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Dahal P, Singh-Phulgenda S, Wilson J, Cota G, Ritmeijer K, Musa A, Alves F, Stepniewska K, Guerin PJ. Blood transfusion in the care of patients with visceral leishmaniasis: a review of practices in therapeutic efficacy studies. Trans R Soc Trop Med Hyg 2024:trae018. [PMID: 38690667 DOI: 10.1093/trstmh/trae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/04/2024] [Accepted: 03/27/2024] [Indexed: 05/02/2024] Open
Abstract
Blood transfusion remains an important aspect of patient management in visceral leishmaniasis (VL). However, transfusion triggers considered are poorly understood. This review summarises the transfusion practices adopted in VL efficacy studies using the Infectious Diseases Data Observatory VL clinical trials library. Of the 160 studies (1980-2021) indexed in the IDDO VL library, description of blood transfusion was presented in 16 (10.0%) (n=3459 patients) studies. Transfusion was initiated solely based on haemoglobin (Hb) measurement in nine studies, combining Hb measurement with an additional condition (epistaxis/poor health/clinical instability) in three studies and the criteria was not mentioned in four studies. The Hb threshold range for triggering transfusion was 3-8 g/dL. The number of patients receiving transfusion was explicitly reported in 10 studies (2421 patients enrolled, 217 underwent transfusion). The median proportion of patients who received transfusion in a study was 8.0% (Interquartile range: 4.7% to 47.2%; range: 0-100%; n=10 studies). Of the 217 patients requiring transfusion, 58 occurred before VL treatment initiation, 46 during the treatment/follow-up phase and the time was not mentioned in 113. This review describes the variation in clinical practice and is an important initial step in policy/guideline development, where both the patient's Hb concentration and clinical status must be considered.
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Affiliation(s)
- Prabin Dahal
- Infectious Diseases Data Observatory (IDDO), OX3 7LG, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7LG, Oxford, UK
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory (IDDO), OX3 7LG, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7LG, Oxford, UK
| | - James Wilson
- Infectious Diseases Data Observatory (IDDO), OX3 7LG, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7LG, Oxford, UK
| | - Glaucia Cota
- Instituto René Rachou (IRR), Fiocruz Minas, Augusto de Lima Avenue, 1517, Barro Preto, Belo Horizonte, Minas Gerais Brazil, ZIP code 30.190-002, Brazil
| | - Koert Ritmeijer
- Médecins Sans Frontiéres, Plantage Middenlaan 14, 1018 DD Amsterdam, Netherlands
| | - Ahmed Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum 11111, Sudan
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative, CH1202, Geneva, Switzerland
| | - Kasia Stepniewska
- Infectious Diseases Data Observatory (IDDO), OX3 7LG, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7LG, Oxford, UK
| | - Philippe J Guerin
- Infectious Diseases Data Observatory (IDDO), OX3 7LG, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, OX3 7LG, Oxford, UK
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Dahal P, Singh-Phulgenda S, Olliaro PL, Guerin PJ. Gender disparity in cases enrolled in clinical trials of visceral leishmaniasis: A systematic review and meta-analysis. PLoS Negl Trop Dis 2021; 15:e0009204. [PMID: 33725005 PMCID: PMC7963105 DOI: 10.1371/journal.pntd.0009204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND A higher caseload of visceral leishmaniasis (VL) has been observed among males in community-based surveys. We carried out this review to investigate how the observed disparity in gender distribution is reflected in clinical trials of antileishmanial therapies. METHODS We identified relevant studies by searching a database of all published clinical trials in VL from 1980 through 2019 indexed in the Infectious Diseases Data Observatory (IDDO) VL clinical trials library. The proportion of male participants enrolled in studies eligible for inclusion in this review were extracted and combined using random effects meta-analysis of proportion. Results were expressed as percentages and presented with respective 95% confidence intervals (95% CIs). Heterogeneity was quantified using I2 statistics and sub-group meta-analyses were carried out to explore the sources of heterogeneity. RESULTS We identified 135 published studies (1980-2019; 32,177 patients) with 68.0% [95% CI: 65.9%-70.0%; I2 = 92.6%] of the enrolled participants being males. The corresponding estimates were 67.6% [95% CI: 65.5%-69.7%; n = 91 trials; I2 = 90.5%; 24,218 patients] in studies conducted in the Indian sub-continent and 74.1% [95% CI: 68.4%-79.1%; n = 24 trials; I2 = 94.4%; 6,716 patients] in studies from Eastern Africa. The proportion of male participants was 57.9% [95% CI: 54.2%-61.5%] in studies enrolling children aged <15 years, 78.2% [95% CI: 66.0%-86.9%] in studies that enrolled adults (≥15 years), and 68.1% [95% CI: 65.9%-70.0%] in studies that enrolled patients of all ages. There was a trend for decreased proportions of males enrolled over time: 77.1% [95% CI: 70.2%-82.8%; 1356 patients] in studies published prior to the 1990s whereas 64.3% [95% CI: 60.3%-68.2%; 15,611 patients] in studies published on or after 2010. In studies that allowed the inclusion of patients with HIV co-infections, 76.5% [95% CI: 63.8%-85.9%; 5,123 patients] were males and the corresponding estimate was 64.0% [95% CI: 61.4%-66.5% 17,500 patients] in studies which excluded patients with HIV co-infections. CONCLUSIONS Two-thirds of the participants enrolled in clinical studies in VL conducted in the past 40 years were males, though the imbalance was less in children and in more recent trials. VL treatment guidelines are informed by the knowledge of treatment outcomes from a population that is heavily skewed towards adult males. Investigators planning future studies should consider this fact and ensure approaches for more gender-balanced inclusion.
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Affiliation(s)
- Prabin Dahal
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Sauman Singh-Phulgenda
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Piero L. Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philippe J. Guerin
- Infectious Diseases Data Observatory–IDDO, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Fenech FF. Leishmaniasis in Malta and the Mediterranean Basin. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2016. [DOI: 10.1080/00034983.1997.11813199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Goto Y, Cheng J, Omachi S, Morimoto A. Prevalence, severity, and pathogeneses of anemia in visceral leishmaniasis. Parasitol Res 2016; 116:457-464. [PMID: 27822583 DOI: 10.1007/s00436-016-5313-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/26/2016] [Indexed: 01/22/2023]
Abstract
Anemia is a typical symptom during visceral leishmaniasis (VL). We performed a systematic analysis of the literature on anemia in VL to understand the prevalence, severity, and possible mechanisms. Anemia is very common in VL patients with an overall prevalence higher than 90 %. The degree of anemia in VL is moderate to severe (hemoglobin level ∼7.5 g/dl), and the status can be recovered by treatment with antileishmanial drugs within a certain period of time. Possible pathogeneses of anemia in VL based on clinical observations included anti-RBC antibodies, dysfunction in erythropoiesis, and hemophagocytosis in the bone marrow or spleen, while hemolysis is a more likely cause than dyserythropoiesis. In hamsters with experimental VL, hemophagocytosis induced by immune complex and changes on erythrocyte membrane is speculated as the pathogenesis for anemia. In contrast, our recent study on murine VL indicated that hemophagocytosis contributes to anemia in contrast to lower contribution of anti-RBC antibodies or dysfunction in erythropoiesis. Together, hemophagocytosis is most likely associated with anemia in VL, and elucidation of the immunological mechanisms may lead to development of novel interventions to manage the symptom.
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Affiliation(s)
- Yasuyuki Goto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan.
| | - Jingjie Cheng
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan.,Faculty of Medicine, Imperial College London, London, England
| | - Satoko Omachi
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Ayako Morimoto
- Laboratory of Molecular Immunology, Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
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Pace D, Williams TN, Grochowska A, Betts A, Attard-Montalto S, Boffa MJ, Vella C. Manifestations of paediatric Leishmania infantum infections in Malta. Travel Med Infect Dis 2011; 9:37-46. [PMID: 21212024 PMCID: PMC3115057 DOI: 10.1016/j.tmaid.2010.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 11/22/2010] [Accepted: 11/30/2010] [Indexed: 11/16/2022]
Abstract
Leishmania infantum is endemic in the Maltese archipelago, a group of islands in the Mediterranean which are visited frequently by tourists from Northern European countries. The burden of leishmaniasis is highest in children who may present with cutaneous or visceral manifestations. We describe systematically the manifestations, diagnosis and management of leishmaniasis in children <14 years of age, who had a histopathological diagnosis of leishmaniasis in Malta, from 2004 to 2008. Eleven children were diagnosed with leishmaniasis; 8 children (15–44 months of age) had visceral disease and three (aged 9–13 years) suffered cutaneous infections. Prolonged high grade fever, pallor, hepatosplenomegaly, and pancytopenia were common presenting features of visceralisation. Diagnosis was based on the visualisation of amastigotes from bone marrow aspirates. Pentavalent antimonials were associated with treatment failure in two children, whilst liposomal amphotericin B was curative in all. Children with cutaneous leishmaniasis had dry crusted ulcero-nodular lesions on exposed areas which responded to intra-lesional instillation of sodium stibogluconate or to cryotherapy. Leishmaniasis should be included in the differential diagnosis of fever and hepatosplenomegaly or chronic cutaneous lesions in children who travel to Malta.
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Affiliation(s)
- David Pace
- Paediatric Infectious Diseases Clinic, Mater Dei Hospital, Msida, Malta.
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de Oliveira-Neto MP, Mattos MDS. Successful therapeutic response of resistant cases of mucocutaneous leishmaniasis to a very low dose of antimony. Rev Soc Bras Med Trop 2006; 39:376-8. [PMID: 17119754 DOI: 10.1590/s0037-86822006000400011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Accepted: 05/15/2005] [Indexed: 11/22/2022] Open
Abstract
Two mucocutaneous leishmaniasis cases resistant to therapy are reported here. After the failure of initial therapies (antimony, amphotericin B and/or pentamidine) patients received a low-dose schedule: one ampoule of meglumine antimoniate (405mg of pentavalent antimony [Sb v]) by intramuscular injection, three times a week until complete healing of the lesions. One patient was cured with a total of 30 ampoules in 10 weeks and the other received 36 ampoules in 12 weeks. Both remain clinically cured after one year of follow-up.
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Mocan H, Gedik Y, Okten A, Erduran E, Gacar N. Kala-azar in Trabzon (eastern Black Sea) region of Turkey. Indian J Pediatr 1993; 60:819-22. [PMID: 8200708 DOI: 10.1007/bf02751057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- H Mocan
- Department of Pediatrics, Black Sea (Karadeniz) Technical University, Faculty of Medicine, Trabzon, Turkey
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Balzan M, Fenech F. Acute renal failure in visceral leishmaniasis treated with sodium stibogluconate. Trans R Soc Trop Med Hyg 1992; 86:515-6. [PMID: 1335622 DOI: 10.1016/0035-9203(92)90091-p] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- M Balzan
- Department of Medicine, St Luke's Hospital, Guardamangia, Malta
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Gradoni L, Gramiccia M, Léger N, Pesson B, Madulo-Leblond G, Killick-Kendrick R, Killick-Kendrick M, Walton BC. Isoenzyme characterization of Leishmania from man, dog and sandflies in the Maltese islands. Trans R Soc Trop Med Hyg 1991; 85:217-9. [PMID: 1887474 DOI: 10.1016/0035-9203(91)90027-v] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
As a part of a general survey on leishmaniases and sandflies of the Maltese islands, 22 Leishmania stocks were isolated from human visceral (1) and cutaneous (1) cases, dogs (16) and sandflies (4). They were characterized by the analysis of 15 enzymes. The commonest Mediterranean L. infantum zymodeme, MON 1, was found to cause human and canine visceral leishmaniasis; L. infantum MON 78, which has so far been isolated only in Malta, was the agent of human cutaneous leishmaniasis. Both zymodemes were isolated from the same sandfly species, Phlebotomus perniciosus.
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Affiliation(s)
- L Gradoni
- Laboratorio di Parassitologia, Istituto Superiore di Sanità, Roma, Italy
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Sharma S. Vector-borne diseases. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 1990; 35:365-485. [PMID: 2290983 DOI: 10.1007/978-3-0348-7133-4_8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- S Sharma
- Medicinal Chemistry Division, Central Drug Research Institute, Lucknow, India
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Ornvold K, Carstensen H, Magnussen P, Nielsen MH, Pedersen FK. Kala-azar in a four-year-old child 18 months after brief exposure in Malta. ACTA PAEDIATRICA SCANDINAVICA 1989; 78:650-2. [PMID: 2551125 DOI: 10.1111/j.1651-2227.1989.tb17958.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A four-year-old Danish boy developed kala-azar 18 months after a holiday in Malta. Splenectomy, with liver biopsy, was performed six months after onset of symptoms because of hypersplenism, and the diagnosis of kala-azar was only made four months later, when the histopathological specimens were reviewed. Previous bone marrow biopsies did not show Leishmania. Treatment with sodium stibogluconate was successful. The development of kala-azar after one week's stay in an endemic area stresses the importance of including this potentially fatal disease in the differential diagnosis of cases presenting with fever, splenomegaly, and pancytopenia.
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Affiliation(s)
- K Ornvold
- Department of Paediatric Pathology, Rigshospitalet, Unniversity Hospital, Copenhagen, Denmark
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13
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Abstract
Two infants who presented with anaemia and hepatosplenomegaly were found to have visceral leishmaniasis. Diagnosis was made immediately after bone marrow aspiration in one infant, but in the other there was considerable delay. Both responded well to a course of sodium stibogluconate.
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Steck EA. The leishmaniases. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 1974; 18:289-351. [PMID: 4453608 DOI: 10.1007/978-3-0348-7087-0_22] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Hicsönmez G, Ozsoylu S. Kala-azar in childhood: a survey of clinical and laboratory findings and prognosis in 44 childhood cases. Clin Pediatr (Phila) 1972; 11:465-7. [PMID: 5052920 DOI: 10.1177/000992287201100810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Discussion. Trans R Soc Trop Med Hyg 1966. [DOI: 10.1016/0035-9203(66)90181-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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