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Sundar S, Chakravarty J, Singh J, Verma D, Agrawal N, Dinkar A. Amphotericin B Deoxycholate Treatment of Post-Kala-Azar Dermal Leishmaniasis in India. Am J Trop Med Hyg 2024; 111:59-63. [PMID: 38834057 PMCID: PMC11229639 DOI: 10.4269/ajtmh.23-0738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/21/2024] [Indexed: 06/06/2024] Open
Abstract
Post-kala-azar dermal leishmaniasis (PKDL) is widely prevalent in the endemic regions of India, but its treatment remains unsatisfactory. The WHO recommends a 12-week treatment with oral miltefosine, but its ocular toxicities are a serious concern. The late 1980s and early 1990s saw the use of sodium stibogluconate and amphotericin B (AmB) for a brief period. Both drugs had frequent adverse events and were expensive, and the duration of treatments was unacceptably long. This retrospective study evaluated, analyzed, and reported the outcomes of PKDL patients treated with a shorter course of AmB, the most effective antileishmanial drug. The hospital records of PKDL patients treated with AmB by 30 alternate-day infusions over 60 days (instead of conventional 60-80 infusions over 100-120 days) between September 2010 and August 2016 were reviewed. Only patients with confirmed parasitological diagnosis were included. Their records were studied for treatment-related adverse events, end-of-treatment parasitological status, and 12-month follow-up results. One hundred two patients were eligible for this study between September 2010 and August 2016. After therapy, 92/102 (90.2%) patients improved; 3 (2.9%) had to cease treatment owing to severe adverse effects, and one died of severe diarrhea unrelated to AmB. Six (5.9%) patients withdrew consent before the treatment was complete. At the 12-month evaluation, 89/102 (87.3%) patients attained a final cure. A 30-infusion regimen of AmB remains highly effective in PKDL. Without a shorter, safer, and more economical regimen for the treatment of PKDL, it should be used until a better regimen is available.
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Affiliation(s)
- Shyam Sundar
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Kala-Azar Medical Research Center, Muzaffarpur, India
| | - Jaya Chakravarty
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Jitendra Singh
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Deepak Verma
- Kala-Azar Medical Research Center, Muzaffarpur, India
| | - Neha Agrawal
- Department of Medicine, University of Florida, Jacksonville, Florida
| | - Anju Dinkar
- Department of Microbiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
- Department of Microbiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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Palić S, Chu WY, Sundar S, Mondal D, Das P, Pandey K, Raja S, Rijal S, Roseboom IC, Hamadeh A, Malik PRV, Beijnen JH, Huitema ADR, Sjögren E, Alves F, Dorlo TPC. Skin pharmacokinetics of miltefosine in the treatment of post-kala-azar dermal leishmaniasis in South Asia. J Antimicrob Chemother 2024; 79:1547-1554. [PMID: 38727613 PMCID: PMC11215536 DOI: 10.1093/jac/dkae129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/04/2024] [Indexed: 07/02/2024] Open
Abstract
INTRODUCTION Post-kala-azar dermal leishmaniasis (PKDL) arises as a dermal complication following a visceral leishmaniasis (VL) infection. Current treatment options for PKDL are unsatisfactory, and there is a knowledge gap regarding the distribution of antileishmanial compounds within human skin. The present study investigated the skin distribution of miltefosine in PKDL patients, with the aim to improve the understanding of the pharmacokinetics at the skin target site in PKDL. METHODS Fifty-two PKDL patients underwent treatment with liposomal amphotericin B (20 mg/kg) plus miltefosine (allometric dosing) for 21 days. Plasma concentrations of miltefosine were measured on study days 8, 15, 22 and 30, while a punch skin biopsy was taken on day 22. A physiologically based pharmacokinetic (PBPK) model was developed to evaluate the distribution of miltefosine into the skin. RESULTS Following the allometric weight-based dosing regimen, median miltefosine concentrations on day 22 were 43.73 µg/g (IQR: 21.94-60.65 µg/g) in skin and 33.29 µg/mL (IQR: 25.9-42.58 µg/mL) in plasma. The median individual concentration ratio of skin to plasma was 1.19 (IQR: 0.79-1.9). In 87% (45/52) of patients, skin exposure was above the suggested EC90 PK target of 10.6 mg/L associated with in vitro susceptibility. Simulations indicated that the residence time of miltefosine in the skin would be more than 2-fold longer than in plasma, estimated by a mean residence time of 604 versus 266 hours, respectively. CONCLUSION This study provides the first accurate measurements of miltefosine penetration into the skin, demonstrating substantial exposure and prolonged retention of miltefosine within the skin. These findings support the use of miltefosine in cutaneous manifestations of leishmaniasis. In combination with parasitological and clinical data, these results are critical for the future optimization of combination therapies with miltefosine in the treatment of PKDL.
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Affiliation(s)
- Semra Palić
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Wan-Yu Chu
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Shyam Sundar
- Department of Medicine, Banaras Hindu University, Varanasi, India
| | - Dinesh Mondal
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Pradeep Das
- Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Krishna Pandey
- Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, India
| | - Sheeraz Raja
- Drugs for Neglected Diseases initiative (DNDi) South Asia, New Delhi, India
| | - Suman Rijal
- Drugs for Neglected Diseases initiative (DNDi) South Asia, New Delhi, India
| | - Ignace C Roseboom
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Abdullah Hamadeh
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Paul R V Malik
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Jos H Beijnen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Alwin D R Huitema
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Erik Sjögren
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
- Pharmetheus AB, Uppsala, Sweden
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Singh-Phulgenda S, Kumar R, Dahal P, Munir A, Rashan S, Chhajed R, Naylor C, Maguire BJ, Siddiqui NA, Harriss E, Rahi M, Alves F, Sundar S, Stepniewska K, Musa A, Guerin PJ, Pandey K. Post-kala-azar dermal leishmaniasis (PKDL) drug efficacy study landscape: A systematic scoping review of clinical trials and observational studies to assess the feasibility of establishing an individual participant-level data (IPD) platform. PLoS Negl Trop Dis 2024; 18:e0011635. [PMID: 38626228 PMCID: PMC11051605 DOI: 10.1371/journal.pntd.0011635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/26/2024] [Accepted: 03/27/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis which can occur after successful treatment of visceral leishmaniasis (VL) and is a public health problem in VL endemic areas. We conducted a systematic scoping review to assess the characteristics of published PKDL clinical studies, understand the scope of research and explore the feasibility and value of developing a PKDL individual patient data (IPD) platform. METHODS A systematic review of published literature was conducted to identify PKDL clinical studies by searching the following databases: PubMed, Scopus, Ovid Embase, Web of Science Core Collection, WHO Global Index Medicus, PASCAL, Clinicaltrials.gov, Ovid Global Health, Cochrane Database and CENTRAL, and the WHO International Clinical Trials Registry Platform. Only prospective studies in humans with PKDL diagnosis, treatment, and follow-up measurements between January 1973 and March 2023 were included. Extracted data includes variables on patient characteristics, treatment regimens, diagnostic methods, geographical locations, efficacy endpoints, adverse events and statistical methodology. RESULTS A total of 3,418 records were screened, of which 56 unique studies (n = 2,486 patients) were included in this review. Out of the 56 studies, 36 (64.3%) were from India (1983-2022), 12 (21.4%) from Sudan (1992-2021), 6 (10.7%) were from Bangladesh (1991-2019), and 2 (3.6%) from Nepal (2001-2007). Five (8.9%) studies were published between 1981-1990 (n = 193 patients), 10 (17.9%) between 1991-2000 (n = 230 patients), 10 (17.9%) between 2001-2010 (n = 198 patients), and 31 (55.4%) from 2011 onwards (n = 1,865 patients). Eight (14.3%) were randomised clinical trials, and 48 (85.7%) were non-randomised studies. The median post-treatment follow-up duration was 365 days (range: 90-540 days) in 8 RCTs and 360 days (range: 28-2,373 days) in 48 non-randomised studies. Disease diagnosis was based on clinical criterion in 3 (5.4%) studies, a mixture of clinical and parasitological methods in 47 (83.9%) and was unclear in 6 (10.7%) studies. Major drugs used for treatment were miltefosine (n = 636 patients), liposomal amphotericin B (L-AmB) (n = 508 patients), and antinomy regimens (n = 454 patients). Ten other drug regimens were tested in 270 patients with less than 60 patients per regimen. CONCLUSIONS Our review identified studies with very limited sample size for the three major drugs (miltefosine, L-AmB, and pentavalent antimony), while the number of patients combined across studies suggest that the IPD platform would be valuable. With the support of relevant stakeholders, the global PKDL community and sufficient financing, a PKDL IPD platform can be realised. This will allow for exploration of different aspects of treatment safety and efficacy, which can potentially guide future healthcare decisions and clinical practices.
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Affiliation(s)
- 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
| | - Rishikesh Kumar
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
| | - 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
| | - Abdalla Munir
- Department of Clinical Pathology and Immunology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Sumayyah Rashan
- 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
| | - Rutuja Chhajed
- 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
| | - Caitlin Naylor
- 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
| | - Brittany J. Maguire
- 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
| | - Niyamat Ali Siddiqui
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
| | - Eli Harriss
- The Knowledge Centre, Bodleian Health Care Libraries, University of Oxford, Oxford, United Kingdom
| | - Manju Rahi
- Indian Council of Medical Research (ICMR), New Delhi, India
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Kasia Stepniewska
- 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
| | - Ahmed Musa
- Department of Clinical Pathology and Immunology, Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - 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
| | - Krishna Pandey
- ICMR—Rajendra Memorial Research Institute of Medical Sciences (RMRIMS), Patna, Bihar, India
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Pal B, Kumari S, Kaur M, Wadhwa P, Murti K, Kumar R, Pandey K, Siddiqui NA, Dhingra S, Padmakar S. Barriers to the effective management and prevention of post kala-azar dermal leishmaniasis (PKDL) in the Indian subcontinent. Med J Armed Forces India 2023; 79:500-505. [PMID: 37719909 PMCID: PMC10499647 DOI: 10.1016/j.mjafi.2023.03.010] [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: 11/22/2022] [Accepted: 03/26/2023] [Indexed: 09/19/2023] Open
Abstract
Post kala-azar dermal leishmaniasis (PKDL) is a skin disease that usually occurs among individuals with a past history of visceral leishmaniasis (VL). PKDL cases act as a reservoir of parasites and may play a significant role in disease transmission. Hence, prompt detection and complete treatment of PKDL cases are crucial for the control and elimination of VL. The purpose of this review was to highlight the barriers to effective control and prevention of VL/PKDL as well as potential solutions in India. Main obstacles are lack of knowledge about the disease and its vector, poor treatment-seeking behaviours, ineffective vector control measures, lack of confirmatory diagnostics in endemic areas, limited drug choices, treatment noncompliance among patients, drug resistance, and a lack of an adequate number of trained personnel in the health system. Therefore, in order to control and successfully eliminate VL in the Indian subcontinent, early detection of PKDL cases, improved diagnosis and treatment, raising awareness, and effective vector control mechanisms are necessary.
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Affiliation(s)
- Biplab Pal
- Assistant Professor, School of Pharmaceutical Science, Lovely Professional University, Punjab, India
| | - Sweta Kumari
- Assistant Professor, School of Pharmaceutical Science, Lovely Professional University, Punjab, India
| | - Manpreet Kaur
- Student, School of Pharmaceutical Science, Lovely Professional University, Punjab, India
| | - Pankaj Wadhwa
- Associate Professor, School of Pharmaceutical Science, Lovely Professional University, Punjab, India
| | - Krishna Murti
- Assistant Professor (Pharmacy Practice), National Institute of Pharmaceutical Education and Research, Hajipur, Bihar, India
| | - Rishikesh Kumar
- Consultant (Biostatistics), Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Agamkuan, Patna, Bihar, India
| | - Krishna Pandey
- Director, Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Agamkuan, Patna, Bihar, India
| | - Niyamat Ali Siddiqui
- Scientist E, (Biostatistics), Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Agamkuan, Patna, Bihar, India
| | - Sameer Dhingra
- Associate Professor (Pharmacy Practice), National Institute of Pharmaceutical Education and Research, Hajipur, Bihar, India
| | - Somanaboina Padmakar
- PhD Scholar, School of Pharmaceutical Science, Lovely Professional University, Punjab, India
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Dinani MS, Noushabadi SAE, Namdar F, Abharian PH, Hejazi SH, Sebghatollahi Z. In Vitro Study of the Leishmanicidal Activity of Perovskia Abrotanoides Terpenoid-Rich Fractions Against Leishmania Major (MRHO/IR/75/ER). Adv Biomed Res 2023; 12:67. [PMID: 37200741 PMCID: PMC10186040 DOI: 10.4103/abr.abr_175_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 02/13/2022] [Accepted: 03/05/2022] [Indexed: 05/20/2023] Open
Abstract
Background Cutaneous leishmaniasis (CL) is an ulcerative skin disease caused by some species of the genus Leishmania. Evidence shows that Perovskia abrotanoides is an important herbal medicine against Leishmania. This study was conducted to investigate the killing effect of terpenoid-rich fractions on promastigotes of L. major (MRHO/IR/75/ER). Material and Method The eluates of reverse phased medium pressure liquid chromatography (RP-MPLC) of the extract were subjected to thin-layer chromatography (TLC) and categorized into six final fractions. Primary proton nuclear magnetic resonance (H-NMR) spectroscopy confirmed fractions' nature. Fractions 4, 5, and 6 (F4, F5, F6) were identified as terpenoid-rich content. Two concentrations of 50 and 100 μg/ml were prepared to test leishmanicidal activity. Followed by treating promastigotes of L. major by the fractions in incubation times of 12, 24, and 48 hours, their viability was determined using a cell proliferation MTS ((3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium) assay. Result F4, F5, and F6 showed significant killing activity on promastigotes of L. major in a concentration-dependent manner. The viability of promastigotes was significantly reduced at a concentration of 100 μg/ml compared to 50 μg/ml (P-value <0.05). Also, over time a significant decreasing trend in the viability of promastigotes confirmed the time-dependent manner of the fractions (P-value <0.01). Furthermore, F5 had the highest leishmanicidal activity at the first incubation time compared with other fractions. Conclusion Terpenoid-rich fractions of the P. abrotanoides have a leishmanicidal activity that depends on time and concentration. Among them, F5 has the highest potency that may contain potent terpenoid constituents.
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Affiliation(s)
- Masoud Sadeghi Dinani
- Department of Pharmacognosy, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed A. Emarati Noushabadi
- Department of Pharmacognosy, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Namdar
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Parastoo Hassani Abharian
- Skin Diseases and Leishmaniasis Research Center, Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - S. H. Hejazi
- Skin Diseases and Leishmaniasis Research Center, Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Sebghatollahi
- Skin Diseases and Leishmaniasis Research Center, Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Address for correspondence: Mrs. Zahra Sebghatollahi, Skin Diseases and Leishmaniasis Research Center, Department of Parasitology and Mycology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail:
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Immune recovery-related patterns of post kala-azar dermal and ocular leishmaniasis in people living with HIV. AIDS 2022; 36:1819-1827. [PMID: 35848585 DOI: 10.1097/qad.0000000000003336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Post kala-azar dermal leishmaniasis (PKDL) is a rare complication of visceral leishmaniasis. We aimed at reporting PKDL cases in people living with HIV (PLHIV) and compare their characteristics based on whether PKDL occurred in the context of immune recovery under antiretroviral therapy (ART) or not. DESIGN National survey and literature review. METHODS We called for observations in France in October 2020 and performed a literature review from PubMed (Medline) and Web of Science up to December 2020. Two groups of patients were defined based on whether PKDL occurred in the context of immune recovery under ART (group 1) or not (group 2), and compared. RESULTS Three PLHIV with PKDL identified in France in the last decade were described and added to 33 cases from the literature. Compared with group 2 (16/36, 44.4%), patients from group 1 (20/36, 55.6%) originated more frequently from Europe (12/20, 60% vs. 2/16, 12.5%; P = 0.0038), had higher median blood CD4 + cell counts (221/μl vs. 61/μl; P = 0.0005) and increase under ART (122/μl, interquartile range 73-243 vs. 33/μl, interquartile range 0-53; P = 0.0044), had less frequently concomitant visceral leishmaniasis (3/20, 15% vs. 8/12, 66.7%; P = 0.006), and a trend to more frequent ocular involvement (7/20, 35% vs. 1/16, 6.25%; P = 0.0531). CONCLUSION In PLHIV, PKDL occurs after a cured episode of visceral leishmaniasis as part of an immune restoration disease under ART, or concomitant to a visceral leishmaniasis relapse in a context of AIDS. For the latter, the denomination 'disseminated cutaneous lesions associated with visceral leishmaniasis' seems more accurate than PKDL.
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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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Abdel-Hafez Y, Siaj H, Janajri M, Abu-Baker Y, Nazzal Z, Hamdan Z, Adwan R, Aiesh BM, Anaya AI. Tolerability and epidemiology of nephrotoxicity associated with conventional amphotericin B therapy: a retrospective study in tertiary care centers in Palestine. BMC Nephrol 2022; 23:132. [PMID: 35382766 PMCID: PMC8982299 DOI: 10.1186/s12882-022-02770-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In the light of recent years, an increase in the number of life-threatening infections due to various fungi has been observed, especially in tertiary care centres. With Amphotericin B labelled as the first choice in treating these infections, one of its common side effects, nephrotoxicity, along with hypokalemia, were studied to determine the epidemiology, risk factors, and protective measures. METHODOLOGY The study was a retrospective observational chart review study in which patients were receiving conventional Amphotericin B in two tertiary hospitals in Palestine from January 2018 to December 2020 were evaluated for the development of hypokalemia and nephrotoxicity; according to the KDIGO criteria. A total of 117 patients were included in the study. Patients who have received the drug intermittently, in fewer than two doses, through non-IV routes and patients under the age of 12 were excluded. The data collected included, but were not limited to, age, gender, comorbidities, Amphotericin B treatment details, medications, COVID-19 status, risk factors, and hypothesized protective measures. RESULTS The incidence of conventional Amphotericin B nephrotoxicity and hypokalemia was 46% and 33%, respectively. With a roughly equal representation of both genders and a median age of 52 years in a range of 13-89. No association between the variables and the development of nephrotoxicity was found. However, a 3.4 increased risk (p-value = 0.01) of developing hypokalemia in females compared to males was observed. CONCLUSION Our research has shown a relatively lower yet consistent, incidence of conventional amphotericin B nephrotoxicity and hypokalemia compared to literature with gender being a risk factor for developing hypokalemia.
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Affiliation(s)
- Yusri Abdel-Hafez
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Hani Siaj
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Mohammad Janajri
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Yazan Abu-Baker
- Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Zaher Nazzal
- Community Medicine, Department of Family and Community Medicine, Faculty of Medicine and Health Sciences, An-Najah National University, Box 7, 707, Nablus, Palestine.
| | - Zakaria Hamdan
- Internal Medicine Department, An-Najah National University Hospital, Box 7, 707, Nablus, Palestine.
| | - Rabee Adwan
- Infectious Diseases Unit, Makassed Charitable Society Hospital, East Jerusalem, Palestine
| | - Banan M Aiesh
- Infection Control Department, An-Najah National University Hospital, Nablus, Palestine
| | - Ahmad I Anaya
- Internal Medicine Department, An-Najah National University Hospital, Nablus, Palestine
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Agarwal A, Kar B. Amphotericin-B in dermatology. Indian Dermatol Online J 2022; 13:152-158. [PMID: 35198495 PMCID: PMC8809177 DOI: 10.4103/idoj.idoj_573_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/06/2021] [Accepted: 11/07/2021] [Indexed: 11/23/2022] Open
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Pandey K, Pal B, Siddiqui NA, Lal CS, Ali V, Bimal S, Kumar A, Verma N, Das VNR, Singh SK, Topno RK, Das P. A randomized, open-label study to evaluate the efficacy and safety of liposomal amphotericin B (AmBisome) versus miltefosine in patients with post-kala-azar dermal leishmaniasis. Indian J Dermatol Venereol Leprol 2021; 87:34-41. [PMID: 33580944 DOI: 10.25259/ijdvl_410_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/01/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Treatment of post-kala-azar dermal leishmaniasis cases is of paramount importance for kala-azar elimination; however, limited treatment regimens are available as of now. AIM To compare the effectiveness of liposomal amphotericin B vs miltefosine in post-kala-azar dermal leishmaniasis patients. METHODOLOGY This was a randomized, open-label, parallel-group study. A total of 100 patients of post kala azar dermal leishmaniasis, aged between 5 and 65 years were recruited, 50 patients in each group A (liposomal amphotericin B) and B (miltefosine). Patients were randomized to receive either liposomal amphotericin B (30 mg/kg), six doses each 5 mg/kg, biweekly for 3 weeks or miltefosine 2.5 mg/kg or 100 mg/day for 12 weeks. All the patients were followed at 3rd, 6th and 12th months after the end of the treatment. RESULTS In the liposomal amphotericin B group, two patients were lost to follow-up, whereas four patients were lost to follow-up in the miltefosine group. The initial cure rate by "intention to treat analysis" was 98% and 100% in liposomal amphotericin B and miltefosine group, respectively. The final cure rate by "per protocol analysis" was 74.5% and 86.9% in liposomal amphotericin B and miltefosine, respectively. Twelve patients (25.5%) in the liposomal amphotericin B group and six patients (13%) in the miltefosine group relapsed. None of the patients in either group developed any serious adverse events. LIMITATIONS Quantitative polymerase chain reaction was not performed at all the follow-up visits and sample sizes. CONCLUSION Efficacy of miltefosine was found to be better than liposomal amphotericin B, hence, the use of miltefosine as first-line therapy for post-kala-azar dermal leishmaniasis needs to be continued. However, liposomal amphotericin B could be considered as one of the treatment options for the elimination of kala-azar from the Indian subcontinent.
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Affiliation(s)
- Krishna Pandey
- Department of Clinical Medicine, Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Patna, Bihar, India
| | - Biplab Pal
- Department of Pharmacology, Lovely Professional University, Phagwara, Punjab
| | | | - Chandra Shekhar Lal
- Department of Biochemistry, Lovely Professional University, Phagwara, Punjab
| | - Vahab Ali
- Department of Microbiology, Lovely Professional University, Phagwara, Punjab
| | - Sanjiva Bimal
- Department of Immunology, Lovely Professional University, Phagwara, Punjab
| | - Ashish Kumar
- Department of Molecular Biology, Lovely Professional University, Phagwara, Punjab
| | - Neena Verma
- Department of Pathology, Lovely Professional University, Phagwara, Punjab
| | - Vidya Nand Rabi Das
- Department of Clinical Medicine, Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Patna, Bihar, India
| | | | - Roshan Kamal Topno
- Department of Epidemiology, Rajendra Memorial Research Institute of Medical Sciences (Indian Council of Medical Research), Patna, Bihar, India
| | - Pradeep Das
- Department of Molecular Biology, Lovely Professional University, Phagwara, Punjab
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Datta A, Podder I, Das A, Sil A, Das NK. Therapeutic Modalities in Post Kala-azar Dermal Leishmaniasis: A Systematic Review of the Effectiveness and Safety of the Treatment Options. Indian J Dermatol 2021; 66:34-43. [PMID: 33911291 PMCID: PMC8061474 DOI: 10.4103/ijd.ijd_264_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Post-kala-azar dermal Leishmaniasis (PKDL) is one of the important neglected tropical diseases, which has a tremendous epidemiological significance, being the reservoir of kala-azar. Relapse and resistance to treatment along with the lack of a drug of choice and consensus treatment guideline pose a significant problem in the management of PKDL. The aim of this article was to review the available therapeutic options for PKDL, with special emphasis on their pharmaco-dynamics, pharmaco-kinetics, effectiveness, safety, tolerability, and cost factor. A comprehensive English language literature search was done for therapeutic options in PKDL across multiple databases (PubMed, EMBASE, MEDLINE, and Cochrane) for keywords (alone and in combination). MeSH as well as non-MeSH terms such as “Kala-azar,” “Leishmaniasis” AND “Treatment,” “Management,” “Antimony Sodium Gluconate,” “Meglumine Antimoniate,” “Amphotericin B,” “Paromomycin,” “Miltefosine” were taken into consideration. Among 576 relevant articles, 15 were deemed relevant to this review. These articles were evaluated using “Oxford Centre for Evidence-Based Medicine (OCEBM)” AND “strength of recommendation taxonomy” (SORT) with respect to the level of evidence and grade of recommendation. The review includes 15 studies. The use of sodium stibogluconate is being discouraged because of multiple documented reports of treatment failure. Liposomal amphotericin B is emerging as a favorable option, owing to its superiority in terms of effectiveness and safety profile. Miltesfosine is the drug of choice in India because of the ease of oral administration and minimal risk of toxicity. Isolated Paromomycin alone is not effective in PKDL; however, combination therapy with sodium stibogluconate is found to be safe and effective. Combination of amphotericin B and miltefosine is one of the excellent options. Immunotherapy with combination of alum-precipitated autoclaved Leishmania major (Alum/ALM) vaccine + Bacille Calmette-Gu´erin (BCG) has shown promising results. Kala-azar continues to haunt the tropical countries and PKDL being its reservoir is threatening its elimination. With the availability of drugs such as liposomal amphotericin B and miltefosine, apart from the advent of immunotherapy, the future of treatment of this condition looks promising.
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Affiliation(s)
- Adrija Datta
- Department of Dermatology, Institute of Post Graduate Medical Education and Research, Kamarhati, West Bengal, India
| | - Indrashis Podder
- Department of Dermatology, Venereology and Leprosy, College of Medicine and Sagore Dutta Hospital, Kamarhati, West Bengal, India
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Jadavpur, West Bengal, India
| | - Amrita Sil
- Department of Pharmacology, Rampurhat Government Medical College, Rampurhat, West Bengal, India
| | - Nilay Kanti Das
- Department of Dermatology, Bankura Sammilani Medical College, Bankura, West Bengal, India
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12
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Tharakan SJ, Peter Cv D, Karthik R, Rupa V, Rose W, Thomas M, Manuel M, Rupali P, Pulimood S, Rao Ajjampur SS. Case Report: A Single-Center Case Series on Skin Manifestations of Leishmaniasis from a Non-Endemic State in Southern India. Am J Trop Med Hyg 2020; 104:928-933. [PMID: 33377447 DOI: 10.4269/ajtmh.20-0938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022] Open
Abstract
Leishmaniasis is endemic in the Indian subcontinent with predominance of visceral leishmaniasis (VL) due to Leishmania donovani. Cutaneous leishmaniasis (CL) is uncommon, and mucocutaneous leishmaniasis (MCL) is rarely reported in this region. Recent reports reveal a changing epidemiology and atypical manifestations. A retrospective study of 52 suspected cases with cutaneous and mucosal involvement seen from January 2008 to December 2018 in a tertiary care setting in a non-endemic state in southern India is reported. Twelve patients were confirmed to have leishmaniasis; seven had MCL, two had CL, and three had post-kala-azar dermal leishmaniasis (PKDL). All cases were male, with a median age of 41.5 years (interquartile range, 30-55.5 years), and the median duration of the disease was 6 years (interquartile range, 1-9.5 years). Patients with MCL had mucosal involvement including destructive ulcero-proliferative lesions due to delayed diagnosis; none had a history of travel to countries endemic for MCL and all were attributable to L. donovani species. On the other hand, Leishmania major which was the causative species in both CL patients was associated with travel to the Middle East. Patients with PKDL presented with multiple plaques and hypopigmented patches; one had concomitant VLand all were from endemic areas. Hitherto uncommon MCL, caused by potentially atypical variants of L. donovani, has emerged as a new manifestation of leishmaniasis in this region. A high index of suspicion based on lesions seen and history of travel combined with PCR-based diagnostics are required to confirm diagnosis for the various skin manifestations of leishmaniasis.
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Affiliation(s)
| | - Dincy Peter Cv
- Departments of Dermatology Unit-II, Christian Medical College, Vellore, India
| | - Rajiv Karthik
- Infectious Diseases, Christian Medical College, Vellore, India
| | - Vedantam Rupa
- ENT Unit-III, Christian Medical College, Vellore, India
| | - Winsley Rose
- Child Health Unit-III, Christian Medical College, Vellore, India
| | - Meera Thomas
- Pathology, Christian Medical College, Vellore, India
| | - Malathi Manuel
- The Wellcome Trust Research Laboratory, Christian Medical College, Vellore, India
| | | | - Susanne Pulimood
- Departments of Dermatology Unit-II, Christian Medical College, Vellore, India
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Ramesh V, Dixit KK, Sharma N, Singh R, Salotra P. Assessing the Efficacy and Safety of Liposomal Amphotericin B and Miltefosine in Combination for Treatment of Post Kala-Azar Dermal Leishmaniasis. J Infect Dis 2020; 221:608-617. [PMID: 31854451 DOI: 10.1093/infdis/jiz486] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/08/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND No satisfactory canonical treatment is available for post-kala-azar dermal leishmaniasis (PKDL), clinical sequela of visceral leishmaniasis. Confined treatment options and substantial increase in relapse rate after miltefosine (MIL) treatment warrant the need to adapt resilient combination therapies. In this study, we assessed the safety and efficacy of combination therapy using liposomal amphotericin B (LAmB) and MIL for treating PKDL. METHODS Thirty-two PKDL patients, confirmed by microscopy or quantitative polymerase chain reaction (qPCR), were included in the study. An equal number of cases (n = 16) were put on MIL monotherapy (100 mg/day for 90 days) or MIL and LAmB combination for 45 days (3 injections of LAmB, 5 mg/kg body weight, and 100 mg/day MIL). Parasite load in slit aspirate was monitored using qPCR. RESULTS Patients treated with combination therapy demonstrated a rapid decline in parasite load and achieved 100% cure, with no reports of relapse. Those treated with MIL monotherapy attained clinical cure with a gradual decrease in parasite load; however, 25% relapsed within 18 months of follow-up. CONCLUSIONS Liposomal amphotericin B and MIL combination for treating PKDL is efficacious and safe, with high tolerability. Furthermore, this study established the utility of minimally invasive slit aspirate method for monitoring of parasite load and assessment of cure in PKDL.
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Affiliation(s)
- V Ramesh
- Department of Dermatology, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India
| | - Keerti Kaumudee Dixit
- Indian Council of Medical Research- National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India.,Faculty of Health and Biological Sciences, Symbiosis International (Deemed University), Pune, India
| | - Neha Sharma
- Department of Dermatology, Safdarjung Hospital and Vardhman Mahavir Medical College, New Delhi, India
| | - Ruchi Singh
- Indian Council of Medical Research- National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
| | - Poonam Salotra
- Indian Council of Medical Research- National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India
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14
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Gedda MR, Singh B, Kumar D, Singh AK, Madhukar P, Upadhyay S, Singh OP, Sundar S. Post kala-azar dermal leishmaniasis: A threat to elimination program. PLoS Negl Trop Dis 2020; 14:e0008221. [PMID: 32614818 PMCID: PMC7332242 DOI: 10.1371/journal.pntd.0008221] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Leishmaniasis remains a public health concern around the world that primarily affects poor folks of the developing world spanning across 98 countries with mortality of 0.2 million to 0.4 million annually. Post kala-azar dermal leishmaniasis (PKDL) is the late skin manifestation of visceral leishmaniasis (VL). It has been reported that about 2.5% to 20% of patients recovered from VL develop PKDL having stilted macular or nodular lesions with parasites. In the Indian subcontinent (ISC), it manifests a few months after recovery from VL, though in Africa it can occur simultaneously with VL or a little later. New cases of PKDL are also observed without prior VL in the ISC. These individuals with PKDL represent an important but largely neglected reservoir of infection that perpetuates anthroponotic Leishmania donovani transmission in the ISC and can jeopardize the VL elimination program as these cases can infect the sand flies and spread the endemic. Therefore, it becomes imperative to eradicate PKDL as a part of the VL elimination program. With the limited treatment options besides little knowledge on PKDL, this review stands out in focusing on different aspects that should be dealt for sustained VL elimination.
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Affiliation(s)
- Mallikarjuna Rao Gedda
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Center for Cellular Engineering, NIH Clinical Center, Bethesda, Maryland, United States of America
| | - Bhawana Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Dhiraj Kumar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
- Department of Zoology, Rameshwar College, BRA Bihar University, Muzaffarpur, India
| | - Abhishek Kumar Singh
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Prasoon Madhukar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shreya Upadhyay
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Om Prakash Singh
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
| | - Shyam Sundar
- Infectious Disease Research Laboratory, Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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15
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Conversion of asymptomatic infection to symptomatic visceral leishmaniasis: A study of possible immunological markers. PLoS Negl Trop Dis 2020; 14:e0008272. [PMID: 32555598 PMCID: PMC7326279 DOI: 10.1371/journal.pntd.0008272] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 06/30/2020] [Accepted: 04/07/2020] [Indexed: 12/31/2022] Open
Abstract
Introduction Presence of asymptomatic individuals in endemic areas is common. The possible biomarkers in asymptomatic individuals once they get exposed to infection as well as following conversion to symptomatic disease are yet to be identified.We identified asymptomatic Visceral leishmaniasis (VL) infection amongst rK39+sorted direct agglutination test positive (DAT+) endemic healthy population and confirmed it by quantitative PCR(qPCR).The immunological determinants such as Adenosine deaminase (ADA), Interferon gamma (IFN-γ), Tumour Necrosis Factor alpha (TNF-α) and Interleukin 10 (IL-10)were examined to predict probable biomarkers for conversion to symptomatic VL. Methods Sample size was 5794 healthy individuals from VL endemic region. Antibody tests(DAT &rK39) were performed and later a qPCR assay was employed using kDNA specific primers and probes. Immunological biomarkers examined were ADA level by ADA–MTP kit and quantitative cytokines(IFN-γ, IL-10 and TNF-α) by ELISA. Results 120 asymptomatic individuals of 308 rK39 sero-positives were DAT positive comprising of 56 with previous history and 64 with no history of VL. RT-PCR confirmed asymptomatic VL in 42 sero-positives. These were followed up through repeated qPCR and evaluation of immunological determinants. We observed10 symptomatic cases converted from a total of 42 asymptomatic individuals identified at base-line. The level of ADA, IL-10 and IFN-γ remained consistently high in asymptomatic cases and amongst these, ADA and IL-10 but not IFN-γ remained higher at the development of clinical symptoms into active VL. On the contrary, there was no significant change in the mean concentration of TNF-α at both stages of the disease. Discussion We surmise from our data that considerable proportion of asymptomatic cases can be a reservoir and may play a crucial role in transmission of visceral leishmaniasis in endemic areas. The data also suggests that ADA and IL-10 can serve as a potential biomarker during the conversion of asymptomatic into symptomatic VL. The most threatening form of leishmaniasis is human visceral leishmaniasis, which is caused by L. donovani in Indian subcontinent. The disease accounts for huge annual burden of infectious disease in India. Efforts towards disease elimination programme are far beyond satisfaction and there is need to re-strengthen health monitoring, surveillance programme in endemic areas. There is a greater need to identify asymptomatic individuals amongst endemic healthy control by active surveillance programme. Further, except a few, many asymptomatic subjects become sero-negative without developing VL due to strong inherent cellular immunity possessed by them. This study enumerates use of rK39, DAT and quantitative PCR(qPCR) in asymptomatic detection and then evaluate immunological biomarkers(Adenosine deaminase, IFN-γ, TNF-α and IL-10) which help in disease conversion to symptomatic VL, at 6 month follow- up. Follow–up analysis revealed that antibody testing with rK39 (3.24%), DAT (8.33%) had poor agreement with disease conversion. By qPCR, we could identify the level of parasitemia, and collectively with serology, the test detected 23.80% of asymptomatic cases converted into disease. The level of ADA and IL-10 remained consistently high during conversion. IFN-γ became high in asymptomatic infection but became low on conversion, whereas, no significant change in level of TNF-α was observed at both stages of disease. Thus by use of qPCR, concomitantly with DAT over rK39+ sorted endemic healthy control may be employed for early case detection. Adenosine is produced by ecto-nucleotide during L.donovaniinfection, has been previously reported and in parallel to this study we conclude that determination of adenosine deaminase level (ADA) might help identify early cases with more tendency to convert into disease. This will help to boost health monitoring programme to eradicate Kala-azar in Bihar, India.
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16
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Zijlstra EE, Kumar A, Sharma A, Rijal S, Mondal D, Routray S. Report of the Fifth Post-Kala-Azar Dermal Leishmaniasis Consortium Meeting, Colombo, Sri Lanka, 14-16 May 2018. Parasit Vectors 2020; 13:159. [PMID: 32228668 PMCID: PMC7106569 DOI: 10.1186/s13071-020-04011-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022] Open
Abstract
The 5th Post-Kala-Azar Dermal Leishmaniasis (PKDL) Consortium meeting brought together PKDL experts from all endemic areas to review and discuss existing and new data on PKDL. This report summarizes the presentations and discussions and provides the overall conclusions and recommendations.
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Affiliation(s)
- Eduard E Zijlstra
- Drugs for Neglected Diseases Initiative, 15 Chemin Louis Dunant, 1202, Geneva, Switzerland.
| | - Amresh Kumar
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
| | - Abhijit Sharma
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
| | - Suman Rijal
- Drugs for Neglected Diseases Initiative, PHD House, 3rd Floor, 4/2 Siri Institutional Area, New Delhi, 110016, India
| | - Dinesh Mondal
- Nutrition and Clinical Services Division, International Center For Diarrheal Disease Research, Bangladesh (icddr,b), 63 Shaheed Taj Uddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Satyabrata Routray
- PATH, 15th Floor, Dr. Gopaldas Building, 28 Barakhamba Road, Connaught Place, New Delhi, 110001, India
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17
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Le Rutte EA, Chapman LAC, Coffeng LE, Ruiz-Postigo JA, Olliaro PL, Adams ER, Hasker EC, Boelaert MC, Hollingsworth TD, Medley GF, de Vlas SJ. Policy Recommendations From Transmission Modeling for the Elimination of Visceral Leishmaniasis in the Indian Subcontinent. Clin Infect Dis 2019; 66:S301-S308. [PMID: 29860292 PMCID: PMC5982727 DOI: 10.1093/cid/ciy007] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Visceral leishmaniasis (VL) has been targeted by the World Health Organization (WHO) and 5 countries in the Indian subcontinent for elimination as a public health problem. To achieve this target, the WHO has developed guidelines consisting of 4 phases of different levels of interventions, based on vector control through indoor residual spraying of insecticide (IRS) and active case detection (ACD). Mathematical transmission models of VL are increasingly used for planning and assessing the efficacy of interventions and evaluating the intensity and timescale required to achieve the elimination target. Methods This paper draws together the key policy-relevant conclusions from recent transmission modeling of VL, and presents new predictions for VL incidence under the interventions recommended by the WHO using the latest transmission models. Results The model predictions suggest that the current WHO guidelines should be sufficient to reach the elimination target in areas that had medium VL endemicities (up to 5 VL cases per 10000 population per year) prior to the start of interventions. However, additional interventions, such as extending the WHO attack phase (intensive IRS and ACD), may be required to bring forward elimination in regions with high precontrol endemicities, depending on the relative infectiousness of different disease stages. Conclusions The potential hurdle that asymptomatic and, in particular, post-kala-azar dermal leishmaniasis cases may pose to reaching and sustaining the target needs to be addressed. As VL incidence decreases, the pool of immunologically naive individuals will grow, creating the potential for new outbreaks.
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Affiliation(s)
- Epke A Le Rutte
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Lloyd A C Chapman
- Zeeman Institute, University of Warwick, Coventry, United Kingdom.,London School of Hygiene and Tropical Medicine, United Kingdom
| | - Luc E Coffeng
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | | | - Piero L Olliaro
- Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Emily R Adams
- Liverpool School of Tropical Medicine, United Kingdom
| | | | | | - T Deirdre Hollingsworth
- Zeeman Institute, University of Warwick, Coventry, United Kingdom.,Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford
| | - Graham F Medley
- London School of Hygiene and Tropical Medicine, United Kingdom
| | - Sake J de Vlas
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands
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18
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Moulik S, Chaudhuri SJ, Sardar B, Ghosh M, Saha B, Das NK, Chatterjee M. Monitoring of Parasite Kinetics in Indian Post-Kala-azar Dermal Leishmaniasis. Clin Infect Dis 2019; 66:404-410. [PMID: 29020350 DOI: 10.1093/cid/cix808] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 09/12/2017] [Indexed: 12/13/2022] Open
Abstract
Background The potential reservoirs of leishmaniasis in South Asia include relapsed cases of visceral leishmaniasis (VL), patients with post-kala-azar dermal leishmaniasis (PKDL), and an asymptomatically infected population. Therefore, assessment of cure in terms of parasite clearance, early detection of PKDL, and asymptomatic VL are pivotal for ensuring elimination. This study aimed to monitor the efficacy of miltefosine and liposomal amphotericin B (LAmB) in PKDL based on parasite load. Methods Patients with PKDL were recruited from the dermatology outpatient departments or during active field surveys. Skin biopsies were collected at disease presentation, immediately at the end of treatment, and 6 months later. The presence of parasite DNA was assessed by internal transcribed spacer-1 polymerase chain reaction, and quantified by amplification of parasite kinetoplastid DNA. Results At disease presentation (n = 184), the median parasite load was 5229 (interquartile range [IQR], 896-50898)/μg genomic DNA (gDNA). Miltefosine cleared the parasites to <10 in the macular (n = 17) and polymorphic (n = 21) variants, and remained so up to 6 months later (<10 parasites). LAmB reduced the parasite burden substantially in macular (n = 34; 2128 [IQR, 544-5763]/µg gDNA) and polymorphic PKDL (n = 36; 2541 [IQR, 650-9073]/µg gDNA). Importantly, in patients who returned 6 months later (n = 38), a resurgence of parasites was evident, as the parasites increased to 5665 (IQR, 1840-17067)/µg gDNA. Conclusions This study established that quantifying parasite load is an effective approach for monitoring patients with PKDL, wherein miltefosine demonstrated near-total parasite clearance and resolution of symptoms. However, in cases treated with LAmB, the persistence of parasites suggested treatment inadequacy. This needs immediate redressal in view of the leishmaniasis elimination program targeted for 2020.
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Affiliation(s)
- Srija Moulik
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, India
| | | | - Bikash Sardar
- Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India
| | - Manab Ghosh
- Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India
| | - Bibhuti Saha
- Department of Tropical Medicine, School of Tropical Medicine, Kolkata, India
| | - Nilay Kanti Das
- Department of Dermatology, Calcutta Medical College, Kolkata, India
| | - Mitali Chatterjee
- Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, India
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19
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Mendonça DVC, Martins VT, Lage DP, Dias DS, Ribeiro PAF, Carvalho AMRS, Dias ALT, Miyazaki CK, Menezes-Souza D, Roatt BM, Tavares CAP, Barichello JM, Duarte MC, Coelho EAF. Comparing the therapeutic efficacy of different amphotericin B-carrying delivery systems against visceral leishmaniasis. Exp Parasitol 2018; 186:24-35. [PMID: 29448040 DOI: 10.1016/j.exppara.2018.02.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 12/20/2017] [Accepted: 02/11/2018] [Indexed: 12/23/2022]
Abstract
Amphotericin B (Amp) has been well-successfully used to treat against Leishmania infection, although high toxicity has been found in patients. In the present study, Amp was administered in Leishmania infantum-infected BALB/c mice by three distinct delivery systems aiming to compare their efficacy against challenge infection, as well as their side effects in a murine visceral leishmaniasis (VL) model. This product was administered in a Poloxamer P407 (Pluronic® F127)-based polymeric micelle system (Amp/M), in the Ambisome® formulation (Lip-Amp) or in a free format (free Amp). Glucantime® (Gluc) was used as a comparative drug. Aiming to evaluate different endpoints of the treatments, the efficacy of the compounds was investigated one and 15-days after the therapeutic regimens, determining the parasite load by a limiting dilution assay and a quantitative PCR (qPCR) technique, as well as evaluating the immune response generated in the infected and treated animals. In the results, Amp/M or Lip-Amp-treated mice presented the best outcomes, since significant parasite load reductions were found in the evaluated organs, as well as a parasite-specific Th1 immune response was observed in the animals. In addition, no hepatic or renal damage was found in these mice. On the other hand, free Amp or Gluc induced toxicity in the animals, which was associated with a low Th1 immune response. Comparatively, Amp/M was the most effective drug in our experimental model, and results showed that the Amp-carrying system could be considered as a future alternative in studies against VL.
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Affiliation(s)
- Débora V C Mendonça
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Vívian T Martins
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Daniela P Lage
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Daniel S Dias
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Patrícia A F Ribeiro
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Ana Maria R S Carvalho
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Anna Letícia T Dias
- Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil
| | - Carolina K Miyazaki
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil
| | - Daniel Menezes-Souza
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil; Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil
| | - Bruno M Roatt
- Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil
| | - Carlos A P Tavares
- Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil
| | - José Mário Barichello
- Laboratório de Tecnologia Farmacêutica, Centro de Ciências Químicas, Farmacêuticas e de Alimentos, Universidade Federal de Pelotas, 96900-010, Pelotas, Rio Grande do Sul, Brazil
| | - Mariana C Duarte
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil; Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil
| | - Eduardo A F Coelho
- Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, 30130-100, Minas Gerais, Brazil; Departamento de Patologia Clínica, COLTEC, Universidade Federal de Minas Gerais, Belo Horizonte, 31270-901, Minas Gerais, Brazil.
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Zijlstra EE, Alves F, Rijal S, Arana B, Alvar J. Post-kala-azar dermal leishmaniasis in the Indian subcontinent: A threat to the South-East Asia Region Kala-azar Elimination Programme. PLoS Negl Trop Dis 2017; 11:e0005877. [PMID: 29145397 PMCID: PMC5689828 DOI: 10.1371/journal.pntd.0005877] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background The South-East Asia Region Kala-azar Elimination Programme (KAEP) is expected to enter the consolidation phase in 2017, which focuses on case detection, vector control, and identifying potential sources of infection. Post-kala-azar dermal leishmaniasis (PKDL) is thought to play a role in the recurrence of visceral leishmaniasis (VL)/kala-azar outbreaks, and control of PKDL is among the priorities of the KAEP. Methodology and principal finding We reviewed the literature with regard to PKDL in Asia and interpreted the findings in relation to current intervention methods in the KAEP in order to make recommendations. There is a considerable knowledge gap regarding the pathophysiology of VL and PKDL, especially the underlying immune responses. Risk factors (of which previous VL treatments may be most important) are poorly understood and need to be better defined. The role of PKDL patients in transmission is largely unknown, and there is insufficient information about the importance of duration, distribution and severity of the rash, time of onset, and self-healing. Current intervention methods focus on active case detection and treatment of all PKDL cases with miltefosine while there is increasing drug resistance. The prevention of PKDL by improved VL treatment currently receives insufficient attention. Conclusion and significance PKDL is a heterogeneous and dynamic condition, and patients differ with regard to time of onset after VL, chronicity, and distribution and appearance of the rash, as well as immune responses (including tendency to self-heal), all of which may vary over time. It is essential to fully describe the pathophysiology in order to make informed decisions on the most cost-effective approach. Emphasis should be on early detection of those who contribute to transmission and those who are in need of treatment, for whom short-course, effective, and safe drug regimens should be available. The prevention of PKDL should be emphasised by innovative and improved treatment for VL, which may include immunomodulation.
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Affiliation(s)
- Eduard E. Zijlstra
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
- Rotterdam Centre for Tropical Medicine, Rotterdam, the Netherlands
- * E-mail:
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Suman Rijal
- Drugs for Neglected Diseases initiative, India Office, New Delhi, India
| | - Byron Arana
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Jorge Alvar
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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