Nephrotoxicity attributed to meglumine antimoniate (Glucantime) in the treatment of generalized cutaneous leishmaniasis

Self-application of aminoglycoside-based creams to treat cutaneous leishmaniasis in travelers

BACKGROUND

In endemic foci, the use of an aquaphilic cream containing paromomycin with/without gentamicin to treat cutaneous leishmaniasis (CL) is safe, painless and cures 78-82% of patients with New and Old World CL. Self-application in travelers requires evaluation.

METHODS

Travelers with 1-10 lesions of confirmed CL were prospectively treated with the paromomycin-gentamicin formulation (WR279396, 2012-2017, Group 1) and carefully follow up, or treated with a locally produced paromomycin-only cream (2018-2022, Group 2). The cream was applied once under supervision, then self-applied daily for 20-30 days. A cured lesion was defined as 100% re-epithelialization at day 42 without relapse at three months.

RESULTS

Medical features were similar in Group 1 (17 patients), and Group 2 (23 patients). Patients were infected with either Leishmania major, L. infantum, L. killicki, L. guyanensis, L. braziliensis, or L. naiffi. Intention-to-treat and per-protocol cure rates were 82% (95% confidence interval (CI) [64.23;100.00]) and 87% (95% CI [71,29;100.00]) in Group 1, and 69% (95% CI [50.76; 88.37]) and 76% (95% CI [57.97; 94.41]) in Group 2. In the pooled Group 1&2, 75% (95% CI [61.58;88.42]) (30/40) and 81% (95% CI [68,46;93.6]) (30/37) of patients were cured in intention-to-treat and per-protocol, respectively. There were no significant differences observed in the success rates between Old World and New World CL (83.3% vs. 60%, p = 0.14). Prospective observations in Group 1 showed that adverse events were mainly pruritus (24%) and pain (18%) on lesions (all mild or moderate). No mucosal involvement was observed in either group.

DISCUSSION

In this representative population of travelers who acquired CL either in the Old or New World, the 81% per-protocol cure rate of a self-applied aminoglycoside cream was similar to that observed in clinical trials.

Evaluation of the Efficacy of Amphotericin B and Terbinafine Microemulsions and Their Combination on Cutaneous Leishmaniasis and Comparison with the Conventional Drug Form in BALB/c Mice

Intracellular parasitic protozoa of Leishmania sp. causes leishmaniasis. The restricted access of the drugs to affected cells in the treatment of intracellular infections such as leishmaniasis is frequently hampered. Furthermore, most of today's drugs have limited uses due to some containing toxic compounds, and drug resistance is on the rise. In the present investigation, Amphotericin B (AmB) and Terbinafine (Tbf) were loaded in microemulsion (ME) in combination and alone, and the in vivo efficacy was considered in BALB/c mice infected with Leishmania major (L. major). The wound size at the base of the mouse tail was measured, and real-time PCR was performed to quantify the parasite load after the infection challenge. The study demonstrated that the ME-AmB and ME-Tbf formulations are safe and effective compounds for the treatment of cutaneous leishmaniasis by enhancing the effectiveness of AmB and Tbf in reducing the parasite burden.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Drug reaction with eosinophilia and systemic symptoms (DRESS) and multiple organ dysfunction syndrome (MODS): one more reason for a new effective treatment against leishmaniasis

INTRODUCTION

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe drug-induced reaction associated with eosinophilia and systemic manifestations. Anticonvulsants, sulfonamides, and antivirals are the most related and described drugs in DRESS syndrome.

METHODS AND CASE

We present a case of severe multiple organ dysfunction syndrome (MODS) with the risk of death associated with DRESS syndrome due to antileishmanial pentavalent antimonial drug and its simultaneous toxicity. Consequently, a comprehensive review of the main clinical problems and comparative discussion of both clinical conditions was made.

DISCUSSION

The overlap of DRESS syndrome and antileishmanial pentavalent antimonial drug toxicity can be life-threatening. Both conditions represent a true clinical, diagnostic, and therapeutic challenge. We exposed specific clinical and laboratory results with rare occurrence.

CONCLUSION

Any physician and dermatologists should keep in mind the broad spectrum of clinical manifestations and laboratory findings associated with the use of pentavalent antimonial drugs. The clinical suspicion, an early diagnosis, and aggressive treatment are essential to prevent complications and death.

Efficacy of cryotherapy plus topical Juniperus excelsa M. Bieb cream versus cryotherapy plus placebo in the treatment of Old World cutaneous leishmaniasis: A triple-blind randomized controlled clinical trial

Background

Cutaneous leishmaniasis is one of the highly prevalent endemic diseases in the Middle East and North Africa. Many treatment modalities have been recommended for this condition but success rates remain limited. Herbal remedies have also been used for treatment but evidence-based clinical trials with these products are sparse. In-vitro and in-vivo studies have shown the anti-leishmanial and curative effects of extract of fruits and leaves of Juniperus excelsa (J. excelsa). The aim of this study was to determine the efficacy of topical J. excelsa M. Bieb extract as an adjuvant to cryotherapy for the treatment of human CL.

Materials and methods

This study was designed as a two-arm triple-blind randomized placebo-controlled clinical trial using a parallel design. Seventy-two patients with clinical diagnosis of CL confirmed by leishmania smears were allocated to receive either a topical formulation of leaf of J. excelsa extract (group A) or placebo (group B) for 3 months. Both groups received cryotherapy as baseline standard treatment. Patients were evaluated before and weekly after the intervention was initiated until complete cure.

Results

Overall, 82% of patients in group A, experienced complete cure and 9% of them had partial cure. On the other hand, 34% in group B reported complete cure, while 14% of them had partial cure at the end of treatment protocol with a significant difference between the two groups (P< 0.001). The mean duration to healing of the lesions in patients who received J. excelsa extract was statistically significantly shorter than the placebo group (p = 0.04). No significant side effect was seen in the J. excelsa extract group except for mild to moderate local irritation after a few weeks in a few numbers of patients.

Conclusion

The results of this study showed that topical J. excelsa extract can be used as an adjuvant treatment modality in addition to cryotherapy for accelerating the time to cure in addition to increasing the complete cure rate in CL.

Trial registration

ClinicalTrials.gov IRCT2015082523753N1

Many people are afflicted in the world by cutaneous leishmaniasis (CL). The pathogen in this disease is an intracellular parasite. In 2007, The World Health Organization, defined leishmaniasis as a neglected disease. Many treatment modalities have been recommended for cutaneous leishmaniasis, but success rates remain limited. Experimental studies have shown the anti-leishmanial and curative effects of extract of fruits and leaves of Juniperus excelsa (J. excelsa), but there are no documentation in this regard in humans. This is the first randomized controlled clinical trial which evaluated the efficacy of the leaf extract of J. excelsa M. Bieb on human CL. According to the results of this present study, topical J. excelsa M. Bieb hydroalcoholic extract could be a good choice for treatment of CL in conjunction with cryotherapy. Using this extract along with cryotherapy can decrease the duration of CL treatment and also increase the success rate of CL treatment without any significant adverse effect.

Treatment of canine leishmaniasis with marbofloxacin in dogs with renal disease

Treatment of canine leishmaniasis (CanL) represents a challenge. Due to the high prevalence of renal disease associated to CanL, it is important to find an effective drug that does not damage the kidneys. Marbofloxacin has been shown to be effective and well tolerated in non-azotemic dogs with leishmaniasis. To evaluate the safety and efficacy of marbofloxacin in dogs with leishmaniasis and decreased renal function, 28 dogs suffering from leishmaniasis and chronic kidney disease (CKD) were treated with oral marbofloxacin at 2 mg/Kg/day for 28 days. During treatment dogs were assessed by performing weekly physical exams, measuring blood pressure and evaluating blood and urine parameters. Lymph node aspirations were also obtained at days 0 and 28. The global clinical score decreased significantly, from 6.2±3.4 to 4.7±3.1 (p = 0.0001), after treatment. Marbofloxacin also decreased parasitic load in 72% of the dogs. No significant differences in plasma creatinine, urine specific gravity, urinary concentrations of cystatin C, ferritin and urinary protein loss were detected during treatment. A transient but significant decrease in blood pressure was detected up to day 14 (from 180.1±36.6 to 166.0±32.7 mmHg; p = 0.016). Moreover, dogs showed a significant increase in plasma albumin concentration (from 15.0±5.2 to 16.6±3.9 g/L; p = 0.014) and a significant decrease in globulin concentration (from 59.0±18.1 to 54.1±18.0 g/L; p = 0.005). The results demonstrate that, in addition to being effective for treatment of CanL, marbofloxacin is a very safe drug in dogs with CKD and leishmaniasis.

Immucillins ImmA and ImmH Are Effective and Non-toxic in the Treatment of Experimental Visceral Leishmaniasis

BACKGROUND

Immucillins ImmA (IA), ImmH (IH) and SerMe-ImmH (SMIH) are synthetic deazapurine nucleoside analogues that inhibit Leishmania (L.) infantum chagasi and Leishmania (L.) amazonensis multiplication in vitro without macrophage toxicity. Immucillins are compared to the Glucantime standard drug in the chemotherapy of Leishmania (L.) infantum chagasi infection in mice and hamsters. These agents are tested for toxicity and immune system response.

METHODOLOGY/PRINCIPAL FINDINGS

BALB/c mice were infected with 107 amastigotes, treated with IA, IH, SMIH or Glucantime (2.5mg/kg/day) and monitored for clinical variables, parasite load, antibody levels and splenocyte IFN-γ, TNF-α, and IL-10 expression. Cytokines and CD4+, CD8+ and CD19+ lymphocyte frequencies were assessed in uninfected controls and in response to immucillins. Urea, creatinine, GOT and GPT levels were monitored in sera. Anti-Leishmania-specific IgG1 antibodies (anti-NH36) increased in untreated animals. IgG2a response, high levels of IFN-γ, TNF-α and lower levels of IL-10 were detected in mice treated with the immucillins and Glucantime. Immucillins permitted normal weight gain, prevented hepato-splenomegaly and cleared the parasite infection (85-89%) without renal and hepatic toxicity. Immucillins promoted 35% lower secretion of IFN-γ in uninfected controls than in infected mice. IA and IH increased the CD4+ T and CD19+ B cell frequencies. SMIH increased only the proportion of CD-19 B cells. IA and IH also cured infected hamsters with lower toxicity than Glucantime.

CONCLUSIONS/SIGNIFICANCE

Immucillins IA, IH and SMIH were effective in treating leishmaniasis in mice. In hamsters, IA and IH were also effective. The highest therapeutic efficacy was obtained with IA, possibly due to its induction of a TH1 immune response. Low immucillin doses were required and showed no toxicity. Our results disclose the potential use of IA and IH in the therapy of visceral leishmaniasis.

Kidney involvement in leishmaniasis--a review

Leishmaniasis is an infectious disease caused by protozoa of the genus Leishmania transmitted by insects of the genus Lutzomyia sp. or Phlebotomus sp. The main syndromes are cutaneous leishmaniasis, mucocutaneous leishmaniasis, visceral leishmaniasis (kala-azar) and post-kala-azar dermal leishmaniasis. This article reviews kidney involvement in cutaneous and visceral leishmaniasis, highlighting the aspects of their pathophysiology, clinical manifestations, histopathological findings, outcome and treatment.

LeishMan recommendations for treatment of cutaneous and mucosal leishmaniasis in travelers, 2014

BACKGROUND

Treatment of cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML) in travelers is still controversial. Over the last decade, national and international consortia have published recommendations for treating CL in travelers. These guidelines harmonize many issues, but there are some discrepancies.

METHODS

Leishmania parasites causing CL can now be genotyped by polymerase chain reaction techniques for detecting Leishmania DNA. Therefore, treatment recommendations can now be species based rather than based on geographical exposure. To review the evidence on which the recommendations were based, "LeishMan" (Leishmaniasis Management), a group of experts from 13 institutions in eight European countries, performed a PubMed MEDLINE) literature search and considered unpublished evidence and the experts' own personal experiences. The Oxford evidence grading system was used to evaluate the information.

RESULTS AND CONCLUSION

In this article, the authors provide practical treatment recommendations for imported CL and ML in Europe, drawn up from the review by the European experts.

Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis

This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm(2)), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.

Drug resistance in leishmaniasis: current drug-delivery systems and future perspectives

Leishmaniasis is a complex of diseases with numerous clinical manifestations for instance harshness from skin lesions to severe disfigurement and chronic systemic infection in the liver and spleen. So far, the most classical leishmaniasis therapy, despite its documented toxicities, remains pentavalent antimonial compounds. The arvailable therapeutic modalities for leishmaniasis are overwhelmed with resistance to leishmaniasis therapy. Mechanisms of classical drug resistance are often related with the lower drug uptake, increased efflux, the faster drug metabolism, drug target modifications and over-expression of drug transporters. The high prevalence of leishmaniasis and the appearance of resistance to classical drugs reveal the demand to develop and explore novel, less toxic, low cost and more promising therapeutic modalities. The review describes the mechanisms of classical drug resistance and potential drug targets in Leishmania infection. Moreover, current drug-delivery systems and future perspectives towards Leishmaniasis treatment are also covered.

Renal function evaluation in patients with American cutaneous leishmaniasis after specific treatment with pentavalent antimonial

Background

Renal evaluation studies are rare in American Cutaneous Leishmaniasis (ACL). The aim of this study is to investigate whether specific treatment reverts ACL-associated renal dysfunction.

Methods

A prospective study was conducted with 37 patients with ACL. Urinary concentrating and acidification ability was assessed before and after treatment with pentavalent antimonial.

Results

The patients mean age was 35.6 ± 12 years and 19 were male. Before treatment, urinary concentrating defect (U/P_osm <2.8) was identified in 27 patients (77%) and urinary acidification defect in 17 patients (46%). No significant glomerular dysfunction was observed before and after specific ACL treatment. There was no reversion of urinary concentrating defects, being observed in 77% of the patients before and in 88% after treatment (p = 0.344). Urinary acidification defect was corrected in 9 patients after treatment, reducing its prevalence from 40% before to only 16% after treament, (p = 0.012). Microalbuminuria higher than 30 mg/g was found in 35% of patients before treatment and in only 8% after treatment. Regarding fractional excretion of sodium, potassium, calcium, phosphorus and magnesium, there was no significant difference between pre and post-treatment period.

Conclusion

As previously described, urinary concentrating and acidification defects were found in an important number of patients with ACL. Present results demonstrate that only some patients recover urinary acidification capacity, while no one returned to normal urinary concentration capacity.

Use of a fluorescent stain for evaluating in vitro infection with Leishmania panamensis

Leishmaniasis is a group of endemic diseases produced by infection with Leishmania parasites and affects tropical and subtropical regions of the world. Due to the severe problems related to the treatment of this condition (resistance and toxicity), further studies are needed to evaluate new antileishmanial compounds. The activity of antileishmanial prototypes should be analyzed in models that allow a better interpretation of the findings with respect to natural infection. In this sense, the use of an infection model with macrophages and dendritic cells is a better than using promastigotes alone, in order to establish the potential leishmanicidal activity of a prototype compound. For infection analysis, staining with polychromatic dyes such as Giemsa plus microscopic examination is the gold standard. However, it is common to find problems associated with color uniformity, expertise of the observer, sensitivity and specificity of the technique. For this reason, it's necessary to develop tools and protocols to overcome such limitations. This study assessed the utility of the SYBR® Safe fluorescent dye, considering its affinity for nucleic acids as a useful property for staining the nucleus and kinetoplast of Leishmania parasites within an infected cell. Infection (and subsequent treatment) assays were performed in dendritic cells and macrophages infected with Leishmania panamensis parasites to compare SYBR® Safe and Giemsa stain for the same assay. Correlation coefficients were found to be above 0.9 for both techniques; however, unlike Giemsa, SYBR® Safe staining was easier and provided a clearer observation of internalized parasites. These results support the use of SYBR® Safe as a promising tool for evaluating potential antileishmanials given its advantages over the traditional technique.

Systematic review of the adverse effects of cutaneous leishmaniasis treatment in the New World

Pentavalent antimonials are first-line drugs for the treatment of the cutaneous form of American tegumentary leishmaniasis. Second-line drugs include amphotericin B and pentamidine. Although these drugs have been used for decades, there are no systematic reviews about their safety. The objective of this review was to identify and classify the main adverse effects associated with these drugs and to estimate the frequency of these effects, whenever possible. Intervention studies, case series and case reports containing information regarding clinical, laboratory or electrocardiographic adverse effects of drugs used for the treatment of cutaneous leishmaniasis were systematically retrieved from 10 databases searched between August 13, 2008 and March 31, 2009. The 65 studies included in this review had treated a total of 4359 patients from 12 countries infected with eight different Leishmania species. Despite the small number of drugs used in these studies, a wide variability in the therapeutic regimens was observed. As a consequence, the adverse effects of pentavalent antimonials and pentamidine needed to be classified jointly according to system, irrespective of formulation, daily dose, duration of treatment, and route of administration. The frequencies of adverse effects were calculated based on the data of 32 articles involving 1866 patients. The most frequently reported clinical adverse effects of pentavalent antimonials and pentamidine were musculoskeletal pain, gastrointestinal disturbances, and mild to moderate headache. Electrocardiographic QTc interval prolongation and a mild to moderate increase in liver and pancreatic enzymes were additional adverse effects of pentavalent antimonials. Patients treated with liposomal amphotericin B had mild dyspnea and erythema. The adverse effects associated with miltefosine were vomiting, nausea, kinetosis, headache, diarrhea, and a mild to moderate increase in aminotransferases and creatinine. Although closer surveillance is needed for the treatment of cutaneous leishmaniasis, antileishmanial drugs are basically safe and severe side effects requiring the discontinuation of treatment are relatively uncommon.

Renal involvement in leishmaniasis: a review of the literature

Leishmaniasis, an infectious disease endemic in tropical, Asian and southern European countries, is caused by obligate intramacrophage protozoa and is transmitted through the bite of infected female sandflies. More than 20 leishmanial species are responsible for four main clinical syndromes: cutaneous leishmaniasis; mucocutaneous leishmaniasis; visceral leishmaniasis, also known as kala-azar, and post-kala-azar dermal leishmaniasis. Visceral leishmaniasis can present with varying clinical features and the kidney can also be involved. Both glomerular and tubular function can be altered and patients can develop proteinuria, haematuria, abnormalities in urinary concentration and acidification and acute and chronic renal insufficiency. Not only the disease itself but also the therapy administered might be responsible for the renal involvement in kala-azar. Indeed, some of the agents with efficiency against visceral leishmaniasis, such as pentavalent antimonial drugs, amphotericin B, pentamidine, miltefosine, paromomycin and simataquine, may be associated with a high risk of renal toxicity. In this article, the literature on renal involvement in visceral leishmaniasis is reviewed.

Administration of Miltefosine and Meglumine Antimoniate in Healthy Dogs: Clinicopathological Evaluation of the Impact on the Kidneys

In canine leishmaniosis (CanL), kidneys are affected in virtually all dogs. Treatment of CanL is limited in Europe to meglumine antimoniate and miltefosine. This study evaluated the pharmacological, toxicological, and pathological effects of both drugs in healthy beagle dogs. Four male and four female dogs were divided into two groups. The animals in Group 1 were administered an oral solution of 2% of miltefosine at 2 mg/kg b.w. once a day, for twenty-eight days. The animals in Group 2 were administered a preparation of meglumine antimoniate at 100 mg/kg b.w. subcutaneously once a day for twenty-eight days. After treatment, all dogs were followed-up for a further twenty-eight days. Dogs were observed daily and clinically examined ten times throughout the study. On days -1 and 55 a renal biopsy was performed on all dogs and analyzed by light microscopy, immunofluorescence, and electron microscopy. All the examinations failed to demonstrate any lesions in the miltefosine-treated dogs. Conversely, all the meglumine antimoniate–treated dogs demonstrated severe tubular damage, characterized by tubular cell necrosis and apoptosis. In conclusion, although no clinical signs of renal disease were evident, the use of meglumine antimoniate in the pharmacological treatment approach of CanL-affected dogs should be carefully considered.

Leishmaniose mucosa fatal em criança

A leishmaniose tegumentar americana, doença endêmica e crescente no Brasil, pode manifestar-se por úlceras na pele e lesões nas mucosas nasal, oral e faringiana. O antimônio pentavalente é a droga de primeira escolha no tratamento, com resposta menos favorável nas formas mucosas. Destaca-se a dificuldade para diagnosticar e tratar um caso de leishmaniose mucosa em criança de cinco anos que teve exames parasitológicos, imunológicos e reação em cadeia da polimerase negativos. Somente após várias repetições o esfregaço foi positivo. A paciente apresentou infecção bacteriana secundária persistente das lesões e falta de resposta a drogas específicas e antibióticos, evoluindo para septicemia e óbito.