Cutaneous leishmaniasis in French Guiana: revising epidemiology with PCR-RFLP

Migration in French Guiana: Implications in health and infectious diseases

In French Guiana, more than a third of the population, and nearly half of the adults, are of foreign origin. This immigration is explained by the French standard of living, which is attractive to nationals of surrounding countries. Infectious diseases remain in the top 10 causes of premature death, often in the most precarious populations. In this context we aimed to synthesize the state of the knowledge regarding immigration and infectious diseases in French Guiana and the general implications that follow this diagnosis. For HIV, although the majority of patients are of foreign origin, estimates of the presumed date of infection based on CD4 erosion modelling and from molecular analyses suggest that the majority of transmissions in foreign-born individuals occur in French Guiana and that the Guiana shield has been a crossroad between Latin America and the Caribbean. Among key populations bridging these regions illegal gold miners are very mobile and have the greatest proportion B Caribbean HIV viruses. Gold miners have been a key vulnerable population for falciparum malaria and other tropical diseases such as leishmaniasis, leprosy, or leptospirosis. The complex history of migrations in French Guiana and on the Guiana Shield is also reflected in the fingerprinting of mycobacterium tuberculosis and the high incidence of tuberculosis in French Guiana, notably in immigrants, reflects the incidences in the countries of origin of patients. The high burden of infectious diseases in immigrants in French Guiana is first and foremost a reflection of the precarious living conditions within French Guiana and suggests that community-based proactive interventions are crucial to reduce transmission, morbidity, and mortality from infectious diseases.

Clinical and immunological spectra of human cutaneous leishmaniasis in North Africa and French Guiana

Cutaneous leishmaniasis (CL) caused by infection with the parasite Leishmania exhibits a large spectrum of clinical manifestations ranging from single healing to severe chronic lesions with the manifestation of resistance or not to treatment. Depending on the specie and multiple environmental parameters, the evolution of lesions is determined by a complex interaction between parasite factors and the early immune responses triggered, including innate and adaptive mechanisms. Moreover, lesion resolution requires parasite control as well as modulation of the pathologic local inflammation responses and the initiation of wound healing responses. Here, we have summarized recent advances in understanding the in situ immune response to cutaneous leishmaniasis: i) in North Africa caused by Leishmania (L.) major, L. tropica, and L. infantum, which caused in most cases localized autoresolutives forms, and ii) in French Guiana resulting from L. guyanensis and L. braziliensis, two of the most prevalent strains that may induce potentially mucosal forms of the disease. This review will allow a better understanding of local immune parameters, including cellular and cytokines release in the lesion, that controls infection and/or protect against the pathogenesis in new world compared to old world CL.

Using pentamidine to treat cutaneous leishmaniasis in children: a 10-year study in French Guiana

There are little data on pentamidine as a treatment for paediatric cutaneous leishmaniasis (CL). The objective of this study was to describe the effectiveness and safety of pentamidine over a 10-year period. Every child seen in French Guiana between 2010 and 2020 with proven CL and treated with pentamidine was included. In total, 55 children met the inclusion criteria - 23 girls and 32 boys. There were 38 patients (38/55, 69%) with a > 50% improvement at 1 month after pentamidine treatment and a complete cure at 3 months; 16 children had a < 50% improvement at 1 month and were given a second dose. Of these 16, 8 showed a complete cure at 3 months, 5 were lost to follow-up and 3 showed therapeutic failure at 3 months. The overall cure rate was 84% (46/55) after one or two doses. In terms of the safety of pentamidine, no severe adverse events (grade ≥ 3) were reported.

Updated estimation of cutaneous leishmaniasis incubation period in French Guiana

BACKGROUND

The cutaneous leishmaniasis (CL) incubation period (IP) is defined as the time between parasite inoculation by sandfly bite and the onset of the first CL lesion. IP distribution is difficult to assess for CL because the date of exposure to an infectious bite cannot be accurately determined in endemic areas. IP current estimates for CL range from 14 days to several months with a median around 30-60 days, as established by a few previous studies in both New and Old Worlds.

METHODOLOGY

We estimated CL incubation period distribution using time-to-event models adapted to interval-censored data based on declared date of travels from symptomatic military personnel living in non-endemic areas that were exposed during their short stays in French Guiana (FG) between January 2001 and December 2021.

PRINCIPAL FINDINGS

A total of 180 patients were included, of which 176 were men (97.8%), with a median age of 26 years. When recorded, the parasite species was always Leishmania guyanensis (31/180, 17.2%). The main periods of CL diagnosis spread from November to January (84/180, 46.7%) and over March-April (54/180, 30.0%). The median IP was estimated at 26.2 days (95% Credible Level, 23.8-28.7 days) using a Bayesian accelerated failure-time regression model. Estimated IP did not exceed 62.1 days (95% CI, 56-69.8 days) in 95% of cases (95th percentile). Age, gender, lesion number, lesion evolution and infection date did not significantly modify the IP. However, disseminated CL was significantly associated with a 2.8-fold shortening of IP.

CONCLUSIONS

This work suggests that the CL IP distribution in French Guiana is shorter and more restricted than anticipated. As the incidence of CL in FG usually peaks in January and March, these findings suggest that patients are contaminated at the start of the rainy season.

[Overview of infectious and non-infectious diseases in French Guiana in 2022]

Source of many myths, French Guiana represents an exceptional territory due to the richness of its biodiversity and the variety of its communities. The only European territory in Amazonia, surrounded by the Brazilian giant and the little-known Suriname, Ariane 6 rockets are launched from Kourou while 50% of the population lives below the poverty line. This paradoxical situation is a source of health problems specific to this territory, whether they be infectious diseases with unknown germs, intoxications or chronic pathologies.Some infectious diseases such as Q fever, toxoplasmosis, cryptococcosis or HIV infection are in common with temperate countries, but present specificities leading to sometimes different management and medical reasoning. In addition to these pathologies, many tropical diseases are present in an endemic and / or epidemic mode such as malaria, leishmaniasis, Chagas disease, histoplasmosis or dengue. Besides, Amazonian dermatology is extremely varied, ranging from rare but serious pathologies (Buruli ulcer, leprosy) to others which are frequent and benign such as agouti lice (mites of the family Trombiculidae) or papillonitis. Envenomations by wild fauna are not rare, and deserve an appropriate management of the incriminated taxon. Obstetrical, cardiovascular and metabolic cosmopolitan pathologies sometimes take on a particular dimension in French Guiana that must be taken into account in the management of patients. Finally, different types of intoxication are to be known by practitioners, especially due to heavy metals.European-level resources offer diagnostic and therapeutic possibilities that do not exist in the surrounding countries and regions, thus allowing the management of diseases that are not well known elsewhere.Thanks to these same European-level resources, research in Guyana occupies a key place within the Amazon region, despite a smaller population than in the surrounding countries. Thus, certain pathologies such as histoplasmosis of the immunocompromised patient, Amazonian toxoplasmosis or Q fever are hardly described in neighboring countries, probably due to under-diagnosis linked to more limited resources. French Guiana plays a leading role in the study of these diseases.The objective of this overview is to guide health care providers coming to or practicing in French Guiana in their daily practice, but also practitioners taking care of people returning from French Guiana.

Zinc and Manganese Imbalances in BALB/c Mice Experimentally Infected with Leishmania (Leishmania) amazonensis

PURPOSE

The clinical progression of Leishmania (Leishmania) amazonensis infection depends on multiple factors, including immunological status of the host and their genotypic interaction. Several immunological processes depend directly on minerals for an efficient performance. Therefore, this study used an experimental model to investigate the alterations of trace metals in L. amazonensis infection associate with clinical outcome, parasite load, and histopathological lesions, and the effect of CD4 + T cells depletion on these parameters.

METHODS

A total of 28 BALB/c mice were divided into 4 groups: 1-non-infected; 2-treated with anti-CD4 antibody; 3-infected with L. amazonensis; and 4-treated with anti-CD4 antibody and infected with L. amazonensis. After 24 weeks post-infection, levels of calcium (Ca), iron (Fe), magnesium (Mg), manganese (Mn), Cu, and Zn were determined by inductively coupled plasma optical emission spectroscopy using tissue samples of the spleen, liver, and kidneys. Additionally, parasite burdens were determined in the infected footpad (inoculation site) and samples of inguinal lymph node, spleen, liver, and kidneys were submitted to histopathological analysis.

RESULTS

Despite no significant difference was observed between groups 3 and 4, L. amazonensis-infected mice had a significant reduction of Zn (65.68-68.32%) and Mn (65.98 to 82.17%) levels. Presence of L. amazonensis amastigotes was also detected in the inguinal lymph node, spleen, and liver samples in all infected animals.

CONCLUSION

The results showed that significant alterations in micro-elements levels occur in BALB/c mice experimentally infected with L. amazonensis and may increase the susceptibility of individuals to the infection.

Imported cases of cutaneous leishmaniasis in Cuba, 2017: role of human movement

Background

Leishmaniasis is a vector-borne disease caused by several species from genus Leishmania. An increase in the number of cases related to human movement has been informed in the last years. Due to the increase of suspicious leishmaniasis cases arriving in Cuba during 2017, a general analysis is presented herein.

Methods

Clinical samples were collected from 5 patients suspicious of leishmaniasis, received from January to December 2017 at the Institute of Tropical Medicine Pedro Kourí, Cuba. Skin lesion samples were analyzed using different diagnostic assays: direct smear, histological examination, and molecular analysis for species identification. Epidemiological and demographic data were requested from each case and analyzed. Treatment and follow up of patient was also performed.

Results

Five cases were confirmed as Leishmania infection according to microscopic observation and molecular methods results. PCR-18S, PCR-N/RFLP and PCR-F/RFLP identified the following species: L. panamensis (2 cases), L. braziliensis (1 case), L.panamensis/L.guyanensis (1 case), L. mexicana complex (1 case). In treated patients, drugs were well tolerated, cure were documented and no relapse have been currently reported (3 years later).

Conclusions

Clinical characteristics, demographic data, and epidemiological features of infection for each case evidence the potential risk related with travel to endemic areas of leishmaniasis.

Keyworks

Cutaneous leishmaniasis, Epidemiology, Imported cases.

Leishmaniasis epidemiology in endemic areas of metropolitan France and its overseas territories from 1998 to 2020

BACKGROUND

In France, leishmaniasis is endemic in the Mediterranean region, in French Guiana and to a lesser extent, in the French West Indies. This study wanted to provide an updated picture of leishmaniasis epidemiology in metropolitan France and in its overseas territories.

METHODOLOGY/PRINCIPAL FINDINGS

Leishmaniasis cases were collected by passive notification to the French National Reference Centre for Leishmaniases (NRCL) in Montpellier from 1998 to 2020 and at the associated Centre in Cayenne (French Guiana) from 2003 to 2020. In metropolitan France, 517 autochthonous leishmaniasis cases, mostly visceral forms due to Leishmania infantum (79%), and 1725 imported cases (French Guiana excluded), mainly cutaneous leishmaniasis from Maghreb, were recorded. A slight decrease of autochthonous cases was observed during the survey period, from 0.48 cases/100,000 inhabitants per year in 1999 (highest value) to 0.1 cases/100,000 inhabitants per year in 2017 (lowest value). Conversely, imported cases increased over time (from 59.7 in the 2000s to 94.5 in the 2010s). In French Guiana, 4126 cutaneous and mucocutaneous leishmaniasis cases were reported from 2003 to 2020. The mean incidence was 103.3 cases per 100,000 inhabitants/year but varied in function of the year (from 198 in 2004 to 54 in 2006). In Guadeloupe and Martinique (French West Indies), only sporadic cases were reported.

CONCLUSIONS/SIGNIFICANCE

Because of concerns about disease expansion and outbreaks in other Southern Europe countries, and leishmaniasis monitoring by the NRCL should be continued and associated with a more active surveillance.

Zoonoses and gold mining: A cross-sectional study to assess yellow fever immunization, Q fever, leptospirosis and leishmaniasis among the population working on illegal mining camps in French Guiana

Background

Most emerging pathogens are zoonoses and have a wildlife origin. Anthropization and disruption of ecosystems favor the crossing of inter-species barriers. We hypothesize that the marginalized population of undocumented goldminers in the Amazon is at risk of acquiring zoonoses.

Method

A multicentric cross-sectional study included consenting gold-mining adult workers in 2019. A clinical examination recorded dermatological signs of leishmaniosis and past history of yellow fever vaccination. Biological tests were performed for yellow fever, Q fever and leptospirosis serologies. Additional blood samples from a previous study in 2015 were also tested for leptospirosis.

Results

In 2019, 380 individuals were included in the study, along with 407 samples from the 2015 biological collection. The seroprevalence of leptospirosis was 31.0% [95%CI = 26.4–35.5] in 2015 and 28.1% [23.5–32.7] in 2019. The seroprevalence of Q fever was 2.9% [1.2–4.6]. The majority of participants reported being vaccinated against yellow fever (93.6%) and 97.9% had seroneutralizing antibodies. The prevalence of suspected active mucocutaneous leishmaniasis was 2.4% [0.8–3.9].

Discussion

These unique data shed new light on the transmission cycles of zoonoses still poorly understood in the region. They support the existence of a wild cycle of leptospirosis but not of Q fever. Leishmaniasis prevalence was high because of life conditions and tree felling. High yellow fever vaccine coverage was reassuring in this endemic area. In the era of global health, special attention must be paid to these vulnerable populations in direct contact with the tropical ecosystem and away from the health care system.

Many pathogens are zoonotic in origin and human transmission can occur via vector, direct contact, inhalation, absorption, among other routes enabling human-reservoir interaction. In Amazonia, the cycle of these pathogens (the reservoir, the mode of transmission …) is not always well known. It is important to better understand these cycles in order to evaluate and anticipate the potential risk for human health, both on an individual and collective scale (risk of epidemic). In French Guiana, a French territory located in the Amazon, undocumented gold miners represent several thousand people mainly from Brazil who work in very remote areas in the middle of the rainforest. Documenting several zoonotic diseases among this population living in the middle of biodiversity is very valuable to better understand these cycles but also to assess the impact for their own health and to identify risks for public health. This article provides new data for four zoonoses: Q-fever, leptospirosis, leishmaniasis and yellow fever in this population and discusses the contributions to the understanding of cycles and public health issues.

Spectrum of skin diseases in Maroon villages of the Maroni area, French Guiana

BACKGROUND

Due to their genetic characteristics and their high exposure to infectious diseases, Maroons are likely to suffer from a specific spectrum of skin diseases. However, skin disorders have never been explored in this population. We aimed to describe all skin diseases in Maroon villages of the Maroni region in French Guiana.

METHODS

This retrospective study concerned all patients who consulted in the remote health centers of Apatou, Grand-Santi, Papaichton, and Maripasoula between October 5, 2017, and June 30, 2020. We included all patients registered with a skin disorder (International Classification of Diseases) in the medical database. We excluded patients whose diagnosis was invalidated after cross-checking by a dermatologist.

RESULTS

A total of 4741 patients presented at least one skin disease, for 6058 different disorders. Nonsexually transmitted infections represented 71.6% of all diagnoses, followed by inflammatory diseases (9.8%) and bites/envenomations (4.6%). The three most frequent conditions were scabies, abscesses, and impetigo. Besides scabies, neglected tropical diseases (NTDs) were still prevalent as we reported 13 cases of leprosy and 63 cutaneous leishmaniasis. Atopic dermatitis (AD) represented only 2.5% of our diagnoses.

CONCLUSIONS

With the exception of AD, which was less frequent among Maroons, these results are similar to those previously reported in Amerindians. Therefore, a common exposure to rainforest pathogens seems to induce a common spectrum of skin diseases dominated by infections. The high prevalence of NTDs requires specific public health actions.

Treating leishmaniasis in Amazonia, part 2: Multi-target evaluation of widely used plants to understand medicinal practices

ETHNOPHARMACOLOGICAL RELEVANCE

Leishmaniasis are widely distributed among tropical and subtropical countries, and remains a crucial health issue in Amazonia. Indigenous groups across Amazonia have developed abundant knowledge about medicinal plants related to this pathology.

AIM OF THE STUDY

We intent to explore the weight of different pharmacological activities driving taxa selection for medicinal use in Amazonian communities. Our hypothesis is that specific activity against Leishmania parasites is only one factor along other (anti-inflammatory, wound healing, immunomodulating, antimicrobial) activities.

MATERIALS AND METHODS

The twelve most widespread plant species used against leishmaniasis in Amazonia, according to their cultural and biogeographical importance determined through a wide bibliographical survey (475 use reports), were selected for this study. Plant extracts were prepared to mimic their traditional preparations. Antiparasitic activity was evaluated against promastigotes of reference and clinical New-World strains of Leishmania (L. guyanensis, L. braziliensis and L. amazonensis) and L. amazonensis intracellular amastigotes. We concurrently assessed the extracts immunomodulatory properties on PHA-stimulated human PBMCs and RAW264.7 cells, and on L. guyanensis antigens-stimulated PBMCs obtained from Leishmania-infected patients, as well as antifungal activity and wound healing properties (human keratinocyte migration assay) of the selected extracts. The cytotoxicity of the extracts against various cell lines (HFF1, THP-1, HepG2, PBMCs, RAW264.7 and HaCaT cells) was also considered. The biological activity pattern of the extracts was represented through PCA analysis, and a correlation matrix was calculated.

RESULTS

Spondias mombin L. bark and Anacardium occidentale L. stem and leaves extracts displayed high anti-promatigotes activity, with IC₅₀ ≤ 32 μg/mL against L. guyanensis promastigotes for S. mombin and IC₅₀ of 67 and 47 μg/mL against L. braziliensis and L. guyanensis promastigotes, respectively, for A. occidentale. In addition to the antiparasitic effect, antifungal activity measured against C. albicans and T. rubrum (MIC in the 16-64 μg/mL range) was observed. However, in the case of Leishmania amastigotes, the most active species were Bixa orellana L. (seeds), Chelonantus alatus (Aubl.) Pulle (leaves), Jacaranda copaia (Aubl.) D. Don. (leaves) and Plantago major L. (leaves) with IC₅₀ < 20 μg/mL and infection rates of 14-25% compared to the control. Concerning immunomodulatory activity, P. major and B. orellana were highlighted as the most potent species for the wider range of cytokines in all tested conditions despite overall contrasting results depending on the model. Most of the species led to moderate to low cytotoxic extracts except for C. alatus, which exhibited strong cytotoxic activity in almost all models. None of the tested extracts displayed wound healing properties.

CONCLUSIONS

We highlighted pharmacologically active extracts either on the parasite or on associated pathophysiological aspects, thus supporting the hypothesis that antiparasitic activities are not the only biological factor useful for antileishmanial evaluation. This result should however be supplemented by in vivo studies, and attracts once again the attention on the importance of the choice of biological models for an ethnophamacologically consistent study. Moreover, plant cultural importance, ecological status and availability were discussed in relation with biological results, thus contributing to link ethnobotany, medical anthropology and biology.

Outbreak of Cutaneous Leishmaniasis among military personnel in French Guiana, 2020: Clinical, phylogenetic, individual and environmental aspects

Background

Cutaneous Leishmaniasis (CL) is endemic in French Guiana but cases are usually sporadic. An outbreak signal was issued on May 15^th 2020 with 15 suspected cases after a military training course in the rainforest. An outbreak investigation was carried out.

Methodology/Principal findings

Thirty cases were confirmed. Leishmania guyanensis was the most frequent species (90%). The most frequent presentation was ulcerative (90%). Lesions on the face and hands were frequent (40% each). Eight cases (26%) presented a poor outcome after treatment with pentamidine and required a second line with amphotericin B. Three of them required further treatments with meglumine antimoniate or miltefosine. Two spots within the training area were deemed as likely sites of contamination, due to illegal logging. The isolated Leishmania strains did not form a separate cluster. Participation in Week 13 of year 2020 was associated with infection (OR = 4.59 [1.10–19.83]; p = 0.016) while undergoing only the “Fighting” exercise was protective (OR = 0.1 [0–0.74]; p = 0.021). There was no association between infection and other risk factors at the individual level. The attack rate of Regiment B (14/105 = 13.3%) was significantly higher (OR = 4.22 [1.84–9.53], p = 0.0001) compared to Regiment A (16/507 = 3.2%). The attack rate during this training course (30/858 = 3.5%) was significantly higher (OR 2.29 [1.28–4.13]; p = 0.002) than for other missions in French Guiana during the same period (22/1427 = 1.5%).

Conclusions

This outbreak could be explained by a combination of factors: climatic conditions around week 13, at-risk activities including night trainings, absence of impregnation, a lesser experience of rainforest duties in Regiment B and illegal logging attracting sandflies on military training grounds.

Cutaneous Leishmaniasis is caused by parasites of the Leishmania genus and infects humans after a sandfly bite. Outbreaks are rare and hard to investigate in isolated tropical areas. In this study, the authors explored the different possible origins of an outbreak of cutaneous leishmaniasis among soldiers training in the rainforest of French Guiana. The outbreak occurred in March 2020. Concerning the symptoms, several patients presented resistant infections and multiple lines of treatment, raising the issue of resistant Leishmania strains. The different strains isolated during the outbreak were not genetically closed, as far as routine PCR techniques would indicate. The authors looked for individual behaviours exposing soldiers to sandfly bites but none was significantly associated with infection. The authors found two spots in the military training areas where illegal logging probably increased the density of sandflies and put service members at risk. The 13^th week of 2020 was associated to a higher risk of infection due to climatic conditions. This study shows how interactions between humans and the rainforest can increase the risk of parasitic outbreaks.

Epidemiological features of cutaneous leishmaniasis in diagnosed patients from an endemic area (central Morocco)

Cutaneous leishmaniasis represents the most neglected tropical disease across the world. In Morocco, this disease is endemic and constitutes a major public health problem, with a national control program been implemented. The current study aimed to determine the pattern and epidemiological features of cutaneous leishmaniasis in affected patients in an area covered by the CL control and prevention program (Central Morocco). A total of 161 patients suspected for cutaneous leishmaniasis were diagnosed according to WHO laboratory methods, and 82 cases were confirmed positive for CL. The reports were analysed by patients' socio-geographic status, gender and age. The number and distribution of CL lesions by location, gender and age were investigated. Overall the confirmed cases, 89 % were infected by Leishmania tropica versus 21 % for Leishmania major. Females were significantly more affected than males (p < 0.01). Children (0-15 years), especially those ≤ 7 years of age, were the most affected. For the distribution of lesions, single lesion cases were largely preponderant (70.7 %) compared to multiple lesions. Face location was significantly more frequent (62.2 %) compared to limbs (26.8 %). Face lesions were found more prevalent in children than in adults while limb lesions were highly observed in adults. The pattern of the disease is affected by many factors (e.g. environment, gender, age, etc.) and has specifics to be considered in prevention and control programs in endemic areas.

Spatial variations in Leishmaniasis: A biogeographic approach to mapping the distribution of Leishmania species

Cutaneous Leishmaniasis (CL) is the most prevalent form of Leishmaniasis and is widely endemic in the Americas. Several species of Leishmania are responsible for CL, a severely neglected tropical disease and the treatment of CL vary according to the different species of Leishmania. We proposed to map the distribution of the Leishmania species reported in French Guiana (FG) using a biogeographic approach based on environmental predictors. We also measured species endemism i.e., the uniqueness of species to a defined geographic location. Our results show that the distribution patterns varied between Leishmania spp. and were spatially dependent on climatic covariates. The species distribution modelling of the eco-epidemiological spatial patterns of Leishmania spp. is the first to measure endemism based on bioclimatic factors in FG. The study also emphasizes the impact of tree cover loss and climate on the increasing distribution of L. (Viannia) braziliensis in the most anthropized regions. Detection of high-risk regions for the different between Leishmania spp. is essential for monitoring and active surveillance of the vector. As climate plays a major role in the spatial distribution of the vector and reservoir and the survival of the pathogen, climatic covariates should be included in the analysis and mapping of vector-borne diseases. This study underscores the significance of local land management and the urgency of considering the impact of climate change in the development of vector-borne disease management strategies at the global scale.

Ecology, evolution, and epidemiology of zoonotic and vector-borne infectious diseases in French Guiana: Transdisciplinarity does matter to tackle new emerging threats

French Guiana is a European ultraperipheric region located on the northern Atlantic coast of South America. It constitutes an important forested region for biological conservation in the Neotropics. Although very sparsely populated, with its inhabitants mainly concentrated on the Atlantic coastal strip and along the two main rivers, it is marked by the presence and development of old and new epidemic disease outbreaks, both research and health priorities. In this review paper, we synthetize 15 years of multidisciplinary and integrative research at the interface between wildlife, ecosystem modification, human activities and sociodemographic development, and human health. This study reveals a complex epidemiological landscape marked by important transitional changes, facilitated by increased interconnections between wildlife, land-use change and human occupation and activity, human and trade transportation, demography with substantial immigration, and identified vector and parasite pharmacological resistance. Among other French Guianese characteristics, we demonstrate herein the existence of more complex multi-host disease life cycles than previously described for several disease systems in Central and South America, which clearly indicates that today the greater promiscuity between wildlife and humans due to demographic and economic pressures may offer novel settings for microbes and their hosts to circulate and spread. French Guiana is a microcosm that crystallizes all the current global environmental, demographic and socioeconomic change conditions, which may favor the development of ancient and future infectious diseases.

Immunoblot for the Diagnosis of Cutaneous Leishmaniasis in French Guiana

Cutaneous leishmaniasis (CL) is firmly established in South America. We aimed to assess the detection of IgG antibodies against 14 and/or 16 kDa antigens by immunoblot (IB) for CL serological diagnosis in French Guiana, an area where many endemic pathogens could interfere with it. This study was performed retrospectively on sera from 141 patients at the Cayenne tertiary hospital: 30 were patients with confirmed CL, 71 were diagnosed with various other endemic pathogens, 11 were diagnosed with an autoimmune disease, and 29 controls had no history of CL. Antibodies bound to the 14 and/or 16 kDa antigens in 27 of the 30 CL patients' sera and in 39 of the 111 non-CL patients' sera (26 from the infectious diseases group, four from the autoimmune diseases group, and nine from the dermatology department). The method tested showed a high sensitivity (90%) and a low specificity (66%), and a diagnosis odds ratio of 17.5 (95% CI [4.6-78.0]). This IB may be helpful to exclude the diagnosis of CL, prompting physicians to look for another diagnosis in the case of a negative IB.

Validation of Swab Sampling and SYBR Green-Based Real-Time PCR for the Diagnosis of Cutaneous Leishmaniasis in French Guiana

Recent studies have highlighted the interest in noninvasive sampling procedures coupled with real-time PCR methods for the detection of Leishmania species in South America. In French Guiana, the sampling method still relied on skin biopsies. Noninvasive protocols should be tested on a large annual cohort to improve routine laboratory diagnosis of cutaneous leishmaniasis. Therefore, we evaluated the performance of a new Leishmania detection and species identification protocol involving cotton swabs and SYBR green-based real-time PCR of the Hsp70 gene, coupled with Sanger sequencing. Between May 2017 and May 2018, 145 patients with ulcerated lesions compatible with cutaneous leishmaniasis were included in the study at the Cayenne Hospital and its remote health centers. Each patient underwent scrapings for a smear, skin biopsies for parasite culture and PCR-restriction fragment length polymorphism (RFLP) (RNA polymerase II), and sampling with a cotton swab for SYBR green-based PCR. The most accurate diagnostic test was the SYBR green-based PCR on swab samples, showing 98% sensitivity. The mean PCR cycle threshold (C_T ) was 24.4 (minimum C_T , 17; maximum C_T , 36) and was <35 in 97.6% of samples. All samples positive by SYBR green-based real-time PCR were successfully identified at the species level by DNA sequencing. This new method should be considered for routine diagnosis of cutaneous leishmaniasis in South America and especially for remote areas, since noninvasive collection tools are easier to use and require fewer precautions for transportation.

Further insights into the eco-epidemiology of American cutaneous leishmaniasis in the Belem metropolitan region, Pará State, Brazil

INTRODUCTION:

In the Belém Metropolitan Region (BMR), Pará State, Brazil, American cutaneous leishmaniasis (ACL) is endemic; however, very little is known regarding its causative agents. Therefore, we used our standard diagnostic approach combined with an RNA polymerase II largest subunit (RNAPOIILS)-polymerase chain reaction (PCR) followed by analysis of restriction fragment length polymorphism (PCR-RFLP) to identify Leishmania spp. ACL agents in this region.

METHODS:

Thirty-two Leishmania spp. isolates from patients with ACL in the BMR during 1995-2018 were analyzed. Leishmania spp. DNA samples were amplified using the primers RPOR2/RPOF2, and the 615-bp PCR products were subjected to enzymatic digestion using TspRI and HgaI endonucleases.

RESULTS:

ACL etiological agents in the BMR comprised Leishmania (Viannia) lindenbergi (43.7%) followed by Leishmania (Viannia) lainsoni (34.4%), Leishmania (Leishmania) amazonensis (12.5%), and Leishmania (Viannia) braziliensis (9.4%).

CONCLUSIONS:

To our knowledge, the results of the study revealed for the first time that L. (V.) lindenbergi and L. (V.) lainsoni are the main ACL agents in BMR.

Leishmania naiffi and lainsoni in French Guiana: Clinical features and phylogenetic variability

In French Guiana, five species are associated with Cutaneous Leishmaniasis (CL). Though infections with Leishmania guyanensis, L. (V.) braziliensis and L. (L.) amazonensis have been extensively described, there are few available clinical and genetic data on L. (V.) lainsoni and L. (V.) naiffi. We determined the clinical and epidemiological features of all cases of CL due to L. (V.) naiffi and L. (V.) lainsoni diagnosed in French Guiana between 2003 and 2019. Phylogenetic analysis was performed by sequencing a portion of HSP70 and cyt b genes. Five cases of L. naiffi and 25 cases of L. lainsoni were reported. Patients infected by L. (V.) lainsoni were usually infected on gold camps, mostly along the Maroni river (60%), while L. naiffi was observed in French patients infected on the coast (100%). A high number of pediatric cases (n = 5; 20%) was observed for L. (V.) lainsoni. A mild clinical course was observed for all cases of L. (V.) naiffi. HSP70 and cyt b partial nucleotide sequence analysis revealed different geographical clusters within L. (V.) naiffi and L. (V.) lainsoni but no association were found between phylogenetic and clinical features. Our data suggest distinct socio-epidemiological features for these two Leishmania species. Patients seem to get infected with L. (V.) naiffi during leisure activities in anthropized coastal areas, while L. (V.) lainsoni shares common features with L. (V.) guyanensis and braziliensis and seems to be acquired during professional activities in primary forest regions. Phylogenetic analysis has provided information on the intraspecific genetic variability of L. (V.) naiffi and L. (V.) lainsoni and how these genotypes are distributed at the geographic level.

Spectrum of skin diseases in Amerindian villages of the Upper Oyapock, French Guiana

Background

Due to their genetic characteristics, their isolation in rainforest areas, and their traditional way of life, Amerindian populations are likely to suffer from a specific spectrum of dermatoses. However, there are few available data on such skin disorders. Our aims were to describe all skin disorders in two Amerindian villages of French Guiana.

Methods

This retrospective study concerned all patients who consulted in the Health Centres of Camopi and Trois‐Sauts between July 1, 2017, and December 31, 2018. We included all patients classified with an ICD code linked to a skin disorder. All medical records were cross‐checked by two dermatologists to correct misclassifications.

Results

A total of 639 patients formed the study population, for 866 different skin disorders. Non‐sexually transmitted infections represented 57.6% of all skin disorders, followed by eczema (11.5%) and bites/envenomations (9.1%). Bacteria were responsible for 238 skin infections, followed by fungi (141 cases) and parasites (69 cases, including 43 scabies, nine cutaneous leishmaniasis, and two tungiasis). We reported a low prevalence of sexually transmitted infections (10 cases) and an absence of skin cancers.

Conclusions

This study revealed the absence of skin cancer in the Amerindian population of the Upper Oyapock and the important burden of infectious and animal‐related diseases. Future studies should assess a possible underestimation of sexually transmitted diseases in this area. Public health policies should target neglected diseases such as cutaneous leishmaniasis, tungiasis, scabies, and envenomations. Atopic dermatitis was a significant and unexpected cause of consultations.

Geospatial analysis of tegumentary leishmaniasis in Rio de Janeiro state, Brazil from 2000 to 2015: Species typing and flow of travelers and migrants with leishmaniasis

Background

We identified the species of Leishmania isolated from traveling and migrant patients attended in a reference center from 2000 to 2015, we performed the georeferencing of these species in Rio de Janeiro (RJ) state and we had knowledge about the human flows between the likely location of infection (LLI) and place of residence (PR) in RJ state, Brazil.

Methodology/Principal findings

This is a retrospective cross-sectional study including 171 patients diagnosed with ATL. Google Maps, OpenStreetMap, and Bing Maps were tools used to georeference LLI and PR. For etiological identification, we used isoenzyme electrophoresis, polymerase chain reaction-restriction fragment length polymorphism (molecular target hsp70C with restriction enzymes HaeIII and BstUI), and sequencing of the internal transcribed spacer of ribosomal DNA. ARCGIS software was used to create maps of the geographic distribution of Leishmania species in the state and municipality of RJ, together with flows between the LLI and PR. Isolates from 104 patients were identified as: L. (Viannia) braziliensis (80.8%), L. (V.) naiffi (7.7%), L. (V.) guyanensis (6.7%), L. (Leishmania) amazonensis (1%), and genetic variants of L. (V.) braziliensis (3.8%). The flow maps showed that the LLI included 4 countries, 19 Brazilian states, and 18 municipalities of RJ state. The Brazilian states with the highest density of cases were Amazonas (n = 32), Bahia (n = 18), and Ceará (n = 15).

Conclusions/Significance

This work is the first contribution to the knowledge of the routes of Leishmania species introduced in RJ state by migrants and travelers patients. L. (V.) braziliensis, L. (V.) guyanensis, L. (V.) naiffi, L. (L.) amazonensis, and genetic variants of L. (V.) braziliensis were identified in RJ state. To determine whether the autochthonous transmission of these imported species is possible it is necessary the adaptation of these species to environmental conditions as well as the presence of reservoirs and phlebotomine vectors in this region.

Leishmaniasis is one of the most important neglected parasitic diseases in humans worldwide. American Tegumentary Leishmaniasis (ATL) is a disease caused by protozoa of the genus Leishmania, which are injected into the skin by small insects known by sandflies. Many different Leishmania species may cause ATL, which can affect the skin and/or oral and nasal mucosa. In this study, we analyzed flows between the likely location of infection (LLI) and the place of residence (PR) in Rio de Janeiro (RJ) state and identified Leishmania species isolated from travelers and migrants attended between 2000 and 2015 in a reference hospital for the care of patients with ATL. This work is the first contribution to knowledge about the routes of Leishmania species introduced to RJ state by migrant and traveling patients. In addition to Leishmania (Viannia) braziliensis, which was the most common species, other species have also been introduced to RJ state, including L. (V.) guyanensis, L. (V.) naiffi, L. (Leishmania) amazonensis, and genetic variants of L. (V.) braziliensis. Knowledge of the migratory flow and geographic location of these imported Leishmania species may contribute to the surveillance and control of ATL in RJ state, Brazil.

American cutaneous leishmaniasis in French Guiana: an epidemiological update and study of environmental risk factors

Background

American cutaneous leishmaniasis (ACL) is endemic in French Guiana. Its epidemiology is evolving, notably because of immigration, anthropization of natural areas, and new microbiological methods. Our first objective was to update epidemiological data. Our second objective was to look for risk factors of ACL.

Methods

This multicentric study was conducted from October 2017 to June 2018 in French Guiana. Patients with suspicion of mucocutaneous leishmaniasis were included in case of positive smear, culture, or PCR‐RFLP on skin biopsy.

Results

One hundred and twenty‐three patients met the inclusion criteria. Among those patients, 59.3% were Brazilian, mostly gold miners. Most of them (58%) were between 16 and 40 years old, and 69% were male. A large proportion of patients lived in traditional wooden houses (51%). Patients living in coastal towns were usually infected during trips to the primary forest (60%) and had a shorter time to diagnosis than workers of the hinterland. Among environmental risk factors, the presence of a water spring (40%) and dogs around houses (40%) were frequently reported. Leishmania guyanensis represented 80% of cases, followed by Leishmania braziliensis (6%), Leishmania naiffi (2%), and Leishmania amazonensis (1%).

Conclusions

Gold mining and trips to the primary forest represent high‐risk situations for ACL in French Guiana, where the population of infected patients is dominated by Brazilian immigrants. Possible environmental risk factors such as the presence of dogs, water sources, and traditional wooden houses require further investigation.

Ecological niche modelling for predicting the risk of cutaneous leishmaniasis in the Neotropical moist forest biome

A major challenge of eco-epidemiology is to determine which factors promote the transmission of infectious diseases and to establish risk maps that can be used by public health authorities. The geographic predictions resulting from ecological niche modelling have been widely used for modelling the future dispersion of vectors based on the occurrence records and the potential prevalence of the disease. The establishment of risk maps for disease systems with complex cycles such as cutaneous leishmaniasis (CL) can be very challenging due to the many inference networks between large sets of host and vector species, with considerable heterogeneity in disease patterns in space and time. One novelty in the present study is the use of human CL cases to predict the risk of leishmaniasis occurrence in response to anthropogenic, climatic and environmental factors at two different scales, in the Neotropical moist forest biome (Amazonian basin and surrounding forest ecosystems) and in the surrounding region of French Guiana. With a consistent data set never used before and a conceptual and methodological framework for interpreting data cases, we obtained risk maps with high statistical support. The predominantly identified human CL risk areas are those where the human impact on the environment is significant, associated with less contributory climatic and ecological factors. For both models this study highlights the importance of considering the anthropogenic drivers for disease risk assessment in human, although CL is mainly linked to the sylvatic and peri-urban cycle in Meso and South America.

Molecular Evidence of Leishmania infantum and Leishmania guyanensis in Red Howler Monkey (Alouatta seniculus) from French Guiana

Presence of Leishmania spp. was evaluated in the blood of nine red howler monkeys (Alouatta seniculus) from a specific area of French Guiana, located in the northeast of the Amazon. The molecular detection was performed based on PCR targeting the markers 18S rRNA, kDNA and ITS2 genes, as well as rapid immunomigration tests. Two monkeys were positive for Leishmania infantum and one for Leishmania guyanensis. While L. guyanensis cutaneous leishmaniasis is common, visceral leishmaniasis (human and canine) caused by L. infantum has never been described in this area. The howler monkey proved to be a sentinel and a potential reservoir of a serious zoonosis. These results must be carefully considered by public health officials and veterinarians in the future.

Leishmania DNA detection and species characterization within phlebotomines (Diptera: Psychodidae) from a peridomicile-forest gradient in an Amazonian/Guianan bordering area

In the border region between Brazil and French Guiana, American cutaneous leishmaniasis is a worrisome public health issue, and entomological studies are required there to better identify classical and putative emerging transmission patterns. The present study aimed to detect and characterize Leishmania DNA in the phlebotomine population of Oiapoque (Amapá State, Brazil). Phlebotomines were captured in anthropized and wild environments in the outskirts of Oiapoque municipality, using CDC light traps installed in vertical (ground/canopy level) and horizontal (peridomicile/extradomicile/forest-edge/forest) strata. Captured specimens were identified according to their morphology. Females were processed for Leishmania DNA detection and characterization using a multiplex polymerase chain reaction targeting kinetoplast DNA (kDNA) and the phlebotomine cacophony gene. The kDNA positive samples were characterized by cloning and sequencing the Leishmania 234 bp-hsp70 gene. Among the 3957 phlebotomine specimens captured, 26 pooled female samples were positive for Leishmania (Viannia) spp. DNA. Sequencing analysis allowed species-specific identification of L. (V.) braziliensis DNA in Trichophoromyia ininii, Bichromomyia flaviscutellata, Nyssomyia umbratilis, and Evandromyia infraspinosa, and L. (V.) guyanensis DNA in Ny. umbratilis. A pooled sample of Ny. umbratilis was positive for both L. (V.) braziliensis and L. (V.) guyanensis DNA. The present study provided additional information regarding ACL ecology in Oiapoque, highlighting the presence of L. (V.) braziliensis DNA in different phlebotomine species. The epidemiological implications of these findings and the determinant incrimination of L. (V.) braziliensis as proven vectors in that region must be clarified. In this regard, studies on Leishmania spp. infection and suggestive anthropophilic behavior of associated phlebotomines need to be prioritized in entomological surveillance.

Potential animal reservoirs (dogs and bats) of human visceral leishmaniasis due to Leishmania infantum in French Guiana

In French Guiana, cutaneous leishmaniasis is highly endemic, whereas no autochthonous case of visceral leishmaniasis have been reported so far. However, due to its proximity to Brazil which is highly endemic for visceral leishmaniasis, and the high transboundary population flow, an epidemiological challenge could arise at any time. As an overseas department and region and the largest outermost region of the European Union, epidemiological surveillance of visceral leishmaniasis is of great importance. Our study aimed to investigate the presence of Leishmania spp. in domestic (dogs) and sylvatic (bats) animals from French Guiana. Over the 2008-2018 period, samples from 349 animals were collected. They included blood from 179 autochthonous dogs and 59 bats, spleen samples from 33 bats and, blood from 78 military working dogs (MWD) collected before their departure from continental France and at the end of their four-month stay in French Guiana. Samples were screened using real-time polymerase chain reaction (qPCR) assays targeting Leishmania DNA followed by sequencing of 18S rRNA, kDNA and ITS2 genes. L. infantum was detected in 2.3% (8/349) of animals with 1.7% (3/179) of autochthonous dogs, 5.1% (4/78) of MWD returning from French Guiana, whereas they were negative before their departure. One of them dates back to 2012. All these dogs were positive for serological tests. In addition, L. infantum DNA was detectable in one bat spleen sample, belonging to Carollia perspicillata species. We report here for the first time an infection with L. infantum in dogs and bat from French Guiana. Our results suggest the existence of potential reservoir and transmission cycle for visceral leishmaniasis, at least since 2012, which was unknown in this territory until now. Further studies are needed to determine how these animals were infected and which vectors are involved in the transmission in this area.

A review on the occurrence of companion vector-borne diseases in pet animals in Latin America

Companion vector-borne diseases (CVBDs) are an important threat for pet life, but may also have an impact on human health, due to their often zoonotic character. The importance and awareness of CVBDs continuously increased during the last years. However, information on their occurrence is often limited in several parts of the world, which are often especially affected. Latin America (LATAM), a region with large biodiversity, is one of these regions, where information on CVBDs for pet owners, veterinarians, medical doctors and health workers is often obsolete, limited or non-existent. In the present review, a comprehensive literature search for CVBDs in companion animals (dogs and cats) was performed for several countries in Central America (Belize, Caribbean Islands, Costa Rica, Cuba, Dominican Republic, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Puerto Rico) as well as in South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, French Guiana, Guyana (British Guyana), Paraguay, Peru, Suriname, Uruguay, Venezuela) regarding the occurrence of the following parasitic and bacterial diseases: babesiosis, heartworm disease, subcutaneous dirofilariosis, hepatozoonosis, leishmaniosis, trypanosomosis, anaplasmosis, bartonellosis, borreliosis, ehrlichiosis, mycoplasmosis and rickettsiosis. An overview on the specific diseases, followed by a short summary on their occurrence per country is given. Additionally, a tabular listing on positive or non-reported occurrence is presented. None of the countries is completely free from CVBDs. The data presented in the review confirm a wide distribution of the CVBDs in focus in LATAM. This wide occurrence and the fact that most of the CVBDs can have a quite severe clinical outcome and their diagnostic as well as therapeutic options in the region are often difficult to access and to afford, demands a strong call for the prevention of pathogen transmission by the use of ectoparasiticidal and anti-feeding products as well as by performing behavioural changes.

Identification of French Guiana sand flies using MALDI-TOF mass spectrometry with a new mass spectra library

Phlebotomine sand flies are insects that are highly relevant in medicine, particularly as the sole proven vectors of leishmaniasis. Accurate identification of sand fly species is an essential prerequisite for eco-epidemiological studies aiming to better understand the disease. Traditional morphological identification is painstaking and time-consuming, and molecular methods for extensive screening remain expensive. Recent studies have shown that matrix-assisted laser desorption and ionization time-of-flight mass spectrometry (MALDI-TOF MS) is a promising tool for rapid and cost-effective identification of arthropod vectors, including sand flies. The aim of this study was to validate the use of MALDI-TOF MS for the identification of Northern Amazonian sand flies. We constituted a MALDI-TOF MS reference database comprising 29 species of sand flies that were field-collected in French Guiana, which are expected to cover many of the more common species of the Northern Amazonian region, including known vectors of leishmaniasis. Carrying out a blind test, all the sand flies tested (n = 157) with a log (score) threshold greater than 1.7 were correctly identified at the species level. We confirmed that MALDI-TOF MS protein profiling is a useful tool for the study of sand flies, including neotropical species, known for their great diversity. An application that includes the spectra generated here will be available to the scientific community in the near future via an online platform.

Phlebotomine sand flies are small insects, mostly known for their role in the transmission of Leishmania parasites to humans and other mammals. In French Guiana, the main clinical form of the disease manifests as cutaneous lesions also called American cutaneous leishmaniasis. The transmission of Leishmania from wild mammals to humans depends on the species of sand fly involved in the transmission. To better understand the mechanism of disease transmission, it is essential to accurately identify sand flies, including both vector and non-vector species. Until now, sand flies have mainly been identified using morphological and molecular methods. Recent studies have shown that a new tool based on protein profiling compiled in a library of spectra may be useful for the identification of arthropod vectors. This tool has the advantage of being less time-consuming, less expensive and does not require technical skills. The aim of this study was to assess the usefulness and accuracy of this new tool in identifying Northern Amazonian sand flies.

Ecological aspects of Phlebotomines (Diptera: Psychodidae) and the transmission of American cutaneous leishmaniasis agents in an Amazonian/ Guianan bordering area

BACKGROUND

An entomological study was conducted in the municipality of Oiapoque (lower Oyapock River Basin) in the Brazilian side bordering French Guiana to gain information on the transmission pattern of American cutaneous leishmaniasis (ACL) in that region, presumed to reflect the classical Amazonian/Guianan enzootic scenario.

METHODS

Three ecologically isolated forested areas near urban environments were surveyed during the rainy and dry seasons of 2015 and 2016, using a multi-trapping approach comprising ground-level and canopy light traps, black and white colored cloth Shannon traps and manual aspiration on tree bases. Female phlebotomines were dissected to find infections and isolate flagellates from Leishmania spp. The strains were characterized by restriction fragment length polymorphism analysis and compared with those of local ACL cases and World Health Organization reference strains.

RESULTS

Nyssomyia umbratilis, Trichopygomyia trichopyga and Evandromyia infraspinosa were the most frequently found species. Findings on relative abundance, spatiotemporal vector/ACL congruence, natural infections and anthropophilic insights strengthened the Guianan classical transmission of Leishmania (Viannia) guyanensis by Ny. umbratilis and suggested further investigations for Ev. infraspinosa. Nyssomyia umbratilis showed an eclectic feeding habit, including bird blood. Ecological data and literature reports also included Psychodopygus squamiventris maripaensis and Bichromomyia flaviscutellata on the list of suspected vectors.

CONCLUSIONS

These findings contributed to understanding ACL ecoepidemiology in the Amazonian/Guianan scenario. Local studies are required to better comprehend the Leishmania spp. enzootic mosaic in specific ecotopes.

Use of the intramuscular route to administer pentamidine isethionate in Leishmania guyanensis cutaneous leishmaniasis increases the risk of treatment failure

BACKGROUND

New world cutaneous leishmaniasis (NWCL) can be found in French Guiana as well as in several other parts of Central and South America. Leishmania guyanensis accounts for nearly 90% of cases in French Guiana and is treated with pentamidine isethionate, given by either intramuscular or intravenous injection. The military population is particularly exposed due to repeated missions in the rainforest. The purpose of the present study was to identify the factors associated with pentamidine isethionate treatment failure in a series of service members with L. guyanensis NWCL acquired in French Guiana.

METHOD

All the French service members reported as having acquired leishmaniasis in French Guiana from December 2013 to June 2016 were included.

RESULTS

Seventy-three patients infected with L. guyanensis were included in the final analysis. Patients treated with IV pentamidine isethionate had better response rates than those treated with IM pentamidine isethionate (p = 0.002, adjusted odds ratio (AOR) = 0.15, 95% CI [0.04-0.50]). The rate of treatment success was 85.3% (95% CI [68.9-95.0]) for IV pentamidine isethionate and 51.3% (95% CI [34.8-67.6]) for IM pentamidine isethionate.

CONCLUSIONS

The use of intramuscular pentamidine isethionate in the treatment of Leishmania guyanensis cutaneous leishmaniasis is associated with more treatment failures than intravenous pentamidine isethionate.

Failure of fluconazole in treating cutaneous leishmaniasis caused by Leishmania guyanensis in the Brazilian Amazon: An open, nonrandomized phase 2 trial

BACKGROUND

The treatment of Leishmaniasis caused by Leishmania (Viannia) guyanensis is based on a weak strength of evidence from very few clinical trials and some case series reports. Current treatment guidelines recommend pentamidine isethionate or meglumine antimoniate (Glucantime) as the first-line choices. Both are parenteral drugs with a low therapeutic indexes leading to a high risk of undesired effects. Imidazole derivatives interfere with the production of leishmanial ergosterol, an essential component of their membrane structure. One drug that has been studied in different clinical presentations of Leishmania is fluconazole, a hydrophilic bis-triazole, which is easily absorbed through the oral route with a low toxicity profile and is considered safe for children. This drug is readily available in poor countries with a reasonable cost making it a potential option for treating leishmaniasis.

METHODS AND FINDINGS

An adaptive nonrandomized clinical trial with sequential groups with dose escalation of oral fluconazole was designed to treat adult men with localized cutaneous leishmaniasis (LCL) in Manaus, Brazil. Eligible participants were patients with LCL with confirmed Leishmania guyanensis infection.

RESULTS

Twenty adult male patients were treated with 450 mg of fluconazole daily for 30 days. One patient (5%) was cured within 30 days of treatment. Of the 19 failures (95%), 13 developed a worsening of ulcers and six evolved lymphatic spreading of the disease. Planned dose escalation was suspended after the disappointing failure rate during the first stage of the trial.

CONCLUSION/SIGNIFICANCE

Oral fluconazole, at the dose of 450mg per day, was not efficacious against LCL caused by Leishmania guyanensis in adult men.

TRIAL REGISTRATION

Brazilian Clinical Trial Registration (ReBec)-RBR-8w292w; UTN number-1158-2421.

Unraveling the genetic diversity and phylogeny of Leishmania RNA virus 1 strains of infected Leishmania isolates circulating in French Guiana

Introduction

Leishmania RNA virus type 1 (LRV1) is an endosymbiont of some Leishmania (Vianna) species in South America. Presence of LRV1 in parasites exacerbates disease severity in animal models and humans, related to a disproportioned innate immune response, and is correlated with drug treatment failures in humans. Although the virus was identified decades ago, its genomic diversity has been overlooked until now.

Methodology/Principles findings

We subjected LRV1 strains from 19 L. (V.) guyanensis and one L. (V.) braziliensis isolates obtained from cutaneous leishmaniasis samples identified throughout French Guiana with next-generation sequencing and de novo sequence assembly. We generated and analyzed 24 unique LRV1 sequences over their full-length coding regions. Multiple alignment of these new sequences revealed variability (0.5%–23.5%) across the entire sequence except for highly conserved motifs within the 5’ untranslated region. Phylogenetic analyses showed that viral genomes of L. (V.) guyanensis grouped into five distinct clusters. They further showed a species-dependent clustering between viral genomes of L. (V.) guyanensis and L. (V.) braziliensis, confirming a long-term co-evolutionary history. Noteworthy, we identified cases of multiple LRV1 infections in three of the 20 Leishmania isolates.

Conclusions/Significance

Here, we present the first-ever estimate of LRV1 genomic diversity that exists in Leishmania (V.) guyanensis parasites. Genetic characterization and phylogenetic analyses of these viruses has shed light on their evolutionary relationships. To our knowledge, this study is also the first to report cases of multiple LRV1 infections in some parasites. Finally, this work has made it possible to develop molecular tools for adequate identification and genotyping of LRV1 strains for diagnostic purposes. Given the suspected worsening role of LRV1 infection in the pathogenesis of human leishmaniasis, these data have a major impact from a clinical viewpoint and for the management of Leishmania-infected patients.

Leishmaniasis is a well-known parasitosis due to an infection by the protozoan Leishmania parasites firmly established in South America. In French Guiana, where leishmaniasis is a public health problem, having an annual incidence of 5.6 cases/10,000 inhabitants, 80% of Leishmania spp. parasites are infected by an endosymbiotic virus, Leishmania RNA virus 1 (LRV1). The purpose of this study was to gain insights on the genetic variability and evolution of LRV1 at the genomic level. We subjected 20 Leishmania isolates obtained from cutaneous lesions with next generation sequencing and de novo sequence assembly. This allowed generating 24 LRV1 full-length coding sequences presenting among themselves a significant genetic diversity. The inferred phylogenetic relationships enabled to identify distinct well-supported genotypes and support the hypothesis of co-evolution between LRV1 strains and their parasite hosts. In addition, we identified multiple LRV1 infections in three parasite isolates. Based on these data, future characterization of new strains from other geographic areas and other parasite species should extend knowledge of LRV1 diversification processes. Finally, these results allowed us to identify genomic regions where best to allocate resources for subsequent analyses of LRV1 viral diversity and genotyping that could serve for accurate routine molecular diagnostic applications.