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Dash SK, Benival D, Jindal AB. Formulation Strategies to Overcome Amphotericin B Induced Toxicity. Mol Pharm 2024. [PMID: 39373243 DOI: 10.1021/acs.molpharmaceut.4c00485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2024]
Abstract
Fungal infection poses a major global threat to public health because of its wide prevalence, severe mortality rate, challenges involved in diagnosis and treatment, and the emergence of drug-resistant fungal strains. Millions of people are getting affected by fungal infection, and around 3.8 million people face death per year due to fungal infection, as per the latest report. The polyene antibiotic AmB has an extensive record of use as a therapeutic moiety against systemic fungal infection and leishmaniasis since 1960. AmB has broad-spectrum fungistatic and fungicidal activity. AmB exerts its therapeutic activity at the cellular level by binding to fungal sterol and forming hydrophilic pores, releasing essential cellular components and ions into the extracellular fluid, leading to cell death. Despite using AmB as an antifungal and antileishmanial at a broad scale, its clinical use is limited due to drug-induced nephrotoxicity resulting from binding the aggregated form of the drug to mammalian sterol. To mitigate AmB-induced toxicity and to get better anti-fungal therapeutic outcomes, researchers have developed nanoformulations, self-assembled formulations, prodrugs, cholesterol- and albumin-based AmB formulations, AmB-mAb combination therapy, and AmB cochleates. These formulations have helped to reduce toxicity to a certain extent by controlling the aggregation state of AmB, providing sustained drug release, and altering the physicochemical and pharmacokinetic parameters of AmB. Although the preclinical outcome of AmB formulations is quite satisfactory, its parallel result at the clinical level is insignificant. However, the safety and efficacy of AmB therapy can be improved at the clinical stage by continuous investigation and collaboration among researchers, clinicians, and pharmaceutical companies.
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Affiliation(s)
- Sanat Kumar Dash
- Department of Pharmacy, Birla Institute of Technology and Science Pilani (BITS Pilani), Pilani Campus, Pilani, Rajasthan 333031, India
| | - Derajram Benival
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER) - Ahmedabad, Gandhinagar, Gujurat 382355, India
| | - Anil B Jindal
- Department of Pharmacy, Birla Institute of Technology and Science Pilani (BITS Pilani), Pilani Campus, Pilani, Rajasthan 333031, India
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Karampas G, Koulouraki S, Daikos GL, Nanou C, Aravantinos L, Eleftheriades M, Metallinou D, Christopoulos P. Visceral Leishmaniasis in a Twin Pregnancy: A Case Report and Review of the Literature. J Clin Med 2024; 13:2400. [PMID: 38673673 PMCID: PMC11051246 DOI: 10.3390/jcm13082400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/10/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Visceral leishmaniasis (VL), often referred to as kala-azar, is quite rare in developed countries during pregnancy. Only few studies have evaluated its impact on perinatal outcome. It is caused primarily by Leishmania donovani or Leishmania infantum and presents with a wide spectrum of clinical manifestations from cutaneous ulcers to multisystem disease. Differential diagnosis is challenging as symptoms and signs are insidious, mimicking other diseases. Misdiagnosis can result in severe adverse perinatal outcomes, even maternal/neonatal death. Early treatment with liposomal amphotericin-B (LAmB) is currently the first choice with adequate effectiveness. We report a rare case of VL in a twin pregnancy with onset at the second trimester, presenting with periodic fever with rigors, right flank pain, and gradual dysregulation of all three cell lines. The positive rK39 enzyme-linked immunosorbent assay test confirmed the diagnosis. Treatment with LAmB resulted in clinical improvement within 48 h and in the delivery of two late-preterm healthy neonates with no symptoms or signs of vertical transmission. The one-year follow-up, of the mother and the neonates, was negative for recurrence. To our knowledge, this is the first reported case of VL in a twin pregnancy, and consequently treatment and perinatal outcome are of great importance.
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Affiliation(s)
- Grigorios Karampas
- Second Department of Obstetrics and Gynaecology, Aretaieio University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (G.K.); (S.K.); (L.A.); (M.E.); (P.C.)
| | - Sevasti Koulouraki
- Second Department of Obstetrics and Gynaecology, Aretaieio University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (G.K.); (S.K.); (L.A.); (M.E.); (P.C.)
| | - George L. Daikos
- Mitera Hospital, 6, Erythrou Stavrou Str., 151 23 Athens, Greece;
| | - Christina Nanou
- Department of Midwifery, University of West Attica, 122 43 Athens, Greece;
| | - Leon Aravantinos
- Second Department of Obstetrics and Gynaecology, Aretaieio University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (G.K.); (S.K.); (L.A.); (M.E.); (P.C.)
| | - Makarios Eleftheriades
- Second Department of Obstetrics and Gynaecology, Aretaieio University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (G.K.); (S.K.); (L.A.); (M.E.); (P.C.)
| | - Dimitra Metallinou
- Department of Midwifery, University of West Attica, 122 43 Athens, Greece;
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynaecology, Aretaieio University Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece; (G.K.); (S.K.); (L.A.); (M.E.); (P.C.)
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Roy K, Ghosh S, Karan M, Karmakar S, Nath S, Das B, Paul S, Mandal P, Ray M, Das M, Mukherjee S, Dey S, Pal C. Activation of neutrophils excels the therapeutic potential of Mycobacterium indicus pranii and heat-induced promastigotes against antimony-resistant Leishmania donovani infection. Scand J Immunol 2024; 99:e13350. [PMID: 39008005 DOI: 10.1111/sji.13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 11/08/2023] [Accepted: 12/22/2023] [Indexed: 07/16/2024]
Abstract
Repurposing drugs and adjuvants is an attractive choice of present therapy that reduces the substantial costs, chances of failure, and systemic toxicity. Mycobacterium indicus pranii was originally developed as a leprosy vaccine but later has been found effective against Leishmania donovani infection. To extend our earlier study, here we reported the immunotherapeutic modulation of the splenic and circulatory neutrophils in favour of hosts as neutrophils actually serve as the pro-parasitic portable shelter to extend the Leishmania infection specifically during the early entry into the hosts' circulation. We targeted to disrupt this early pro-parasitic incidence by the therapeutic combination of M. indicus pranii and heat-induced promastigotes against antimony-resistant L. donovani infection. The combination therapy induced the functional expansion of CD11b+Ly6CintLy6Ghi neutrophils both in the post-infected spleen, and also in the circulation of post-treated animals followed by the immediate Leishmania infection. More importantly, the enhanced expression of MHC-II, phagocytic uptake of the parasites by the circulatory neutrophils as well as the oxidative burst were induced that limited the chances of the very early establishment of the infection. The enhanced expression of pro-inflammatory cytokines, like IL-1α and TNF-α indicated resistance to the parasite-mediated takeover of the neutrophils, as these cytokines are critical for the activation of T cell-mediated immunity and host-protective responses. Additionally, the induction of essential transcription factors and cytokines for early granulocytic lineage commitment suggests that the strategy not only contributed to the peripheral activation of the neutrophils but also promoted granulopoiesis in the bone marrow.
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Affiliation(s)
- Kamalika Roy
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Sanhita Ghosh
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Mintu Karan
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Suman Karmakar
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Supriya Nath
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Bedanta Das
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Sharmistha Paul
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Pritam Mandal
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Monalisa Ray
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Mousumi Das
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Soumyadip Mukherjee
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Somaditya Dey
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
| | - Chiranjib Pal
- Cellular Immunology and Vector Molecular Biology Laboratory, Department of Zoology, West Bengal State University, Barasat, West Bengal, India
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Saini I, Joshi J, Kaur S. Unwelcome prevalence of leishmaniasis with several other infectious diseases. Int Immunopharmacol 2022; 110:109059. [DOI: 10.1016/j.intimp.2022.109059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022]
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Kumari S, Kumar V, Tiwari RK, Ravidas V, Pandey K, Kumar A. - Amphotericin B: A drug of choice for Visceral Leishmaniasis. Acta Trop 2022; 235:106661. [PMID: 35998680 DOI: 10.1016/j.actatropica.2022.106661] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/01/2022]
Abstract
Visceral leishmaniasis or Kala-azar is a vector-borne disease caused by an intracellular parasite of the genus leishmania. In India, Amphotericin B (AmB) is a first-line medication for treating leishmaniasis. After a large-scale resistance to pentavalent antimony therapy developed in Bihar state, it was rediscovered as an effective treatment for Leishmania donovani infection. AmB which binds to the ergosterol of protozoan cells causes a change in membrane integrity resulting in ions leakage, and ultimately leading to cell death. The treatment effect of liposomal AmB can be seen more quickly than deoxycholate AmB because, it has some toxic effects, but liposomal AmB is significantly less toxic. Evidence from studies suggested that ABLC (Abelcet) and ABCD (Amphotec) are as effective as L-AmB but Liposomal form (Ambisome) is a more widely accepted treatment option than conventional ones. Nevertheless, the world needs some way more efficient antileishmanial drugs that are less toxic and less expensive for people living with parasitic infections caused by Leishmania. So, academics, researchers, and sponsors need to focus on finding such drugs. This review provides a summary of the chemical, pharmacokinetic, drug-target interactions, stability, dose efficacy, and many other characteristics of the AmB and their various formulations. We have also highlighted the clinically significant aspects of PKDL and VL co-infection with HIV/TB.
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Affiliation(s)
- Shobha Kumari
- Department of Biochemistry, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India
| | - Vikash Kumar
- Department of Biochemistry, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India
| | - Ritesh Kumar Tiwari
- Department of Biochemistry, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India
| | - Vidyanand Ravidas
- Department of Clinical Medicine, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India
| | - Krishna Pandey
- Department of Clinical Medicine, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India
| | - Ashish Kumar
- Department of Biochemistry, Rajendra Memorial Research Institute of Medical Sciences, Agamkuan, Patna 800007, Bihar, India.
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Ibarra-Meneses AV, Corbeil A, Wagner V, Beaudry F, do Monte-Neto RL, Fernandez-Prada C. Exploring direct and indirect targets of current antileishmanial drugs using a novel thermal proteomics profiling approach. Front Cell Infect Microbiol 2022; 12:954144. [PMID: 35992178 PMCID: PMC9381709 DOI: 10.3389/fcimb.2022.954144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Visceral leishmaniasis (VL), caused by Leishmania infantum, is an oft-fatal neglected tropical disease. In the absence of an effective vaccine, the control of leishmaniasis relies exclusively on chemotherapy. Due to the lack of established molecular/genetic markers denoting parasite resistance, clinical treatment failure is often used as an indicator. Antimony-based drugs have been the standard antileishmanial treatment for more than seven decades, leading to major drug resistance in certain regions. Likewise, drug resistance to miltefosine and amphotericin B continues to spread at alarming rates. In consequence, innovative approaches are needed to accelerate the identification of antimicrobial drug targets and resistance mechanisms. To this end, we have implemented a novel approach based on thermal proteome profiling (TPP) to further characterize the mode of action of antileishmanials antimony, miltefosine and amphotericin B, as well as to better understand the mechanisms of drug resistance deployed by Leishmania. Proteins become more resistant to heat-induced denaturation when complexed with a ligand. In this way, we used multiplexed quantitative mass spectrometry-based proteomics to monitor the melting profile of thousands of expressed soluble proteins in WT, antimony-resistant, miltefosine-resistant, and amphotericin B-resistant L. infantum parasites, in the presence (or absence) of the above-mentioned drugs. Bioinformatics analyses were performed, including data normalization, melting profile fitting, and identification of proteins that underwent changes (fold change > 4) caused by complexation with a drug. With this unique approach, we were able to narrow down the regions of the L. infantum proteome that interact with antimony, miltefosine, and amphotericin B; validating previously-identified and unveiling novel drug targets. Moreover, analyses revealed candidate proteins potentially involved in drug resistance. Interestingly, we detected thermal proximity coaggregation for several proteins belonging to the same metabolic pathway (i.e., tryparedoxin peroxidase and aspartate aminotransferase in proteins exposed to antimony), highlighting the importance of these pathways. Collectively, our results could serve as a jumping-off point for the future development of innovative diagnostic tools for the detection and evaluation of antimicrobial-resistant Leishmania populations, as well as open the door for new on-target therapies.
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Affiliation(s)
- Ana Victoria Ibarra-Meneses
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- The Research Group on Infectious Diseases in Production Animals (GREMIP), Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Audrey Corbeil
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- The Research Group on Infectious Diseases in Production Animals (GREMIP), Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Victoria Wagner
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- The Research Group on Infectious Diseases in Production Animals (GREMIP), Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Francis Beaudry
- Département de Biomédecine, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- Centre de recherche sur le cerveau et l’apprentissage (CIRCA), Université de Montréal, Montréal, QC, Canada
| | - Rubens L. do Monte-Neto
- Biotechnology Applied to Pathogens (BAP) - Instituto René Rachou – Fundação Oswaldo Cruz/Fiocruz Minas, Belo Horizonte, Minas Gerais, Brazil
| | - Christopher Fernandez-Prada
- Département de Pathologie et Microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- The Research Group on Infectious Diseases in Production Animals (GREMIP), Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
- *Correspondence: Christopher Fernandez-Prada,
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Wijnant GJ, Dumetz F, Dirkx L, Bulté D, Cuypers B, Van Bocxlaer K, Hendrickx S. Tackling Drug Resistance and Other Causes of Treatment Failure in Leishmaniasis. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.837460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Leishmaniasis is a tropical infectious disease caused by the protozoan Leishmania parasite. The disease is transmitted by female sand flies and, depending on the infecting parasite species, causes either cutaneous (stigmatizing skin lesions), mucocutaneous (destruction of mucous membranes of nose, mouth and throat) or visceral disease (a potentially fatal infection of liver, spleen and bone marrow). Although more than 1 million new cases occur annually, chemotherapeutic options are limited and their efficacy is jeopardized by increasing treatment failure rates and growing drug resistance. To delay the emergence of resistance to existing and new drugs, elucidating the currently unknown causes of variable drug efficacy (related to parasite susceptibility, host immunity and drug pharmacokinetics) and improved use of genotypic and phenotypic tools to define, measure and monitor resistance in the field are critical. This review highlights recent progress in our understanding of drug action and resistance in Leishmania, ongoing challenges (including setbacks related to the COVID-19 pandemic) and provides an overview of possible strategies to tackle this public health challenge.
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Kajal S, Naeem SS, Gupta P, Kairo AK, Ahmed A, Verma P, Saini A. Sinonasal mucormycosis and liposomal amphotericin B: A quest for dose optimization. Indian J Pharmacol 2022; 54:90-96. [PMID: 35546459 PMCID: PMC9249146 DOI: 10.4103/ijp.ijp_644_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Sinonasal mucormycosis is a serious fungal infection. Early diagnosis and prompt antifungal therapy along with surgical intervention is the key to its management. Liposomal amphotericin B (LAmB) given intravenously is the antifungal agent of choice. However, the current literature is not clear on its optimum dosage. We did a retrospective study to find the optimum dose of LAmB in cases with sinonasal mucormycosis. MATERIALS AND METHODS Thirty patients diagnosed with mucormycosis involving sinonasal, rhino-orbital, or rhino-orbito-cerebral regions and receiving only LAmB as pharmacotherapy were included in our retrospective study from 2017 to 2020. A multiple logistic regression model was developed to correlate the total dose of LAmB and other parameters with the final outcome which was defined clinico-radiologically as improved, worsened, or death. The dose of LAmB which led to the first significant change in urea, creatinine, and potassium levels was also determined. RESULTS The model showed a good fit in goodness-to-fit analysis (Pearson = 0.999, deviance = 0.995), while the likelihood ratio was statistically significant (0.001). The overall model prediction was 83.3%. However, the correlation of outcome with any of the variables, including mean LAmB dose per kilogram (82.2 ± 13.02 mg/kg), was statistically not significant. CONCLUSION Many patient-related factors (such as age, comorbidities, extent of the disease, and side effects from LAmB therapy), which vary on a case-to-case basis, contribute to the outcome in a mucormycosis patient. The optimum dose of LAmB for improved outcome still requires individualization guided by experience, till well-designed studies address the question.
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Affiliation(s)
- Smile Kajal
- Department of Otorhinolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Syed Shariq Naeem
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Dr. Pooja Gupta, Department of Pharmacology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail:
| | - Arvind Kumar Kairo
- Department of Otorhinolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anam Ahmed
- Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India
| | - Prankur Verma
- Department: Otorhinolaryngology and Head-Neck Surgery, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Ashish Saini
- Department of Otorhinolaryngology and Head-Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
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Improved kala-azar case management through implementation of health facility-based sentinel sites surveillance system in Bihar, India. PLoS Negl Trop Dis 2021; 15:e0009598. [PMID: 34428232 PMCID: PMC8384155 DOI: 10.1371/journal.pntd.0009598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/26/2021] [Indexed: 11/23/2022] Open
Abstract
Background Visceral leishmaniasis (VL), also known as kala-azar (KA), is a neglected vector-borne disease, targeted for elimination, but several affected blocks of Bihar are posing challenges with the high incidence of cases, and moreover, the disease is spreading in newer areas. High-quality kala-azar surveillance in India, always pose great concern. The complete and accurate patient level data is critical for the current kala-azar management information system (KMIS). On the other side, no accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections are available under the current surveillance system, which might emerge as a serious concern. Additionally, in low case scenario, sentinel surveillance may be useful in addressing post-elimination activities and sustaining kala-azar (KA) elimination. Health facility-based sentinel site surveillance system has been proposed, first time to do a proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions. Methodology/principal findings Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar, India, using stratified sampling technique during 2011 to 2014. Data were collected through specially designed performa from all patients attending the outpatient departments of sentinel sites. Among 20968 symptomatic cases attended sentinel sites, 2996 cases of KA and 53 cases of PKDL were registered from 889 endemic villages. Symptomatic cases meant a person with fever of more than 15 days, weight loss, fatigue, anemia, and substantial swelling of the liver and spleen (enlargement of spleen and liver).The proportion of new and old cases was 86.1% and 13.9% respectively. A statistically significant difference was observed for reduction in KA incidence from 4.13/10000 in 2011 to 1.75/10000 in 2014 (p<0.001). There were significant increase (0.08, 0.10 per 10 000 population) in the incidences of PKDL and co-infection respectively in the year 2014 as compared to that of 2011 (0.03, 0.06 per 10 000 population). The proportion of HIV-VL co-infection was significantly higher (1.6%; p<0.05) as compared to other co-infections. Proportions of male in all age groups were higher and found statistically significant (Chi-square test = 7.6; P = 0.026). Utilization of laboratory services was greatly improved. Friedman test showed statistically significant difference between response of different anti kala-azar drugs (F = 25.0, P = 0.004).The initial and final cure rate of AmBisome was found excellent (100%). The results of the signed rank sum test showed significant symmetry of unresponsiveness rate (P = 0.03). Similarly, relapse rate of sodium antimony gluconate (SAG) was also found significantly higher as compared to other drugs (95%CI 0.2165 to 19.7035; P = 0.03). A statistically significant difference was found (p<0.001) between villages having 1–2 cases (74%) and villages with 3–5 cases (15%). Significantly higher proportion (95%) of cases were captured by existing Govt. surveillance system (KMIS) (p<0.001), as compared to private providers (5%). Conclusions/significance Establishment of a sentinel site based kala-azar surveillance system in Bihar, India effectively detected the rising trend of PKDL and co-infections and captured complete and accurate patient level data. Further, this system may provide a model for improving laboratory services, KA, PKDL and co-infection case management in other health facilities of Bihar without further referral. Program managers may use these results for evaluating program’s effectiveness. It may provide an example for changing the practices of health care workers in Bihar and set a benchmark of high quality surveillance data in a resource limited setting. However, the generalizability of this sentinel surveillance finding to other context remains a major limitation of this study. The justifications for this; the sentinel sites were made in the traditionally high endemic PHC’s. The other conditions were Program commitment for diagnostic (rk-39) and the first line anti kala-azar drug i.e. miltefosine throughout the study period in the sentinel sites. In addition, there were clause of fulfillment of readiness criteria at each sentinel site (already described in the line no 171 to 180 at page no-8, 181–189 at page no-9 and 192–212 at page no-10). Rigorous efforts were taken to improve all the sentinel sites to meet the readiness criteria and research activities started only after meeting readiness criteria at the site. Therefore sentinel site surveillance described under the present study cannot be integrated into other set up (medium and low endemic areas). However, it can be integrated into highly endemic areas with program commitment and fulfillment of readiness criteria. Visceral leishmaniasis is a neglected vector-borne disease, and one of the major public health problems of Bihar. The disease has been targeted for elimination by 2020. Bihar still posing challenge i.e. incidence is much high in a number of affected blocks, and even the disease is spreading in newer areas. None availability of an accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections under the current surveillance system may emerge as a serious concern. Therefore, health facility-based sentinel site surveillance system has been attempted for the first time in Bihar for proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions. A system for capturing regional transmission is essential that can target focal areas of infection to monitor progress towards kala-azar elimination. Kala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar during 2011 to 2014. The results showed a significant increase in PKDL and co-infection in 2014 when compared to 2011. Findings further revealed that utilization of laboratory services and case management were greatly improved, as majority of patients with KA, PKDL & co-infections were managed by the sentinel sites itself. The final cure rate of AmBisome was found excellent (100%). These observations may be useful to provide the basis for the design, refinement and resource allocation of the kala-azar control program. This system may also be useful in measuring impact of elimination interventions, their effectiveness and finally help in improving program management. It may further be used as an example for changing the practices of health care workers in Bihar and a lesson how to achieve high quality surveillance data in a resource limited setting. Standardization of sentinel site surveillance in terms of improved procedure, training, logistics, etc may further increase the effectiveness of this system. It may possibly be used as a cost-effective approach for capturing real-time kala-azar data under national kala-azar elimination programme.
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Medina J, Cruz-Saavedra L, Patiño LH, Muñoz M, Ramírez JD. Comparative analysis of the transcriptional responses of five Leishmania species to trivalent antimony. Parasit Vectors 2021; 14:419. [PMID: 34419127 PMCID: PMC8380399 DOI: 10.1186/s13071-021-04915-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Leishmaniasis is a neglected tropical disease caused by several species of Leishmania. The resistance phenotype of these parasites depends on the characteristics of each species, which contributes to increased therapeutic failures. Understanding the mechanism used by the parasite to survive under treatment pressure in order to identify potential common and specific therapeutic targets is essential for the control of leishmaniasis. The aim of this study was to investigate the expression profiles and potential shared and specific resistance markers of the main Leishmania species of medical importance [subgenus L. (Leishmania): L. donovani, L. infantum and L. amazonensis; subgenus L. (Viannia): L. panamensis and L. braziliensis)] resistant and sensitive to trivalent stibogluconate (SbIII). METHODS We conducted comparative analysis of the transcriptomic profiles (only coding sequences) of lines with experimentally induced resistance to SbIII from biological replicates of five Leishmania species available in the databases of four articles based on ortholog attribution. Simultaneously, we carried out functional analysis of ontology and reconstruction of metabolic pathways of the resulting differentially expressed genes (DEGs). RESULTS Resistant lines for each species had differential responses in metabolic processes, compound binding, and membrane components concerning their sensitive counterpart. One hundred and thirty-nine metabolic pathways were found, with the three main pathways comprising cysteine and methionine metabolism, glycolysis, and the ribosome. Differentially expressed orthologous genes assigned to species-specific responses predominated, with 899 self-genes. No differentially expressed genes were found in common among the five species. Two common upregulated orthologous genes were found among four species (L. donovani, L. braziliensis, L. amazonensis, and L. panamensis) related to an RNA-binding protein and the NAD(P)H cytochrome-B5-oxidoreductase complex, associated with transcriptional control and de novo synthesis of linoleic acid, critical mechanisms in resistance to antimonials. CONCLUSION Herein, we identified potential species-specific genes related to resistance to SbIII. Therefore, we suggest that future studies consider a treatment scheme that is species-specific. Despite the limitations of our study, this is the first approach toward unraveling the pan-genus genetic mechanisms of resistance in leishmaniasis.
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Affiliation(s)
- Julián Medina
- Centro de Investigaciones en Microbiología y Biotecnología- UR (CIMBIUR), Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá, Colombia
| | - Lissa Cruz-Saavedra
- Centro de Investigaciones en Microbiología y Biotecnología- UR (CIMBIUR), Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá, Colombia
| | - Luz Helena Patiño
- Centro de Investigaciones en Microbiología y Biotecnología- UR (CIMBIUR), Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá, Colombia
| | - Marina Muñoz
- Centro de Investigaciones en Microbiología y Biotecnología- UR (CIMBIUR), Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá, Colombia
| | - Juan David Ramírez
- Centro de Investigaciones en Microbiología y Biotecnología- UR (CIMBIUR), Facultad de Ciencias Naturales, Universidad del Rosario, Bogotá, Colombia.
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11
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Dahal P, Singh-Phulgenda S, Olliaro PL, Guerin PJ. Gender disparity in cases enrolled in clinical trials of visceral leishmaniasis: A systematic review and meta-analysis. PLoS Negl Trop Dis 2021; 15:e0009204. [PMID: 33725005 PMCID: PMC7963105 DOI: 10.1371/journal.pntd.0009204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A higher caseload of visceral leishmaniasis (VL) has been observed among males in community-based surveys. We carried out this review to investigate how the observed disparity in gender distribution is reflected in clinical trials of antileishmanial therapies. METHODS We identified relevant studies by searching a database of all published clinical trials in VL from 1980 through 2019 indexed in the Infectious Diseases Data Observatory (IDDO) VL clinical trials library. The proportion of male participants enrolled in studies eligible for inclusion in this review were extracted and combined using random effects meta-analysis of proportion. Results were expressed as percentages and presented with respective 95% confidence intervals (95% CIs). Heterogeneity was quantified using I2 statistics and sub-group meta-analyses were carried out to explore the sources of heterogeneity. RESULTS We identified 135 published studies (1980-2019; 32,177 patients) with 68.0% [95% CI: 65.9%-70.0%; I2 = 92.6%] of the enrolled participants being males. The corresponding estimates were 67.6% [95% CI: 65.5%-69.7%; n = 91 trials; I2 = 90.5%; 24,218 patients] in studies conducted in the Indian sub-continent and 74.1% [95% CI: 68.4%-79.1%; n = 24 trials; I2 = 94.4%; 6,716 patients] in studies from Eastern Africa. The proportion of male participants was 57.9% [95% CI: 54.2%-61.5%] in studies enrolling children aged <15 years, 78.2% [95% CI: 66.0%-86.9%] in studies that enrolled adults (≥15 years), and 68.1% [95% CI: 65.9%-70.0%] in studies that enrolled patients of all ages. There was a trend for decreased proportions of males enrolled over time: 77.1% [95% CI: 70.2%-82.8%; 1356 patients] in studies published prior to the 1990s whereas 64.3% [95% CI: 60.3%-68.2%; 15,611 patients] in studies published on or after 2010. In studies that allowed the inclusion of patients with HIV co-infections, 76.5% [95% CI: 63.8%-85.9%; 5,123 patients] were males and the corresponding estimate was 64.0% [95% CI: 61.4%-66.5% 17,500 patients] in studies which excluded patients with HIV co-infections. CONCLUSIONS Two-thirds of the participants enrolled in clinical studies in VL conducted in the past 40 years were males, though the imbalance was less in children and in more recent trials. VL treatment guidelines are informed by the knowledge of treatment outcomes from a population that is heavily skewed towards adult males. Investigators planning future studies should consider this fact and ensure approaches for more gender-balanced inclusion.
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Affiliation(s)
- Prabin Dahal
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Piero L. Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philippe J. Guerin
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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12
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Choi HL, Jain S, Ruiz Postigo JA, Borisch B, Dagne DA. The global procurement landscape of leishmaniasis medicines. PLoS Negl Trop Dis 2021; 15:e0009181. [PMID: 33600475 PMCID: PMC7924782 DOI: 10.1371/journal.pntd.0009181] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/02/2021] [Accepted: 01/26/2021] [Indexed: 02/02/2023] Open
Abstract
Ensuring access to essential medicines for leishmaniasis control is challenging, as leishmaniasis is a very small and unattractive market for pharmaceutical industry. Furthermore, control programmes are severely underfunded. We conducted an analysis of global procurement of leishmaniasis medicines for the past 5 years in order to shed light on the current leishmaniasis market landscape and supply and demand dynamics. We estimated global demand of each leishmaniasis medicines, the amount of each medicine required to treat all reported cases, based on the number of cases reported to WHO and the first-line treatment regimen used in each country. Procurement data were obtained from procurement agencies, international organizations, WHO, national leishmaniasis programmes and manufacturers. Expert interviews were conducted to have a better understanding of how medicines were procured and used. The comparison of estimated need and procurement data indicated discrepancies in supply and demand at global level as well as in the most endemic countries. The extent of the gap in supply was up to 80% of the needs for one of the leishmaniasis medicines. Mismatch between supply and demand was much wider for cutaneous leishmaniasis than visceral leishmaniasis. This study presents a current picture of procurement patterns and imbalance in global supply and demand. Addressing improved access and supply barriers requires concerted and coordinated efforts at the global and national levels. Priority actions include setting up a procurement coordination mechanism among major procurers, partners and national programmes where forecasting and supply planning is jointly developed and communicated with manufacturers. In addition, continuous engagement of manufacturers and advocacy is critical to diversify the supplier base and ensure quality-assured and affordable generic medicines for leishmaniasis.
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Affiliation(s)
- Hye Lynn Choi
- World Health Organization, Geneva, Switzerland
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- * E-mail:
| | | | | | - Bettina Borisch
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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13
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Mukherjee D, Yousuf M, Dey S, Chakraborty S, Chaudhuri A, Kumar V, Sarkar B, Nath S, Hussain A, Dutta A, Mishra T, Roy BG, Singh S, Chakraborty S, Adhikari S, Pal C. Targeting the Trypanothione Reductase of Tissue-Residing Leishmania in Hosts’ Reticuloendothelial System: A Flexible Water-Soluble Ferrocenylquinoline-Based Preclinical Drug Candidate. J Med Chem 2020; 63:15621-15638. [PMID: 33296601 DOI: 10.1021/acs.jmedchem.0c00690] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Debarati Mukherjee
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Md Yousuf
- Department of Chemistry, University of Calcutta, Kolkata, Pin-700009 West Bengal, India
| | - Somaditya Dey
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Sondipon Chakraborty
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Ankur Chaudhuri
- Department of Microbiology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Vinay Kumar
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research, Mohali, Pin-160062 Punjab, India
| | - Biswajyoti Sarkar
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Supriya Nath
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Aabid Hussain
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Aritri Dutta
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Tanushree Mishra
- Department of Chemistry, University of Calcutta, Kolkata, Pin-700009 West Bengal, India
| | - Biswajit Gopal Roy
- Department of Chemistry, Sikkim University,Tadong, Pin-737102 Gangtok, Sikkim, India
| | - Sushma Singh
- Department of Biotechnology, National Institute of Pharmaceutical Education and Research, Mohali, Pin-160062 Punjab, India
| | - Sibani Chakraborty
- Department of Microbiology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
| | - Susanta Adhikari
- Department of Chemistry, University of Calcutta, Kolkata, Pin-700009 West Bengal, India
| | - Chiranjib Pal
- Cellular Immunology and Experimental Therapeutics Laboratory, Department of Zoology, West Bengal State University, Barasat, North 24 Parganas, Pin-700126, West Bengal, India
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14
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Rapid Clinical Management of Leishmaniasis in Emergency Department: A Case Report with Clinical Review of Recent Literature. BIOLOGY 2020; 9:biology9110351. [PMID: 33113951 PMCID: PMC7690715 DOI: 10.3390/biology9110351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/20/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
Simple Summary In this article, we have briefly described the various forms of leishmania infection occur in emergency settings as well as the principal differential diagnoses, and we propose a decision algorithm to facilitate its early recognition in the emergency department (ED). Regarding the last point, the costs and validity of the most common modern diagnostic technologies have been examined, with particular attention to their sensibility and specificity; particularly, rk39-based RTD has been examined. To reinforce the importance of a quick diagnosis performed in the emergency room, we introduce a rather paradigmatic case report of a 19-year-old patient presenting with suspected lymphoproliferative disease and subsequently addressed to the incorrect hospital ward. As often happens, signs and symptoms tended toward the diagnosis of a hematologic disease rather than an infectious one: therefore, it is crucial to include a variety of diagnostic possibilities when a patient presents with fever and associated lympho-adenomegaly with minor symptoms: Leishmaniasis always needs to be considered among them. Abstract Systemic or localized lympho-adenomegaly is a common cause of access to the emergency department (ED), and differential diagnosis is often complicated. The combination of anamnesis, physical examination, laboratory tests, and instrumental diagnosis are extremely important to orientate toward a rapid and correct therapy, even if a prompt discrimination of the etiology of this lymphadenomegaly is not often possible. Our aim with this review is to improve the management of a differential diagnosis between hematological and infective diseases as leishmaniasis in ED and suggest quick diagnostic techniques that might be useful for early identification. Together in the review, we describe a case report of a young man affected from visceral leishmaniasis who presented to our ED and was incorrectly addressed to the wrong ward for the study of his condition. Subsequently, we focus on the clinical presentation of visceral leishmaniasis and compare it to the most common differential diagnoses that are usually taken into account in the management of such patients.
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15
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Calvo A, Moreno E, Larrea E, Sanmartín C, Irache JM, Espuelas S. Berberine-Loaded Liposomes for the Treatment of Leishmania infantum-Infected BALB/c Mice. Pharmaceutics 2020; 12:pharmaceutics12090858. [PMID: 32916948 PMCID: PMC7558179 DOI: 10.3390/pharmaceutics12090858] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 01/19/2023] Open
Abstract
Berberine (BER)—an anti-inflammatory quaternary isoquinoline alkaloid extracted from plants—has been reported to have a variety of biologic properties, including antileishmanial activity. This work addresses the preparation of BER-loaded liposomes with the aim to prevent its rapid liver metabolism and improve the drug selective delivery to the infected organs in visceral leishmaniasis (VL). BER liposomes (LP-BER) displayed a mean size of 120 nm, negative Z-potential of −38 mV and loaded 6 nmol/μmol lipid. In vitro, the loading of BER in liposomes enhanced its selectivity index more than 7-fold by decreasing its cytotoxicity to macrophages. In mice, LP-BER enhanced drug accumulation in the liver and the spleen. Consequently, the liposomal delivery of the drug reduced parasite burden in the liver and spleen by three and one logarithms (99.2 and 93.5%), whereas the free drug only decreased the infection in the liver by 1-log. The organ drug concentrations—far from IC50 values— indicate that BER immunomodulatory activity or drug metabolites also contribute to the efficacy. Although LP-BER decreased 10-fold—an extremely rapid clearance of the free drug in mice—the value remains very high. Moreover, LP-BER reduced plasma triglycerides levels.
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Affiliation(s)
- Alba Calvo
- ISTUN Institute of Tropical Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain; (A.C.); (E.M.); (E.L.); (C.S.)
- Chemistry and Pharmaceutical Technology Department, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain;
| | - Esther Moreno
- ISTUN Institute of Tropical Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain; (A.C.); (E.M.); (E.L.); (C.S.)
- Chemistry and Pharmaceutical Technology Department, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain;
- IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Esther Larrea
- ISTUN Institute of Tropical Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain; (A.C.); (E.M.); (E.L.); (C.S.)
- IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Carmen Sanmartín
- ISTUN Institute of Tropical Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain; (A.C.); (E.M.); (E.L.); (C.S.)
- Chemistry and Pharmaceutical Technology Department, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain;
- IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Juan Manuel Irache
- Chemistry and Pharmaceutical Technology Department, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain;
- IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
| | - Socorro Espuelas
- ISTUN Institute of Tropical Health, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain; (A.C.); (E.M.); (E.L.); (C.S.)
- Chemistry and Pharmaceutical Technology Department, University of Navarra, Irunlarrea 1, 31008 Pamplona, Spain;
- IdisNA, Navarra Institute for Health Research, 31008 Pamplona, Spain
- Correspondence: ; Tel.: +34-948-425-600 (ext. 806310)
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Offenbacher R, Rybinski B, Joseph T, Rahmani N, Boucher T, Weiser DA. An 8-Year-Old Boy With Fever, Splenomegaly, and Pancytopenia. Pediatrics 2020; 146:peds.2019-2372. [PMID: 32532792 DOI: 10.1542/peds.2019-2372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 11/24/2022] Open
Abstract
An 8-year-old boy with no significant past medical history presented to his pediatrician with 5 days of fever, diffuse abdominal pain, and pallor. The pediatrician referred the patient to the emergency department (ED), out of concern for possible malignancy. Initial vital signs indicated fever, tachypnea, and tachycardia. Physical examination was significant for marked abdominal distension, hepatosplenomegaly, and abdominal tenderness in the right upper and lower quadrants. Initial laboratory studies were notable for pancytopenia as well as an elevated erythrocyte sedimentation rate and C-reactive protein. Computed tomography (CT) of the abdomen and pelvis showed massive splenomegaly. The only significant history of travel was immigration from Albania 10 months before admission. The patient was admitted to a tertiary care children's hospital and was evaluated by hematology-oncology, infectious disease, genetics, and rheumatology subspecialty teams. Our multidisciplinary panel of experts will discuss the evaluation of pancytopenia with apparent multiorgan involvement and the diagnosis and appropriate management of a rare disease.
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Affiliation(s)
- Rachel Offenbacher
- The Children's Hospital at Montefiore, Bronx, New York; and .,Albert Einstein College of Medicine, Bronx, New York
| | - Brad Rybinski
- Albert Einstein College of Medicine, Bronx, New York
| | - Tuhina Joseph
- The Children's Hospital at Montefiore, Bronx, New York; and.,Albert Einstein College of Medicine, Bronx, New York
| | - Nora Rahmani
- The Children's Hospital at Montefiore, Bronx, New York; and.,Albert Einstein College of Medicine, Bronx, New York
| | | | - Daniel A Weiser
- The Children's Hospital at Montefiore, Bronx, New York; and.,Albert Einstein College of Medicine, Bronx, New York
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17
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Duthie MS, Goto Y, Ghosh P, Mondal D. Impact of sequelae of visceral leishmaniasis and their contribution to ongoing transmission of Leishmania donovani. Pathog Dis 2020; 77:5582598. [PMID: 31589291 PMCID: PMC6830496 DOI: 10.1093/femspd/ftz057] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/03/2019] [Indexed: 12/04/2022] Open
Abstract
Visceral leishmaniasis (VL) in the Old World is caused by infection with Leishmania donovani. Although the numbers of new reported cases of VL in Africa have been relatively stable for several years, the low numbers currently reported on the Indian subcontinent suggest a positive impact of new treatments and intervention strategies. In both regions, however, VL relapse and post-kala-azar dermal leishmaniasis (PKDL) maintain infectious reservoirs and therefore present a threat to control programs. In this review, we outline the evolving appreciation of PKDL as an impactful disease in its own right and discuss the various diagnostic methods that can be applied for the detection and characterization of PKDL cases. We also highlight the data that indicate the potential, and likely contribution, of PKDL cases to ongoing transmission of L. donovani.
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Affiliation(s)
- Malcolm S Duthie
- Infectious Disease Research Institute, 1616 Eastlake Ave E, Suite 400, Seattle, WA 98102, USA
| | - Yasuyuki Goto
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, University of Tokyo, 1-1-1 Yayoi, Bungkyo-ku, Tokyo 113-8657, Japan
| | - Prakash Ghosh
- 68 Shaheed Tajuddin Ahmed Saranai, Mokakhali, Dhaka-1212, Bangladesh
| | - Dinesh Mondal
- 68 Shaheed Tajuddin Ahmed Saranai, Mokakhali, Dhaka-1212, Bangladesh
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18
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Sundar S, Singh A, Agrawal N, Chakravarty J. Effectiveness of Single-Dose Liposomal Amphotericin B in Visceral Leishmaniasis in Bihar. Am J Trop Med Hyg 2020; 101:795-798. [PMID: 31436156 DOI: 10.4269/ajtmh.19-0179] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Liposomal amphotericin B (LAmB) is recommended for treatment of Indian visceral leishmaniasis (VL), with a cure rate of more than 95% in the Indian subcontinent. A prospective observational study of 1,143 subjects was performed with a longer follow-up than prior studies (12 months) to evaluate the long-term effectiveness and safety of LAmB for the treatment of VL. Patients received a single dose of 10 mg/kg LAmB and were evaluated for initial cure at day 30 and final cure at 6 and 12 months to see the response to the therapy. Furthermore, predictors of relapse were also calculated. At day 30, the initial cure rate was 100%; however, at 6 months and 12 months, cure rates were 97.0% and 94.2% by per-protocol analysis and 96.9% and 93.9% by intension-to-treat analysis, respectively. Fever was the most common adverse event (AE). There were no deaths and serious AEs. Male gender, weight less than 30 kg, and spleen size more than 4 cm at the start of the treatment were significant risk factors of relapse. Liposomal amphotericin B was found to be very effective and safe in the treatment of VL. A longer follow-up period of 12 months is recommended to pick up late relapses.
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Affiliation(s)
- Shyam Sundar
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Anup Singh
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Jaya Chakravarty
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Cloots K, Burza S, Malaviya P, Hasker E, Kansal S, Mollett G, Chakravarty J, Roy N, Lal BK, Rijal S, Sundar S, Boelaert M. Male predominance in reported Visceral Leishmaniasis cases: Nature or nurture? A comparison of population-based with health facility-reported data. PLoS Negl Trop Dis 2020; 14:e0007995. [PMID: 31995564 PMCID: PMC7010295 DOI: 10.1371/journal.pntd.0007995] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 02/10/2020] [Accepted: 12/09/2019] [Indexed: 12/20/2022] Open
Abstract
Background Bangladesh, India, and Nepal aim for the elimination of Visceral Leishmaniasis (VL), a systemic parasitic infectious disease, as a public health problem by 2020. For decades, male patients have comprised the majority of reported VL cases in this region. By comparing this reported VL sex ratio to the one observed in population-based studies conducted in the Indian subcontinent, we tested the working hypothesis that mainly socio-cultural gender differences in healthcare-seeking behavior explain this gender imbalance. Methodology/Principal findings We compared the observed sex ratio of male versus female among all VL cases reported by the health system in Nepal and in the two most endemic states in India with that observed in population-based cohort studies in India and Nepal. Also, we assessed male sex as a potential risk factor for seroprevalence at baseline, seroconversion, and VL incidence in the same population-based data. The male/female ratio among VL cases reported by the health systems was 1.40 (95% CI 1.37–1.43). In the population cohort data, the age- and study site-adjusted male to female risk ratio was 1.27 (95% CI 1.08–1.51). Also, males had a 19% higher chance of being seropositive at baseline in the population surveys (RR 1.19; 95% CI 1.11–1.27), while we observed no significant difference in seroconversion rate between both sexes at the DAT cut-off titer defined as the primary endpoint. Conclusions/Significance Our population-based data show that male sex is a risk factor for VL, and not only as a socio-cultural determinant. Biological sex-related differences likely play an important role in the pathogenesis of this disease. Visceral Leishmaniasis (VL) is a parasitic disease that is lethal if not treated timely and mainly affects impoverished populations. Bangladesh, India, and Nepal have targeted the elimination of this disease as a public health problem by 2020. The majority of VL patients attending the health services are male, and this is usually attributed to unequal access to health care for men and women in this sociocultural context. We analyzed two large datasets obtained in population surveillance projects, including regular door-to-door screening for VL, in India and Nepal. Thereby we minimized any potential differences in access to health care between both sexes, as every suspect VL case occurring in the community received a full diagnostic work-up, and the research project facilitated transport to treatment centers if needed. By comparing the observed sex ratio in the health services records with those of the population surveillance records, we aimed to reach meaningful conclusions about the pathway through which male gender exerts its leverage for increasing VL risk: socio-cultural determinants blocking women from accessing care (nurture) or biological factors (nature) making men more vulnerable to VL. Because in the population-based age adjusted-data, male VL cases were significantly more frequent than female, our findings strongly suggest that in the Indian subcontinent, biological differences between men and women play a more critical role in the pathogenesis of VL than previously assumed, and the observed male predominance in VL cases in health services cannot be explained by socio-cultural factors only. Moreover, data show that above the age of 14 years, males are seropositive more often than females and are at higher risk to develop VL disease.
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Affiliation(s)
- Kristien Cloots
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | | | | | - Epco Hasker
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sangeeta Kansal
- Department of Medicine, Banaras Hindu University, Varanasi, India
| | - Guy Mollett
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jaya Chakravarty
- Department of Medicine, Banaras Hindu University, Varanasi, India
| | - Nurpur Roy
- National Vector Borne Disease Control Program, Ministry of Health & Family Welfare, New Delhi, India
| | - Bibek Kumar Lal
- Epidemiology and Disease Control Division, Ministry of Health, Kathmandu, Nepal
| | - Suman Rijal
- Drugs for Neglected Diseases initiative, New Delhi, India
| | - Shyam Sundar
- Department of Medicine, Banaras Hindu University, Varanasi, India
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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van Griensven J, Diro E. Visceral Leishmaniasis: Recent Advances in Diagnostics and Treatment Regimens. Infect Dis Clin North Am 2019; 33:79-99. [PMID: 30712769 DOI: 10.1016/j.idc.2018.10.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diagnostic advances in visceral leishmaniasis include the development of the rK39 and rK28 rapid diagnostic test. The direct agglutination test is also increasingly used, as well as conventional and real-time polymerase chain reaction, which also performs well on peripheral blood. The choice of treatment for visceral leishmaniasis depends on the geographic region where the infection is acquired. Liposomal amphotericin B is generally found to be safe and effective in most endemic regions of the world; antimonials still remain to be the most effective in eastern Africa despite its high toxicity. Combination therapy is increasingly explored. Immunosuppressed patients require adapted diagnostic and therapeutic strategies.
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Affiliation(s)
- Johan van Griensven
- Department of Clinical Sciences, Institute of Tropical Medicine, Nationalestraat 155, Antwerp 2000, Belgium.
| | - Ermias Diro
- Department of Internal Medicine, University of Gondar, Post Office Box 196, Gondar, Ethiopia
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21
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Goyal V, Burza S, Pandey K, Singh SN, Singh RS, Strub-Wourgaft N, Das VNR, Bern C, Hightower A, Rijal S, Sunyoto T, Alves F, Lima N, Das P, Alvar J. Field effectiveness of new visceral leishmaniasis regimens after 1 year following treatment within public health facilities in Bihar, India. PLoS Negl Trop Dis 2019; 13:e0007726. [PMID: 31557162 PMCID: PMC6782108 DOI: 10.1371/journal.pntd.0007726] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 10/08/2019] [Accepted: 08/23/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND An earlier open label, prospective, non-randomized, non-comparative, multi-centric study conducted within public health facilities in Bihar, India (CTRI/2012/08/002891) measured the field effectiveness of three new treatment regimens for visceral leishmaniasis (VL): single dose AmBisome (SDA), and combination therapies of AmBisome and miltefosine (AmB+Milt) and miltefosine and paromomycin (Milt+PM) up to 6 months follow-up. The National Vector Borne Disease Control Program (NVBDCP) recommended an extended follow up at 12 months post-treatment of the original study cohort to quantify late relapses. METHODS The 1,761 patients enrolled in the original study with the three new regimens were contacted and traced between 10 and 36 months following completion of treatment to determine their health status and any occurrence of VL relapse. RESULTS Of 1,761 patients enrolled in the original study, 1,368 were traced at the extended follow-up visit: 711 (80.5%), 295 (83.2%) and 362 (71.5%) patients treated with SDA, AmB+Milt and Milt+PM respectively. Of those traced, a total of 75 patients were reported to have relapsed by the extended follow-up; 45 (6.3%) in the SDA, 25 (8.5%) in the AmB+Milt and 5 (1.4%) in the Milt+PM arms. Of the 75 relapse cases, 55 had already been identified in the 6-months follow-up and 20 were identified as new cases of relapse at extended follow-up; 7 in the SDA, 10 in the AmB+Milt and 3 in the Milt+PM arms. CONCLUSION Extending follow-up beyond the standard 6 months identified additional relapses, suggesting that 12-month sentinel follow-up may be useful as a programmatic tool to better identify and quantify relapses. With limited drug options, there remains an urgent need to develop effective new chemical entities (NCEs) for VL.
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Affiliation(s)
- Vishal Goyal
- Drugs for Neglected Diseases initiative (DNDi), New York, United States of America
- * E-mail:
| | - Sakib Burza
- Médecins Sans Frontières (MSF), New Delhi, India
| | - Krishna Pandey
- Rajendra Memorial Research Institute of Medical Sciences (RMRI), Patna, Bihar, India
| | | | | | | | - Vidya Nand Rabi Das
- Rajendra Memorial Research Institute of Medical Sciences (RMRI), Patna, Bihar, India
| | - Caryn Bern
- University of California San Francisco, San Francisco, California, United States of America
| | | | - Suman Rijal
- Drugs for Neglected Diseases initiative (DNDi), New Delhi, India
| | | | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | | | - Pradeep Das
- Rajendra Memorial Research Institute of Medical Sciences (RMRI), Patna, Bihar, India
| | - Jorge Alvar
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
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Jayakumar B, Murthy N, Misra K, Burza S. "It's just a fever": Gender based barriers to care-seeking for visceral leishmaniasis in highly endemic districts of India: A qualitative study. PLoS Negl Trop Dis 2019; 13:e0007457. [PMID: 31247011 PMCID: PMC6597040 DOI: 10.1371/journal.pntd.0007457] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 05/10/2019] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Diagnosis and treatment for visceral leishmaniasis (VL) is considered to be delayed amongst poor, rural women in highly endemic districts of Bihar and Jharkhand. The objective of this study was to assess and understand barriers to VL diagnosis and treatment for women in endemic districts with a high burden of VL. METHODS The study used a stratified and purposive sample of 33 female patients with VL, 11 health staff, 11 local (unqualified) health providers and 12 groups of community elders drawn from ten districts in Bihar and four in Jharkhand with high burdens of VL. The study was conducted within an exploratory and inductive framework, using semi-structured in-depth interviews and discussions. RESULTS Women accessing treatment more quickly tended to move faster from treating their symptoms on their own to seeking care from local providers. Perception among female patients of the illness being not serious (owing to initially non-specific and mild symptoms), lack of money, prioritisation of household chores over their need to seek care and the absence of a male guardian to accompany them in seeking care at facilities worked together to drive these choices. Most patients and their families did not suspect VL as the cause for their non-specific symptoms, but when VL was suspected, treatment shopping ended. Lack of prioritization of women's health issues appears to be a pervasive underlying factor. Public health facilities were not an early treatment choice for the majority, but where it was, the diagnosis of VL was often not considered when presenting with under 2 weeks of symptoms, nor were appropriate follow-up plans instituted. CONCLUSION The insidious presentation of VL and the low prioritisation of women's health need to be jointly addressed through messages that emphasise the importance of early diagnosis and treatment of disease, which is low-cost in time and money when managed in public health facilities. Clear messages that project prioritising women's care-seeking over household work as a smart choice and the need for rallying male support are needed. Additionally, efforts to reduce missed opportunities through early case suspicion and engaging private providers to better counsel women with suspected VL could close critical gaps in the continuum of care.
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Affiliation(s)
| | - Nirmala Murthy
- Foundation for Research in Health Systems, Bangalore, India
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23
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Chakravarty J, Sundar S. Current and emerging medications for the treatment of leishmaniasis. Expert Opin Pharmacother 2019; 20:1251-1265. [DOI: 10.1080/14656566.2019.1609940] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jaya Chakravarty
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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24
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Álvarez-Velilla R, Gutiérrez-Corbo MDC, Punzón C, Pérez-Pertejo MY, Balaña-Fouce R, Fresno M, Reguera RM. A chronic bioluminescent model of experimental visceral leishmaniasis for accelerating drug discovery. PLoS Negl Trop Dis 2019; 13:e0007133. [PMID: 30763330 PMCID: PMC6392311 DOI: 10.1371/journal.pntd.0007133] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 02/27/2019] [Accepted: 01/06/2019] [Indexed: 12/20/2022] Open
Abstract
Background Visceral leishmaniasis is a neglected parasitic disease with no vaccine available and its pharmacological treatment is reduced to a limited number of unsafe drugs. The scarce readiness of new antileishmanial drugs is even more alarming when relapses appear or the occurrence of hard-to-treat resistant strains is detected. In addition, there is a gap between the initial and late stages of drug development, which greatly delays the selection of leads for subsequent studies. Methodology/Principal findings In order to address these issues, we have generated a red-shifted luminescent Leishmania infantum strain that enables long-term monitoring of parasite burden in individual animals with an in vivo limit of detection of 106 intracellular amastigotes 48 h postinfection. For this purpose, we have injected intravenously different infective doses (104—5x108) of metacyclic parasites in susceptible mouse models and the disease was monitored from initial times to 21 weeks postinfection. The emission of light from the target organs demonstrated the sequential parasite colonization of liver, spleen and bone marrow. When miltefosine was used as proof-of-concept, spleen weight parasite burden and bioluminescence values decreased significantly. Conclusions In vivo bioimaging using a red-shifted modified Leishmania infantum strain allows the appraisal of acute and chronic stage of infection, being a powerful tool for accelerating drug development against visceral leishmaniasis during both stages and helping to bridge the gap between early discovery process and subsequent drug development. Visceral leishmaniasis is a neglected disease that poses a significant threat to impoverished human populations of low-income countries. Due to the unavailability of vaccines, pharmacological treatment is the only approach to control the disease that otherwise can be lethal. To date, drug management in endemic regions is based on combinations of a handful of mostly unsafe drugs, where the emergence of resistant strains is an additional problem. To accelerate the discovery of new drug entities, several gaps from the early discovery of a compound to its public use, should be filled. One of these gaps is the need of a rapid go/no-go testing system for compounds based on robust preclinical models. Here, we propose a new long-term model of murine visceral leishmaniasis using in vivo bioluminescent imaging. For this purpose, a red-shifted bioluminescent Leishmania infantum strain was engineered. This strain has allowed the appraisal of the disease in individual animals and the monitoring of parasite colonization in liver, spleen and bone marrow. As proof of concept of this platform, mice were infected with the transgenic L. infantum strain treated with a standard schedule of miltefosine, the only oral drug available against Leishmania parasites. Bioluminescence and parasite load in the target organs were compared showing a good correlation. Our findings provide a robust and reproducible tool for drug discovery in a chronic model of murine visceral leishmaniasis.
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Affiliation(s)
- Raquel Álvarez-Velilla
- Departamento de Biología Molecular, Centro de Biología Molecular Severo Ochoa, Consejo Superior de Investigaciones Científicas, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Carmen Punzón
- Diomune S.L Parque Científico de Madrid, Madrid, Spain
| | | | | | - Manuel Fresno
- Departamento de Biología Molecular, Centro de Biología Molecular Severo Ochoa, Consejo Superior de Investigaciones Científicas, Universidad Autónoma de Madrid, Madrid, Spain
- Diomune S.L Parque Científico de Madrid, Madrid, Spain
| | - Rosa María Reguera
- Departamento de Ciencias Biomédicas, Universidad de León, León, Spain
- * E-mail:
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25
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Sundar S, Chakravarty J, Meena LP. Leishmaniasis: treatment, drug resistance and emerging therapies. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2019.1552853] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Jaya Chakravarty
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Lalit P Meena
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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26
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Chapman LAC, Morgan ALK, Adams ER, Bern C, Medley GF, Hollingsworth TD. Age trends in asymptomatic and symptomatic Leishmania donovani infection in the Indian subcontinent: A review and analysis of data from diagnostic and epidemiological studies. PLoS Negl Trop Dis 2018; 12:e0006803. [PMID: 30521526 PMCID: PMC6283524 DOI: 10.1371/journal.pntd.0006803] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/30/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Age patterns in asymptomatic and symptomatic infection with Leishmania donovani, the causative agent of visceral leishmaniasis (VL) in the Indian subcontinent (ISC), are currently poorly understood. Age-stratified serology and infection incidence have been used to assess transmission levels of other diseases, which suggests that they may also be of use for monitoring and targeting control programmes to achieve elimination of VL and should be included in VL transmission dynamic models. We therefore analysed available age-stratified data on both disease incidence and prevalence of immune markers with the aim of collating the currently available data, estimating rates of infection, and informing modelling and future data collection. METHODOLOGY/PRINCIPAL FINDINGS A systematic literature search yielded 13 infection prevalence and 7 VL incidence studies meeting the inclusion criteria. Statistical tests were performed to identify trends by age, and according to diagnostic cut-off. Simple reversible catalytic models with age-independent and age-dependent infection rates were fitted to the prevalence data to estimate infection and reversion rates, and to test different hypotheses about the origin of variation in these rates. Most of the studies showed an increase in infection prevalence with age: from ≲10% seroprevalence (<20% Leishmanin skin test (LST) positivity) for 0-10-year-olds to >10% seroprevalence (>20% LST-positivity) for 30-40-year-olds, but overall prevalence varied considerably between studies. VL incidence was lower amongst 0-5-year-olds than older age groups in most studies; most showing a peak in incidence between ages 5 and 20. The age-independent catalytic model provided the best overall fit to the infection prevalence data, but the estimated rates for the less parsimonious age-dependent model were much closer to estimates from longitudinal studies, suggesting that infection rates may increase with age. CONCLUSIONS/SIGNIFICANCE Age patterns in asymptomatic infection prevalence and VL incidence in the ISC vary considerably with geographical location and time period. The increase in infection prevalence with age and peaked age-VL-incidence distribution may be due to lower exposure to infectious sandfly bites in young children, but also suggest that acquired immunity to the parasite increases with age. However, poor standardisation of serological tests makes it difficult to compare data from different studies and draw firm conclusions about drivers of variation in observed age patterns.
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Affiliation(s)
- Lloyd A. C. Chapman
- Zeeman Institute, University of Warwick, Coventry, United Kingdom
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alex L. K. Morgan
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- School of Biological Sciences, University of Edinburgh, Edinbugh, United Kingdom
| | - Emily R. Adams
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, United States of America
| | - Graham F. Medley
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - T. Déirdre Hollingsworth
- Zeeman Institute, University of Warwick, Coventry, United Kingdom
- School of Life Sciences, University of Warwick, Coventry, United Kingdom
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, United Kingdom
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Abstract
Leishmaniasis is a poverty-related disease with two main clinical forms: visceral leishmaniasis and cutaneous leishmaniasis. An estimated 0·7-1 million new cases of leishmaniasis per year are reported from nearly 100 endemic countries. The number of reported visceral leishmaniasis cases has decreased substantially in the past decade as a result of better access to diagnosis and treatment and more intense vector control within an elimination initiative in Asia, although natural cycles in transmission intensity might play a role. In east Africa however, the case numbers of this fatal disease continue to be sustained. Increased conflict in endemic areas of cutaneous leishmaniasis and forced displacement has resulted in a surge in these endemic areas as well as clinics across the world. WHO lists leishmaniasis as one of the neglected tropical diseases for which the development of new treatments is a priority. Major evidence gaps remain, and new tools are needed before leishmaniasis can be definitively controlled.
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Affiliation(s)
- Sakib Burza
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; Médecins Sans Frontières, Delhi, India
| | - Simon L Croft
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
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28
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Recent Development of Visceral Leishmaniasis Treatments: Successes, Pitfalls, and Perspectives. Clin Microbiol Rev 2018; 31:31/4/e00048-18. [PMID: 30158301 DOI: 10.1128/cmr.00048-18] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Research in visceral leishmaniasis in the last decade has been focused on how better to use the existing medicines as monotherapy or in combination. Systematic research by geographical regions has shown that a universal treatment is far from today's reality. Substantial progress has been made in the elimination of kala-azar in South Asia, with a clear strategy on first- and second-line therapy options of single-dose liposomal amphotericin B and a combination of paromomycin and miltefosine, respectively, among other interventions. In Eastern Africa, sodium stibogluconate (SSG) and paromomycin in combination offer an advantage compared to the previous SSG monotherapy, although not exempted of limitations, as this therapy requires 17 days of painful double injections and bears the risk of SSG-related cardiotoxicity. In this region, attempts to improve the combination therapy have been unsuccessful. However, pharmacokinetic studies have led to a better understanding of underlying mechanisms, like the underexposure of children to miltefosine treatment, and an improved regimen using an allometric dosage. Given this global scenario of progress and pitfalls, we here review what steps need to be taken with existing medicines and highlight the urgent need for oral drugs. Furthermore, it should be noted that six candidates belonging to five new chemical classes are reaching phase I, ensuring an optimistic near future.
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Abstract
Treatment of Visceral Leishmaniasis (VL), a neglected tropical disease, is very challenging with few treatment options. Long duration of treatment and drug toxicity further limit the target of achieving VL elimination. Chemotherapy remains the treatment of choice. Single dose of liposomal amphotericin B (LAmB) and multidrug therapy (LAmB + miltefosine, LAmB + paromomycin (PM), or miltefosine + PM) are recommended treatment regimen for treatment of VL in Indian sub-continent. Combination therapy of pentavalent antimonials (Sbv) and PM in East Africa and LAmB in the Mediterranean region/South America remains the treatment of choice. Various drugs having anti-leishmania properties are in preclinical phase and need further development. An effective treatment and secondary prophylaxis of HIV-VL co-infection should be developed to decrease treatment failure and drug resistance.
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Affiliation(s)
- Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005
| | - Anup Singh
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005
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30
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van Griensven J, Mohammed R, Ritmeijer K, Burza S, Diro E. Tuberculosis in Visceral Leishmaniasis-Human Immunodeficiency Virus Coinfection: An Evidence Gap in Improving Patient Outcomes? Open Forum Infect Dis 2018; 5:ofy059. [PMID: 29732379 PMCID: PMC5925430 DOI: 10.1093/ofid/ofy059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/14/2018] [Indexed: 11/14/2022] Open
Abstract
Background Visceral leishmaniasis (VL)-human immunodeficiency virus (HIV) coinfection remains a major problem in Ethiopia, India, and Brazil. Tuberculosis (TB), a treatable factor, could contribute to high mortality (up to 25%) in VL-HIV coinfection. However, the current evidence on the prevalence and clinical impact of TB in VL-HIV coinfection is very limited. In previous reports on routine care, TB prevalence ranged from 5.7% to 29.7%, but information on how and when TB was diagnosed was lacking. Methods Field observations suggest that TB work-up is often not done systematically, and it is only done in patients who do not respond well to VL treatment. Here, we advocate high-quality diagnostic studies in VL-HIV-coinfected patients, during which all patients are systematically screened for TB, including a comprehensive work-up, to obtain reliable estimates. Results Cost-effective and feasible diagnostic algorithms can be developed for field use, and this can be integrated in VL clinical guidelines. Conclusions An accurate diagnosis of TB can allow clinicians to assess its clinical impact and evaluate the impact of early TB diagnosis.
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Affiliation(s)
| | | | - Koert Ritmeijer
- Médecins sans Frontières, Amsterdam, The Netherlands.,Médecins sans Frontières, Barcelona, Spain
| | - Sakib Burza
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
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31
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Jervis S, Chapman LAC, Dwivedi S, Karthick M, Das A, Le Rutte EA, Courtenay O, Medley GF, Banerjee I, Mahapatra T, Chaudhuri I, Srikantiah S, Hollingsworth TD. Variations in visceral leishmaniasis burden, mortality and the pathway to care within Bihar, India. Parasit Vectors 2017; 10:601. [PMID: 29216905 PMCID: PMC5719561 DOI: 10.1186/s13071-017-2530-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 11/12/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Visceral leishmaniasis (VL) has been targeted by the WHO for elimination as a public health problem (< 1 case/10,000 people/year) in the Indian sub-continent (ISC) by 2020. Bihar State in India, which accounts for the majority of cases in the ISC, remains a major target for this elimination effort. However, there is considerable spatial, temporal and sub-population variation in occurrence of the disease and the pathway to care, which is largely unexplored and a threat to achieving the target. METHODS Data from 6081 suspected VL patients who reported being clinically diagnosed during 2012-2013 across eight districts in Bihar were analysed. Graphical comparisons and Chi-square tests were used to determine differences in the burden of identified cases by season, district, age and sex. Log-linear regression models were fitted to onset (of symptoms)-to-diagnosis and onset-to-treatment waiting times to estimate their associations with age, sex, district and various socio-economic factors (SEFs). Logistic regression models were used to identify factors associated with mortality. RESULTS Comparisons of VL caseloads suggested an annual cycle peaking in January-March. A 17-fold variation in the burden of identified cases across districts and under-representation of young children (0-5 years) relative to age-specific populations in Bihar were observed. Women accounted for a significantly lower proportion of the reported cases than men (41 vs 59%, P < 0.0001). Age, district of residence, house wall materials, caste, treatment cost, travelling for diagnosis and the number of treatments for symptoms before diagnosis were identified as correlates of waiting times. Mortality was associated with age, district of residence, onset-to-treatment waiting time, treatment duration, cattle ownership and cost of diagnosis. CONCLUSIONS The distribution of VL in Bihar is highly heterogeneous, and reported caseloads and associated mortality vary significantly across different districts, posing different challenges to the elimination campaign. Socio-economic factors are important correlates of these differences, suggesting that elimination will require tailoring to population and sub-population circumstances.
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Affiliation(s)
- Sarah Jervis
- School of Life Sciences, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Lloyd A C Chapman
- School of Life Sciences, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK.
| | - Shweta Dwivedi
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Morchan Karthick
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Aritra Das
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | - Epke A Le Rutte
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Orin Courtenay
- School of Life Sciences, University of Warwick, Gibbet Hill Campus, Coventry, CV4 7AL, UK
| | - Graham F Medley
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
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Alonso S, Tachfouti N, Najdi A, Sicuri E, Picado A. Cost-effectiveness of diagnostic-therapeutic strategies for paediatric visceral leishmaniasis in Morocco. BMJ Glob Health 2017; 2:e000315. [PMID: 29018581 PMCID: PMC5620433 DOI: 10.1136/bmjgh-2017-000315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/15/2017] [Indexed: 11/12/2022] Open
Abstract
Introduction Visceral leishmaniasis (VL) is a neglected parasitic disease with a high fatality rate if left untreated. Endemic in Morocco, as well as in other countries in the Mediterranean basin, VL mainly affects children living in rural areas. In Morocco, the direct observation of Leishmania parasites in bone marrow (BM) aspirates is used to diagnose VL and meglumine antimoniate (SB) is the first line of treatment. Less invasive, more efficacious and safer alternatives exist. In this study we estimate the cost-effectiveness of alternative diagnostic-therapeutic algorithms for paediatric VL in Morocco. Methods A decision tree was used to estimate the cost-effectiveness of using BM or rapid diagnostic tests (RDTs) as diagnostic tools and/or SB or two liposomal amphotericin B (L-AmB) regimens: 6-day and 2-day courses to treat VL. Incremental cost-effectiveness ratios, expressed as cost per death averted, were estimated by comparing costs and effectiveness of the alternative algorithms. A threshold analysis evaluated at which price L-AmB became cost-effective compared with current practices. Results Implementing RDT and/or L-AmB treatments would be cost-effective in Morocco according to the WHO thresholds. Introducing the 6-day course L-AmB, current second-line treatment, would be highly cost-effective if L-AmB price was below US$100/phial. The 2-day L-AmB treatment, current standard treatment of paediatric VL in France, is highly cost-effective, with L-AmB at its market price (US$165/phial). Conclusions The results of this study should encourage the implementation of RDT and/or short-course L-AmB treatments for paediatric VL management in Morocco and other North African countries.
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Affiliation(s)
- Sergi Alonso
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelon, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Manhica, Mozambique
| | - Nabil Tachfouti
- Laboratory of Epidemiology, clinical Research and Community Health, Sidi Mohamed Ben Abdillah University, Fez, Morocco
| | - Adil Najdi
- Laboratory of Epidemiology, clinical Research and Community Health, Sidi Mohamed Ben Abdillah University, Fez, Morocco.,School of Medicine of Tangier, Tangier, Morocco
| | - Elisa Sicuri
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelon, Barcelona, Spain.,Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Albert Picado
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic - Universitat de Barcelon, Barcelona, Spain.,Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
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Nanoliposomal Buparvaquone Immunomodulates Leishmania infantum-Infected Macrophages and Is Highly Effective in a Murine Model. Antimicrob Agents Chemother 2017; 61:AAC.02297-16. [PMID: 28167544 DOI: 10.1128/aac.02297-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/22/2017] [Indexed: 11/20/2022] Open
Abstract
Visceral leishmaniasis is a fatal parasitic neglected disease affecting 1.5 million people worldwide. Based on a drug repositioning approach, the aim of this work was to investigate the in vitro immunomodulatory potential of buparvaquone (BPQ) and to establish a safe regimen to evaluate the in vivo efficacy of BPQ entrapped by negatively charged nanoliposomes (BPQ-LP) in Leishmania infantum-infected hamsters. Small-angle X-ray scattering, dynamic light scattering, and the ζ-potential were applied in order to study the influence of BPQ on the liposome structure. Our data revealed that BPQ was located in the polar-apolar interface, snorkeling the polar region, and protected against aggregation inside the lipophilic region. The presence of BPQ also decreased the Z-average hydrodynamic diameter and increased the surface charge. Compared to intravenous and intramuscular administration, a subcutaneous route was a more effective route for BPQ-LP; at 0.4 mg/kg, BPQ-LP reduced infection in the spleen and liver by 98 and 96%, respectively. Treatment for 5 days resulted in limited efficacy, but 10 days of treatment resulted in an efficacy similar to that of a 15-day regimen. The nanoliposomal drug was highly effective, with a mean 50% effective dose of 0.25 mg/kg, reducing the parasite load in bone marrow by 80%, as detected using quantitative PCR analysis. In addition, flow cytometry studies showed that BPQ upregulated cytokines as tumor necrosis factor, monocyte chemoattractant protein 1, interleukin-10 (IL-10), and IL-6 in Leishmania-infected macrophages, eliminating the parasites via a nitric oxide-independent mechanism. This new formulation proved to be a safe and effective treatment for murine leishmaniasis that could be a useful candidate against visceral leishmaniasis.
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Transmission Dynamics of Visceral Leishmaniasis in the Indian Subcontinent - A Systematic Literature Review. PLoS Negl Trop Dis 2016; 10:e0004896. [PMID: 27490264 PMCID: PMC4973965 DOI: 10.1371/journal.pntd.0004896] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/12/2016] [Indexed: 12/24/2022] Open
Abstract
Background As Bangladesh, India and Nepal progress towards visceral leishmaniasis (VL) elimination, it is important to understand the role of asymptomatic Leishmania infection (ALI), VL treatment relapse and post kala-azar dermal leishmaniasis (PKDL) in transmission. Methodology/ Principal Finding We reviewed evidence systematically on ALI, relapse and PKDL. We searched multiple databases to include studies on burden, risk factors, biomarkers, natural history, and infectiveness of ALI, PKDL and relapse. After screening 292 papers, 98 were included covering the years 1942 through 2016. ALI, PKDL and relapse studies lacked a reference standard and appropriate biomarker. The prevalence of ALI was 4–17-fold that of VL. The risk of ALI was higher in VL case contacts. Most infections remained asymptomatic or resolved spontaneously. The proportion of ALI that progressed to VL disease within a year was 1.5–23%, and was higher amongst those with high antibody titres. The natural history of PKDL showed variability; 3.8–28.6% had no past history of VL treatment. The infectiveness of PKDL was 32–53%. The risk of VL relapse was higher with HIV co-infection. Modelling studies predicted a range of scenarios. One model predicted VL elimination was unlikely in the long term with early diagnosis. Another model estimated that ALI contributed to 82% of the overall transmission, VL to 10% and PKDL to 8%. Another model predicted that VL cases were the main driver for transmission. Different models predicted VL elimination if the sandfly density was reduced by 67% by killing the sandfly or by 79% by reducing their breeding sites, or with 4–6y of optimal IRS or 10y of sub-optimal IRS and only in low endemic setting. Conclusion/ Significance There is a need for xenodiagnostic and longitudinal studies to understand the potential of ALI and PKDL as reservoirs of infection. The role of asymptomatic Leishmania infection (ALI), PKDL and VL relapse in transmission is unclear as VL elimination is achieved in the Indian subcontinent. ALI, PKDL and relapse studies lacked a reference standard and appropriate biomarker. ALI was 4–17-fold more prevalent than VL. The risk of ALI was higher in VL case contacts. Most infections remained asymptomatic or resolved spontaneously. The natural history of PKDL showed variability. Twenty nine percent had no past history of VL treatment. The risk of VL relapse was higher with HIV co-infection. Modelling studies predicted different effects. Early diagnosis was unlikely to eliminate VL in the long term. ALI was predicted to contribute to 82% of the overall transmission, VL to 10% and PKDL to 8%. Another model predicted that VL cases were the main driver for transmission. VL elimination was predicted if the sandfly density was reduced by 67% by killing the sandfly or by 79% by reducing their breeding sites, or with 4–6y of optimal IRS or 10y of sub-optimal IRS and only in low endemic setting. There is a need for more studies to fully understand the potential of ALI and PKDL as reservoirs of infection.
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Identification of Synthetic and Natural Host Defense Peptides with Leishmanicidal Activity. Antimicrob Agents Chemother 2016; 60:2484-91. [PMID: 26883699 DOI: 10.1128/aac.02328-15] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/06/2016] [Indexed: 01/05/2023] Open
Abstract
Leishmaniaparasites are a major public health problem worldwide. Effective treatment of leishmaniasis is hampered by the high incidence of adverse effects to traditional drug therapy and the emergence of resistance to current therapeutics. A vaccine is currently not available. Host defense peptides have been investigated as novel therapeutic agents against a wide range of pathogens. Here we demonstrate that the antimicrobial peptide LL-37 and the three synthetic peptides E6, L-1018, and RI-1018 exhibit leishmanicidal activity against promastigotes and intramacrophage amastigotes ofLeishmania donovaniandLeishmania major We also report that theLeishmaniaprotease/virulence factor GP63 confers protection toLeishmaniafrom the cytolytic properties of alll-form peptides (E6, L-1018, and LL-37) but not thed-form peptide RI-1018. The results suggest that RI-1018, E6, and LL-37 are promising peptides to develop further into components for antileishmanial therapy.
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Adler-Moore JP, Gangneux JP, Pappas PG. Comparison between liposomal formulations of amphotericin B. Med Mycol 2016; 54:223-31. [PMID: 26768369 DOI: 10.1093/mmy/myv111] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/08/2015] [Indexed: 11/13/2022] Open
Abstract
Given the clinical success of commercial amphotericin B lipid products, investigators have begun making generic formulations of liposomal amphotericin B. Generic medicines are an attractive approach to help decrease the cost and accessibility to healthcare, provided that appropriate studies are performed to ensure bioequivalence with the parent product. This is of particular concern for liposomal drugs such as amphotericin B where liposomes are used as a carrier system to reduce the toxicity of the active agent. A favorable therapeutic profile for this form of the drug has to include the proper chemical composition along with strictly controlled manufacturing processes. Studies have shown that a comparison of liposomal amphotericin B products with different or the same chemical compositions, using different methods of production, will vary in size, and have significantly dissimilar in vitro and in vivo toxicities along with reduced efficacy. These results underscore the importance of establishing appropriate bioequivalence testing for liposome products to ensure uniformity of their therapeutic index.
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Affiliation(s)
- Jill P Adler-Moore
- Department of Biological Sciences, California State Polytechnic University, Pomona, California, USA
| | - Jean-Pierre Gangneux
- Centre Hospitalier Universitaire de Rennes, Laboratoire de Parasitologie-Mycologie, Rennes, France INSERM U1085, IRSET (Institut de Recherche en Santé Environnement Travail), Université Rennes 1, Rennes, France
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, 1900 University Blvd, 229 THT, Birmingham, Alabama 35294-0006, USA
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Collier MA, Peine KJ, Gautam S, Oghumu S, Varikuti S, Borteh H, Papenfuss TL, Sataoskar AR, Bachelder EM, Ainslie KM. Host-mediated Leishmania donovani treatment using AR-12 encapsulated in acetalated dextran microparticles. Int J Pharm 2016; 499:186-194. [PMID: 26768723 DOI: 10.1016/j.ijpharm.2016.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/15/2022]
Abstract
Leishmaniasis is a disease caused by parasites of Leishmania sp., which effects nearly 12 million people worldwide and is associated with treatment complications due to widespread parasite resistance toward pathogen-directed therapeutics. The current treatments for visceral leishmaniasis (VL), the systemic form of the disease, involve pathogen-mediated drugs and have long treatment regimens, increasing the risk of forming resistant strains. One way to limit emergence of resistant pathogens is through the use of host-mediated therapeutics. The host-mediated therapeutic AR-12, which is FDA IND-approved for cancer treatment, has shown activity against a broad spectrum of intracellular pathogens; however, due to hydrophobicity and toxicity, it is difficult to reach therapeutic doses. We have formulated AR-12 into microparticles (AR-12/MPs) using the novel biodegradable polymer acetalated dextran (Ace-DEX) and used this formulation for the systemic treatment of VL. Treatment with AR-12/MPs significantly reduced liver, spleen, and bone marrow parasite loads in infected mice, while combinatorial therapies with amphotericin B had an even more significant effect. Overall, AR-12/MPs offer a unique, host-mediated therapy that could significantly reduce the emergence of drug resistance in the treatment of VL.
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Affiliation(s)
- M A Collier
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - K J Peine
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - S Gautam
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, United States
| | - S Oghumu
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - S Varikuti
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - H Borteh
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, United States
| | - T L Papenfuss
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - A R Sataoskar
- College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - E M Bachelder
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - K M Ainslie
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
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Goswami RP, Goswami RP, Das S, Satpati A, Rahman M. Short-Course Treatment Regimen of Indian Visceral Leishmaniasis with an Indian Liposomal Amphotericin B Preparation (Fungisome™). Am J Trop Med Hyg 2015; 94:93-8. [PMID: 26526926 DOI: 10.4269/ajtmh.14-0657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 09/20/2015] [Indexed: 11/07/2022] Open
Abstract
India bears the burden of about half of global visceral leishmaniasis (VL) cases with emerging problems of stibanate resistance. Liposomal preparations have improved treatment outcome through shorter duration of therapy and lower toxicity compared with conventional amphotericin B. We report the efficacy of two short-course regimens of an Indian preparation of liposomal amphotericin B (Fungisome™) for VL caused by Leishmania donovani in India. An open-label, randomized, single-center comparative study was undertaken from 2008 to 2011, involving 120 treatment naive non-human immunodeficiency virus VL patients randomly allocated to two groups. Fungisome™ was given, in groups A (N = 60), 5 mg/kg daily for 2 days and B (N = 60), 7.5 mg/kg daily for 2 days, as intravenous infusion. Initial cure rate was 100% in both the groups after 1 month posttreatment. At 6 months after completion of treatment, definitive cure rate was group A 90% (54/60, 95% confidence interval (CI): 80.55-95.72%); group B: 100% (95% CI: 95.92-100%); (P = 0.027). No serious adverse events occurred in either group. The short-course, 2-day regimen of 15 mg/kg Fungisome™ infusion is easy to administer, effective, and safe for treatment of VL caused by L. donovani in India.
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Affiliation(s)
- Rama P Goswami
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, West Bengal, India; Department of Rheumatology, Institution of Post Graduate Medical Education and Research, West Bengal, India; Department of Medicine, ESI Hospital, Joka, West Bengal, India
| | - Rudra P Goswami
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, West Bengal, India; Department of Rheumatology, Institution of Post Graduate Medical Education and Research, West Bengal, India; Department of Medicine, ESI Hospital, Joka, West Bengal, India
| | - Sukhen Das
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, West Bengal, India; Department of Rheumatology, Institution of Post Graduate Medical Education and Research, West Bengal, India; Department of Medicine, ESI Hospital, Joka, West Bengal, India
| | - Aditya Satpati
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, West Bengal, India; Department of Rheumatology, Institution of Post Graduate Medical Education and Research, West Bengal, India; Department of Medicine, ESI Hospital, Joka, West Bengal, India
| | - Mehebubar Rahman
- Department of Tropical Medicine, Calcutta School of Tropical Medicine, West Bengal, India; Department of Rheumatology, Institution of Post Graduate Medical Education and Research, West Bengal, India; Department of Medicine, ESI Hospital, Joka, West Bengal, India
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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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Mahajan R, Das P, Isaakidis P, Sunyoto T, Sagili KD, Lima MA, Mitra G, Kumar D, Pandey K, Van Geertruyden JP, Boelaert M, Burza S. Combination Treatment for Visceral Leishmaniasis Patients Coinfected with Human Immunodeficiency Virus in India. Clin Infect Dis 2015; 61:1255-62. [PMID: 26129756 PMCID: PMC4583582 DOI: 10.1093/cid/civ530] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/24/2015] [Indexed: 11/15/2022] Open
Abstract
We describe the safety and efficacy of treating visceral leishmaniasis (VL) in patients with human immunodeficiency virus-VL coinfection with concurrent intravenous liposomal amphotericin B (AmBisome) and oral miltefosine (Impavido) in India. The regimen was safe, well tolerated, with lower relapse rates than monotherapy. Background. There are considerable numbers of patients coinfected with human immunodeficiency virus (HIV) and visceral leishmaniasis (VL) in the VL-endemic areas of Bihar, India. These patients are at higher risk of relapse and death, but there are still no evidence-based guidelines on how to treat them. In this study, we report on treatment outcomes of coinfected patients up to 18 months following treatment with a combination regimen. Methods. This retrospective analysis included all patients with confirmed HIV-VL coinfection receiving combination treatment for VL at a Médecins Sans Frontières treatment center between July 2012 and September 2014. Patients were treated with 30 mg/kg body weight intravenous liposomal amphotericin B (AmBisome) divided as 6 equal dose infusions combined with 14 days of 100 mg/day oral miltefosine (Impavido). All patients were encouraged to start or continue on antiretroviral therapy (ART). Results. 102 patients (76% males, 57% with known HIV infection, 54% with a prior episode of VL) were followed-up for a median of 11 months (interquartile range: 4–18). Cumulative incidence of all-cause mortality and VL relapse at 6, 12, and 18 months was 11.7%, 14.5%, 16.6% and 2.5%, 6.0%,13.9%, respectively. Cumulative incidence of poor outcome at 6, 12, and 18 months was 13.9%, 18.4%, and 27.2%, respectively. Not initiating ART and concurrent tuberculosis were independent risk factors for mortality, whereas no factors were associated with relapse. Conclusions. In this Bihar-based study, combination therapy appeared to be well tolerated, safe, and effective and may be considered as an option for treatment of VL in HIV coinfected patients.
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Affiliation(s)
| | - Pradeep Das
- Rajendra Mamorial Research Institute, Patna, India
| | | | | | - Karuna D Sagili
- International Union Against Tuberculosis and Lung Disease (The Union), New Delhi, India
| | | | | | | | | | | | | | - Sakib Burza
- Médecins Sans Frontières, New Delhi Institute of Tropical Medicine, Antwerp, Belgium
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Aluru S, Hide M, Michel G, Bañuls AL, Marty P, Pomares C. Multilocus microsatellite typing of Leishmania and clinical applications: a review. ACTA ACUST UNITED AC 2015; 22:16. [PMID: 25950900 PMCID: PMC4423940 DOI: 10.1051/parasite/2015016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/17/2015] [Indexed: 12/03/2022]
Abstract
Microsatellite markers have been used for Leishmania genetic studies worldwide, giving useful insight into leishmaniasis epidemiology. Understanding the geographic distribution, dynamics of Leishmania populations, and disease epidemiology improved markedly with this tool. In endemic foci, the origins of antimony-resistant strains and multidrug treatment failures were explored with multilocus microsatellite typing (MLMT). High genetic variability was detected but no association between parasite genotypes and drug resistance was established. An association between MLMT profiles and clinical disease manifestations was highlighted in only three studies and this data needs further confirmation. At the individual level, MLMT provided information on relapse and reinfection when multiple leishmaniasis episodes occurred. This information could improve knowledge of epidemiology and guide therapeutic choices for active chronic visceral leishmaniasis, the disease form in some HIV-positive patients.
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Affiliation(s)
- Srikanth Aluru
- Aix-Marseille Université, Marseille, France - INSERM, U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Toxines Microbiennes dans la Relation Hôte Pathogènes, 06204 Nice Cedex 3, France
| | - Mallorie Hide
- UMR MIVEGEC IRD 224-CNRS 5290, Universités Montpellier 1 et 2, Montpellier, France
| | - Gregory Michel
- INSERM, U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Toxines Microbiennes dans la Relation Hôte Pathogènes, 06204 Nice Cedex 3, France - Université de Nice Sophia Antipolis, Faculté de Médecine, 06107 Nice Cedex 2, France
| | - Anne-Laure Bañuls
- UMR MIVEGEC IRD 224-CNRS 5290, Universités Montpellier 1 et 2, Montpellier, France
| | - Pierre Marty
- INSERM, U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Toxines Microbiennes dans la Relation Hôte Pathogènes, 06204 Nice Cedex 3, France - Université de Nice Sophia Antipolis, Faculté de Médecine, 06107 Nice Cedex 2, France - Parasitologie-Mycologie, Centre Hospitalier Universitaire l'Archet, CS 23079, 06202 Nice Cedex 3, France
| | - Christelle Pomares
- INSERM, U1065, Centre Méditerranéen de Médecine Moléculaire, C3M, Toxines Microbiennes dans la Relation Hôte Pathogènes, 06204 Nice Cedex 3, France - Université de Nice Sophia Antipolis, Faculté de Médecine, 06107 Nice Cedex 2, France - Parasitologie-Mycologie, Centre Hospitalier Universitaire l'Archet, CS 23079, 06202 Nice Cedex 3, France
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Khadem F, Uzonna JE. Immunity to visceral leishmaniasis: implications for immunotherapy. Future Microbiol 2015; 9:901-15. [PMID: 25156379 DOI: 10.2217/fmb.14.43] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Visceral leishmaniasis, caused by Leishmania donovani, L. infantum (syn. Leishmania chagasi), is a globally widespread disease with a burden of about 400,000 new infections reported annually. It is the most dangerous form of human leishmaniasis in terms of mortality and morbidity and is spreading to several nonendemic areas because of migration, global traveling and military conflicts. The emergence of Leishmania-HIV co-infection and increased prevalence of drug-resistant strains have worsened the impact of the disease. The traditional low-cost drugs are often toxic with several adverse effects, highlighting the need for development of new therapeutic and prophylactic strategies. Therefore, a detailed understanding of mechanisms of protective immunity is extremely important in order to develop new therapeutics in the form of vaccines or immunotherapies. This review gives an overview of visceral leishmaniasis, with particular emphasis on the innate and adaptive immune responses, vaccine and vaccination strategies and their potentials for immunotherapy against the disease.
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Affiliation(s)
- Forough Khadem
- Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Lucero E, Collin SM, Gomes S, Akter F, Asad A, Kumar Das A, Ritmeijer K. Effectiveness and safety of short course liposomal amphotericin B (AmBisome) as first line treatment for visceral leishmaniasis in Bangladesh. PLoS Negl Trop Dis 2015; 9:e0003699. [PMID: 25837313 PMCID: PMC4383421 DOI: 10.1371/journal.pntd.0003699] [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: 12/16/2014] [Accepted: 03/12/2015] [Indexed: 12/14/2022] Open
Abstract
Background Bangladesh is one of the endemic countries for Visceral Leishmaniasis (VL). Médecins Sans Frontières (MSF) ran a VL treatment clinic in the most endemic district (Fulbaria) between 2010 and 2013 using a semi-ambulatory regimen for primary VL of 15mg/kg Liposomal Amphotericin-B (AmBisome) in three equal doses of 5mg/kg. The main objective of this study was to analyze the effectiveness and safety of this regimen after a 12 month follow-up period by retrospective analysis of routinely collected program data. A secondary objective was to explore risk factors for relapse. Methods and Principal Findings Our analysis included 1521 patients who were initially cured, of whom 1278 (84%) and 1179 (77.5%) were followed-up at 6 and 12 months, respectively. Cure rates at 6 and 12 months were 98.7% (1262/1278) and 96.4% (1137/1179), respectively. Most relapses (26/39) occurred between 6 and 12 months after treatment. Serious adverse events (SAE) were recorded for 7 patients (0.5%). Odds of relapse at 12 months were highest in the youngest and oldest age groups. There was some evidence that spleen size measured on discharge (one month after initiation of treatment) was associated with risk of relapse: OR=1.25 (95% CI 1.01 to 1.55) per cm below lower costal margin (P=0.04). Conclusions Our study demonstrates that 15mg/kg AmBisome in three doses of 5mg/kg is an effective (>95% cure rate) and safe (<1% SAE) treatment for primary VL in Bangladesh. The majority of relapses occurred between 6 and 12 months, justifying the use of a longer follow-up period when feasible. Assessment of risk of relapse based on easily measured clinical parameters such as spleen size could be incorporated in VL treatment protocols in resource-poor settings where test-of-cure is not always feasible. Visceral Leishmaniasis (VL) is a parasitic disease which is endemic in more than 80 countries, although 90% of cases occur in India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil. Most treatments are complex, expensive and require long application periods. AmBisome is one of the newest treatments available, but evidence for its safety and effectiveness under routine program conditions in resource-poor endemic areas remains sparse. Médecins Sans Frontières (MSF) ran a VL clinic from 2010 until 2014 in Fulbaria District, Bangladesh. Our retrospective study was based on all available data from this clinic, comprising 1521 patients diagnosed with primary VL who were treated with AmBisome 15mg/kg in three equal doses of 5mg/kg. We found that this treatment was safe (less than 1% of patients experienced a severe adverse event) and effective (more than 95% of patients were cured with one treatment) after 12 months. The youngest and oldest patients, and patients with large spleen size at the end of treatment, were more likely to experience a relapse. More than half of the relapses occurred between 6 and 12 months after treatment, therefore we recommend that clinical trials and treatment protocols adopt a minimum 12-month follow-up period.
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Affiliation(s)
- Emiliano Lucero
- Institute of Tropical Medicine and International Health, Charité—Universitätsmedizin Berlin, Germany
- Centro de Estudios e Investigación de la Enfermedad de Chagas y Leishmaniasis—Universidad Nacional de Cordoba, Argentina
| | - Simon M. Collin
- School of Social & Community Medicine, University of Bristol, United Kingdom
| | - Sujit Gomes
- Médecins Sans Frontières, Fulbaria, Bangladesh
| | | | | | | | - Koert Ritmeijer
- Médecins Sans Frontières, Amsterdam, The Netherlands
- * E-mail:
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Abstract
INTRODUCTION Leishmaniasis broadly manifests as visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis. The treatment of leishmaniasis is challenging and the armamentarium of drugs is small, duration of treatment is long, and most drugs are toxic. AREAS COVERED A literature search on treatment of leishmaniasis was done on PubMed. Single dose of liposomal amphotericin B (L-AmB) and multidrug therapy (L-AmB + miltefosine, L-AmB + paromomycin (PM), or miltefosine + PM) are the treatment of choice for VL in the Indian subcontinent. A 17-day combination therapy of pentavalent antimonials (Sb(v)) and PM remains the treatment of choice for East African VL. L-AmB at a total dose of 18 - 21 mg/kg is the recommended regimen for VL in the Mediterranean region and South America. Treatment of CL should be decided by the severity of clinical lesions, etiological species and its potential to develop into mucosal leishmaniasis. EXPERT OPINION There is an urgent need to implement a single-dose L-AmB or combination therapy in the Indian subcontinent. Shorter and more acceptable regimens are needed for the treatment of post - kala-azar dermal leishmaniasis. Combination therapy with newer drugs needs to be tested in Africa. Due to the toxicity of systemic therapy, a trend toward local treatment for New World CL is preferred in patients without risk of mucosal disease.
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Affiliation(s)
- Shyam Sundar
- Banaras Hindu University, Institute of Medical Sciences, Department of Medicine , Varanasi , India +91 542 2369632 ;
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Burza S, Mahajan R, Sinha PK, van Griensven J, Pandey K, Lima MA, Sanz MG, Sunyoto T, Kumar S, Mitra G, Kumar R, Verma N, Das P. Visceral leishmaniasis and HIV co-infection in Bihar, India: long-term effectiveness and treatment outcomes with liposomal amphotericin B (AmBisome). PLoS Negl Trop Dis 2014; 8:e3053. [PMID: 25101665 PMCID: PMC4125300 DOI: 10.1371/journal.pntd.0003053] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Accepted: 06/15/2014] [Indexed: 11/19/2022] Open
Abstract
Background Visceral Leishmaniasis (VL; also known as kala-azar) is an ultimately fatal disease endemic in the Indian state of Bihar, while HIV/AIDS is an emerging disease in this region. A 2011 observational cohort study conducted in Bihar involving 55 VL/HIV co-infected patients treated with 20–25 mg/kg intravenous liposomal amphotericin B (AmBisome) estimated an 85.5% probability of survival and a 26.5% probability of VL relapse within 2 years. Here we report the long-term field outcomes of a larger cohort of co-infected patients treated with this regimen between 2007 and 2012. Methods and Principal Findings Intravenous AmBisome (20–25 mg/kg) was administered to 159 VL/HIV co-infected patients (both primary infections and relapses) in four or five doses of 5 mg/kg over 4–10 days. Initial cure of VL at discharge was defined as improved symptoms, cessation of fever, improvement of appetite and recession of spleen enlargement. Test of cure was not routinely performed. Antiretroviral treatment (ART) was initiated in 23 (14.5%), 39 (24.5%) and 61 (38.4%) before, during and after admission respectively. Initial cure was achieved in all discharged patients. A total of 36 patients died during follow-up, including six who died shortly after admission. Death occurred at a median of 11 weeks (IQR 4–51) after starting VL treatment. Estimated mortality risk was 14.3% at six months, 22.4% at two years and 29.7% at four years after treatment. Among the 153 patients discharged from the hospital, 26 cases of VL relapse were diagnosed during follow-up, occurring at a median of 10 months (IQR 7–14) after discharge. After accounting for competing risks, the estimated risk of relapse was 16.1% at one year, 20.4% at two years and 25.9% at four years. Low hemoglobin level and concurrent infection with tuberculosis were independent risk factors for mortality, while ART initiated shortly after admission for VL treatment was associated with a 64–66% reduced risk of mortality and 75% reduced risk of relapse. Significance This is the largest cohort of HIV-VL co-infected patients reported from the Indian subcontinent. Even after initial cure following treatment with AmBisome, these patients appear to have much higher rates of VL relapse and mortality than patients not known to be HIV-positive, although relapse rates appear to stabilize after 2 years. These results extend the earlier findings that co-infected patients are at increased risk of death and require a multidisciplinary approach for long-term management. Fifty percent of all visceral leishmaniasis (VL) cases globally occur in India, where up to 90% of cases occur in the state of Bihar. There are also an estimated 300,000 people in Bihar living with HIV/AIDS. Patients with HIV who are treated for VL typically have much worse outcomes than VL patients who are HIV-negative, yet there exists very little evidence suggesting more effective treatments for this group. Between 2007–2012, with support of the Rajendra Memorial Research Institute (RMRI), Médecins Sans Frontières (MSF) treated 8,749 VL patients in Bihar using liposomal amphotericin-B (AmBisome). Here we describe the characteristics and long-term outcomes of a subgroup of 159 HIV-VL co-infected patients treated within this program over the 5-year period. Their estimated mortality risk was 14.3% at six months after treatment, 22.4% at two years and 29.7% at four years. Estimated risk of relapse was 16.1% at one year, 20.4% at two years and 25.9% at four years. We conclude that treatment of HIV-VL co-infected patients with 20–25 mg/kg of liposomal amphotericin-B is well tolerated and relatively effective. However, HIV-VL co-infection is a complex chronic disease with high early mortality and much worse outcomes than VL alone, and requires a multidisciplinary long-term management strategy.
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Affiliation(s)
- Sakib Burza
- Médecins Sans Frontières, New Delhi, India
- Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | | | - Prabhat K. Sinha
- Rajendra Memorial Research Institute of Medical Sciences, Patna, Bihar, India
| | | | | | | | | | | | - Sunil Kumar
- Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, India
| | | | | | - Neena Verma
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Pradeep Das
- Institute of Tropical Medicine, Antwerp, Belgium
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Burza S, Mahajan R, Sanz MG, Sunyoto T, Kumar R, Mitra G, Lima MA. HIV and visceral leishmaniasis coinfection in Bihar, India: an underrecognized and underdiagnosed threat against elimination. Clin Infect Dis 2014; 59:552-5. [PMID: 24814660 DOI: 10.1093/cid/ciu333] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Although human immunodeficiency virus (HIV) and visceral leishmaniasis coinfection is recognized as a major public health challenge in Africa, data regarding the prevalence in India are very limited. Consecutive HIV screening of 2077 patients aged ≥14 years with confirmed visceral leishmaniasis in Bihar, eastern India, found that 5.6% were HIV positive, including 2.4% with newly diagnosed HIV infection.
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Vanaerschot M, Dumetz F, Roy S, Ponte-Sucre A, Arevalo J, Dujardin JC. Treatment failure in leishmaniasis: drug-resistance or another (epi-) phenotype? Expert Rev Anti Infect Ther 2014; 12:937-46. [PMID: 24802998 DOI: 10.1586/14787210.2014.916614] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Two major leishmaniasis treatments have shown a significant decrease in effectiveness in the last few decades, mostly in the Indian subcontinent but also in other endemic areas. Drug resistance of Leishmania correlated only partially to treatment failure (TF) of pentavalent antimonials, and has so far proved not to be important for the increased miltefosine relapse rates observed in the Indian subcontinent. While other patient- or drug-related factors could also have played a role, recent studies identified several parasite features such as infectivity and host manipulation skills that might contribute to TF. This perspective aims to discuss how different parasitic features other than drug resistance can contribute to TF of leishmaniasis and how this may vary between different epidemiological contexts.
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Affiliation(s)
- Manu Vanaerschot
- Molecular Parasitology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium
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