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Lago T, Peixoto F, Mambelli F, Carvalho LP, Guimarães LH, Carvalho AM, Cardoso L, Machado PRL, Scott P, Lago J, Andrade JM, Fahel JS, Oliveira SC, Carvalho EM. Use of topical rSm29 in combination with intravenous meglumine antimoniate in the treatment of cutaneous leishmaniasis: A randomized controlled trial. Int J Infect Dis 2024; 147:107206. [PMID: 39147194 DOI: 10.1016/j.ijid.2024.107206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 08/06/2024] [Accepted: 08/06/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) caused by Leishmania (Viannia) braziliensis is associated with an inflammatory response. Granzyme (GzmB) and IL-1β play a key role in the pathology. Meglumine antimoniate (MA) is the first-choice drug for the treatment of CL, but therapy failure is observed in up to 50% of the cases. The protein, rSm29 of Schistosoma mansoni, down-modulates pro-inflammatory cytokine production. We evaluate if the combination of topical rSm29 plus MA increases the cure rate of CL. METHODS In this randomized clinical trial, 91 CL patients were allocated in 3 groups. All cases received MA (20 mg/kg/weight) for 20 days. Group 1 used topical rSm29 (10 µg), group 2 a placebo topically applied, and group 3 received only MA. RESULTS The cure rate on day 90 was 71% in subjects treated with rSm29 plus MA, and 43% in patients who received MA plus placebo or MA alone (P < 0.05). There was a decrease in GzmB and an increase in IFN-γ (P < 0.05) in supernatants of skin biopsies of the lesions obtained on D7 of therapy (P < 0.05) in patients who received rSm29. CONCLUSION rSm29 associated with MA reduces GzmB levels, is more effective than MA alone, and decreases CL healing time. CLINICAL TRIALS REGISTRATION ClinicalTrial.gov under NCT06000514.
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Affiliation(s)
- Tainã Lago
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; Post Graduate Program of Health Sciences, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Fábio Peixoto
- Gonçalo Moniz Institute, Fiocruz, Salvador, Bahia, Brazil
| | - Fábio Mambelli
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Lucas P Carvalho
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; Post Graduate Program of Health Sciences, Federal University of Bahia, Salvador, Bahia, Brazil; National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil; Health Science Institute, Federal University of Bahia, Salvador, Bahia, Brazil; Gonçalo Moniz Institute, Fiocruz, Salvador, Bahia, Brazil
| | - Luiz Henrique Guimarães
- National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil; Federal University of the Recôncavo da Bahia, Cruz das Almas, Bahia, Brazil
| | - Augusto M Carvalho
- National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil; Gonçalo Moniz Institute, Fiocruz, Salvador, Bahia, Brazil
| | - Luciana Cardoso
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil
| | - Paulo R L Machado
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil
| | - Phillip Scott
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, PA, USA
| | - Jamile Lago
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; Post Graduate Program of Health Sciences, Federal University of Bahia, Salvador, Bahia, Brazil
| | | | - Júlia S Fahel
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Sérgio C Oliveira
- Federal University of Minas Gerais, Belo Horizonte, Brazil; National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil; University of São Paulo, São Paulo, Brazil
| | - Edgar M Carvalho
- Immunology Service of University Hospital Professor Edgard Santos, Federal University of Bahia, Salvador, Bahia, Brazil; National Institute of Science and Technology of Tropical Diseases (INCT-DT), Ministry of Science, Technology, Innovations and Communications, CNPq, Brasília, Distrito Federal, Brazil; Gonçalo Moniz Institute, Fiocruz, Salvador, Bahia, Brazil.
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Laphanuwat P, Gomes DCO, Akbar AN. Senescent T cells: Beneficial and detrimental roles. Immunol Rev 2023; 316:160-175. [PMID: 37098109 PMCID: PMC10952287 DOI: 10.1111/imr.13206] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/20/2023] [Accepted: 04/01/2023] [Indexed: 04/27/2023]
Abstract
As the thymus involutes during aging, the T-cell pool has to be maintained by the periodic expansion of preexisting T cells during adulthood. A conundrum is that repeated episodes of activation and proliferation drive the differentiation of T cells toward replicative senescence, due to telomere erosion. This review discusses mechanisms that regulate the end-stage differentiation (senescence) of T cells. Although these cells, within both CD4 and CD8 compartments, lose proliferative activity after antigen-specific challenge, they acquire innate-like immune function. While this may confer broad immune protection during aging, these senescent T cells may also cause immunopathology, especially in the context of excessive inflammation in tissue microenvironments.
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Affiliation(s)
- Phatthamon Laphanuwat
- Division of MedicineUniversity College LondonLondonUK
- Department of PharmacologyFaculty of Medicine, Khon Kaen UniversityKhon KaenThailand
| | - Daniel Claudio Oliveira Gomes
- Division of MedicineUniversity College LondonLondonUK
- Núcleo de Doenças InfecciosasUniversidade Federal do Espírito SantoVitoriaBrazil
- Núcleo de BiotecnologiaUniversidade Federal do Espírito SantoVitoriaBrazil
| | - Arne N. Akbar
- Division of MedicineUniversity College LondonLondonUK
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Barroso DH, Gonçalves RT, Barbosa JS, da Motta JDOC, Freire GSM, Gomes CM, Sampaio RNR. Meglumine antimoniate was associated with a higher cure rate than liposomal amphotericin B in the treatment of American tegumentary leishmaniasis: A retrospective cohort study from a Leishmania braziliensis-endemic area. Front Cell Infect Microbiol 2022; 12:993338. [PMID: 36211958 PMCID: PMC9538529 DOI: 10.3389/fcimb.2022.993338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPentavalent antimonials (PAs) are the primary therapeutic option for American tegumentary leishmaniasis (ATL). However, the use of these drugs is complicated by adverse events (AEs), resistance and contraindications. Alternative therapies relative effectiveness is not well established.ObjectiveThis study compared the effectiveness of liposomal amphotericin B (LAB) with intravenous meglumine antimoniate (NMG) in the treatment of ATL. We also analysed and compared associated AEs and treatment interruption rates.MethodsThis was a retrospective cohort study from Brazil. The potential risk factors for the primary outcome were age, sex, total cutaneous lesion area, presence of mucosal lesions, AEs and treatment interruption. The primary outcome was lesion healing within 6 months of treatment. AEs and treatment interruption were also analysed. Multiple analytic strategies were employed to evaluate the reliability of the results.ResultsBefore propensity score (PS) matching, patients in the LAB group were older and had a higher frequency of mucosal lesions. The NMG group had a higher cure rate than the LAB group (cure rate 88% versus 55% respectively) in the adjusted analysis (relative risk (RR)=1.55 95% CI: 1.19 - 2.02) and after PS matching (RR=1.63 95% CI: 1.20 - 2.21). NMG group had a higher AE rate (event rate 52% versus 44%) in the adjusted analysis (RR= 1.61, 95% CI: 1.06 - 2.43, p=0.02), but this result was not observed after PS matching (RR= 0.87, 95% CI: 0.49 -1.52, p= 0.61).ConclusionsWe observed that the NMG group had a higher cure rate than the LAB group, with an equivocally higher EV rate in the adjusted analysis.
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Affiliation(s)
- Daniel Holanda Barroso
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
- Laboratório de Dermatomicologia da Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- *Correspondence: Daniel Holanda Barroso,
| | | | | | | | | | - Ciro Martins Gomes
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
- Laboratório de Dermatomicologia da Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
| | - Raimunda Nonata Ribeiro Sampaio
- Hospital Universitário de Brasília, Universidade de Brasília, Brasília, Brazil
- Laboratório de Dermatomicologia da Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, Brazil
- Pós-Graduação de Ciências da Saúde da Faculdade de Ciências Saúde, Universidade de Brasília, Brasília, Brazil
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de Carvalho BC, Vital T, Osiro J, Gomes CM, Noronha E, Dallago B, Rosa ADC, Carvalho JL, Hagström L, Hecht M, Nitz N. Multiparametric analysis of host and parasite elements in new world tegumentary leishmaniasis. Front Cell Infect Microbiol 2022; 12:956112. [PMID: 36017367 PMCID: PMC9395741 DOI: 10.3389/fcimb.2022.956112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Tegumentary leishmaniasis is a tropical disease caused by protozoa of the genus Leishmania. Clinically, the disease presents a broad spectrum of symptoms, the mechanisms underlying the development of lesions remaining to be fully elucidated. In the present work, we performed a correlation and multiparametric analysis to evaluate how parasite- and host-related aspects associate with each other, and with the different clinical manifestations of tegumentary leishmaniasis. This cross-sectional study involved 75 individuals from endemic areas of Brazil, grouped according to their symptoms. Leishmania species were determined by DNA sequencing, and parasite load, antibody production, and cytokine profile were evaluated by kDNA qPCR, ELISA, and flow cytometry. Data were analyzed using the Chi-square test, principal component analysis, canonical discriminant analysis, and correlation analysis. Among the recruited patients, 23 (31%) were asymptomatic, 34 (45%) had primary cutaneous leishmaniasis, 10 (13%) presented recurrent cutaneous leishmaniasis, and eight (11%) had mucocutaneous leishmaniasis. Leishmania species identified included L. amazonensis, L. braziliensis, and L. guyanensis. Surprisingly, no Leishmania RNA virus infection was detected in any sample. In summary, our work showed that parasite load, antibody production, and cytokine levels alone are not determinants for tegumentary leishmaniasis symptoms. However, the correlation analysis allowed us to observe how these factors are correlated to each other within the groups, which revealed a unique network for each clinical manifestation. Our work reinforces the complexity of tegumentary leishmaniasis outcomes - which are associated with multiple host and parasite-related elements and provides a holistic model of the disease.
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Affiliation(s)
- Bruna Caroline de Carvalho
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Tamires Vital
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Jaqueline Osiro
- Dermatology Diagnostic Group, Dermatomicology Laboratory, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Ciro Martins Gomes
- Dermatology Diagnostic Group, Dermatomicology Laboratory, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Elza Noronha
- Brasília University Hospital, University of Brasília, Brasília, Brazil
| | - Bruno Dallago
- Laboratory of Animal Welfare, Faculty of Agronomy and Veterinary medicine, University of Brasília, Brasília, Brazil
| | - Ana de Cássia Rosa
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Juliana Lott Carvalho
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Luciana Hagström
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Mariana Hecht
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
| | - Nadjar Nitz
- Interdisciplinary Laboratory of Biosciences, Faculty of Medicine, University of Brasília, Brasília, Brazil
- *Correspondence: Nadjar Nitz,
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Loureiro Salgado C, Mendéz Corea AF, Covre LP, De Matos Guedes HL, Falqueto A, Gomes DCO. Ageing impairs protective immunity and promotes susceptibility to murine visceral leishmaniasis. Parasitology 2022; 149:1249-1256. [PMID: 35670372 PMCID: PMC11010576 DOI: 10.1017/s0031182022000828] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/14/2022] [Accepted: 05/30/2022] [Indexed: 11/06/2022]
Abstract
It is well accepted that the impact of diseases is generally more detrimental in elderly individuals than in younger ones. Changes in the immune system due to ageing can directly affect the ability to respond effectively to infections and may contribute to the higher morbidities and mortalities in the elderly population. Leishmaniasis is a complex of clinically unique diseases caused by obligate intracellular protozoa belonging to genus Leishmania, wherein visceral leishmaniasis (VL) is the most severe form and is fatal if left untreated. In this study, aged mice (72 weeks old) presented increased susceptibility to L. infantum infection compared to younger mice (4–6-week-old), with notable parasitism in both the spleen and liver, as well as exhibiting hepatosplenomegaly. A pronounced inflammatory profile was observed in the aged-infected mice, with excessive production of TNF-α and nitrite, along with diminished IFN-γ production and reduced proliferative capacity of T cells (assessed by expression of the Ki67 marker). Additionally, both CD4+ and CD8+ T cells from the aged-infected mice presented increased expression of the inhibitory receptors PD-1 and KLRG1 that strongly correlated with the parasitism found in the liver and spleen of this group. Overall, the data reported in this study suggests for the first time that ageing may negatively impact the VL outcome and provides a perspective for new therapeutic strategies involving manipulation of immunosenescence features against Leishmania infection.
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Affiliation(s)
- Caio Loureiro Salgado
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | | | | | - Herbet Leonel De Matos Guedes
- Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
- Instituto de Microbiologia Professor Paulo de Goes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aloisio Falqueto
- Departamento de Medicina Social, Universidade Federal do Espírito Santo, Vitoria, Brazil
| | - Daniel Cláudio Oliviera Gomes
- Núcleo de Doenças Infecciosas, Universidade Federal do Espírito Santo, Vitoria, Brazil
- Núcleo de Biotecnologia, Universidade Federal do Espírito Santo, Vitoria, Brazil
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Oliveira-Ribeiro C, Pimentel MIF, Oliveira LDFA, Vasconcellos ÉDCFE, Conceição-Silva F, Schubach ADO, Fagundes A, de Mello CX, Mouta-Confort E, Miranda LDFC, Valete-Rosalino CM, Martins ACDC, de Oliveira RDVC, Quintella LP, Lyra MR. An old drug and different ways to treat cutaneous leishmaniasis: Intralesional and intramuscular meglumine antimoniate in a reference center, Rio de Janeiro, Brazil. PLoS Negl Trop Dis 2021; 15:e0009734. [PMID: 34555016 PMCID: PMC8491910 DOI: 10.1371/journal.pntd.0009734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 10/05/2021] [Accepted: 08/16/2021] [Indexed: 01/25/2023] Open
Abstract
Background Treatment of cutaneous leishmaniasis (CL) remains challenging since the drugs currently used are quite toxic, thus contributing to lethality unrelated to the disease itself but to adverse events (AE). The main objective was to evaluate different treatment regimens with meglumine antimoniate (MA), in a reference center in Rio de Janeiro, Brazil. Methodology A historical cohort of 592 patients that underwent physical and laboratory examination were enrolled between 2000 and 2017. The outcome measures of effectiveness were epithelialization and complete healing of cutaneous lesions. AE were graded using a standardized scale. Three groups were evaluated: Standard regimen (SR): intramuscular (IM) MA 10–20 mg Sb5+/kg/day during 20 days (n = 46); Alternative regimen (AR): IM MA 5 mg Sb5+/kg/day during 30 days (n = 456); Intralesional route (IL): MA infiltration in the lesion(s) through subcutaneous injections (n = 90). Statistical analysis was performed through Fisher exact and Pearson Chi-square tests, Kruskal-Wallis, Kaplan-Meier and log-rank tests. Results SR, AR and IL showed efficacy of 95.3%, 84.3% and 75.9%, with abandonment rate of 6.5%, 2.4% and 3.4%, respectively. IL patients had more comorbidities (58.9%; p = 0.001), were mostly over 50 years of age (55.6%), and had an evolution time longer than 2 months (65.6%; p = 0.02). Time for epithelialization and complete healing were similar in IL and IM MA groups (p = 0.9 and p = 0.5; respectively). Total AE and moderate to severe AE that frequently led to treatment interruption were more common in SR group, while AR and IL showed less toxicity. Conclusions/Significance AR and IL showed less toxicity and may be good options especially in CL cases with comorbidities, although SR treatment was more effective. IL treatment was an effective and safe strategy, and it may be used as first therapy option as well as a rescue scheme in patients initially treated with other drugs. Treatment of cutaneous leishmaniasis remains a challenge since the drugs used are quite toxic. Currently, there is a global effort to reduce the morbidity associated with the treatment of this disease and life-threatening complications due to drugs or treatment approaches. Meglumine antimoniate (MA) in different regimens was evaluated in cutaneous leishmaniasis patients in the state of Rio de Janeiro, Brazil. Effectiveness and toxicity were compared among the groups: standard regimen (SR) [intramuscular (IM) MA in the dosage of 10 to 20 mg of pentavalent antimony (Sb5+)/kg/day]; alternative regimen (AR) [IM MA in the dosage of 5 mg Sb5+/kg/day]; and intralesional route (IL) [patients treated with MA through the infiltration of the lesion]. AR and IL regimens demonstrated good effectiveness, with reduced abandonment rate and toxicity. Total adverse events were higher in the SR group, which frequently led to treatment interruptions. AR and IL showed less toxicity especially in CL cases with comorbidities, although SR treatment was more effective than AR and IL regimens. IL was an effective and safe treatment and may be used as a first therapy option as well as a rescue scheme.
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Affiliation(s)
- Carla Oliveira-Ribeiro
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
- Centro de Transplante de Medula Óssea, Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brazil
- * E-mail:
| | - Maria Inês Fernandes Pimentel
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Liliane de Fátima Antonio Oliveira
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Fatima Conceição-Silva
- Laboratório de Imunoparasitologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Armando de Oliveira Schubach
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Aline Fagundes
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Cintia Xavier de Mello
- Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Eliame Mouta-Confort
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Luciana de Freitas Campos Miranda
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Claudia Maria Valete-Rosalino
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
- Departamento de Otorrinolaringologia e Oftalmologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana Cristina da Costa Martins
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | - Leonardo Pereira Quintella
- Serviço de Anatomia Patológica, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Marcelo Rosandiski Lyra
- Laboratório de Pesquisa Clínica e Vigilância em Leishmanioses, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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Gonçalves SVCB, Costa CHN. Treatment of cutaneous leishmaniasis with thermotherapy in Brazil: an efficacy and safety study. An Bras Dermatol 2018; 93:347-355. [PMID: 29924242 PMCID: PMC6001097 DOI: 10.1590/abd1806-4841.20186415] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/19/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pentavalent antimonials remain as the standard drugs in the treatment of cutaneous leishmaniosis. The high cost, difficult administration, long treatment time, toxicity and increasing morbidity are factors that limit the use of these drugs. OBJECTIVES To describe the response to radiofrequency thermotherapy in the treatment of localized cutaneous leishmaniasis in Brazil, and to evaluate its safety and tolerability. METHODS We conducted a non-comparative open trial with a total of 15 patients confirmed to have cutaneous leishmaniasis on parasitological examination. A single radiofrequency thermotherapy session at 50ºC for 30 seconds was applied to the lesion and its edges. In patients with more than one lesion, only the largest one was treated initially. If after 30 days there was no evidence of healing, the smaller lesion was also treated with thermotherapy. Clinical cure was defined as visible healing for three months after treatment. The patients were followed-up for six months and there was no follow-up loss. RESULTS Of all 23 lesions, only two evolved to complete healing without the need of treatment. Of 21 lesions, 18 (85.7%) achieved full healing. The main observed side effects were itching, burning sensation, pain and blisters. STUDY LIMITATIONS Sample with a small number of patients and short follow-up. CONCLUSION Thermotherapy can be considered a therapeutic alternative in localized cutaneous leishmaniasis, especially in cases of single cutaneous lesions and with formal contraindications to conventional treatment with pentavalent antimonials.
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Lago ASD, Nascimento M, Carvalho AM, Lago N, Silva J, Queiroz JR, Carvalho LP, Schriefer A, Wilson M, Machado P, Carvalho EM. The Elderly Respond to Antimony Therapy for Cutaneous Leishmaniasis Similarly to Young Patients but Have Severe Adverse Reactions. Am J Trop Med Hyg 2018; 98:1317-1324. [PMID: 29582733 DOI: 10.4269/ajtmh.17-0736] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
There is evidence that elderly patients with cutaneous leishmaniasis (CL) have more mucosal and disseminated diseases than young patients and their cells produce less antigen-induced interferon (IFN)-γ. Herein, we compared the roles of interleukin (IL)-10 and IL-15 as modulators of antigen-induced immune responses and the incidence of adverse reaction and response to therapy in young versus elderly patients with CL. Study participants included 35 senior (60-85 years) and 35 young (18-40 years) patients who had a diagnosis of CL documented by typical cutaneous lesions containing Leishmania braziliensis DNA. Elderly patients had less lymph node enlargement. Antigen-induced blood cell cytokine responses were studied in the absence or presence of IL-10 antibody or exogenously added recombinant IL-15. The ratio of IFN-γ/IL-10 was lower in elderly patients, and IFN-γ production was enhanced by either neutralization of IL-10 or exogenous recombinant IL-15 in blood cells from elderly but not young patients. Patients were treated three times weekly with antimony at 20 mg/kg/day for 20 doses. Although there was no difference in response to therapy between the two groups, two young patients needed rescue therapy with amphotericin B. Ventricular arrhythmias and ventricular overload were more frequent in elderly patients. We conclude that elderly patients have alterations in the immune response that may influence clinical manifestations, but we did not find that they had a higher failure rate than young subjects to antimony therapy. However, because of the high rate of electrocardiographic abnormalities during therapy, antimony should not be used in elderly patients with CL.
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Affiliation(s)
- Alexsandro Souza do Lago
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Maurício Nascimento
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Augusto M Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Neuza Lago
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Juliana Silva
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - José Roberto Queiroz
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Lucas P Carvalho
- Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz (IGM), Fiocruz, Salvador, Brazil.,CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil.,Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Albert Schriefer
- CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil.,Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Mary Wilson
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Paulo Machado
- CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil.,Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Edgar M Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil.,Laboratório de Pesquisas Clínicas do Instituto Gonçalo Moniz (IGM), Fiocruz, Salvador, Brazil.,CNPq/MCT, Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Salvador, Brazil
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9
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Saheki MN, Lyra MR, Bedoya-Pacheco SJ, Antônio LDF, Pimentel MIF, Salgueiro MDM, Vasconcellos ÉDCFE, Passos SRL, dos Santos GPL, Ribeiro MN, Fagundes A, Madeira MDF, Mouta-Confort E, Marzochi MCDA, Valete-Rosalino CM, Schubach ADO. Low versus high dose of antimony for American cutaneous leishmaniasis: A randomized controlled blind non-inferiority trial in Rio de Janeiro, Brazil. PLoS One 2017; 12:e0178592. [PMID: 28558061 PMCID: PMC5448803 DOI: 10.1371/journal.pone.0178592] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/12/2017] [Indexed: 11/18/2022] Open
Abstract
Background Although high dose of antimony is the mainstay for treatment of American cutaneous leishmaniasis (ACL), ongoing major concerns remain over its toxicity. Whether or not low dose antimony regimens provide non-inferior effectiveness and lower toxicity has long been a question of dispute. Methods A single-blind, non-inferiority, randomized controlled trial was conducted comparing high dose with low dose of antimony in subjects with ACL treated at a referral center in Rio de Janeiro, an endemic area of Leishmania (Viannia) braziliensis transmission. The primary outcome was clinical cure at 360 days of follow-up in the modified-intention-to-treat (mITT) and per-protocol (PP) populations. Non-inferiority margin was 15%. Secondary objectives included occurrence of epithelialization, adverse events and drug discontinuations. This study was registered in ClinicalTrials.gov: NCT01301924. Results Overall, 72 patients were randomly assigned to one of the two treatment arms during October 2008 to July 2014. In mITT, clinical cure was observed in 77.8% of subjects in the low dose antimony group and 94.4% in the high dose antimony group after one series of treatment (risk difference 16.7%; 90% CI, 3.7–29.7). The results were confirmed in PP analysis, with 77.8% of subjects with clinical cure in the low dose antimony group and 97.1% in the high dose antimony group (risk difference 19.4%; 90% CI, 7.1–31.7). The upper limit of the confidence interval exceeded the 15% threshold and was also above zero supporting the hypothesis that low dose is inferior to high dose of antimony after one series of treatment. Nevertheless, more major adverse events, a greater number of adverse events and major adverse events per subject, and more drug discontinuations were observed in the high dose antimony group (all p<0.05). Interestingly, of all the subjects who were originally allocated to the low dose antimony group and were followed up after clinical failure, 85.7% achieved cure after a further treatment with local therapy or low dose of antimony. Conclusions Compared with high dose, low dose of antimony was inferior at the pre-specified margin after one series of treatment of ACL, but was associated with a significantly lower toxicity. While high dose of antimony should remain the standard treatment for ACL, low dose antimony treatment might be preferred when toxicity is a primary concern.
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Affiliation(s)
- Mauricio Naoto Saheki
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
- * E-mail:
| | - Marcelo Rosandiski Lyra
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Sandro Javier Bedoya-Pacheco
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
- Department of Epidemiology and Quantitative Methods in Health, Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Liliane de Fátima Antônio
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Maria Inês Fernandes Pimentel
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Mariza de Matos Salgueiro
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Érica de Camargo Ferreira e Vasconcellos
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Sonia Regina Lambert Passos
- Clinical Epidemiology Laboratory, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Ginelza Peres Lima dos Santos
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Madelon Novato Ribeiro
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Aline Fagundes
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Maria de Fátima Madeira
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Eliame Mouta-Confort
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Mauro Célio de Almeida Marzochi
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
| | - Cláudia Maria Valete-Rosalino
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
- Department of Otorhinolaryngology and Ophthalmology, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Armando de Oliveira Schubach
- Laboratory for Leishmaniasis Surveillance, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Rio de Janeiro State, Brazil
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10
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Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A. Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 2016; 63:e202-e264. [PMID: 27941151 DOI: 10.1093/cid/ciw670] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 09/22/2016] [Indexed: 12/25/2022] Open
Abstract
It is important to realize that leishmaniasis guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The IDSA and ASTMH consider adherence to these guidelines to be voluntary, with the ultimate determinations regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Naomi Aronson
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Michael Libman
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Peter Weina
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | - Selma Jeronimo
- Federal University of Rio Grande do Norte, Natal, Brazil
| | - Alan Magill
- Bill and Melinda Gates Foundation, Seattle, Washington
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11
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Carvalho AM, Amorim CF, Barbosa JLS, Lago AS, Carvalho EM. Age modifies the immunologic response and clinical presentation of American tegumentary leishmaniasis. Am J Trop Med Hyg 2015; 92:1173-7. [PMID: 25918209 DOI: 10.4269/ajtmh.14-0631] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/08/2015] [Indexed: 01/22/2023] Open
Abstract
Leishmania (Viannia) braziliensis is the main causal agent of American tegumentary leishmaniasis (ATL) that may present as cutaneous, mucosal, or disseminated cutaneous leishmaniasis. The disease is highly prevalent in young males and there is a lack of studies of ATL in the elderly. Herein, we compared clinical manifestations, immunologic response, and response to antimony therapy between patients > 60 years of age (N = 58) and patients who were 21-30 years of age (N = 187). The study was performed in Corte de Pedra, Bahia, Brazil, a well-known area of L. braziliensis transmission. Cytokine production by cultured peripheral blood mononuclear cells stimulated with soluble Leishmania antigen was performed. Elderly subjects more frequently had a previous history of cutaneous leishmaniasis, large lesions, or mucosal leishmaniasis, and they were less likely to have lymphadenopathy. There was no difference regarding gender and response to therapy. Peripheral blood mononuclear cells from elderly subjects produced a similar amount of tumor necrosis factor than young patients but they produced less interferon-gamma and more interleukin-10 than young subjects. We concluded that elderly patients with cutaneous leishmaniasis should be searched for mucosal or disseminated leishmaniasis. The decreased interferon-gamma production and increase in interleukin-10 observed in elderly patients may contribute to parasite persistence and L. braziliensis infection dissemination.
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Affiliation(s)
- Augusto M Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), CNPq/MCT, Salvador, Bahia, Brazil; Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz FIOCRUZ-Salvador, Bahia, Brazil
| | - Camila F Amorim
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), CNPq/MCT, Salvador, Bahia, Brazil; Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz FIOCRUZ-Salvador, Bahia, Brazil
| | - Juliana L S Barbosa
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), CNPq/MCT, Salvador, Bahia, Brazil; Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz FIOCRUZ-Salvador, Bahia, Brazil
| | - Alexsandro S Lago
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), CNPq/MCT, Salvador, Bahia, Brazil; Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz FIOCRUZ-Salvador, Bahia, Brazil
| | - Edgar M Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil; Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), CNPq/MCT, Salvador, Bahia, Brazil; Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz FIOCRUZ-Salvador, Bahia, Brazil
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12
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Silva JSFE, Galvao TF, Pereira MG, Silva MT. Treatment of American tegumentary leishmaniasis in special populations: a summary of evidence. Rev Soc Bras Med Trop 2013; 46:669-77. [DOI: 10.1590/0037-8682-0104-2013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 07/31/2013] [Indexed: 01/16/2023] Open
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