Predominance of Leishmania braziliensis braziliensis in the regions of Três Braços and Corte de Pedra, Bahia, Brazil

Disseminated Leishmaniasis, a Severe Form of Leishmania braziliensis Infection

Disseminated leishmaniasis (DL) is an emergent severe disease manifesting with multiple lesions. To determine the relationship between immune response and clinical and therapeutic outcomes, we studied 101 DL and 101 cutaneous leishmaniasis (CL) cases and determined cytokines and chemokines in supernatants of mononuclear cells stimulated with leishmania antigen. Patients were treated with meglumine antimoniate (20 mg/kg) for 20 days (CL) or 30 days (DL); 19 DL patients were instead treated with amphotericin B, miltefosine, or miltefosine and meglumine antimoniate. High levels of chemokine ligand 9 were associated with more severe DL. The cure rate for meglumine antimoniate was low for both DL (44%) and CL (60%), but healing time was longer in DL (p = 0.003). The lowest cure rate (22%) was found in DL patients with >100 lesions. However, meglumine antimoniate/miltefosine treatment cured all DL patients who received it; therefore, that combination should be considered as first choice therapy.

Presence of parasite DNA in clinically unaffected nasal mucosa during cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis

OBJECTIVES

We aimed to detect Leishmania DNA carriage in nasal mucosa of individuals with cutaneous leishmaniasis (CL) caused by Leishmania (Viannia) braziliensis.

METHODS

A cross-sectional study was performed in all individuals with CL without nasal lesions (n = 153) attended within 2 years in an endemic area of L. (Viannia) braziliensis in Bahia (Brazil). An otorhinolaryngologist assessed the clinical status of the nasal mucosa by anterior rhinoscopy and endoscopic examinations. Swab samples were collected for parasite DNA detection by PCR from all individuals before standard treatment for leishmaniasis. A second evaluation 3 months after treatment was performed to assess clinical outcomes.

RESULTS

Parasite DNA was detected in 7.8% (12/153) of clinically healthy nasal mucosa of individuals with CL. Interestingly, DNA was more frequently identified in individuals with more skin lesions (median 1.5, interquartile range (IQR) 1-3.5 versus 1.0, IQR 1-1.5; p 0.044), or larger injuries (median 2.7, IQR 2-3.8 versus 1.6, IQR 1-2.5; p 0.013). Additionally, the disease of those individuals with positive PCR evolved more frequently to unusual forms of leishmaniasis (recidiva cutis and disseminated) (45.5% (5/11) versus 11.5% (14/122); p 0.009), and required more cycles of treatment to reach clinical cure (median 2, IQR 1-4 versus 1, IQR 1-2; p 0.05).

CONCLUSION

These findings suggest an early parasite tropism to nasal mucosa in L. (Viannia) braziliensis infection and a clinical phenotype of CL cases associated with parasite DNA in nasal mucosa. Future studies should evaluate whether PCR of nasal swab samples could serve as a prognostic tool for individuals at risk of mucocutaneous leishmaniasis.

The microbiological signature of human cutaneous leishmaniasis lesions exhibits restricted bacterial diversity compared to healthy skin

Localised cutaneous leishmaniasis (LCL) is the most common form of cutaneous leishmaniasis characterised by single or multiple painless chronic ulcers, which commonly presents with secondary bacterial infection. Previous culture-based studies have found staphylococci, streptococci, and opportunistic pathogenic bacteria in LCL lesions, but there have been no comparisons to normal skin. In addition, this approach has strong bias for determining bacterial composition. The present study tested the hypothesis that bacterial communities in LCL lesions differ from those found on healthy skin (HS). Using a high throughput amplicon sequencing approach, which allows for better populational evaluation due to greater depth coverage and the Quantitative Insights Into Microbial Ecology pipeline, we compared the microbiological signature of LCL lesions with that of contralateral HS from the same individuals.Streptococcus, Staphylococcus,Fusobacterium and other strict or facultative anaerobic bacteria composed the LCL microbiome. Aerobic and facultative anaerobic bacteria found in HS, including environmental bacteria, were significantly decreased in LCL lesions (p < 0.01). This paper presents the first comprehensive microbiome identification from LCL lesions with next generation sequence methodology and shows a marked reduction of bacterial diversity in the lesions.

Specificity of the rapid rK39 antigen-based immunochromatographic test Kalazar Detect(r) in patients with cutaneous leishmaniasis in Brazil

The aim of this study was to evaluate the specificity of a rapid immunochromatographic test that was developed to detect antibodies against the rK39 antigen for the diagnosis of visceral leishmaniasis (VL). This evaluation was performed using sera from patients with a confirmed diagnosis of active cutaneous leishmaniasis. The sera from 272 patients with a confirmed diagnosis of localised cutaneous leishmaniasis (CL) who resided in an area endemic for Leishmania braziliensis in Brazil were obtained before the initiation of antileishmanial treatment. Kalazar Detect(r)(InBios, Seattle, WA) recombinant K39 antigen-based immunochromatographic strips were used according to the manufacturer's instructions. The test results were evaluated independently by two examiners in sequential order. The positive controls for the test included five serum samples from five patients with parasitologically confirmed diagnosis of VL caused by Leishmania infantum in Brazil. Overall, 100% of the samples obtained from patients with CL were negative, confirming the absence of a serological cross-reaction for individuals with cutaneous disease when these patients were evaluated using the rapid test. The lack of a cross-reaction in patients who were infected by parasites of the same genus highlights the specificity of the rK39 antigen for the diagnosis of VL in areas with the sympatric circulation of L. braziliensis and L. infantum.

Early enlargement of an ulcerated area during leishmaniasis treatment with meglumine antimoniate in Brazil

BACKGROUND

Cutaneous leishmaniasis is a public health problem in Brazil, where meglumine antimoniate is the drug of choice for treatment. Ulcers treated with pentavalent antimonials show increasing diameters during the first weeks of drug exposure.

METHOD

We evaluated data from patients previously enrolled into an open study to compare changes in the ulcerated area of 189 lesions in 101 patients with localized cutaneous leishmaniasis caused by Leishmania braziliensis and L. guyanensis who were treated with i.v. meglumine antimoniate (Glucantime), 20 mg kg(-1) day(-1) for 20 days.

RESULTS

An average increase in the ulcerated area of 0.3 cm(2) (95% CI 0.13-0.47 cm(2); p = 0.001) was observed at Day 10 compared with the baseline measurement. Comparison of Day 20 with Day 10 showed a significant decrease of 0.76 cm(2) (95% CI 0.53-0.99 cm(2); p < 0.001) in ulcer size. At Day 50, compared with Day 20, the ulcerated area was decreased by 0.77 cm(2) (95% CI 0.53-1.01 cm(2); p < 0.001).

CONCLUSION

We conclude that early enlargement of the ulcerated area during treatment of localized cutaneous leishmaniasis with antimonials in Brazil is a common feature and easily detected by the 10th day of treatment. Following the end of the treatment period (20 days), it would be reasonable to observe a significant decrease in size of the ulcerated area.

Lesion size correlates with Leishmania antigen-stimulated TNF-levels in human cutaneous leishmaniasis

Cutaneous leishmaniasis (CL) is a worldwide disease endemic in several regions of the globe. The hallmark of CL is skin ulcers likely driven by efforts of the immune system to control Leishmania growth. Cytokines, such as tumor necrosis factor (TNF) and interferon-gamma can control disease progression in animal models. Nevertheless, the impact of these cytokines in CL ulcer outcome is not well established in humans. In this study, 96 CL patients from an endemic area of Leishmania braziliensis were enrolled for a follow-up study that consisted of clinical and immunological evaluations in a 2-year period. Statistical analysis revealed that healing time (P = 0.029), age (P = 0.002), and TNF levels (P = 0.0002) positively correlate with ulcer size at the time of the first clinical evaluation. Our findings suggest that ulcer size correlates with healing time and TNF levels support the use of TNF inhibitors combined with standard therapy to improve healing in CL patients with severe lesions.

The -2518bp promoter polymorphism at CCL2/MCP1 influences susceptibility to mucosal but not localized cutaneous leishmaniasis in Brazil

Mucosal leishmaniasis (ML) follows localized cutaneous leishmaniasis (CL) caused by Leishmania braziliensis. Proinflammatory responses mediate CL self-healing but are exaggerated in ML. Proinflammatory monocyte chemoattractant protein 1 (MCP-1; encoded by CCL2) is associated with CL. We explore its role in CL/ML through analysis of the regulatory CCL2 -2518bp promoter polymorphism in CL/ML population samples and families from Brazil. Genotype frequencies were compared among ML/CL cases and control groups using logistic regression and the family-based association test (FBAT). MCP-1 was measured in plasma and macrophages. The GG recessive genotype at CCL2 -2518bp was more common in patients with ML (N=67) than in neighborhood control (NC; N=60) subjects (OR 1.78; 95% CI 1.01-3.14; P=0.045), than in NC combined with leishmanin skin-test positive (N=60) controls (OR 4.40; 95% CI 1.42-13.65; P=0.010), and than in controls combined with CL (N=60) patients (OR 2.78; 95% CI 1.13-6.85; P=0.045). No associations were observed for CL compared to any groups. FBAT (91 ML and 223 CL cases in families) confirmed recessive association of ML with allele G (Z=2.679; P=0.007). Higher levels of MCP-1 occurred in plasma (P=0.03) and macrophages (P<0.0001) from GG compared to AA individuals. These results suggest that high MCP-1 increases risk of ML.

Genus-specific kinetoplast-DNA PCR and parasite culture for the diagnosis of localised cutaneous leishmaniasis: applications for clinical trials under field conditions in Brazil

The positivities of two methods for the diagnosis of localised cutaneous leishmaniasis (CL) were estimated in 280 patients enrolled in a clinical trial. The trial was conducted in an endemic area of Leishmania (Viannia) braziliensis and trial participants were patients with skin ulcers and positive leishmanin skin tests. Patients underwent aspirative skin punctures of the ulcerated lesions and lymph nodes for in vitro cultures, which were processed under field conditions at the local health centre. Skin lesion biopsies were tested at a reference laboratory using kinetoplastid DNA (kDNA)-PCR to detect DNA. The median time required to obtain a positive culture from the skin samples was seven days and the contamination rate of the samples was 1.8%. The positivities of the cultures from skin lesions, kDNA-PCR and the combination of the two methods were 78.2% (95% CI: 73-82.6%), 89.3% (95% CI: 85.1-92.4%) and 97.1% (95% CI: 94.5-98.5%). We conclude that parasite culture is a feasible method for the detection of Leishmania in field conditions and that the combination of culture and PCR has a potential role for the diagnosis of CL in candidates for clinical trials.

Sensitivity and reproducibility of a PCR assay for Leishmania detection using skin biopsy imprints on filter paper

The sensitivity and reproducibility of a PCR targeted to amplify the conserved 120 base-pair region of minicircles from Leishmania kDNA was defined using DNA extracted from skin biopsy imprints on filter paper. Seventy-seven patients with cutaneous leishmaniasis from an endemic region of Leishmania (Viannia) braziliensis in Brazil underwent skin biopsy of the ulcer border. Tissue samples were imprinted on filter paper and then, they were stored at -20 degrees C. Imprints on filter paper were stored at 4 degrees C. Samples were processed at three laboratories; Lab1 and Lab2 performed the PCR-kDNA assay using DNA extracted from the filter paper, and Lab3 processed PCR-kDNA using DNA from fresh-frozen tissue used as a gold standard. All samples were codified to maintain blinding during lab processing. Fifty-three (68.8%) patients had parasites isolated and identified by isoenzymes as L. (V.) braziliensis. The positivity of PCR-kDNA was similar between the three laboratories: 87.0, 85.7 and 88.3% (Lab1, Lab2 and Lab3, respectively). The sensitivity of PCR-kDNA in culture-proven cases was better, and showed similar results in all laboratories: 95.8, 95.8 and 97.9% (Lab1, Lab2 and Lab3, respectively). Data from the 77 enrolled patients showed an overall percent agreement of 80.5% (Kappa=0.173) for the filter-paper approach between Lab1 and Lab2. Percent agreement between Lab1 and Lab3 was 83.1% (Kappa=0.22), and it was 94.8% between Lab2 and Lab3 (Kappa=0.77). Fifteen patients were diagnosed in just one of the two laboratories that used DNA extracted from filter paper. We conclude that the sensitivity of the filter paper approach is satisfactory and could be used in clinical trials and field work. Reproducibility could be improved using two separate imprints from the same biopsy sample.

The aetiological agents of American cutaneous leishmaniasis in the municipality of Monte Negro, Rondônia state, western Amazonia, Brazil

Although American cutaneous leishmaniasis (ACL) is one of the most important endemic diseases in the Brazilian state of Rondônia, there is very little information on the species of parasite involved. The objective of the present study was to identify the Leishmania species causing ACL in the Monte Negro municipality of the state. Over a 6-year period (1997-2002), the skin lesions of 233 patients were examined while the patients were attending an outpatients' clinic at the University of São Paulo's Advanced Research Unit in Monte Negro. ACL was diagnosed in 137 (58.8%) of the patients and leishmanial parasites were successfully isolated from 14 of the ACL cases. Using a panel of 24 monoclonal antibodies, 12 of the 14 isolates were identified, as L. (Viannia) braziliensis (seven), L. (V.) lainsoni (one), a L. (V.) lainsoni-like species (two), a L. (V.) guyanensis-like species (one), or a L. (Viannia) species that was different from all named species (one). These are the first records of human infection with L. (V.) braziliensis and L. (V.) lainsoni in Rondônia.

[Clinical findings of tegumentary leishmaniasis in children under five years of age in an endemic area of Leishmania (Viannia) braziliensis]

A retrospective study was performed in a field clinic to characterize the clinical findings of tegumentary leishmaniasis in children from 0 to 5 years old. The clinical records of 4,464 patients were analyzed at the Primary Health Center of Corte de Pedra, Presidente Tancredo Neves, Bahia, Brazil, from May 1987 to December 1995. Four hundred and ninety one (11.8%) children were identified among 4,275 new cases of tegumentary leishmaniasis registered at this Unit. The gender ratio (M:F) for children under six years was 1.1:1. Cutaneous lesions predominated (98%), mainly skin ulcers (99%) located above the waist (p<0.05). Thirty five percent had multiple lesions. The observed magnitude of the disease in children, the similar proportion of cases in both genders and the location of the lesions suggest the possibility of peri or intradomiciliary transmission.

Factores de riesgo para la transmisión de leishmaniasis cutánea en niños de 0 a 5 años en un área endémica de Leishmania (Viannia) braziliensis

Fue realizado un estudio caso-control pareado en Corte de Pedra, Bahía, Brasil, área endémica de Leishmania (Viannia) braziliensis para evaluar los diferentes factores de riesgo asociados a la presencia de leishmaniasis cutánea en niños de 0 a 5 años. Fueron considerados como casos, los niños con prueba de leishmanina positiva y que presentaban en el examen físico, una o más lesiones clínicas, activas o cicatrizales, compatibles con leishmaniasis cutánea. Fueron seleccionados 40 casos y 71 controles que fueron pareados por edad y área de residencia. La presencia de algún otro miembro de la familia con antecedente de leishmaniasis cutánea durante el año anterior a la aparición de la enfermedad en el niño demostró ser un importante factor de riesgo (MÔR MH = 17,75; IC95%: 4,08-77,25). No se encontraron evidencias de asociación con otros factores, como hábitos del niño dentro y fuera de casa, características de la vivienda y del peridomicilio, presencia de vectores y animales como probables reservorios. Estos hallazgos apoyan la hipótesis que el ser humano podría comportarse como un posible reservorio y servir de fuente de contagio para este grupo de edad.

Antibody response in patients with cutaneous leishmaniasis infected by Leishmania (Viannia) braziliensis or Leishmania (Viannia) guyanensis in Brazil

The antibody response against Leishmania (Leishmania) amazonensis crude antigen was measured through the indirect immunofluorescent assay (IFA) and the immunoenzymatic assay (ELISA) in 114 patients with cutaneous leishmaniasis (CL) in Brazil. Fifty-four patients were infected by Leishmania (Viannia) braziliensis, and 60 patients had L. (V.) guyanensis infection. Patients were comparable by age, sex, disease duration and the Montenegro skin test diameter. L. (V.) braziliensis-infected patients showed significant lower number of ulcerated lesions, greater ulcerated area and higher proportion of lymph node enlargement. Sensitivity of IFA was 79.6% (95% CI 66.1-88.9) and 71.7% (95% CI 58.4-82.2) for L. (V.) braziliensis and L. (V.) guyanensis-infected patients, respectively (P=0.324). Sensitivity of ELISA was 98.2% (95% CI 88.8-99.9) and 85.0% (95% CI 72.9-92.5) for L. (V.) braziliensis and L. (V.) guyanensis-infected patients, respectively (P=0.018). Significant differences were observed in the magnitude of the antibody response before treatment with higher levels detected in L. (V.) braziliensis-infected patients by both serologic techniques. Eighty-four patients had serologic evaluations before and 12 weeks after treatment with meglumine antimoniate, 20 mg/kg/day for 20 days. Significant lower optic density values were observed after treatment with both species independent of cure or failure. Our data showed that L. (V.) braziliensis induces a higher antibody response against L. (L.) amazonensis antigens than L. (V.) guyanensis and that down-modulation of the antibody response occurs shortly during disease evolution after treatment. Moreover the data support the use of ELISA as a better tool for detection of antibodies in CL.

Comparison of cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis and L. (V.) guyanensis in Brazil: clinical findings and diagnostic approach

We compared the clinical findings and diagnostic methods for 66 patients with cutaneous leishmaniasis in the state of Bahia, Brazil, who were infected by Leishmania (Viannia) braziliensis (group A), with those for 68 patients in the state of Amazonas, Brazil, who were mainly infected by Leishmania (Viannia) guyanensis (group B). Differences were observed with regard to number, size, and location of skin lesions and to the pattern of lymphatic involvement. Patients in group B had smaller and more numerous lesions, which were frequently located above the waist, versus the larger but less numerous lesions among patients in group A, which were usually located on the lower limbs. Lymphatic involvement was present in 55 (83.3%) of the 66 patients in group A and in 42 (61.8%) of the 68 patients in group B (P=0.005). The positivity rates of imprints and skin culture procedures were higher in group B. Sensitivity of in vitro culture of skin aspirates was 47.0% and 91.2% for groups A and B, respectively (P<.001). Although hamster inoculation showed similar results in both groups, the interval before development of disease was shorter in group B. Our data provide substantial evidence that indicate that the disease caused by these species differs with regard to clinical presentation and diagnostic approach.

[Comparative study between sodium stibogluconate BP 88 and meglumine antimoniate in cutaneous leishmaniasis treatment. II. Biochemical and cardiac toxicity]

Toxicity of two antimonial pentavalents were evaluated in 111 patients with cutaneous leishmaniasis. Forty-seven patients received meglumine antimoniate (Group I) and 64 patients, sodium stibogluconate BP 88 (Group II), 20 mg Sbv/kg/day for 20 days. Evaluation of aminotransferases, alkaline phosphatase, amilase, creatinine, urea, urine analysis and electrocardiogram were performed at baseline, on the tenth and twentieth day of treatment. Greater frequency of aminotransferase abnormal levels were observed on the tenth and twentieth days in group II (p < 0.001) and a greater proportion of amilase abnormal levels at the tenth day in the same group (p < 0.001). There was a greater variation of aminotransferases, alkaline phosphatase and amilase in the first ten days of treatment in group II (p < 0.01). On the twentieth day there was a greater variation of aminotransferase levels in group II (p = 0.02 and p = 0.03, respectively). Forty-three percent of group I and 54% of group II showed electrocardiographic abnormalities (p = 0.30).

[Socioeconomic factors and attitudes towards household prevention of American cutaneous leishmaniasis in an endemic area in Southern Bahia, Brazil]

A survey was conducted to identify socioeconomic conditions and attitudes towards household prevention of American cutaneous leishmaniasis in Corte de Pedra, located in the county of Tancredo Neves, an endemic region in southern Bahia, Brazil. A questionnaire was applied in July 1997, focusing on social and economic variables, habits, and attitudes towards prevention of arthropod bites. All families (100%) living in the study area were surveyed, comprising 168 households with 851 individuals. Approximately 66.7% of the families earned up to one minimum wage, supporting an average of 5.1 residents per household. Most (57.2%) of the families did not use any type of protection against bites. Fumigation by burning various types of materials was the most customary form of prevention. Individual protection measures were rarely used. Since there was evidence of household and peridomiciliary transmission in the study area, use of impregnated bed nets is an alternative for intradomiciliary protection.

[Serological survey for American cutaneous leishmaniasis in stray dogs in the S. Paulo State, Brazil]

A serological survey was made in 973 stray dogs caught near green areas in S. Paulo county by the indirect immunofluorescence test. No positive serum was found, however autochthonous human cases of ACL that occurred in the county show the circulation of the parasite in the environment. This fact, associated with the existence of the vectors and the apparent absence of infected dogs in the areas studied, suggest that stray dog plays an insignificant role in the spread of the parasite. The cycle of the parasite in São Paulo county has been maintained by wild animals, hence the dog would be an accidental host just as humans.

Morphometric and phenetic studies of five geographical populations of Lutzomyia whitmani (Diptera: Psychodidae) in Brazil

A morphometric survey examined adult specimens of Lutzomyia whitmani (Antunes & Coutinho) captured at 5 municipalities in southeastern and northeastern Brazil to compare the populations. The localities were Ilhéus (Bahia), Martinho Campos (Minas Gerais), Corte de Pedra (Bahia), Baturité (Ceará), and Amaraji (Pernambuco): all are known foci of American cutaneous leishmaniasis. Fifteen males and 15 females from each population were analyzed morphometrically for 42 and 37 characters, respectively. Statistical data alone were insufficient to discriminate among the 5 populations. Further analysis generated phenograms that indicated there were 2 spatial clusters: the 1st was composed of specimens from Ilhéus (Bahia) and Baturité (Ceará) and the 2nd of specimens from Martinho Campos (Minas Gerais), Corte de Pedra (Bahia), and Amaraji (Pernambuco). Although insufficient to define the taxonomic status of the populations studied, the results delineated the existence of biogeographical structuring within L. whitmani. Complementary studies on the susceptibility to Leishmania braziliensis infection in the 5 populations are in progress to clarify the relationship between the 2 biogeographical clusters and American cutaneous leishmaniasis transmission in those Brazilian regions.

[Mefloquine in the treatment of cutaneous leishmaniasis in an endemic area of Leishmania (Viannia) braziliensis]

The aim of this study was to evaluate the efficacy of mefloquine in the treatment of skin leishmaniasis in patients infected with Leishmania (Viannia) braziliensis at an endemic region. Mefloquine is an oral drug effective against malaria with a prolonged half-life, less toxicity and easier administration than pentavalent antimonials. At Corte de Pedra in the Southern litoral of Bahia State, two randomized groups of ten patients with leishmaniasis were treated. The first group was treated with oral mefloquine, 250 mg per day in a single dose for six days and repeated three weeks later. The second group received meglumine antimoniate (Glucantime), 20 mg/kg daily administered intravenously for 20 days. Only one patient in the group treated with mefloquine showed evidence of clinical success. During treatment, one patient with four lesions developed a new lesion. The other three patients with clinical leismaniasis did not show evidence of clinical success after nine weeks of treatment. The group treated with Glucantime showed evident clinical improvement of the skin lesions.

[A comparative study between sodium stibogluconate BP 88R and meglumine antimoniate in the treatment of cutaneous leishmaniasis. I. The efficacy and safety]

Efficacy and safety of meglumine antimoniate and sodium stibogluconate BP 88R were compared in cutaneous leishmaniasis treatment in Corte de Pedra, Bahia, an endemic area of leishmaniasis due to Leishmania (Viannia) braziliensis. An open trial was developed with one hundred twenty seven patients who were diagnosed based on clinical criteria and Montenegro's skin test. Fifty eight patients were treated with meglumine antimoniate and 69 received sodium stibogluconate. Both groups received 20 mg/Sbv/kg/day for 20 days. Patients were followed every ten days during treatment and every month thereafter for three months. Sixty two percent patients cured with meglumine antimoniate and 55% cured with sodium stibogluconate (p = 0.42). Headache was more frequent during the first half of treatment in patients receiving sodium stibogluconate (p = 0.026). During the second half, patients treated with sodium stibogluconate showed a greater frequency of myalgia/arthralgia (p = 0.004) and abdominal pain/anorexia (p = 0.004). Three patients treated with sodium stibogluconate had severe side effects.

Sensitivity of a vacuum aspiratory culture technique for diagnosis of localized cutaneous leishmaniasis in an endemic area of Leishmania (Viannia) braziliensis transmission

Sixty eight patients with localized cutaneous leishmaniasis from an area with Leishmania (Viannia) braziliensis transmission had cultures performed with a modified Marzochís vacuum aspiratory puncture technique to establish sensitivity and contamination rate with this new method. Overall sensitivity of three aspirates was 47.1%; (CI95% 39.4; 59.4) significantly greater than the sensitivity of a single one aspirate. Fungal contamination was observed in 6/204 (2.9%) inoculated culture tubes. We recommend that this useful technique should be adopted as routine for primary isolation of L. (V.) braziliensis from localized cutaneous ulcers.

[Treatment of mucosal leishmaniasis with aminosidine sulfate: results of two year follow-up]

In 1996, 20 of 21 patients with mucosal leishmaniasis, treated in 1994 with aminosidine sulfate, 16mg/kg/day salt, by intramuscular injection for 20 days, were clinically evaluated. One patient died due to disease not related to mucosal leishmaniasis. Seven of 14 patients (66.7% N = 21) who achieved complete remission three months after treatment remained clinically cured 24 months later and seven relapsed in the same period (50% N = 14). Sorological follow-up showed poor correlation with the results of clinical examination.

[Open therapeutic study with aminosidine sulfate in mucosal leishmaniasis caused by Leishmania (Viannia) braziliensis]

From September to November 1994. 21 patients with active mucosal leishmaniasis were treated with aminosidine sulphate 16 mg/kg/day by intramuscular injection for 20 days. They were principally adult male agricultural workers. Thirteen patients had not received specific treatment and eight had failed to respond to Glucantime therapy. Diagnosis was based on clinical and epidemiological observations, a search for the parasite, leishmanin skin sensitivity and indirect fluorescent antibody serological tests. Sixty seven percent of patients had leishmania parasites isolated from inoculated hamsters or visualized in imprints or histopathological sections. The mean follow-up period was 12.6 months. All patients completed treatment. Side effects were pain at the injection site (86%); mild proteinuria (24%), elevated serum creatinine (.5%) and subclinical bearing loss in one of two patients who did audiometric tests. Clinical cure was achieved in 48% and the accumulated relapse rate was 29% (4/14).

[Measurement of the volume of the skin ulcer in cutaneous leishmaniasis]

Skin ulcers by Leishmania (Viannia) braziliensis are often deep and irregular and are difficult to measure by just the skin surface transverse and longitudinal diameters. The proposal is to mould the cavity, after local asepsis with fresh water plus soap, with a gelatinous plastic which contains silence, potassium alginate, calcium sulphate, magnesium oxide commercialized under the name of jeltrate (Dentsply Laboratory), by solving 9.5g of jeltrate in 20ml of fresh water and applying the gel on the ulcer which solidifies in 5 minutes. This mould is then filled with a self polymerising acrylic and its volume measured either by weight (by using an analytical balance)-technique 1-or by water displacement by applying Archimeds'principle-technique 2. We show data in a field trial before and after 20 days treatment in 20 patients using three different schedules as follows: 7 received pentamidine isethionate, 7 patients received aminosidine sulphate and 6 received meglumine antimoniate. The results point out that there was a uniform reduction of ulcer volume occurred during this period in the three groups, in both technique. Regarding the therapeutic schedules we are sure that there was a significant statistical difference between the three schedules using the T Student Test, which showed that aminostdine sulphate produced a better volume reduction of the ulcer than the other drugs. Serial moulds reflect clinical billing and are a permanent record. We conclude that the measure of the volume of the skin ulceration can be useful in the therapeutic evaluation, as a practical and cheap procedure, and may be used in field trials.

[Comparative study of meglumine antimoniate, pentamidine isethionate and aminosidine sulfate in the treatment of primary skin lesions caused by Leishmania (Viannia) braziliensis]

With the aim of comparing the therapeutic efficacy, tolerability and toxicity of meglumine antimoniate, aminosidine sulphate and pentamidine isethionate, a field study was conducted on randomized treatment of patients with primary cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis (L(V)b), in Corte de Pedra, BA, from October 1992 up to January 1993. Forty six patients were treated and distributed into three groups, two with 15 and one with 16 subjects. All patients were submitted to clinical examination, histopathological and immunological investigations, as diagnostic criterium. All patients were treated by intramuscular route. Group 1 received pentamidine 4 mg/kg/every 2 days, for 8 applications; Group 2 received aminosidine 20 mg/kg/day, for 20 days, and Group 3 received meglumine 10 mg Sbv/kg/day, for 20 days. Failure of therapy was defined as ulceration of the skin lesion four months after treatment. Such failure occurred in five cases as follows: two cases in patients of group 1 one case in patients of group 2, and two cases in group 3, after the first year of follow up. In the evaluation after three years we reviewed fifteen patients, five in each group; except for one in Group 3, all of them were cured. Statistical significance of the results between the three schedules used was not verified.

Plants used in the treatment of leishmanial ulcers due to Leishmania (Viannia) braziliensis in an endemic area of Bahia, Brazil

This paper records the plants used in the treatment of cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis (L(V)b) among the rural population of a cocoa-producing coastal area of Bahia state, Brazil. An enquiry conducted among a hundred patients identified 49 plants species used to treat skin ulceration caused by this Leishmania species. The principal plants used are caju-branco (Anacardium occidentale, Anacardiaceae), used by 65% of the population, folha-fogo (Clidemia hirta,Melastomataceae) 39%, alfavaca-grossa (Plectranthus amboinicus, Lamiaceae) 33%, mastruz (Chenopodium ambrosioides, Chenopodiaceae) 31%, erva-de-santa-maria (Solanum americanum, Solanaceae) (25%) and transagem (Plantago major, Plantaginaceae) 2%.

[An evolutionary study of mucosal leishmaniasis (a 7- to 17-year follow-up) due to Leishmania (Viannia) braziliensis in Tres Braços, Bahia]

Seventy seven (68%) patients with mucosal leishmaniasis recorded during the period 1976-1986 in the region of Três Braços, Bahia were traced and re-evaluated clinically, diagnostically and therapeutically. Sixty-five patients were alive. The families of 12 dead patients were interviewed about probable cause of death. The 65 patients had a fresh clinical examination supplemented when necessary by a skilled ENT examination. All had a titre of circulating immunofluorescent antibodies estimated at the time. Eight patients with active mucosal lesions had triturated biopsies which were cultivated in NNN medium and inoculated in hamsters to attempt to recover Leishmania. The isolates were identified by monoclonal antibodies as Leishmania (Viannia) braziliensis. Fifty-six (86%) patients were judged clinically cured. Nine (13%) had active lesions. Of the 12 patients who died 5 (41%) had no signs of activity at death. Mucosal leishmaniasis was thought to be the direct cause of death in 3 patients. The field treatment programme at Três Braços has managed to clinically cure 61 patients (79%) during 17 years. Follow-up periods were a mean of 10 years (range 7-17).

[An evaluation of the effect of a bark extract from the cashew (Anacardium occidentale L.) on infection by Leishmania (Viannia) braziliensis]

This paper presents an evaluation of the therapeutic effect of an hydroalcoholic extract of A. occidentale L. bark against Leishmania (Viannia) brasiliensis. The extract showed high activity in the in vitro model against the promastigotes of this species. However in the in vivo model no curative activity was observed.

Long-term follow-up of patients with Leishmania (Viannia) braziliensis infection and treated with Glucantime

Seventy-nine patients with cutaneous (62) or mucosal (17) infection with Leishmania (Viannia) braziliensis in Três Braços, Bahia, Brazil, were followed for at least 4 years after initiating treatment with antimony. Cutaneous relapses occurred in 6/62 (10%), mucosal relapse after cutaneous infection in 2/62 (3%), and mucosal relapse after mucosal disease in 2/17 (17%). It is concluded that relapse (cutaneous and mucosal) is rare after adequate antimony therapy and that no definite prediction of relapse (clinical, serological or by skin reaction) is possible.

Histological analysis and the pathogenesis of mucocutaneous leishmaniasis

A series of over 400 well-documented biopsies of mucocutaneous leishmaniasis was evaluated to elucidate the histological processes associated with the elimination of parasites, and their correlation with the course of the disease. Non-specific inflammation was the most frequent and least effective response; its onset might be delayed, and in this event particularly the incidence of metastasis from skin to mucosa was high. Lysis of parasite-laden macrophages appeared to be the basic mechanism of parasite reduction, even when it was not overt. When it was acute the onset was usually rapid, and though it resulted in much tissue destruction the prognosis was generally better and mucosal metastasis rare. Lysis and non-specific inflammation both led to the formation of a post-necrotic type of granuloma, but reversion of the process was almost as common as progression. Ultimately a tuberculoid granuloma evolved and proceeded to resolution. In about 5 per cent of cases, macrophage activation appeared to bring about early resolution; neither reversion nor mucosal metastasis was seen.