CpG ODN D35 improves the response to abbreviated low-dose pentavalent antimonial treatment in non-human primate model of cutaneous leishmaniasis

Cutaneous leishmaniasis (CL) affects the lives of 0.7–1 million people every year causing lesions that take months to heal. These lesions can result in disfiguring scars with psychological, social and economic consequences. Antimonials are the first line of therapy for CL, however the treatment is lengthy and linked to significant toxicities; further, its efficacy is variable and resistant parasites are emerging. Shorter or lower dose antimonial treatment regimens, which would decrease the risk of adverse events and improve patient compliance, have shown reduced efficacy and further increase the risk emergence of antimonial-resistant strains. The progression of lesions in CL is partly determined by the immune response it elicits, and previous studies showed that administration of immunomodulatory type D CpG ODNs, magnifies the immune response to Leishmania and reduces lesion severity in nonhuman primates (NHP) challenged with Leishmania major or Leishmania amazonensis. Here we explored whether the addition of a single dose of immunomodulating CpG ODN D35 augments the efficacy of a short-course, low-dose pentavalent antimonial treatment regimen. Results show that macaques treated with D35 plus 5mg/kg sodium stibogluconate (Sb^V) for 10 days had smaller lesions and reduced time to re-epithelization after infection with Leishmania major. No toxicities were evident during the studies, even at doses of D35 10 times higher than those used in treatment. Critically, pentavalent antimonial treatment did not modify the ability of D35 to induce type I IFNs. The findings support the efficacy of D35 as adjuvant therapy for shorter, low dose pentavalent antimonial treatment.

Cutaneous leishmaniasis is a devastating disease that affects close to a million people every year. Its clinical presentation ranges from small uncomplicated lesions that heal over a few months to debilitating large chronic or recurring lesions that result in disfigurement, stigma, and economic loss. Antimonials are the first line treatment for cutaneous leishmaniasis in most countries, but the lengthy treatment schedules, significant associated toxicities, and the emergence of resistant strains, require the development of alternative strategies. As the immune response is a key determinant of disease course, immunomodulatory therapies could be harnessed to act in concert with antimonials to improve the safety and efficacy of CL treatment. Synthetic oligonucleotide D35 selectively activates plasmacytoid dendritic cells and was previously shown to reduce the severity of L. major and L. amazonensis lesions in rhesus macaques, but its activity in combination with antimonials was unknown. Our studies show that a single subcutaneous dose of innate immune modulator D35 improved the response to a low-dose abbreviated antimonial course, reducing the severity of the lesions and accelerating healing in primates. No toxicities were evident with D35 at doses ten-fold higher than the effective dose. The studies suggest that the combined therapy strategy shows clinical promise.

Antimony-Induced Neurobehavioral and Biochemical Perturbations in Mice

Groundwater used for drinking has been contaminated with naturally occurring inorganic arsenic and other metals, and metal-contaminated drinking water is the biggest threat to public health in Bangladesh. Toxic metals present in the drinking water have a strong relationship with chronic diseases in humans. Antimony (Sb), a naturally occurring metal, has been reported to be present in the drinking water along with other heavy metals in Bangladesh. Although Sb is present in the environment, very little attention has been given to the toxic effects of Sb. The present study was designed to investigate the in vivo effects of Sb on neurobehavioral changes like anxiety, learning and memory impairment, and blood indices related to organ dysfunction. Mice exposed to antimony potassium-tartrate hydrate (Sb) (10 mg/kg body weight) significantly (p < 0.05) decreased the time spent in open arms while increased the time spent in closed arms compared to the control mice in elevated plus maze. The mean latency time of control group to find the platform decreased (p < 0.05) significantly during 7 days learning as compared to Sb-treated group in Morris water maze test, and Sb-exposed group spent significantly (p < 0.05) less time in the desired quadrant as compared to the control group in probe trial. Sb treatment also significantly altered blood indices related to liver and kidney dysfunction. Additionally, Sb-induced biochemical alterations were associated with significant perturbations in histological architecture of liver and kidney of Sb-exposed mice. These data suggest that Sb has a toxic effect on neurobehavioral and biochemical changes in mice.

In vitro additive interaction between ketoconazole and antimony against intramacrophage Leishmania (Leishmania) amazonensis amastigotes

Leishmaniasis is a group of diseases caused by protozoa of Leishmania genus. The currently available treatments for this disease are expensive, present high toxicity and are associated to difficulties of healing and parasite resistance. Therefore, the development of strategies for leishmaniasis treatment is indispensable and includes reposition of existing drugs, as well as drug combination therapy. The aim of this study was to assess the nature of ketoconazole and antimony association on the cytotoxic effect against Leishmania (Leishmania) amazonensis amastigotes. The calculated mean sum of fractional 50% inhibitory concentration (x¯ΣFIC₅₀) was 2.54 and 1.43 for free and intracellular amastigotes, respectively, values that suggest an additive interaction between ketoconazole and antimony concerning to Leishmania toxicity only in the intramacrophage parasite form. Despite the clinical efficacy of ketoconazole-antimony combination has been shown in the literature, our study is the first to describe the nature of ketoconazole-antimony interaction against L. (L.) amazonensis amastigotes. Moreover, our results point out the need for future in vivo studies to confirm the nature of ketoconazole-antimony interaction and also to determine possible effective dosage regimens related to ketoconazole administration in association with the optimal lower dose of antimony.

Association of liposome-encapsulated trivalent antimonial with ascorbic acid: an effective and safe strategy in the treatment of experimental visceral leishmaniasis

BACKGROUND

Visceral leishmaniasis (VL) is a chronic debilitating disease endemic in tropical and subtropical areas, caused by protozoan parasites of the genus Leishmania. Annually, it is estimated the occurrence of 0.2 to 0.4 million new cases of the disease worldwide. Considering the lack of an effective vaccine the afflicted population must rely on both, an accurate diagnosis and successful treatment to combat the disease. Here we propose to evaluate the efficacy of trivalent antimonial encapsulated in conventional liposomes, in association with ascorbic acid, by monitoring its toxicity and efficacy in BALB/c mice infected with Leishmania infantum.

METHODOLOGY/PRINCIPAL FINDINGS

Infected mice were subjected to single-dose treatments consisting in the administration of either free or liposome-encapsulated trivalent antimony (SbIII), in association or not with ascorbic acid. Parasite burden was assessed in the liver, spleen and bone marrow using the serial limiting dilution technique. After treatment, tissue alterations were examined by histopathology of liver, heart and kidney and confirmed by serum levels of classic biomarkers. The phenotypic profile of splenocytes was also investigated by flow cytometry. Treatment with liposome-encapsulated SbIII significantly reduced the parasite burden in the liver, spleen and bone marrow. Co-administration of ascorbic acid, with either free SbIII or its liposomal form, did not interfere with its leishmanicidal activity and promoted reduced toxicity particularly to the kidney and liver tissues.

CONCLUSIONS/SIGNIFICANCE

Among the evaluated posological regimens treatment of L. infantum-infected mice with liposomal SbIII, in association with ascorbic acid, represented the best alternative as judged by its high leishmanicidal activity and absence of detectable toxic effects. Of particular importance, reduction of parasite burden in the bone marrow attested to the ability of SbIII-carrying liposomes to efficiently reach this body compartment.

Mixed antimony(V) complexes with different sugars to modulate the oral bioavailability of pentavalent antimonial drugs

Previous studies have shown that the association of the drug meglumine antimoniate (MA) with β-cyclodextrin can improve its bioavailability by the oral route. In this work, ribose and maltose were investigated for their ability to form mixed or association complexes with MA, release MA and modulate the serum levels of Sb after oral administration in mice. Analysis of the MA/ribose composition by high performance liquid chromatography coupled to mass spectrometry (LCMS-IT-TOF) revealed the presence of mixed meglumine-Sb-ribose and Sb-ribose complexes. Analysis of the MA/maltose composition suggested the formation of MA-maltose association compounds. Circular dichroism characterization of these compositions following dilution in water at 37 °C suggested a partial and slow dissociation of the association compounds. When the MA/ribose composition was administered orally and compared to MA, the serum concentration of Sb was significantly lower after 1 h and greater after 3 h. On the other hand, the MA/maltose composition showed similar serum Sb concentration after 1 h and higher level of Sb after 3 h, when compared to MA. In conclusion, the present study has demonstrated the formation of mixed or association complexes of MA with sugars, such as maltose and ribose, which promoted sustained serum level of Sb after oral administration.

Liposomal amphotericin B versus pentavalent antimony salts for visceral Leishmania in children

The aim of this study was to investigate the efficacy of a 21-day schedule of liposomal amphotericin B compared to pentavalent antimony salts in the treatment of patients during a first episode of visceral leishmaniasis. In this study, 17 cases of visceral leishmaniasis admitted to Behçet Uz Children's Hospital between January 2005 and April 2012 were reviewed retrospectively. The study group was composed of 11 males (64.7%) and 6 females (35.3%). One group included 11 patients who were treated with pentavalent antimony salts, sodium stibogluconate or meglumine antimoniate, intramuscularly for 28 days. The second group was treated with amphotericin B intravenously at a dosage of 3 mg/kg on days 1-5, 10 and 21 (a cumulative dose of 21 mg/kg/day). While pentavalent antimony salts were found to increase biochemical and hematological findings, liposomal amphotericin B was responsible for rapid recovery in fever and shorter hospital stay. As a result, our study shows the advantages of both medications independent of their costs.

Imipramine is an orally active drug against both antimony sensitive and resistant Leishmania donovani clinical isolates in experimental infection

Background

In an endeavor to find an orally active and affordable antileishmanial drug, we tested the efficacy of a cationic amphiphilic drug, imipramine, commonly used for the treatment of depression in humans. The only available orally active antileishmanial drug is miltefosine with long half life and teratogenic potential limits patient compliance. Thus there is a genuine need for an orally active antileishmanial drug. Previously it was shown that imipramine, a tricyclic antidepressant alters the protonmotive force in promastigotes, but its in vivo efficacy was not reported.

Methodology/Principal Findings

Here we show that the drug is highly active against antimony sensitive and resistant Leishmania donovani in both promastigotes and intracellular amastigotes and in LD infected hamster model. The drug was found to decrease the mitochondrial transmembrane potential of Leishmania donovani (LD) promastigotes and purified amastigotes after 8 h of treatment, whereas miltefosine effected only a marginal change even after 24 h. The drug restores defective antigen presenting ability of the parasitized macrophages. The status of the host protective factors TNF α, IFN γ and iNOS activity increased with the concomitant decrease in IL 10 and TGF β level in imipramine treated infected hamsters and evolution of matured sterile hepatic granuloma. The 10-day therapeutic window as a monotherapy, showing about 90% clearance of organ parasites in infected hamsters regardless of their SSG sensitivity.

Conclusions

This study showed that imipramine possibly qualifies for a new use of an old drug and can be used as an effective orally active drug for the treatment of Kala-azar.

The disease Kala-azar or visceral leishmaniasis is still a big problem in the Indian subcontinent. The antimonials were used for the chemotherapy of Kala-azar but with time its efficacy has reduced dramatically. The newer version of orally active drug miltefosine has been introduced, but its efficacy has decreased considerably as relapse cases are on the rise. Other drugs like liposomal form of amphotericin B is expensive and the patients require hospitalization. Thus there is a genuine need for an orally active antileishmanial drug. There are reports that the cationic amphiphilic molecule, imipramine, a drug used for the treatment of depression in humans, kills the promastigotes of Leishmania donovani. We tested the efficacy of imipramine in experimental infection in hamster and mouse model. Our study showed that the drug is highly effective against antimony sensitive and antimony resistant Leishmania donovani infected hamsters as well as mouse and offered almost sterile cure.

Treatment of visceral leishmaniasis: model-based analyses on the spread of antimony-resistant L. donovani in Bihar, India

Background

Pentavalent antimonials have been the mainstay of antileishmanial therapy for decades, but increasing failure rates under antimonial treatment have challenged further use of these drugs in the Indian subcontinent. Experimental evidence has suggested that parasites which are resistant against antimonials have superior survival skills than sensitive ones even in the absence of antimonial treatment.

Methods and Findings

We use simulation studies based on a mathematical L. donovani transmission model to identify parameters which can explain why treatment failure rates under antimonial treatment increased up to 65% in Bihar between 1980 and 1997. Model analyses suggest that resistance to treatment alone cannot explain the observed treatment failure rates. We explore two hypotheses referring to an increased fitness of antimony-resistant parasites: the additional fitness is (i) disease-related, by causing more clinical cases (higher pathogenicity) or more severe disease (higher virulence), or (ii) is transmission-related, by increasing the transmissibility from sand flies to humans or vice versa.

Conclusions

Both hypotheses can potentially explain the Bihar observations. However, increased transmissibility as an explanation appears more plausible because it can occur in the background of asymptomatically transmitted infection whereas disease-related factors would most probably be observable. Irrespective of the cause of fitness, parasites with a higher fitness will finally replace sensitive parasites, even if antimonials are replaced by another drug.

The protozoan flagellate Leishmania donovani causes the neglected, life-threatening disease visceral leishmaniasis. Parasites are transmitted from man to man by the bite of the sand fly Phlebotomus argentipes, the vector of the disease. Pentavalent antimonials have been the mainstay of antileishmanial therapy for decades but rapidly increasing failure rates up to 65% observed between 1980 and 1997 in the state of Bihar, India, have challenged further use of these drugs. Comparative in vitro and in vivo experiments indicate that antimony-resistant parasites have a higher fitness than antimony-sensitive ones even in the absence of antimonial treatment. Simulation studies based on a previously published mathematical L. donovani transmission model suggest that resistance to antimonial treatment alone cannot explain the Bihar observations but that resistance together with higher fitness offers the potential to explain the data. After an antimony-resistant parasite with higher fitness has emerged, it will finally replace the antimony-sensitive ones, even in complete absence of antimonial treatment.

Reproducibility of lymphoscintigraphy before and after excisional biopsy of primary breast lesions: a study using superficial peri-areolar injection of the radiotracer

OBJECTIVE

A major controversial issue in the sentinel node biopsy of the breast is the applicability of sentinel node mapping in patients with the history of previous excisional biopsy of the breast lesions. In the current study, we evaluated the reproducibility of lymphoscintigraphy before and after excisional biopsy of the primary breast lesions using superficial peri-areolar injection of the radiotracer.

MATERIAL AND METHODS

Eighteen patients scheduled for excisional biopsy of breast lesions were included into the study. The patients received intra-dermal injection of the radiotracer in the peri-areolar area of the index quadrant 1 to 2h before surgery. Imaging was performed the day after surgery. Immediately after completion of the first imaging, the patients received another injection of the radiotracer with the same technique, dose, and location. Other sets of lymphoscintigraphy imaging were taken immediately and 4h post second injection. The two sets of lymphoscintigraphy images were compared.

RESULTS

In 2 patients, sentinel node could not be identified in either set of images. In the remaining 16 patients, one sentinel node was detected in both lymphoscintigraphy image sets. The sentinel nodes of the second image sets were all in the same location of the first sets with at least 5 times higher count.

CONCLUSIONS

Excisional biopsy of the primary breast lesions does not seem to change the superficial lymphatic drainage pattern from the areola of the breast and sentinel node mapping can be performed after this procedure using superficial periareolar technique.

Prediction score for antimony treatment failure in patients with ulcerative leishmaniasis lesions

Background

Increased rates for failure in leishmaniasis antimony treatment have been recently recognized worldwide. Although several risk factors have been identified there is no clinical score to predict antimony therapy failure of cutaneous leishmaniasis.

Methods

A case control study was conducted in Peru from 2001 to 2004. 171 patients were treated with pentavalent antimony and followed up to at least 6 months to determine cure or failure. Only patients with ulcerative cutaneous leishmaniasis (N = 87) were considered for data analysis. Epidemiological, demographical, clinical and laboratory data were analyzed to identify risk factors for treatment failure. Two prognostic scores for antimonial treatment failure were tested for sensitivity and specificity to predict antimony therapy failure by comparison with treatment outcome.

Results

Among 87 antimony-treated patients, 18 (21%) failed the treatment and 69 (79%) were cured. A novel risk factor for treatment failure was identified: presence of concomitant distant lesions. Patients presenting concomitant-distant lesions showed a 30.5-fold increase in the risk of treatment failure compared to other patients. The best prognostic score for antimonial treatment failure showed a sensitivity of 77.78% and specificity of 95.52% to predict antimony therapy failure.

Conclusions

A prognostic score including a novel risk factor was able to predict antimonial treatment failure in cutaneous leishmaniasis with high specificity and sensitivity. This prognostic score presents practical advantages as it relies on clinical and epidemiological characteristics, easily obtained by physicians or health workers, and makes it a promising clinical tool that needs to be validated before their use for developing countries.

The manuscript is relevant because of the finding of a new risk factor for chemotherapy failure and the development of a prognosis score for cutaneous leishmaniasis. The proportion of patients that have multiple lesions in American Tegumentary Leishmaniasis (ATL) is considerable. Publications and our experience permit to estimate that they represent around 20% of the affected population from the Amazon basin with cutaneous lesions. In addition, about 1/3 of them would correspond to the concomitant distant lesions category, the novel risk factor identified with a very high odds ratio (20–30) associated. Such numbers merit study of concomitant distant ulcers category on its own, not only because of clinical management implications, but also to search for factors that are contributing to chemotherapy failure. Finally, the simple equation proposed in the manuscript can be easily adapted to smart phone technologies. Similar prognosis equations are scarce for other pathologies and do not exist for Cutaneous Leishmaniasis at all. The simplicity of this tool should be followed by subsequent epidemiologic studies in other ATL endemic regions.

Miltefosine in the treatment of cutaneous leishmaniasis caused by Leishmania braziliensis in Brazil: a randomized and controlled trial

Background

Cutaneous leishmaniasis (CL) is treated with parenteral drugs for decades with decreasing rate cures. Miltefosine is an oral medication with anti-leishmania activity and may increase the cure rates and improve compliance.

Methodology/Principal Findings

This study is a randomized, open-label, controlled clinical trial aimed to evaluate the efficacy and safety of miltefosine versus pentavalent antimony (Sb^v) in the treatment of patients with CL caused by Leishmania braziliensis in Bahia, Brazil. A total of 90 patients were enrolled in the trial; 60 were assigned to receive miltefosine and 30 to receive Sb^v. Six months after treatment, in the intention-to-treat analyses, the definitive cure rate was 53.3% in the Sb^v group and 75% in the miltefosine group (difference of 21.7%, 95% CI 0.08% to 42.7%, p = 0.04). Miltefosine was more effective than Sb^v in the age group of 13–65 years-old compared to 2–12 years-old group (78.9% versus 45% p = 0.02; 68.2% versus 70% p = 1.0, respectively). The incidence of adverse events was similar in the Sb^v and miltefosine groups (76.7% vs. 78.3%). Vomiting (41.7%), nausea (40%), and abdominal pain (23.3%) were significantly more frequent in the miltefosine group while arthralgias (20.7%), mialgias (20.7%) and fever (23.3%) were significantly more frequent in the Sb^v group.

Conclusions

This study demonstrates that miltefosine therapy is more effective than standard Sb^v and safe for the treatment of CL caused by Leishmania braziliensis in Bahia, Brazil.

Trial Registration

Clinicaltrials.gov Identifier NCT00600548

Cutaneous leishmaniasis (CL) is characterized by skin ulcerations and occurs in rural poor areas of developing countries. It is treated with daily injections of antimony for 20 days, which is associated with irregular use and increasingly lower cure rates. Miltefosine is an oral medication with activity against the agent of CL (Leishmania). We have studied the efficacy and safety of miltefosine compared with antimony in patients with CL caused by Leishmania braziliensis in Bahia, Brazil. A total of 90 patients participated; 60 received miltefosine and 30 were treated with antimony. Six months after treatment, 75% of patients treated with miltefosine were cured, compared with 53% of the patients in the antimony group, a difference considered significant (p = 0.04). We also found that miltefosine was more effective than antimony in adults than in children. The incidence of side effects was similar with both drugs (76.7% vs. 78.3%), but all patients were able to finish the treatments. Our study shows that miltefosine is more effective than antimony for the treatment of CL in Bahia, Brazil and can contribute to the control of this disease due to its activity and easier administration.

Comparison of early and delayed lymphoscintigraphy images of early breast cancer patients undergoing sentinel node mapping

OBJECTIVE

We compared early and delayed lymphoscintigraphy images using intradermal injection of (99m)Tc-antimony sulfide colloid, which has small particles.

METHODS

Eighty patients with early-stage breast cancer were included into the study. Intradermal injection of (99m)Tc-antimony sulfide colloid was used for sentinel node mapping. After radiotracer injection, 30 min and 20 h later, lymphoscitigraphy images were obtained in lateral and anterior views. After the completion of each image sets, the location of the visible nodes in the axilla was marked on the skin. Two nuclear medicine specialists reviewed the images independently and the number and location of detected nodes were recorded.

RESULTS

At least one hotspot was detected in the axillary region in 78 (97.5%) and 79 (98.75%) patients on the early and delayed images, respectively. No extra-axillary drainage was noted in the patients. The number and location of detected hot spots were the same in 77 patients on both image sets. In one patient the early image did not show any axillary hot spot despite its visualization on the delayed image set and in one patient no hot spot was noted on either images. In one patient an additional axillary hot spot was noted on the delayed image, which was not apparent on the early image.

CONCLUSION

Our study showed that a delay of up to 20 h in sentinel lymph node biopsy using intradermal injection of (99m)Tc-antimony sulfide colloid does not result in washout of the tracer from the true sentinel node or migration of the radiotracer into second-echelon nodes.

The efficacy of Tc-99m sestamibi for sentinel node mapping in breast carcinomas: comparison with Tc-99m antimony sulphide colloid

BACKGROUND

To study the value of periareolar intra-dermal injection of Tc-99m sestamibi (MIBI) for sentinel node mapping in breast carcinoma.

MATERIAL AND METHODS

Fifty patients with early-stage breast cancer were included in our study. 17.5 MBq Tc-99m-MIBI was injected intradermally to 25 patients and the remainders were injected with the same dose of Tc-99m-antimony sulphide colloid. Anterior and lateral static images were taken at 2 minutes. If sentinel lymph node was not detected, delayed imaging by up to 180 minutes was carried out. The patients were operated on 2-4 hours post-injection. Sentinel lymph node biopsy was performed by the aid of gamma probe and blue dye during surgery.

RESULTS

In the Tc-99m-MIBI group, 23 patients had lymph nodes on scintigraphy images, and sentinel nodes were detected during surgery in all 23 patients. In the Tc-99m-antimony sulphide colloid group, 24 patients had lymph nodes on scintigraphy images, and sentinel nodes were identified during surgery in 24 patients.

CONCLUSIONS

We concluded that 99mTc-MIBI is a suitable radiopharmaceutical for sentinel node detection.

[Effects of trivalent antimony on the rat hormonal status under experimental conditions]

The paper gives the data of experimental studies of oral trivalent antimony used at 1 and 20 maximum permissible concentrations (MPC) on the rat hormonal status. The findings are indicative of the specific features of changes in the hormonal status of experimental animals depending on the dose of trivalent antimony. The concentration of trivalent antimony at the level of 20 MPC is shown to act as a role of a reprotoxic agent that causes a change in the serum content of hormones, such as follicle-stimulating and luteinizing ones.

Effects of fluconazole on the pharmacokinetics and pharmacodynamics of antimony in cutaneous leishmaniasis-infected hamsters

Pentavalent antimony (Sb(V)) compounds are the drugs of choice for the treatment of all forms of leishmaniasis. For 20 years there has been an interest in antifungal azoles for treating leishmaniasis, with variable success. In the current study, we examined the effects of co-administration of fluconazole (FLZ) on the pharmacokinetics and pharmacodynamics of Sb(V) in cutaneous leishmaniasis-infected hamsters. Hamsters were divided into four groups. All hamsters were injected with 0.1 mL of 1x10(8)promastigotes/mL into the right foot on Day 1. Treatment was started 5 days after the infection. The antimony group received 80 mg/kg/day of Pentostam intramuscularly whilst the FLZ group received FLZ 20 mg/kg/day orally for 14 days. The combination group received both Pentostam and FLZ at the above mentioned doses for 14 days. Animals in the control group received no treatment. The infected footpads were measured on Days 1 and 14. A pharmacokinetic study was conducted on Days 1 and 14 of treatment, representing single- and multiple-dose pharmacokinetics, respectively. Blood samples were collected at different time intervals up to 24h. Sb(V) was determined using flameless atomic absorption spectrophotometry. Pharmacokinetic parameters were calculated using a non-compartmental analysis. In the single-dose study, there was no statistically significant difference in any of the pharmacokinetic parameters of Sb(V) when given alone or with FLZ. However, on Day 14 a significant increase in peak plasma concentration (C(max)) (three-fold) and area under the concentration-time curve (AUC) (four-fold) of antimony was observed when Sb(V) was co-administered with FLZ. A statistically significant prolongation of the terminal half-life from 1.63 to 8.67 h (P<0.05) was also observed. A significant reduction in clearance was detected. However, FLZ had no effect on the pharmacodynamics of Sb(V) as measured by footpad sizes. In conclusion, FLZ did not improve the therapeutic effect of Sb(V) when given concomitantly despite the significant increase in blood concentration and prolongation of the elimination half-life of Sb(V).

Cutaneous leishmaniasis treatment

The causative species of cutaneous leishmaniasis determines the clinical features and courses, and treatments. Intralesional or systemic antimonials are the gold standard for the treatment of these diseases. However, as for visceral leishmaniasis, other therapeutic options appear promising. Paromomycin ointments are effective in Leishmania major, L. tropica, L. mexicana, and L. panamensis lesions. In L. braziliensis localized leishmaniasis, both paromomycin and imiquimod may be topically applied. Oral fluconazole and zinc sulfate are useful in L. major. Oral azithromycin, effective in vitro and in mice, needs further investigation in human leishmaniasis. On the contrary, data with oral itraconazole are disappointing. Oral miltefosine, which is very effective in visceral leishmaniasis caused by L. donovani, appears ineffective in L. major and L. braziliensis infections. Intramuscular pentamidine is required for L. guyanensis cutaneous leishmaniasis, for which systemic antimony is not effective. Liposomal amphotericin B could be an alternative to antimony in south American cutaneous leishmaniasis with mucosal involvement (especially L. braziliensis and L. guyanensis infections).

Oral Pentoxifylline Combined with Pentavalent Antimony: A Randomized Trial for Mucosal Leishmaniasis

BACKGROUND

Mucosal leishmaniasis is associated with intense tissue damage and high tumor necrosis factor-alpha production. Therapeutic failure occurs in up to 42% of cases; patients who experience treatment failure will require >1 pentavalent antimony (Sb(v)) course or alternative drugs to achieve a cure. We previously showed that an inhibitor of tumor necrosis factor-alpha (pentoxifylline) combined with Sb(v) cured 90% patients refractory to monotherapy with Sb(v).

METHODS

A double-blind, placebo-controlled trial involving 23 patients with mucosal leishmaniasis evaluated the efficacy of pentoxifylline when administered in association with Sb(v), compared with Sb(v) treatment alone. Eleven patients were randomized to receive Sb(v) plus oral pentoxifylline for 30 days, and 12 patients received Sb(v) plus oral placebo. The criterion for cure was a complete healing of lesions.

RESULTS

All patients in the pentoxifylline group experienced a cure with 1 course of Sb(v), whereas 5 (41.6%) of 12 patients in the placebo group required a second course of Sb(v) (P=.037). The healing time +/- standard deviation in the pentoxifylline group was 83+/-36 days, compared with 145+/-99 days in the placebo group (P=.049). No relapses were documented in either group at the 2-year follow-up visit.

CONCLUSIONS

The addition of pentoxifylline to Sb(v) in mucosal leishmaniasis reduces the healing time significantly and prevents the need for further courses of Sb(v).

[Why was Rocco Jemma the greatest Italian paediatrician?]

Rocco Jemma was the greatest Italian paediatrician, because he left the greatest signs in history. The most important amongst his achievements is certainly the foundation of the Rocco Jemma School which spread all over Italy and provided the greatest number of paediatric teachers who reached excellence levels. He was, among all the presidents of the Italian Society of Paediatrics, the one who was in office for the longest time. The therapy of leishmaniosis, based on antimonial derivatives formulated by Jemma, is still used and respected today.

Successful Internal Mammary Visualization With Periareolar Injections of Tc-99m Antimony Sulfur Colloid in Sentinel Node Breast Lymphoscintigraphy

PURPOSE

The subareolar and periareolar injection techniques result in higher detection rates and do not require tumor localization in impalpable lesions when compared with the peritumoral technique. One of the main criticisms, however, is the widely reported inability to detect internal mammary nodes. This contrasts with our clinical experience using Tc-99m antimony sulfur colloid, in which internal mammary nodes are commonly seen.

METHODS

A retrospective analysis of 241 patients over 38 months was performed to investigate the ability of our periareolar injection technique to detect internal mammary lymph node drainage in breast cancer sentinel node lymphoscintigraphy. Four injections of 5 to 10 MBq (0.14-0.27 mCi) Tc-99m antimony sulfur colloid were administered on the day of surgery followed by massage and imaging. The radioisotope was suspended in 0.1 mL with a 0.5-mL air lock. Each injection was performed over 2 seconds with a 25-gauge needle at a depth of 1.1 to 1.3 cm. Patients whose records could not be retrieved or who underwent an injection technique apart from periareolar or peritumoral were removed from the analysis.

RESULTS

One hundred thirty-three patients underwent the periareolar technique, 72 patients underwent the peritumoral technique, and 36 patients were excluded from the analysis. Internal mammary drainage was seen in 24 of 133 (18.0%) patients, of which 12 (9%) were seen only in the internal mammary chain. This is much higher than previous studies quoting 0.0% to 4.3% and is similar to previously reported rates using the peritumoral technique.

CONCLUSIONS

Our periareolar injection technique using Tc-99m antimony sulfur colloid is able to detect internal mammary lymph nodes in at least 18.0% of patients.

Pseudomonas aeruginosa otochondritis complicating localized cutaneous leishmaniasis: prevention of mutilation by early antibiotic therapy

A patient with an ulcerated cutaneous leishmaniasis of the pinna had suppurative otochondritis after a first unsuccessful course of treatment with meglumine antimoniate. Although the Leishmania ulceration healed after a second course of meglumine antimoniate, and despite three oral dicloxacillin or pristinamycin courses, the otochondritis extended and an abscess developed. Pus from the abscess revealed a pure culture of Pseudomonas aeruginosa. Five days of oral ciprofloxacin plus rifampin led to a marked improvement. The P. aeruginosa isolate was sensitive to ciprofloxacin but fully resistant to rifampin. Healing with minimal mutilation was obtained at the end of a six-week course of multiple antibiotic therapy. Pseudomonas aeruginosa otochondritis was a co-factor of cartilage mutilation in this patient. Thus, infection with P. aeruginosa should be promptly treated when present in tender cutaneous or mucosal leishmaniasis lesions near cartilaginous areas.

Improved targeting of antimony to the bone marrow of dogs using liposomes of reduced size

A novel liposomal formulation of meglumine antimoniate (MA), consisting of vesicles of reduced size, has been evaluated in dogs with visceral leishmaniasis to determine its pharmacokinetics as well as the impact of vesicle size on the targeting of antimony to the bone marrow. Encapsulation of MA in liposomes was achieved through freeze-drying of empty liposomes in the presence of sucrose and rehydration with a solution of MA. The resulting formulation, with a mean vesicle diameter of about 400 nm, was given to mongrel dogs with visceral leishmaniasis as an i.v. bolus injection at 4.2 mgSb/kg of body weight. The pharmacokinetics of antimony were assessed in the blood and in organs of the mononuclear phagocyte system and compared to those achieved with the free drug and the drug encapsulated in large sized liposomes (mean diameter of 1200 nm). The targeting of antimony to the bone marrow was improved (approximately three-fold) with the novel liposomal formulation, when compared to the formulation of MA in large sized liposomes. This study provides the first direct experimental evidence that passive targeting of liposomes to the bone marrow of dogs is improved by the reduction of vesicle size from the micron to the nanometer scale.

Resistance to Antimony and Treatment Failure in HumanLeishmania (Viannia)Infection

BACKGROUND

Failure of antimonial therapy has been increasingly reported in anthroponotic visceral leishmaniasis and in cutaneous disease. The role of drug resistance in treatment failure has been difficult to ascertain because therapeutic response is multifactorial, and the efficacy of antimonial drugs depends on an effective immune response. In this study, we sought to determine whether standard treatment selects for resistant organisms and whether drug resistance contributes to treatment failure.

METHODS

We evaluated the susceptibility to antimony of 19 strains isolated before treatment with meglumine antimoniate and 21 strains isolated at treatment failure from 20 patients. The 50% effective dose (ED50) of antimony in the form of additive-free meglumine antimoniate was determined for intracellular amastigotes in human promonocytic U-937 cells.

RESULTS

Before treatment, 16% of strains (3/19) showed primary resistance (ED50 of >128 microg Sb/mL), whereas 84% (16/19) were susceptible (ED50 of <20 microg Sb/mL). However, 88% of susceptible strains (14/16) had ED90 values of >128 microg Sb/mL. At treatment failure, 40% of strains (8/20) were resistant. Secondary resistance was documented in 4 patients.

CONCLUSIONS

Primary and secondary resistance to antimony can contribute to treatment failure in American cutaneous leishmaniasis. Selection for resistance to antimony occurs during standard treatment with antimonial drugs, and primary resistance to antimony supports the plausibility of anthroponotic transmission.

[The cutaneous leishmaniasis of the face in Gafsa area, Tunisia]

The cutaneous leishmaniasis is a frequent affection in Tunisia. In the Gafsa region it is a endemoepidemic infection. Our prospective study was carried out on 225 cases of cutaneous leishmaniasis of the face collected over two years in the outpatients' department of dermatology at Gafsa hospital. The aim of our study was to know more about the evolutive epidemio-clinical particularities of the cutaneous leishmaniasis of the face. The relative frequency of the cutaneous leishmaniasis of the face for the new patients reached 5%. An equal distribution between the two sexes was noted. The average age of our patients was 24 years old and 6 months old with extremes ranging from 3 months to 77 years. The nodular and ulcerated forms were the most frequent (35.3%), followed by impetiginoid forms (23%), then the lupoid forms (15%). The papular form was quite frequent (13%). Impetiginoid lesions occurred frequently in the child. Lupoid lesions appeared particularly on the nose. The complicated forms: the cutaneuos necrosis or erysipelas of the face appeared after intralesional injections of meglumine antimoniate (Glucantime). The intramuscular meglumine antimoniate was used in 172 patients, among them 47 needed two treatments or more because of a particular resistance of the lesions of the face. The pimple of Gafsa, term initially used for ulcerated skin nodules, was actually characterised by a lesional polymorphism. The prognosis was good however the risk of in aesthetic scar of the face was important.

Tracing the evolution of hepatitis C virus in the United States, Japan, and Egypt by using the molecular clock

The molecular clock has been a very powerful tool in looking back at the epidemic spread of HCV infection in the United States (US) and Japan, as well as in Egypt. This analysis estimates that the growth of the US HCV genotype 1a (HCV-1a)-infected population occurred around 1960, at least 30 years later than the widespread introduction of HCV-1b into the Japanese population. In Japan, the estimated effective number of HCV infections indicated a rapid exponential growth in the 1920s among patients with schistosomiasis, which coincides with injection treatment for schistosomiasis since 1921 in previously schistosomiasis-endemic areas. In Egypt, the spread of HCV-4a would have increased exponentially during the 1940s through 1980, which was also consistent with the duration of intravenous antimony campaigns for the treatment of shistosomiasis in that country. The implications are that Japan has set the model for HCV-related HCC, and that the high HCC incidence in Japan might be replicated by the rest of the world as their HCV-infected population ages and the duration of HCV infection approaches that currently observed in Japan.

Changing pattern of imported cutaneous leishmaniasis in the Netherlands

Cutaneous leishmaniasis (CL) in western countries seems to be appearing more frequently. Our aim was to determine if there has been a shift in countries where CL is acquired and whether the incidence has changed, and to assess current diagnostic procedures and treatment modalities. In a retrospective study medical records of patients with the diagnosis of CL at the Departments of Tropical Dermatology and Tropical Medicine, Academic Medical Center, Amsterdam, the Netherlands, from 1990 to 2000 were analysed. CL was diagnosed in 78 patients. The majority was acquired in Belize, Surinam, French Guyana and Bolivia. Giemsa stains were positive for the parasite in impression smears from 43% and in biopsies from 71%. Seventy-eight per cent of cases were culture-positive and 89% were PCR-positive. Sixty-two patients were treated systemically: pentavalent antimony (32), pentamidine isetionate (11), itraconazole (19), and 13 locally, the majority with a combination of cryosurgery and intralesional pentavalent antimony. Imported CL is becoming more frequent, with South and Middle American countries being important sources of infection. Multiple tests, of which PCR is the most sensitive, are required to confirm the diagnosis. Systemic treatment was given to the majority of the patients.

Antimony-induced cardiomyopathy in guinea-pig and protection by L-carnitine

Antimony (Sb) is the mainstay for the treatment of Leishmaniasis. It has serious, often lethal, cardiovascular side effects. The objective of this study was to examine the effects of Sb treatment upon the electrocardiogram (ECG), myocyte contractility (assessed by monitoring sarcomere length during field stimulation), whole-cell action potential (AP) and calcium current (I(Ca)) of the guinea-pig and to evaluate L-carnitine as a cardioprotective agent. Guinea-pigs received daily injections of either saline, Sb(V), Sb(III), L-carnitine or L-carnitine with Sb(III). Eight lead ECGs were recorded under halothane anaesthesia every 4 days. At the end of each treatment regime, animals were killed and ventricular myocytes were enzymatically isolated. Treatment with Sb(V) for 26 days prolonged the QT interval of the ECG. Treatment with Sb(III) was lethal within 2 days for approximately 50% of the animals. The survivors showed ECG alterations similar to those described in man: T wave flattening and/or inversion, depression of the ST segment, and elongation of RR and QT intervals. Their ventricular myocytes showed impaired contraction responses to changes in stimulus frequency, elongated AP and reduced I(Ca). Combined treatment with L-carnitine and Sb(III) delayed mortality. Prior treatment with L-carnitine followed by combined treatment with L-carnitine and Sb(III) reduced mortality to <10% over 12 days and these animals showed normal ECG. Their myocytes showed normal contractility and AP. It is concluded that L-carnitine has a preventive cardioprotective role against antimony-induced cardiomyopathy. The mechanism of action of L-carnitine may be to counter oxidative stress caused by Sb(III).

[Visceral leishmaniases]

Visceral leishmaniases (VL), with spreading epidemics in India and Sudan, and sporadic cases in mediterranean basin, show clinical, therapeutical and public health aspects varying according to the geographic context. Co-infection of VL with the human immunodeficiency virus emerged in southwestern Europe and could occur in a next future in India, in Sudan, in Ethiopia or in Brazil. Today, lipid formulations of amphotericin B should be the first line drugs in Mediterranean basin. Elsewhere, pentavalent antimonials remain the cornerstone of treatment in non resistant areas, conventional amphotericin B or miltefosine being an alternative in areas of resistance to antimony.

Antimony plus Recombinant Human Granulocyte‐Macrophage Colony‐Stimulating Factor Applied Topically in Low Doses Enhances Healing of Cutaneous Leishmaniasis Ulcers: A Randomized, Double‐Blind, Placebo‐Controlled Study

Cutaneous leishmaniasis (CL) requires 2-6 months to heal. In an effort to reduce this healing time, we studied topically applied granulocyte-macrophage colony-stimulating factor (GM-CSF) as an adjunct to antimonial therapy. Ten patients received antimony plus topical GM-CSF, and 10 patients received antimony plus placebo (saline). GM-CSF was diluted for topical use and was applied 3 times weekly for 3 weeks (1-2 microg/cm2/lesion). The mean +/- SD healing time was 43 +/- 14 days in the GM-CSF group and was 104+/-79 days in the placebo group (P=.043). Ten (100%) of 10 patients in the GM-CSF group healed within 60 days, compared with 5 (50%) of 10 patients in the placebo group. Two of the patients in the placebo group required retreatment with antimony. In conclusion, topically applied GM-CSF is effective in the management of CL.

Visceral leishmaniasis (kala-azar) and pregnancy

OBJECTIVE

The aim of the present review was to close the gap in the approach to pregnant women with visceral leishmaniasis (kala-azar) by providing up-to-date information to obstetricians about physiopathology, epidemiology, vertical transmission, drugs and treatment during pregnancy.

BACKGROUND

Infection with Leishmania chagasi during pregnancy is rare and deserves special attention since little information is available regarding the occurrence of visceral leishmaniasis during gestational period and the real possibility of vertical transmission of this disease. Because specific areas in the world are endemic for the disease and considering the continuous growth of the population, cases of pregnant women with visceral leishmaniasis are becoming more frequent. Unfortunately, textbooks on infectious diseases do not include this specific group of patients, and studies in the literature on aspects related to pregnancy and visceral leishmaniasis are scarce.

CONCLUSIONS

Vertical transmission of leishmaniasis is possible and the institution of treatment is imperative in cases of pregnant women with kala-azar. Amphotericin B is strongly recommended as the first choice drug due to its fewer maternal-fetal adverse effects.

CLINICAL FEATURES, EPIDEMIOLOGY, AND EFFICACY AND SAFETY OF INTRALESIONAL ANTIMONY TREATMENT OF CUTANEOUS LEISHMANIASIS: RECENT EXPERIENCE IN TURKEY

A total of 1,030 patients, 40.2% men and 59.8% women, identified during the period of October 1998 to November 2002 as having cutaneous leishmaniasis (CL), were studied; 1,431 lesions were identified in the 1,030 patients. One lesion was present in 80.7% of the patients. The size of the lesions (longest axis) was 13.6 mm (standard, 12.1 mm; range 3-150 mm). Most of the lesions were of the papular type (51.2%), although several atypical clinical presentations of CL were observed. The duration of the disease ranged between 1 and 72 mo (mean duration, 10.8 mo). The clinical suspicion of CL was confirmed by the observation of amastigotes on lesion tissue samples stained by Giemsa. The test was positive in 851 of 1,030 patients (82.6%). Intralesional meglumine antimonate solution (85 mg Sb/ml, 0.2-1 ml, depending on the size of the lesion) weekly until complete cure or up to 20 wk was used for first-line therapy of 890 patients (86.4%). We found that this regimen of intralesional Sb has an efficacy of 97.2% with a low relapse rate of 3.9% and no serious adverse side effects.

Targeting Leishmania (L.) chagasi amastigotes through macrophage scavenger receptors: the use of drugs entrapped in liposomes containing phosphatidylserine

OBJECTIVES

We devised liposome-entrapped antimony with the negatively charged lipid phosphatidylserine-liposome-entrapped antimony (Sb-LP)-in order to improve their targeting to infected macrophages through the interaction with scavenger receptors (SRs).

METHODS

SR production was indirectly evaluated by its mRNA synthesis in infected and uninfected peritoneal macrophages using RT-PCR. The interaction and cytotoxicity of Sb-LP with SRs and their metabolism were determined by incubation with macrophages in the presence of cytochalasin B, chloroquine or different competitive ligands, with determination of the 50% inhibitory concentration (IC50) in vitro in infected macrophages. The intracellular trafficking of Sb-LP was evaluated by confocal microscopy using trapped fluorescent dyes.

RESULTS

Our results showed an up-regulation of macrophage SR mRNA during the initial steps of Leishmania (L.) chagasi infection. By competitive ligand assays, we demonstrated the preferential uptake of Sb-LP by macrophage SRs. Sb-LP was 16-fold more effective (IC50=14.11 microM) than the free drug (IC50=225.9 microM) against L. (L.) chagasi-infected macrophages. The binding and uptake of Sb-LP in macrophages were shown to be energy-dependent and were reduced in the presence of cytochalasin B, showing the dependency of the cell microfilament system. Confocal analysis using trapped fluorescent dyes showed fluorescence of parasites or in their close proximity, compatible with the localized delivery of the liposomes.

CONCLUSIONS

The uptake of Sb-LP was reduced in infected macrophages, despite their effectiveness and targeting ability, suggesting a low metabolic rate in infected macrophages that could be overcome by the higher efficiency of the liposomal formulation. These in vitro results suggest that liposomes could improve the therapeutic index of old drugs, such as pentavalent antimony, via targeted delivery to Leishmania-infected cells.

Treatment of cutaneous leishmaniasis among travellers

Leishmaniasis is endemic in 88 countries on five continents. There are 1-1.5 million cases of cutaneous leishmaniasis reported yearly worldwide. There has been a sharp increase in recorded cases over the last 10 years. Based on geographical distribution, cutaneous leishmaniasis is divided into Old World and New World leishmaniasis. In the past, species could be inferred from geographical setting or determined by performing culture and isoenzyme analysis. The recently developed and now widely available PCR technology allows a rapid diagnosis with determination of most species, and thus enables a species-orientated treatment. While the Old World species mostly cause benign and often self-limiting cutaneous disease, the American species cause a broad spectrum of conditions from benign to severe manifestations, including mucosal involvement. The response to treatment varies according to the species. Therefore, a species-specific approach is proposed. Drugs for systemic and topical treatment are presented and discussed with regard to their application, use and adverse effects. Indications for local or systemic treatment are proposed. Drugs under investigation are also mentioned. An overview of published treatment options and a treatment recommendation is given for each of the most important species. The level of evidence of the studies leading to these recommendations is given.

Treatment of Old World cutaneous leishmaniasis with intralesionally injected meglumine antimoniate using a Dermojet device

Pentavalent antimonial compounds, the mainstay in the treatment of the various forms of leishmaniasis, have considerable toxicity, are difficult to administer and expensive. We describe a safe and efficient therapeutic modality using a spring-loaded and air-powered device for the intralesional injection of a high-velocity meglumine antimoniate microspray in a patient with cutaneous leishmaniasis.

Successful treatment of non-healing cases of cutaneous leishmaniasis, using a combination of meglumine antimoniate plus allopurinol

Cutaneous leishmaniasis (CL) is endemic in many countries. It has been recognized as a major public health problem in Iran. The pentavalent antimonials are the first line drugs for the treatment of CL. Recently strains resistant to these drugs have been reported. Allopurinol (AL) has also been suggested for treatment of CL. The efficacy of combination of AL and meglumine antimoniate (MA) in treatment of non-healing cases of CL was evaluated. Non-healing cases of CL have been treated with combination of AL (20 mg/kg for 30 days) and meglumine antimoniate (60 mg/kg per day for 20 days). Twenty-six patients with lupoid leishmaniasis, 6 patients with chronic leishmaniasis and 5 patients who had unhealed leishmaniasis due to leishmanization were accepted for the study. All of the patients except two responded well to treatment, no side effects have been observed and a two year follow up showed no recurrence. A combination of AL and MA increase the antileishmanial effects of antimoniate. We suggest this combination therapy for non-healing and resistant cases of CL.

Long term improvement in the treatment of canine leishmaniosis using an antimony liposomal formulation

Pharmacokinetic and clinical effectiveness of liposome-encapsulated N-methylglucamine antimoniate (LMA) was performed in dogs suffering from experimental leishmaniosis. LMA was compared with N-methylglucamine antimoniate (MGA), the same drug in its free form. Sb plasma concentrations for LMA were always higher than those for MGA. Mean residence time (MRT), half-life time (t(1/2)) and clearance (Cl) showed that Sb was eliminated slower after liposome administration. The high volume of distribution (Vd) obtained with LMA suggests that Sb could achieve therapeutic concentrations in parasite-infected tissues. Average plasma concentration at steady state (Css(ave)) shows that Sb body concentrations after LMA treatment (9.8 mg/kg Sb, each 24h) would be effective in Leishmania infantum canine infection. Comparing LMA with MGA in a 1-year follow-up we observed no relapses for LMA and total protein and gammaglobulin concentrations were within normal range, while for MGA both began to rise 3 months after treatment. Use of antimonial liposomal formulations may restore effectiveness to an existing drug and reduce toxicity.

[A Pediatric case of lupoid leishmaniasis diagnosed by PCR]

The purpose of this paper is to describe the clinical features of lupoid leishmaniasis in a child and to underline the use of PRC as a necessary and reliable tool in controversial diagnosis. Lupoid leishmaniasis, also known as chronic or relapsing leishmaniasis, is mainly widespread in the Middle East, where it represents up to 5% of all cutaneous Leishmaniasis. It strongly resembles Lupus Vulgaris, both clinically and histologically, and is therefore not usually diagnosed immediately but after a certain period of time. The amastigotic forms are rare or absent. The cutaneous nodules or plaques can slowly enlarge over the years. The case of an eleven-year-old albanian child living in Durazzo (Albania), suffering since three years with a plaque formed by apple-jelly nodules and scars on his right cheek, is presented. Using PCR, the presence of Leishmania infantum DNA led to a diagnosis of lupoid leishmaniasis. The therapeutic strategy of a combination of oral itraconazole and infiltration of metilglucamina antimoniate has been carried out, with good result, as checked through "telemedicine".

High frequency of serious side effects from meglumine antimoniate given without an upper limit dose for the treatment of visceral leishmaniasis in human immunodeficiency virus type-1-infected patients

Organic pentavalent antimonials are one of the mainstays of treatment for visceral leishmaniasis (VL). Few data are available on the toxicity and efficacy of these drugs at the dosing schedule recommended by the Centers for Disease Control and Prevention (CDC) (Atlanta, GA). We analyzed 25 VL episodes in human immunodeficiency virus (HIV)-infected patients who were treated with meglumine antimoniate (MA) at the CDC-recommended dose in southern Spain. Adverse effects were observed in 14 (56%) VL episodes. In 7 (28%), treatment with MA was permanently discontinued due to serious adverse effects that included acute pancreatitis, acute renal failure, and leukopenia. Three (12%) patients died during therapy due to severe acute pancreatitis attributable to MA. The dosing regimen of MA currently recommended for treating VL is associated with a high rate of serious side effects in HIV-1-infected patients.

Combination allopurinol and antimony treatment versus antimony alone and allopurinol alone in the treatment of canine leishmaniasis (96 cases)

The aim of the present study was to evaluate the long-term clinical outcome for dogs with leishmaniasis that were treated with 3 different protocols: combined treatment with antimony and allopurinol, antimony alone, or allopurinol alone. Ninety-six dogs included in this study were determined to have leishmaniasis on the basis of (1) clinical features, (2) identification of the parasite in smears of lymph node, bone marrow aspirates, or skin biopsies, and (3) specific immunofluorescent assay. Three groups of dogs were defined: 45 dogs (group 1) were treated with antimony (100 mg/kg s.c. q24h) given concurrently for 1 month with allopurinol (15 mg/kg p.o. q12h), and then allopurinol alone for 8 months at the same dosage; 40 dogs (group 2) were treated with antimony alone according to the manufacturer's instructions (200 mg/kg s.c. q24h at 2-day intervals for 3-6 months); and 11 dogs (group 3) were treated with allopurinol alone (15 mg/kg p.o. q12h for 1-20 months). Information concerning signalment, history, physical examination findings, serologic testing and number of dogs becoming seronegative, outcome for each treated dog (clinical cure versus failure), and long-term survival were recorded. The numbers of the clinical cures versus failures were significantly different among the 3 groups (chi2 = 17.77, P < .001), between groups 1 and 2 (chi2 = 8.02, P < .01), between groups 2 and 3 (chi2 = 11.00, P < .01), and between groups 1 and 3 (chi2 = 16.52, P < .001). No significant difference between groups 1 and 2 was noted in the type of failure (relapse or death), serologic test results, and number of survival years (chi2 = 2.79, P > .05). The results of the present study indicate that antimony in combination with allopurinol produces better results than antimony alone or allopurinol alone for the treatment of the canine leishmaniasis. With combination treatment, duration of treatment with antimony is shorter and long-term administration of allopurinol is well tolerated.

Amphotericin B lipid complex in the management of antimony unresponsive Indian visceral leishmaniasis

Fifty-eight Indian patients with visceral leishmaniasis who did not respond or relapsed after 30 days of consecutive sodium stibogluconate therapy were randomised to treatment with amphotericin B lipid complex (ABLC) using a total dose of 7.5 or 10 mg/kg. Treatment induced a prompt clinical response in all patients with resolution of fever and regression in spleen size. Fever and chills developed during ABLC infusion, but it diminished with successive infusions. Fourteen days after treatment, 26 of 28 (93%) patients in the 7.5 mg/kg group and all 30 (100%) in the 10 mg/kg group had splenic aspirate parasite density scores of 0 and were considered apparent clinical and parasitologic responders. Four and three patients in the 7.5 and 10 mg/kg groups respectively relapsed during six months of followup; thus, overall 22 of 28 (79%) patients treated with 7.5 mg/kg and 27 of 30 (90%) treated with 10 mg/kg were definitive cures. All initial non-responders and relapses were retreated successfully with higher dose of ABLC. These results confirm the efficacy of short-course ABLC therapy for antimony-unresponsive Indian patients with visceral leishmaniasis. Since treatment with a total dose of 7.5 mg/kg did not appear to increase efficacy (79% vs. 84% induced by 5 mg/kg in a prior study), initial treatment with a total dose of 5 mg/kg followed by retreatment of any non-responders represents a potentially less costly approach in patients who fail antimony therapy. Though high cure rates are achieved with > or = 10 mg/kg total dose of ABLC, treatment using lower doses with retreatment of non-responders or relapses with higher dose can result in considerable savings.

N-methylglucamine antimonate (SbV+): intralesional canine tegumentary leishmaniasis therapy

Twenty five adult dogs of three municipalities of the State of Rio de Janeiro, Brazil, that had been naturally infected by L. (V) braziliensis were treated with N-methylglucamine antimonate (Glucantime). Nine of the animals (36.0%) presented ulcerated skin lesions, twelve (48.0%) had mucosal lesions and four (16.0%) had multiple lesions. In some cases the mucosal lesions were associated to skin lesions. A dose of 85 mg SbV+ or 1 ml of the drug was intralesionally administered to the dogs. The animals were divided into three groups according to the amount of necessary doses (between one and three) for the complete healing of the lesions. The dogs were observed for six months after the third group received the last dose. Within this period two animals perished. Serial antibody evaluation through IFAT has shown that in 14 samples (63.3%) the titers have remained unaltered, in four of them (16%) there has been a decrease in two titers and in five of them (21%) serology was negative. Nineteen of the dogs (86.6%) had their lesions completely healed. The authors suggest intralesional therapy be the first choice of treatment of canine tegumentary leishmaniasis due to its effectiveness.

Visceral leishmaniasis in patients infected with the human immunodeficiency virus

The experience with 52 episodes of visceral leishmaniasis diagnosed in 43 patients is reported. The most common symptoms were fever (81%), splenomegaly (65%), hepatomegaly (63%), and pancytopenia (73%). In 79% of the patients, CD4+ cell counts were < 100 cells/mm3. Prior or simultaneous diagnosis of AIDS was made in 29 (67%) patients. Diagnosis was considered fortuitous in 19% of the episodes. In 27% of the episodes, the diagnosis was made on the basis of demonstration of parasites outside the reticuloendothelial system, chiefly blood (7 cases) and gastrointestinal mucosa (5 cases). Parasites were frequently observed or cultured from blood (22/37 episodes) or the digestive tract (8/9 episodes). High antimony doses were more effective than low doses in achieving clinical or parasitological cure (rate of cure, 80% vs. 40%, p = 0.11). Severe toxicity was observed in six (11.7%) of the 51 treated episodes. Severe AIDS-related diseases [odds ratio (OR) 10, p < 0.05] and CD4+ counts (OR 12, p < 0.05) were independent factors for early death. Prophylaxis with monthly pentamidine was not useful in reducing relapses of visceral leishmaniasis.

[The evaluation of the tolerance and nephrotoxicity of pentavalent antimony administered in a dose of 40 mg Sb V/kg/day, 12/12 hr, for 30 days in the mucocutaneous form of leishmaniasis]

The renal function of eleven patients with mucocutaneous leishmaniasis was analyzed in a prospective study realized at the School Hospital of University of Brasília. The patients were treated with doses of 40 mg/kg/day of pentavalent antimony (Sb V), in a continuous scheme during thirty days. In this study three patients were excluded, one patient with reversible renal failure and two patients with hepatic and cardiac malfunctions. In the other eight patients, severe nephrotoxic effects were observed, like reduction of glomerular filtration rate, reduction of the urinary concentration capacity, evaluated by a sixteen hours hydric fasting and an increase of sodium fractional excretion. An increase in the number of leucocytes and cylinders were observed at the urinary sediment exam. Finally, the results shows that the treatment with pentavalent antimony in doses of 40 mg Sb/kg/day was less tolerated on account of its renal toxic effects. This scheme seems not be superior than the currently preconized scheme of 20 mg of Sb V/kg/day during 30 days.

Response to interferon-gamma plus pentavalent antimony in Indian visceral leishmaniasis

One hundred fifty-six previously untreated Indian patients with visceral leishmaniasis were treated with pentavalent antimony (Sb) alone for 30 days (group A), Sb plus interferon-gamma (IFN-gamma) for 30 days (group B), or Sb plus IFN-gamma for 15 days (group C). The purpose was to show that IFN-gamma would increase the response to 30 days of Sb treatment and that short-course (15 days) combination therapy was as effective as 30 days of Sb alone. Six months after treatment, 36% of group A, 49% of group B, and 42% of group C patients were designated as definitively cured. The success rates for long-term responses to Sb alone (36%) and Sb plus IFN-gamma (49%) were unexpectedly low, and responses in groups A, B, and C were not significantly different. These results suggest that the beneficial effects of adjunctive IFN-gamma in visceral leishmaniasis may be limited in regions where this disseminated intracellular infection shows high-level resistance to Sb.

Intralesional therapy of American cutaneous leishmaniasis with pentavalent antimony in Rio de Janeiro, Brazil--an area of Leishmania (V.) braziliensis transmission

BACKGROUND

The drug of choice for leishmaniasis is pentavalent antimony and different regimens are under continuous evaluation. The ideal therapy should be simple, effective, and with no or minor side-effects. In this paper we have studied the efficacy of intralesionally applied antimony in New World cutaneous leishmaniasis.

METHODS

Seventy-four patients from Rio de Janeiro state, Brazil, and presenting with single ulcerative cutaneous lesions mainly located on the trunk or extremities were enrolled in the study. The drug employed was N-methyl glucamine (425 mg of Sbv in each 5 ml ampoule). Each lesion was infiltrated with the drug at the four cardinal points in order to achieve complete blanching.

RESULTS

Of the 74 patients, 59 (80%) were healed after a 12-week interval. Extensive follow-up (up to 10 years) disclosed no relapses or the development of mucosal lesions.

CONCLUSIONS

The aim of therapy in New World cutaneous leishmaniasis is the healing of the cutaneous lesion and the prevention of late mucosal damage. Both conditions were achieved with the treatment employed with no side-effects and a considerable decrease in costs. In addition, the method is easy to apply in the field.

Treatment of American cutaneous leishmaniasis: a comparison between low dosage (5 mg/kg/day) and high dosage (20 mg/kg/day) antimony regimens

Twenty-three patients from Rio de Janeiro, Brazil-an area of Leishmania (Viannia) braziliensis transmission-were randomly assigned to receive either a high dose (20 mg/kg/day) of antimony or a lower one (5 mg/kg/day) in a 30 days series. The two treatment regimens showed similar responses. In 10 out of 12 patients receiving a dose of 5 mg/kg/day and 9 out of 11 patients with a dosage of 20 mg/kg/day a complete epithelization was noted by the end of treatment. In addition patients were followed for up to 7 years. No reactivation or development of mucosal lesions were observed in both groups during the extensive follow-up. We think that a low dosage of antimony could be equally effective than a higher one, at least in the presence of the clinical picture usually seen in Rio de Janeiro.