its effectiveness in the in vitro tests performed, opening the possibility of new biological studies in vivo.

Lignans, Amides, and Saponins from Haplophyllum tuberculatum and Their Antiprotozoal Activity

A screening of Sudanese medicinal plants for antiprotozoal activities revealed that the chloroform and water fractions of the ethanolic root extract of Haplophyllum tuberculatum exhibited appreciable bioactivity against Leishmania donovani. The antileishmanial activity was tracked by HPLC-based activity profiling, and eight compounds were isolated from the chloroform fraction. These included lignans tetrahydrofuroguaiacin B (1), nectandrin B (2), furoguaiaoxidin (7), and 3,3'-dimethoxy-4,4'-dihydroxylignan-9-ol (10), and four cinnamoylphenethyl amides, namely dihydro-feruloyltyramine (5), (E)-N-feruloyltyramine (6), N,N'-diferuloylputrescine (8), and 7'-ethoxy-feruloyltyramine (9). The water fraction yielded steroid saponins 11-13. Compounds 1, 2, and 5-13 are reported for the first time from Haplophyllum species and the family Rutaceae. The antiprotozoal activity of the compounds plus two stereoisomeric tetrahydrofuran lignans-fragransin B2 (3) and fragransin B1 (4)-was determined against Leishmania donovani amastigotes, Plasmodium falciparum, and Trypanosoma brucei rhodesiense bloodstream forms, along with their cytotoxicity to rat myoblast L6 cells. Nectandrin B (2) exhibited the highest activity against L. donovani (IC50 4.5 µM) and the highest selectivity index (25.5).

Mining Sudanese Medicinal Plants for Antiprotozoal Agents

Neglected tropical diseases are major health hazards in developing countries. Annually, up to 30 million people are affected by either Chagas disease, African trypansomiasis or leishmaniasis, and more than 200 million by malaria. Most of the currently available drugs have drawbacks in terms of toxicity, limited oral availability, development of resistance, or non-affordability. Tropical plants of the arid zones are a treasure chest for the discovery of bioactive secondary metabolites. This study aims to compile Sudanese medicinal plants, validate their antiprotozoal activities, and identify active molecules. We have performed a survey of medicinal plants of Sudan and selected 62 that are being used in Sudanese traditional medicine. From these, we collected materials such as leaves, stem, bark, or fruit. The plant materials were extracted in 70% ethanol and further fractionated by liquid-liquid partitioning using solvents of increasing polarity. This resulted in a library of 235 fractions. The library was tested in vitro against Plasmodium falciparum (erythrocytic stages), Trypanosoma brucei rhodesiense (bloodstream forms), Trypanosoma cruzi (intracellular amastigotes), and Leishmania donovani (axenic amastigotes). Active fractions were also tested for cytotoxicity. Of the 235 fractions, 125 showed growth inhibitory activity >80% at 10 μg/ml, and >50% at 2 μg/ml against at least one of the protozoan parasites. Plasmodium falciparum was the most sensitive of the parasites, followed by T. b. rhodesiense and L. donovani. Only few hits were identified for T. cruzi, and these were not selective. Contrary to expectation based on phylogeny, but in agreement with previous results, a large number of extracts displayed mutual activity against T. brucei and P. falciparum. HPLC-based activity profiling for selected active extracts was performed to identify the bioactive principles. Active compounds identified by dereplication were guieranone A from Guiera senegalensis J.F.Gmel.; pseudosemiglabrin from Tephrosia apollinea (Delile) DC; ellagic acid and quercetin from Terminalia leiocarpa (DC.) Baill.; and catechin, ethyl gallate, and epicatechin gallate from Vachellia nilotica (L.) P.J.H.Hurter & Mabb. Also the extracts of Croton gratissimus var. gratissimus and Cuscuta hyalina Roth ex Schult. exhibited promising antitrypanosomatid activity. This assessment provides a comprehensive overview of Sudanese medicinal plants and supports the notion that they are a potential source of bioactive molecules against protozoan parasites.

Nutrition, malnutrition, and leishmaniasis

Leishmaniasis is a vector-borne infectious disease with a long history of infecting humans and other animals. It is a known emerging or resurging disease. The host nutritional state has an indispensable role in defense against pathogens. The host defense system disorganization as a result of undernutrition is responsible for asymptomatic infections and even severe diseases. Host susceptibility and pathophysiologic severity to infection can be aggravated owing to undernourishment in a number of pathways, and infection also may aggravate preexisting poor nutrition or further increase host susceptibility. This study suggests that there may be some relationship between malnutrition and the endemicity of the parasite. The susceptibility to and severity of leishmanial infection can be altered by the body weight and serum levels of micronutrients. Nutrition not only affects the vulnerability of the host but also may affect the desire of sandfly to bite a specific host. Apart from host defense mechanism, nutritional stress also greatly influences vector competence and host-seeking behavior, especially during larvae development. The host and sandfly vector nutritional states could also influence the evolution of the parasite. It is essential to elucidate the roles that diets and nutrition play in the leishmanial life cycle. The aim of this article is to review the influences of nutrition and diets on the host susceptibility and severity of infection, preemptive and therapeutic strategy feedback, parasite evolution, and vector competence.

Endlicheria bracteolata (Meisn.) Essential Oil as a Weapon Against Leishmania amazonensis: In Vitro Assay

The difficulties encountered and the numerous side effects present in the treatment of cutaneous leishmaniasis have encouraged the research for new compounds that can complement or replace existing treatment. The growing scientific interest in the study of plants, which are already used in folk remedies, has led our group to test Endlicheria bracteolata essential oil against Leishmania amazonensis. Several species of the Lauraceae family, or their compounds, have relevant antiprotozoal activities Therefore, the biological potential on L. amazonensis forms from the essential oil of Endlicheria bracteolata leaves was verified for the first time in that work. The antileishmanial activity was evaluated against promastigotes and intracellular amastigotes, and cytotoxicity were performed with J774.G8, which were incubated with different concentrations of E. bracteolata essential oil. Transmission electron microscopy and flow cytometry were performed with E. bracteolata essential oil IC₅₀. Promastigote forms showed E. bracteolata essential oil IC₅₀ of 7.945 ± 1.285 µg/mL (24 h) and 6.186 ± 1.226 µg/mL (48 h), while for intracellular amastigote forms it was 3.546 ± 1.184 µg/mL (24 h). The CC₅₀ was 15.14 ± 0.090 µg/mL showing that E. bracteolata essential oil is less toxic to macrophages than to parasites. Transmission electron microscopy showed that E. bracteolata essential oil treatment is capable of inducing mitochondrial damage to promastigote and intracellular amastigote forms, while flow cytometry showed ΔѰm disruption in treated parasites. These results could bring about new possibilities to develop products based on E. bracteolata essential oil to treat cutaneous leishmaniasis, especially for people who cannot receive the conventional therapy.

Potent in vitro antileishmanial activity of a nanoformulation of cisplatin with carbon nanotubes against Leishmania major

OBJECTIVES

The aim of this study was to evaluate the cytotoxicity and antileishmanial activity of cisplatin-bonded carbon nanotubes both against promastigotes and amastigotes of Leishmania major in vitro.

METHODS

Cisplatin-bonded single-walled carbon nanotubes (CP-SWCNT) and cisplatin-bonded multi-walled carbon nanotubes (CP-MWCNT) were considered as test compounds. In addition, SWCNT, MWCNT, free cisplatin and meglumine antimoniate (Glucantime^®) were considered as controls. The effect of each compound was evaluated both on promastigote and amastigote stages of L. major and the results were compared.

RESULTS

There was a statistically significant difference between the half-maximal inhibitory concentration (IC₅₀) of CP-SWCNT and each of the controls, including SWCNT, cisplatin and Glucantime^® (P<0.05). In addition, IC₅₀ values of CP-MWCNT and each of the controls, including MWCNT, cisplatin and Glucantime^®, were significantly different both for promastigotes and amastigotes (P<0.05). However, the selectivity index (SI) of CP-SWCNT was <10 (5.23), indicating that this compound is not completely safe. Moreover, the SI values of CP-MWCNT (12.54) and Glucantime^® (16.28) were >10, indicating the selective effect of these two compounds on the parasite. Moreover, the IC₅₀ of CP-MWCNT (0.11±0.09μM) for amastigotes was 41-fold lower than that of Glucantime^® (4.52±1.31μM), suggesting that a lower dose of CP-MWCNT in comparison with Glucantime^® is required to kill 50% of amastigotes.

CONCLUSIONS

According to the potent in vitro antileishmanial activity of CP-MWCNT at low concentration against L. major, we suggest that they are evaluated in an animal model.

Investigation of anti-leishmanial efficacy of miltefosine and ketoconazole loaded on nanoniosomes

Leishmaniasis is a group of parasitic disease caused by protozoa of Leishmania genus. Leishmania major accounts for the cutaneous leishmaniasis (CL). The current treatments of this disease are expensive with high toxicity and are associated to difficulties of healing and parasite resistance. Miltefosine and ketoconazole have been found to be effective against CL. In this study, miltefosine- and ketoconazole-loaded nanoniosomes were prepared by the thin film-hydration method, and their anti-leishmanial effects against Leishmania major promastigotes and amastigotes were evaluated. The particle size and zeta potential of the nanoniosomes were determined. Release from the formulations showed enhanced and controlled dissolution of the drugs. The miltefosine- and ketoconazole-loaded nanoniosomes inhibited the growth of promastigote and amastigote forms of Leishmania major in vitro after 48 h of incubation and had IC₅₀ values of 53.39 ± 0.02 and 86.38 ± 0.07 μg mL^-1, respectively. The formulations provided improved anti-leishmanial activities for the treatment of cutaneous leishmaniasis.