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Suprien C, Guimarães LH, de Carvalho LP, Machado PRL. Pentavalent Antimony Associated with G-CSF in the Treatment of Cutaneous Leishmaniasis Caused by Leishmania (Viannia) braziliensis. Pathogens 2024; 13:301. [PMID: 38668256 PMCID: PMC11054058 DOI: 10.3390/pathogens13040301] [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: 02/11/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
Cutaneous leishmaniasis (CL), caused by Leishmania braziliensis, in recent decades has shown decreasing cure rates after treatment with meglumine antimoniate (MA). Granulocyte colony-stimulating factor (G-CSF) is a cytokine associated with epithelialization and healing processes. METHODS This study compares the effectiveness of G-CSF associated with MA in the treatment of CL. A total of 32 patients aged between 18 and 50 years with CL confirmed for L. braziliensis were included in this study. G-CSF or placebo (0.9% saline) was applied by intralesional infiltration at four equidistant points on the edges of the largest ulcer on days 0 and 15 of treatment associated with intravenous MA. RESULTS Males predominated in the G-CSF group (59%), while females predominated in the control group (53%). Injuries to the lower limbs predominated in both study groups. The cure rate in the G-CSF group was 65% and in the control group it was 47%, 90 days after initiation of therapy. CONCLUSIONS Our data indicate that the association of G-CSF with MA is not superior to MA monotherapy. Although not significant, the potential benefit of this combination deserves further investigation. The use of higher doses or other routes of application of G-CSF in a greater number of patients should contribute to a definitive response.
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Affiliation(s)
- Carvel Suprien
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Bahia, Salvador 40026-010, Bahia, Brazil; (C.S.); (L.P.d.C.)
| | - Luiz H. Guimarães
- National Institutes of Science and Technology in Tropical Diseases, Ministry of Science and Technology, Salvador, Bahia, Brazil;
- Medicine School, Federal University of Recôncavo Bahia, Santo Antônio de Jesus 44380-000, Bahia, Brazil
| | - Lucas P. de Carvalho
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Bahia, Salvador 40026-010, Bahia, Brazil; (C.S.); (L.P.d.C.)
- National Institutes of Science and Technology in Tropical Diseases, Ministry of Science and Technology, Salvador, Bahia, Brazil;
- Immunology Service of the Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador 40110-060, Bahia, Brazil
- Gonçalo Moniz Institute, Fiocruz, Salvador 40296-710, Bahia, Brazil
| | - Paulo R. L. Machado
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Bahia, Salvador 40026-010, Bahia, Brazil; (C.S.); (L.P.d.C.)
- National Institutes of Science and Technology in Tropical Diseases, Ministry of Science and Technology, Salvador, Bahia, Brazil;
- Immunology Service of the Professor Edgard Santos University Hospital, Federal University of Bahia, Salvador 40110-060, Bahia, Brazil
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Nascimento MT, Cordeiro RSO, Abreu C, Santos CP, Peixoto F, Duarte GA, Cardoso T, de Oliveira CI, Carvalho E, Carvalho LP. Pioglitazone, a Peroxisome Proliferator-Activated Receptor-γ Agonist, Downregulates the Inflammatory Response in Cutaneous Leishmaniasis Patients Without Interfering in Leishmania braziliensis Killing by Monocytes. Front Cell Infect Microbiol 2022; 12:884237. [PMID: 35909958 PMCID: PMC9329526 DOI: 10.3389/fcimb.2022.884237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with cutaneous leishmaniasis (CL) due to Leishmania braziliensis infection have an exacerbated inflammatory response associated with tissue damage and ulcer development. An increase in the rate of patients who fail therapy with pentavalent antimony has been documented. An adjuvant therapy with an anti-inflammatory drug with the potential of Leishmania killing would benefit CL patients. The aim of the present study was to investigate the contribution of peroxisome proliferator-activated receptor-γ (PPAR-γ) activation by pioglitazone in the regulation of the inflammatory response and L. braziliensis killing by monocytes. Pioglitazone is an oral drug used in the treatment of diabetes, and its main mechanism of action is through the activation of PPAR-γ, which is expressed in many cell types of the immune response. We found that activation of PPAR-γ by pioglitazone decreases the inflammatory response in CL patients without affecting L. braziliensis killing by monocytes. Our data suggest that pioglitazone may serve as an adjunctive treatment for CL caused by L. braziliensis.
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Affiliation(s)
- Maurício T. Nascimento
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Serviço de Imunologia, Complexo Hospitalar Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
| | - Ravena S. O. Cordeiro
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
| | - Cayo Abreu
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
| | - Camila P. Santos
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
| | - Fábio Peixoto
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
| | - Gabriela A. Duarte
- Laboratório de Enfermidades Infecciosas Transmitidas por Vetores, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
| | - Thiago Cardoso
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Serviço de Imunologia, Complexo Hospitalar Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
| | - Camila I. de Oliveira
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
- Laboratório de Enfermidades Infecciosas Transmitidas por Vetores, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Ministério de Ciências e Tecnologia, Instituto Nacional de Ciências e Tecnologia-Doenças Tropicais, Salvador, Brazil
| | - Edgar M. Carvalho
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Serviço de Imunologia, Complexo Hospitalar Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
- Ministério de Ciências e Tecnologia, Instituto Nacional de Ciências e Tecnologia-Doenças Tropicais, Salvador, Brazil
| | - Lucas P. Carvalho
- Laboratório de Pesquisas Clínicas, Instituto Gonçalo Moniz, FIOCRUZ, Salvador, Brazil
- Serviço de Imunologia, Complexo Hospitalar Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil
- Ministério de Ciências e Tecnologia, Instituto Nacional de Ciências e Tecnologia-Doenças Tropicais, Salvador, Brazil
- *Correspondence: Lucas P. Carvalho,
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Muñoz-Durango N, Gómez A, García-Valencia N, Roldán M, Ochoa M, Bautista-Erazo DE, Ramírez-Pineda JR. A Mouse Model of Ulcerative Cutaneous Leishmaniasis by Leishmania (Viannia) panamensis to Investigate Infection, Pathogenesis, Immunity, and Therapeutics. Front Microbiol 2022; 13:907631. [PMID: 35770175 PMCID: PMC9234518 DOI: 10.3389/fmicb.2022.907631] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
A mouse model of cutaneous leishmaniasis (CL) by Leishmania (Viannia) panamensis (L(V)p) that reproduces the characteristics of the human disease remains elusive. Here we report the development of a CL model that uses a mouse-adapted L(V)p isolate to reproducibly induce a dermal disease with a remarkable similarity to human CL. BALB/c mice infected intradermally in the ear with 105 stationary UA-946 L(V)p promastigotes develop a progressive cutaneous disease that exhibits the typical ulcerated lesions with indurated borders observed in CL patients. Although most of parasites in the inoculum die within the first week of infection, the survivors vigorously multiply at the infection site during the following weeks, paralleling disease appearance and aggravation. Regional lymphadenopathy as well as lymphatic dissemination of parasites to draining lymph nodes (dLN) was evidenced early after infection. Viable parasites were also isolated from spleen at later timepoints indicating systemic parasitic dissemination, but, strikingly, no signs of systemic disease were observed. Increasing numbers of myeloid cells and T lymphocytes producing IFNγ and IL-4 were observed in the dLN as disease progressed. A mixed adaptive L(V)p-specific T cell-mediated response was induced, since ex vivo recall experiments using dLN cells and splenocytes revealed the production of type 1 (IFNγ, IL-2), type 2 (IL-4, IL-13), regulatory (IL-10), and inflammatory (GM-CSF, IL-3) cytokines. Humoral adaptive response was characterized by early production of IgG1- followed by IgG2a-type of L(V)p-specific antibodies. IFNγ/IL-4 and IgG2a/IgG1 ratios indicated that the initial non-protective Th2 response was redirected toward a protective Th1 response. In situ studies revealed a profuse recruitment of myeloid cells and of IFNγ- and IL-4-producing T lymphocytes to the site of infection, and the typical histopathological changes induced by dermotropic Leishmania species. Evidence that this model is suitable to investigate pharmacological and immunomodulatory interventions, as well as for antigen discovery and vaccine development, is also presented. Altogether, these results support the validity and utility of this novel mouse model to study the pathogenesis, immunity, and therapeutics of L(V)p infections.
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Affiliation(s)
- Natalia Muñoz-Durango
- Grupo Inmunomodulación (GIM), Instituto de Investigaciones Médicas, Facultad de Medicina, Corporación Académica para el Estudio de Patologías Tropicales (CAEPT), Universidad de Antioquia, Medellín, Colombia
| | - Alexander Gómez
- Grupo Inmunomodulación (GIM), Instituto de Investigaciones Médicas, Facultad de Medicina, Corporación Académica para el Estudio de Patologías Tropicales (CAEPT), Universidad de Antioquia, Medellín, Colombia
| | - Natalia García-Valencia
- Grupo Inmunomodulación (GIM), Instituto de Investigaciones Médicas, Facultad de Medicina, Corporación Académica para el Estudio de Patologías Tropicales (CAEPT), Universidad de Antioquia, Medellín, Colombia
| | - Miguel Roldán
- Instituto de Patología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Marcela Ochoa
- Programa de Estudio y Control de Enfermedades Tropicales (PECET), Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - David E. Bautista-Erazo
- Grupo Inmunomodulación (GIM), Instituto de Investigaciones Médicas, Facultad de Medicina, Corporación Académica para el Estudio de Patologías Tropicales (CAEPT), Universidad de Antioquia, Medellín, Colombia
| | - José R. Ramírez-Pineda
- Grupo Inmunomodulación (GIM), Instituto de Investigaciones Médicas, Facultad de Medicina, Corporación Académica para el Estudio de Patologías Tropicales (CAEPT), Universidad de Antioquia, Medellín, Colombia
- *Correspondence: José R. Ramírez-Pineda,
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Sridharan K, Sivaramakrishnan G. Comparative assessment of interventions for treating cutaneous leishmaniasis: A network meta-analysis of randomized clinical trials. Acta Trop 2021; 220:105944. [PMID: 33957088 DOI: 10.1016/j.actatropica.2021.105944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/28/2021] [Accepted: 04/26/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Various interventions including laser therapy, heat therapy, and several drugs have been trialed in patients with cutaneous leishmaniasis. Due to the lack of an evidence-based comparison of all these interventions, we carried out the present network meta-analysis. METHODS Electronic databases were searched for randomized clinical trials evaluating the efficacy and safety of any interventions in patients with cutaneous leishmaniasis. The proportion of patients with complete cure was the primary outcome. The proportion of lesions cured at the end of treatment, the proportion of lesions with minimal/no response to treatment, and proportion of wounds with minimal/no change were the secondary outcomes. Random-effects modeling was used for generating pooled estimates. Rankogram plot was used for identifying the 'best intervention'. For interventions containing a combination of treatments, backslash (/) has been used for depicting the same. RESULTS One-hundred and thirty-one studies were included. Intralesional meglumine, topical paromomycin/gentamicin, topical paromomycin, parenteral sodium stibogluconate, topical honey/intralesional meglumine, topical liposomal amphotericin B, oral zinc sulphate, oral miltefosine, parenteral meglumine, heat therapy, topical liposomal azithromycin, intralesional meglumine/silver dressing, intralesional sodium stibogluconate, parenteral meglumine/intralesional meglumine, oral allopurinol/parenteral meglumine, topical trichloroacetic acid/heat therapy, oral zinc sulphate/oral ketoconazole, topical imiquimod/cryotherapy, intralesional meglumine/cryotherapy, topical herbal extract of Z-HE, parenteral pentamidine, topical trichloroacetic acid/intralesional meglumine, carbon-dioxide laser, topical recombinant granulocyte-macrophage colony-stimulating factor/parenteral meglumine, intralesional dapsone, carbon-dioxide laser/intralesional meglumine, moist wet dressing with sodium hypochlorite, parenteral sodium stibogluconate/intralesional recombinant granulocyte-macrophage colony-stimulating factor, oral dapsone, intralesional sodium stibogluconate/oral ketoconazole, intralesional sodium stibogluconate/parenteral sodium stibogluconate and electrocautery/moist wet dressing with sodium hypochlorite were observed with significantly greater proportion of patients with complete cure compared to placebo/untreated controls. Rankogram analysis revealed that parenteral pentamidine has the highest statistical probability of being the best in the pool. CONCLUSION We observed several interventions to be effective for treating cutaneous leishmaniasis. However, greater caution is required in interpreting the results as the estimates are likely to change with the advent of results from future studies.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
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Mota CA, Oyama J, Souza Terron Monich MD, Brustolin AÁ, Perez de Souza JV, Murase LS, Ghiraldi Lopes LD, Silva Santos TD, Vieira Teixeira JJ, Verzignassi Silveira TG. Three decades of clinical trials on immunotherapy for human leishmaniases: a systematic review and meta-analysis. Immunotherapy 2021; 13:693-721. [PMID: 33853344 DOI: 10.2217/imt-2020-0184] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aim: Current treatments for leishmaniases are not satisfactory, thus alternatives are needed. We searched for clinical trials with immunotherapeutic approaches for patients with leishmaniasis. Materials & methods: Out of 205 articles, 24 clinical trials were selected, and eight submitted to meta-analysis. Results: A reduction in healing time was observed in patients with tegumentary leishmaniasis treated with pentavalent antimony plus granulocyte-macrophage colony-stimulating factor, and therapeutic vaccines. Overall meta-analysis indicated that immunotherapy associated with the standard chemotherapy generated a significantly reduced risk of treatment failure than the pentavalent antimony alone (p = 0.03). Conclusion: Our review confirmed the efficacy of immunotherapies for the treatment of cutaneous and visceral leishmaniasis and highlighted the importance of clinical trials using immunotherapies for leishmaniases.
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Affiliation(s)
- Camila Alves Mota
- Graduate Program in Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | - Jully Oyama
- Graduate Program in Bioscience & Physiopathology, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Aline Ávila Brustolin
- Graduate Program in Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | - João Vítor Perez de Souza
- Graduate Program in Bioscience & Physiopathology, State University of Maringá, Maringá, Paraná, Brazil
| | - Letícia Sayuri Murase
- Graduate Program in Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | - Luciana Dias Ghiraldi Lopes
- Laboratory of Clinical Virology, Department of Clinical Analysis & Biomedicine, State University of Maringá, Maringá, Paraná, Brazil
| | - Thais da Silva Santos
- Graduate Program in Bioscience & Physiopathology, State University of Maringá, Maringá, Paraná, Brazil
| | - Jorge Juarez Vieira Teixeira
- Laboratory of Leishmaniases, Department of Clinical Analysis & Biomedicine, State University of Maringá, Maringá, Paraná, Brazil
| | - Thaís Gomes Verzignassi Silveira
- Laboratory of Leishmaniases, Department of Clinical Analysis & Biomedicine, State University of Maringá, Maringá, Paraná, Brazil
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Machado PRL, Prates FVO, Boaventura V, Lago T, Guimarães LH, Schriefer A, Corte TWF, Penna G, Barral A, Barral-Netto M, Carvalho EM. A double-bind and randomized trial to evaluate Miltefosine and topical GM-CSF in the treatment of cutaneous leishmaniasis caused by Leishmania braziliensis in Brazil. Clin Infect Dis 2020; 73:e2465-e2469. [PMID: 32894278 PMCID: PMC8492114 DOI: 10.1093/cid/ciaa1337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
Background The treatment of cutaneous leishmaniasis (CL) in Brazil using pentavalent antimony (Sbv) is associated with a high rate of failure. Miltefosine has proven efficacy for CL caused by L. braziliensis, with a cure rate (CR) of 75%. A combined treatment with granulocyte macrophage colony-stimulating factor (GM-CSF) and miltefosine could increase CR and decrease healing time. Methods A randomized, double-blind clinical trial to evaluate the efficacy of miltefosine combined with topical GM-CSF (M + GM) vs miltefosine and placebo (M + P) vs Sbv in 133 patients with CL caused by L. braziliensis in Bahia, Brazil. Results The final CR at 180 days after the initiation of treatment was 44.4% in the Sbv group, 76.6% in the M + P group (P = .003 vs Sbv), and 75.6% in the M + GM group (P = .004 vs Sbv). The median healing time for cure was 102 days for the Sbv group and 60 days for both miltefosine groups (P = .0009). During the 6-month follow-up period, 4 relapses were documented: 1 in the Sbv group, 1 in the M + P group, and 2 in the M + GM group. Mild adverse events occurred in 65% of patients from the Sbv group, 76% and 79% from the M + P and M + GM groups respectively. Conclusions Miltefosine is more effective than Sbv for the treatment of CL caused by L. braziliensis in Brazil and accelerates the healing time. Association with GM-CSF does not improve therapeutic outcome. Clinical Trials Registration NCT03023111.
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Affiliation(s)
- Paulo R L Machado
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil.,Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Ministério da Ciência, Tecnologia, Inovações e Comunicações, CNPq, Brasília, DF, Brazil
| | - Fernanda V O Prates
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil.,Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Ministério da Ciência, Tecnologia, Inovações e Comunicações, CNPq, Brasília, DF, Brazil
| | | | - Tainã Lago
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
| | - Luiz H Guimarães
- Universidade Federal do Sul da Bahia, Teixeira de Freitas, Brazil
| | - Albert Schriefer
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil.,Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Ministério da Ciência, Tecnologia, Inovações e Comunicações, CNPq, Brasília, DF, Brazil
| | - Temis W F Corte
- Quatro G Pesquisa & Desenvolvimento, LTDA, Av. Ipiranga, Prédio 92A, Porto Alegre, Brasil
| | - Gerson Penna
- Núcleo de Medicina Tropical, Universidade de Brasília (UnB), Brasília-DF, Brazil
| | - Aldina Barral
- Instituto Gonçalo Moniz (IGM), FIOCRUZ, Bahia, Brazil
| | | | - Edgar M Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil.,Instituto Nacional de Ciência e Tecnologia em Doenças Tropicais (INCT-DT), Ministério da Ciência, Tecnologia, Inovações e Comunicações, CNPq, Brasília, DF, Brazil.,Instituto Gonçalo Moniz (IGM), FIOCRUZ, Bahia, Brazil
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Pinart M, Rueda JR, Romero GA, Pinzón-Flórez CE, Osorio-Arango K, Silveira Maia-Elkhoury AN, Reveiz L, Elias VM, Tweed JA. Interventions for American cutaneous and mucocutaneous leishmaniasis. Cochrane Database Syst Rev 2020; 8:CD004834. [PMID: 32853410 PMCID: PMC8094931 DOI: 10.1002/14651858.cd004834.pub3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND On the American continent, cutaneous and mucocutaneous leishmaniasis (CL and MCL) are diseases associated with infection by several species of Leishmania parasites. Pentavalent antimonials remain the first-choice treatment. There are alternative interventions, but reviewing their effectiveness and safety is important as availability is limited. This is an update of a Cochrane Review first published in 2009. OBJECTIVES To assess the effects of interventions for all immuno-competent people who have American cutaneous and mucocutaneous leishmaniasis (ACML). SEARCH METHODS We updated our database searches of the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and CINAHL to August 2019. We searched five trials registers. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing either single or combination treatments for ACML in immuno-competent people, diagnosed by clinical presentation and Leishmania infection confirmed by smear, culture, histology, or polymerase chain reaction on a biopsy specimen. The comparators were either no treatment, placebo only, or another active compound. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Our key outcomes were the percentage of participants 'cured' at least three months after the end of treatment, adverse effects, and recurrence. We used GRADE to assess evidence certainty for each outcome. MAIN RESULTS We included 75 studies (37 were new), totalling 6533 randomised participants with ATL. The studies were mainly conducted in Central and South America at regional hospitals, local healthcare clinics, and research centres. More male participants were included (mean age: roughly 28.9 years (SD: 7.0)). The most common confirmed species were L. braziliensis, L. panamensis, and L. mexicana. The most assessed interventions and comparators were non-antimonial systemics (particularly oral miltefosine) and antimonials (particularly meglumine antimoniate (MA), which was also a common intervention), respectively. Three studies included moderate-to-severe cases of mucosal leishmaniasis but none included cases with diffuse cutaneous or disseminated CL, considered the severe cutaneous form. Lesions were mainly ulcerative and located in the extremities and limbs. The follow-up (FU) period ranged from 28 days to 7 years. All studies had high or unclear risk of bias in at least one domain (especially performance bias). None of the studies reported the degree of functional or aesthetic impairment, scarring, or quality of life. Compared to placebo, at one-year FU, intramuscular (IM) MA given for 20 days to treat L. braziliensis and L. panamensis infections in ACML may increase the likelihood of complete cure (risk ratio (RR) 4.23, 95% confidence interval (CI) 0.84 to 21.38; 2 RCTs, 157 participants; moderate-certainty evidence), but may also make little to no difference, since the 95% CI includes the possibility of both increased and reduced healing (cure rates), and IMMA probably increases severe adverse effects such as myalgias and arthralgias (RR 1.51, 95% CI 1.17 to 1.96; 1 RCT, 134 participants; moderate-certainty evidence). IMMA may make little to no difference to the recurrence risk, but the 95% CI includes the possibility of both increased and reduced risk (RR 1.79, 95% CI 0.17 to 19.26; 1 RCT, 127 participants; low-certainty evidence). Compared to placebo, at six-month FU, oral miltefosine given for 28 days to treat L. mexicana, L. panamensis and L. braziliensis infections in American cutaneous leishmaniasis (ACL) probably improves the likelihood of complete cure (RR 2.25, 95% CI 1.42 to 3.38), and probably increases nausea rates (RR 3.96, 95% CI 1.49 to 10.48) and vomiting (RR 6.92, 95% CI 2.68 to 17.86) (moderate-certainty evidence). Oral miltefosine may make little to no difference to the recurrence risk (RR 2.97, 95% CI 0.37 to 23.89; low-certainty evidence), but the 95% CI includes the possibility of both increased and reduced risk (all based on 1 RCT, 133 participants). Compared to IMMA, at 6 to 12 months FU, oral miltefosine given for 28 days to treat L. braziliensis, L. panamensis, L. guyanensis and L. amazonensis infections in ACML may make little to no difference to the likelihood of complete cure (RR 1.05, 95% CI 0.90 to 1.23; 7 RCTs, 676 participants; low-certainty evidence). Based on moderate-certainty evidence (3 RCTs, 464 participants), miltefosine probably increases nausea rates (RR 2.45, 95% CI 1.72 to 3.49) and vomiting (RR 4.76, 95% CI 1.82 to 12.46) compared to IMMA. Recurrence risk was not reported. For the rest of the key comparisons, recurrence risk was not reported, and risk of adverse events could not be estimated. Compared to IMMA, at 6 to 12 months FU, oral azithromycin given for 20 to 28 days to treat L. braziliensis infections in ACML probably reduces the likelihood of complete cure (RR 0.51, 95% CI 0.34 to 0.76; 2 RCTs, 93 participants; moderate-certainty evidence). Compared to intravenous MA (IVMA) and placebo, at 12 month FU, adding topical imiquimod to IVMA, given for 20 days to treat L. braziliensis, L. guyanensis and L. peruviana infections in ACL probably makes little to no difference to the likelihood of complete cure (RR 1.30, 95% CI 0.95 to 1.80; 1 RCT, 80 participants; moderate-certainty evidence). Compared to MA, at 6 months FU, one session of local thermotherapy to treat L. panamensis and L. braziliensis infections in ACL reduces the likelihood of complete cure (RR 0.80, 95% CI 0.68 to 0.95; 1 RCT, 292 participants; high-certainty evidence). Compared to IMMA and placebo, at 26 weeks FU, adding oral pentoxifylline to IMMA to treat CL (species not stated) probably makes little to no difference to the likelihood of complete cure (RR 0.86, 95% CI 0.63 to 1.18; 1 RCT, 70 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Evidence certainty was mostly moderate or low, due to methodological shortcomings, which precluded conclusive results. Overall, both IMMA and oral miltefosine probably result in an increase in cure rates, and nausea and vomiting are probably more common with miltefosine than with IMMA. Future trials should investigate interventions for mucosal leishmaniasis and evaluate recurrence rates of cutaneous leishmaniasis and its progression to mucosal disease.
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Affiliation(s)
- Mariona Pinart
- Free time independent Cochrane reviewer, Berlin, Germany
| | - José-Ramón Rueda
- Department of Preventive Medicine and Public Health, University of the Basque Country, Leioa, Spain
| | - Gustavo As Romero
- Center for Tropical Medicine, University of Brasilia, Brasilia, Brazil
| | | | - Karime Osorio-Arango
- Dirección de Redes en Salud Pública, Instituto Nacional de Salud, Bogotá, Colombia
| | - Ana Nilce Silveira Maia-Elkhoury
- Communicable Diseases and Environmental Determinants of Health (CDE), Neglected, Tropical and Vector Borne Diseases (VT), Pan American Health Organization/ World Health Organization (PAHO/WHO), Rio de Janeiro, Brazil
| | - Ludovic Reveiz
- Evidence and Intelligence for Action in Health Department, Pan American Health Organization (PAHO), Washington DC, USA
| | - Vanessa M Elias
- Evidence and Intelligence for Action in Health Department, Pan American Health Organization (PAHO), Washington DC, USA
| | - John A Tweed
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
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Husein‐ElAhmed H, Gieler U, Steinhoff M. Evidence supporting the enhanced efficacy of pentavalent antimonials with adjuvant therapy for cutaneous leishmaniasis: a systematic review and meta‐analysis. J Eur Acad Dermatol Venereol 2020; 34:2216-2228. [DOI: 10.1111/jdv.16333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 02/10/2020] [Indexed: 11/29/2022]
Affiliation(s)
- H. Husein‐ElAhmed
- Department of Dermatology and Venereology Hospital de Baza Granada Spain
- Translational Research Institute Academic Health System Medical School Hamad Medical Corporation Doha Qatar
| | - U. Gieler
- Translational Research Institute Academic Health System Medical School Hamad Medical Corporation Doha Qatar
- Department of Dermatology and Venereology Hamad Medical Corporation Doha Qatar
| | - M. Steinhoff
- Translational Research Institute Academic Health System Medical School Hamad Medical Corporation Doha Qatar
- Department of Dermatology and Venereology Hamad Medical Corporation Doha Qatar
- College of Medicine Weill Cornell Medicine‐Qatar Doha Qatar
- Medical School Qatar University Doha Qatar
- College of Medicine Weill Cornell University New York NY USA
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9
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Leishmaniasis immunopathology-impact on design and use of vaccines, diagnostics and drugs. Semin Immunopathol 2020; 42:247-264. [PMID: 32152715 DOI: 10.1007/s00281-020-00788-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/03/2020] [Indexed: 12/18/2022]
Abstract
Leishmaniasis is a disease complex caused by 20 species of protozoan parasites belonging to the genus Leishmania. In humans, it has two main clinical forms, visceral leishmaniasis (VL) and cutaneous or tegumentary leishmaniasis (CL), as well as several other cutaneous manifestations in a minority of cases. In the mammalian host Leishmania parasites infect different populations of macrophages where they multiply and survive in the phagolysosomal compartment. The progression of both VL and CL depends on the maintenance of a parasite-specific immunosuppressive state based around this host macrophage infection. The complexity and variation of immune responses and immunopathology in humans and the different host interactions of the different Leishmania species has an impact upon the effectiveness of vaccines, diagnostics and drugs.
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Berbert TRN, de Mello TFP, Wolf Nassif P, Mota CA, Silveira AV, Duarte GC, Demarchi IG, Aristides SMA, Lonardoni MVC, Vieira Teixeira JJ, Silveira TGV. Pentavalent Antimonials Combined with Other Therapeutic Alternatives for the Treatment of Cutaneous and Mucocutaneous Leishmaniasis: A Systematic Review. Dermatol Res Pract 2018; 2018:9014726. [PMID: 30675152 PMCID: PMC6323433 DOI: 10.1155/2018/9014726] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/19/2018] [Accepted: 12/05/2018] [Indexed: 11/18/2022] Open
Abstract
The first choice drugs for the treatment of cutaneous and mucocutaneous leishmaniasis are pentavalent antimonials, sodium stibogluconate, or meglumine antimoniate. However, the treatment with these drugs is expensive, can cause serious adverse effects, and is not always effective. The combination of two drugs by different routes or the combination of an alternative therapy with systemic therapy can increase the efficacy and decrease the collateral effects caused by the reference drugs. In this systematic review we investigated publications that described a combination of nonconventional treatment for cutaneous and mucocutaneous with pentavalent antimonials. A literature review was performed in the databases Web of Knowledge and PubMed in the period from 01st of December 2004 to 01st of June 2017, according to Prisma statement. Only clinical trials involving the treatment for cutaneous or mucocutaneous leishmaniasis, in English, and with available abstract were added. Other types of publications, such as reviews, case reports, comments to the editor, letters, interviews, guidelines, and errata, were excluded. Sixteen articles were selected and the pentavalent antimonials were administered in combination with pentoxifylline, granulocyte macrophage colony-stimulating factor, imiquimod, intralesional sodium stibogluconate, ketoconazole, silver-containing polyester dressing, lyophilized LEISH-F1 protein, cryotherapy, topical honey, and omeprazole. In general, the combined therapy resulted in high rates of clinical cure and when relapse or recurrence was reported, it was higher in the groups treated with pentavalent antimonials alone. The majority of the articles included in this review showed that cure rate ranged from 70 to 100% in patients treated with the combinations. Serious adverse effects were not observed in patients treated with drugs combination. The combination of other drugs or treatment modalities with pentavalent antimonials has proved to be effective for cutaneous and mucocutaneous leishmaniasis and for most seemed to be safe. However, new randomized, controlled, and multicentric clinical trials with more robust samples should be performed, especially the combination with immunomodulators.
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Affiliation(s)
- Taisa Rocha Navasconi Berbert
- Graduate Program in Health Sciences, State University Maringá, Avenida Colombo, 5790 Jardim Universitário, 87020-900, Maringá, PR, Brazil
| | - Tatiane França Perles de Mello
- Graduate Program in Bioscience and Physiopathology, State University Maringá, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Priscila Wolf Nassif
- Graduate Program in Health Sciences, State University Maringá, Avenida Colombo, 5790 Jardim Universitário, 87020-900, Maringá, PR, Brazil
| | - Camila Alves Mota
- Graduate Program in Health Sciences, State University Maringá, Avenida Colombo, 5790 Jardim Universitário, 87020-900, Maringá, PR, Brazil
| | - Aline Verzignassi Silveira
- Medical Residency, Santa Casa de São Paulo, R. Dr. Cesário Mota Júnior, 112 Vila Buarque, 01221-900 São Paulo, SP, Brazil
| | - Giovana Chiqueto Duarte
- Undergraduation Course in Medicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Izabel Galhardo Demarchi
- Department of Clinical Analysis and Biomedicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Sandra Mara Alessi Aristides
- Department of Clinical Analysis and Biomedicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Maria Valdrinez Campana Lonardoni
- Department of Clinical Analysis and Biomedicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Jorge Juarez Vieira Teixeira
- Department of Clinical Analysis and Biomedicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
| | - Thaís Gomes Verziganassi Silveira
- Department of Clinical Analysis and Biomedicine, State University Maringa, Avenida Colombo, 5790 Jardim Universitário, 87020-900 Maringá, PR, Brazil
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López-Carvajal L, Vélez I, Arbeláez MP, Olliaro P. Eligibility criteria and outcome measures adopted in clinical trials of treatments of cutaneous leishmaniasis: systematic literature review covering the period 1991-2015. Trop Med Int Health 2018. [PMID: 29524291 DOI: 10.1111/tmi.13048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To document the sources of heterogeneity in outcomes and shortcomings in trial designs reported by previous systematic reviews. METHODS Systematic review of clinical trials of CL treatments published since 1991, to assess and compare eligibility criteria and outcome measures in trials (any type of treatment) of CL (any form) reported before and after the publication of the CONSORT statement. RESULTS We identified 106 eligible trials published between 1991 and 2015, 74% after the 2001 CONSORT statement; 58% (n = 63) were on Old-World CL and 37% (n = 40) in New-World CL; overall, 11 531 patients enrolled in 243 treatment groups on 30 different treatments. Both requirements and definitions for eligibility and outcome criteria varied. Compliance with CONSORT requirements increased for studies published after the 2010 update. As for entry criteria, 94% of studies had a requirement for sex (74% of those enrolling also women excluded those who were pregnant or lactating), 69% for age (variable age ranges), 99% parasitological confirmation, 43% prior duration of illness (14% excluded cases with previous episodes), 46% defined the number, 28% the size and 13% the type of lesions (27% with restrictions as to their anatomical location). Follow-up ranged 1-24 months, with 14% and 91% of studies, respectively, having defined initial and final cure. CONCLUSIONS This review documents changes in reporting before and after the publication of the CONSORT statement. Lack of standardisation, compounded with the small number of trials relative to the magnitude of the disease in its multiple forms, and with the range of treatments tested explains why evidence to inform treatment guidelines is generally weak for CL. Adopting standardised methodologies will improve the quality and consistency of clinical trials, and ultimately yield better treatments for CL.
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Affiliation(s)
- Liliana López-Carvajal
- Programa de Estudio y Control de Enfermedades Tropicales, Universidad de Antioquia, Medellín, Colombia
| | - Iván Vélez
- Programa de Estudio y Control de Enfermedades Tropicales, Universidad de Antioquia, Medellín, Colombia
| | | | - Piero Olliaro
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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13
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Blum J, Buffet P, Visser L, Harms G, Bailey MS, Caumes E, Clerinx J, van Thiel PPAM, Morizot G, Hatz C, Dorlo TPC, Lockwood DNJ. LeishMan recommendations for treatment of cutaneous and mucosal leishmaniasis in travelers, 2014. J Travel Med 2014; 21:116-29. [PMID: 24745041 DOI: 10.1111/jtm.12089] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Treatment of cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML) in travelers is still controversial. Over the last decade, national and international consortia have published recommendations for treating CL in travelers. These guidelines harmonize many issues, but there are some discrepancies. METHODS Leishmania parasites causing CL can now be genotyped by polymerase chain reaction techniques for detecting Leishmania DNA. Therefore, treatment recommendations can now be species based rather than based on geographical exposure. To review the evidence on which the recommendations were based, "LeishMan" (Leishmaniasis Management), a group of experts from 13 institutions in eight European countries, performed a PubMed MEDLINE) literature search and considered unpublished evidence and the experts' own personal experiences. The Oxford evidence grading system was used to evaluate the information. RESULTS AND CONCLUSION In this article, the authors provide practical treatment recommendations for imported CL and ML in Europe, drawn up from the review by the European experts.
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Reveiz L, Maia-Elkhoury ANS, Nicholls RS, Romero GAS, Yadon ZE. Interventions for American cutaneous and mucocutaneous leishmaniasis: a systematic review update. PLoS One 2013; 8:e61843. [PMID: 23637917 PMCID: PMC3639260 DOI: 10.1371/journal.pone.0061843] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 03/14/2013] [Indexed: 12/22/2022] Open
Abstract
Introduction Leishmaniasis is an important public health problem in the Americas. A Cochrane review published in 2009 analyzed 38 randomized controlled trials (RCT). We conducted a systematic review to evaluate the effects of therapeutic interventions for American cutaneous and mucocutaneous leishmaniasis. Methods All studies were extracted from PubMed, Embase, Lilacs (2009 to July, 2012 respectively), the Cochrane Central Register of Controlled Trials (6-2012) and references of identified publications. RCTs’ risk of bias was assessed. Results We identified 1865 references of interest; we finally included 10 new RCTs. The risk of bias scored low or unclear for most domains. Miltefosine was not significantly different from meglumine antimoniate in the complete cure rate at 6 months (4 RCT; 584 participants; ITT; RR: 1.12; 95%CI: 0.85 to 1.47; I2 78%). However a significant difference in the rate of complete cure favoring miltefosine at 6 months was found in L. panamensis and L. guyanensis (2 RCTs, 206 participants; ITT; RR: 1.22; 95%CI: 1.02 to 1.46; I2 0%). One RCT found that meglumine antimoniate was superior to pentamidine in the rate of complete cure for L. braziliensis (80 participants, ITT; RR: 2.21; 95%CI: 1.41 to 3.49), while another RCT assessing L. guyanensis did not find any significant difference. Although meta-analysis of three studies found a significant difference in the rate of complete cure at 3 months favoring imiquimod versus placebo (134 participants; ITT; RR: 1.45; 95%CI: 1.12 to 1.88; I2 0%), no significant differences were found at 6 and 12 months. Thermotherapy and nitric oxide were not superior to meglumine antimoniate. Conclusion Therapeutic interventions for American cutaneous and mucocutaneous leishmaniasis are varied and should be decided according to the context. Since mucosal disease is the more neglected form of leishmaniasis a multicentric trial should be urgently considered.
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Affiliation(s)
- Ludovic Reveiz
- Health Systems Based on Primary Health Care, Pan American Health Organization (PAHO), Washington, DC, United States of America
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15
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Changes in T-Cell and Monocyte Phenotypes In Vitro by Schistosoma mansoni Antigens in Cutaneous Leishmaniasis Patients. J Parasitol Res 2012; 2012:520308. [PMID: 23209879 PMCID: PMC3504418 DOI: 10.1155/2012/520308] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 09/24/2012] [Accepted: 10/08/2012] [Indexed: 12/14/2022] Open
Abstract
High levels of proinflammatory cytokines such as IFN-γ and TNF are associated with tissue lesions in cutaneous leishmaniasis (CL). We previously demonstrated that Schistosoma mansoni antigens downmodulate the in vitro cytokine response in CL. In the current study we evaluated whether S. mansoni antigens alter monocyte and T-lymphocyte phenotypes in leishmaniasis. Peripheral blood mononuclear cells of CL patients were cultured with L. braziliensis antigen in the presence or absence of the S. mansoni antigens rSm29, rSmTSP-2- and PIII. Cells were stained with fluorochrome conjugated antibodies and analyzed by flow cytometry. The addition of rSm29 to the cultures decreased the expression of HLA-DR in nonclassical (CD14+CD16++) monocytes, while the addition of PIII diminished the expression of this molecule in classical (CD14++CD16−) and intermediate (CD14++CD16+) monocytes. The addition of PIII and rSmTSP-2 resulted in downmodulation of CD80 expression in nonclassical and CD86 expression in intermediate monocytes, respectively. These two antigens increased the expression of CTLA-4 in CD4+ T cells and they also expanded the frequency of CD4+CD25highFoxp3+ T cells. Taken together, we show that S. mansoni antigens, mainly rSmTSP-2 and PIII, are able to decrease the activation status of monocytes and also to upregulate the expression of modulatory molecules in T lymphocytes.
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Lindoso JAL, Costa JML, Queiroz IT, Goto H. Review of the current treatments for leishmaniases. Res Rep Trop Med 2012; 3:69-77. [PMID: 30890869 DOI: 10.2147/rrtm.s24764] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Leishmaniases are vector-borne zoonotic diseases that are prevalent in tropical and subtropical areas in the world, with two million new cases occurring yearly. Visceral and tegumentary forms of leishmaniasis are known. The latter form may present as localized cutaneous or mucosal forms, disseminated, diffuse forms, or leishmaniasis recidiva cutis. Visceral leishmaniasis is caused by parasites of the species Leishmania (Leishmania) donovani and L. (L.) infantum, and tegumentary leishmaniasis is caused by 15 other species, with distinct distributions in the Old and New World. The varied clinical manifestations, the multitude of Leishmania species, and the increasing incidence of HIV coinfection make the diagnosis and treatment of leishmaniases complex. Since there are no solid data relating clinical manifestations, treatment outcomes and Leishmania species the decision regarding the best therapeutic option is almost entirely based on clinical manifestations. Because most of the literature is focused on leishmaniasis in the Old World, in this review we present data on the treatment of New World leishmaniasis in more detail. Ranked therapeutic options, clinical trials, and also observations, even with a restricted number of subjects, on treatment outcome of visceral and different forms of tegumentary leishmaniasis, are presented. Treatment for leishmaniasis in HIV-coinfected patients is addressed as well. Some of these data strongly suggest that the differences in the outcome of the treatment are related to the Leishmania species. Therefore, although it is not possible at most points of care to identify the species causing the infection - a process that requires a well equipped laboratory - the infecting species should be identified whenever possible. More recent approaches, such as the use of immunomodulators and immunotherapy, and the lines for development of new candidate drugs are mentioned.
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Affiliation(s)
| | | | - Igor Thiago Queiroz
- Departament of Infectious Diseases, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Sao Paulo, Brazil
| | - Hiro Goto
- Instituto de Medicina Tropical de São Paulo, and Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Sao Paulo, Brazil,
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Newlove T, Guimarães LH, Morgan DJ, Alcântara L, Glesby MJ, Carvalho EM, Machado PR. Antihelminthic therapy and antimony in cutaneous leishmaniasis: a randomized, double-blind, placebo-controlled trial in patients co-infected with helminths and Leishmania braziliensis. Am J Trop Med Hyg 2011; 84:551-5. [PMID: 21460008 DOI: 10.4269/ajtmh.2011.10-0423] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Helminth infections influence the clinical response to certain diseases and are associated with delayed healing time of patients with cutaneous leishmaniasis (CL) caused by Leishmania braziliensis. We conducted a randomized, double-blind, placebo-controlled clinical trial to examine the role of early versus deferred treatment of intestinal helminth infection on the clinical course of patients with CL treated with pentavalent antimony. (Clinicaltrials.gov number NCT00469495). A total of 90 patients were enrolled, 51.1% (N = 23) of control patients had persistent lesions at Day 90, compared with 62.2% (N = 28) in the treatment group (difference 11.1%, 95% confidence interval = -9.1-30.0%). There was no statistically significant difference in overall time to cure between groups, although there was a tendency for shorter cure times in the control group. This study shows that early introduction of antihelminthic therapy does not improve clinical outcome in patients co-infected with helminths and L. braziliensis.
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Affiliation(s)
- Tracey Newlove
- College of Medicine, University of Arizona, Tucson, AZ, USA.
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Almeida OLS, Santos JB. Avanços no tratamento da leishmaniose tegumentar do novo mundo nos últimos dez anos: uma revisão sistemática da literatura. An Bras Dermatol 2011; 86:497-506. [DOI: 10.1590/s0365-05962011000300012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 09/04/2010] [Indexed: 02/02/2023] Open
Abstract
INTRODUÇÃO: O arsenal terapêutico contra a leishmaniose tegumentar é muito restrito. Os antimoniais pentavalentes permanecem como as drogas de escolha para seu tratamento há mais de 50 anos. Apesar da sua eficácia, necessita de injeções diárias, apresenta muitos efeitos colaterais e tempo de cura prolongado. OBJETIVO: Realizar uma revisão sistemática da literatura sobre os avanços no tratamento da leishmaniose tegumentar do novo mundo nos últimos dez anos. METODOLOGIA: Realizou-se em junho de 2009 uma busca eletrônica nas bases de dados Pubmed, LILACS e na biblioteca eletrônica Scielo. As palavras de busca em inglês foram: "cutaneous", "leishmaniasis" e "treatment". Foram incluÃdos apenas ensaios clÃnicos randomizados, duplo-cegos, placebo controlados. Utilizou-se a escala de Jadad para avaliar a qualidade dos estudos selecionados. RESULTADOS: Segundo os critérios de inclusão e exclusão, apenas 8 artigos foram selecionados. As drogas avaliadas nos estudos selecionados foram Glucantime®, miltefosine, imunoterapia, imiquimod, rhGM-CSF, pentoxifilina e paramomicina. CONCLUSÃO: Apesar de a leishmaniose tegumentar ser um importante problema de saúde pública, os dados publicados sobre o uso de novas drogas para o tratamento da leishmaniose tegumentar em nosso meio ainda são bastante limitados
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González U, Pinart M, Rengifo-Pardo M, Macaya A, Alvar J, Tweed JA. Interventions for American cutaneous and mucocutaneous leishmaniasis. Cochrane Database Syst Rev 2009:CD004834. [PMID: 19370612 DOI: 10.1002/14651858.cd004834.pub2] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pentavalent antimonial drugs are the most prescribed treatment for American cutaneous and mucocutaneous leishmaniasis. Other drugs have been used with varying success. OBJECTIVES To assess the effects of therapeutic interventions for American cutaneous and mucocutaneous leishmaniasis. SEARCH STRATEGY We searched the Cochrane Skin Group Specialised Register (January 2009), the Register of Controlled Clinical Trials in The Cochrane Library (Issue 1,2009), MEDLINE (2003 to January 2009), EMBASE (2005 to January 2009), LILACS (from inception to January 2009), CINAHL (1982-May 2007) and other databases. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing treatments for American cutaneous and mucocutaneous leishmaniasis. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS We included 38 trials involving 2728 participants. Results are based on individual studies or limited pooled analyses. There was good evidence in:Leishmania braziliensis and L. panamensis infections:Intramuscular (IM) meglumine antimoniate (MA) was better than oral allopurinol for 28 days (1RCT n=127, RR 0.39; 95% CI 0.26, 0.58). Intravenous (IV)MA for 20-days was better than 3-day and 7-day IVMA plus 15% paromomycin plus 12% methylbenzethonium chloride (PR-MBCL) or 7-day IVMA (1RCT n= 150, RR 0.24; 95% CI 0.11, 0.50; RR 0.69; 95% CI 0.53, 0.90; RR 0.64; 95% CI 0.44, 0.92 respectively). Oral allopurinol plus antimonials was better than IV antimonials (2RCT n= 168, RR 1.90; 95% CI 1.40, 2.59; I(2)=0%).L. braziliensis infections:Oral pentoxifylline plus IV sodium stibogluconate (SSG) was better than IVSSG (1RCT n= 23, RR 1.66; 95% CI 1.03, 2.69); IVMA was better than IM aminosidine sulphate (1RCT n= 38, RR 0.05; 95% CI 0.00, 0.78) and better than IV pentamidine isethionate (1RCT n= 80, RR 0.45; 95% CI 0.29, 0.71). Intramuscular MA was better than Bacillus Calmette-Guérin (1RCT n= 93, RR 0.46; 95% CI 0.32, 0.65).L .panamensis infections:Oral allopurinol was better than IVMA (1RCT n= 58, RR 2.20; 95% CI 1.34, 3.60). Aminosidine sulphate at doses of 12 mg/kg/day and 18 mg/kg/day for 14 days were better than aminosidine sulphate 12 mg/kg/day for 7 days (1RCT n= 60, RR 0.23; 95% CI 0.07, 0.73; RR 0.23; 95% CI 0.07, 0.73 respectively). Oral ketoconazole for 28 days, oral miltefosine and topical PR-MBCL were better than placebo. AUTHORS' CONCLUSIONS Most trials have been designed and reported so poorly that they are inconclusive. There is a need for large well conducted studies that evaluate long-term effects of current therapies to improve quality and standardization of methods.
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Affiliation(s)
- Urbà González
- Department of Dermatology, Research Unit for Evidence-based Dermatology, Hospital Plató, c/ Plato 21, Barcelona, Catalunya, Spain, 08006.
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Affiliation(s)
- Johannes A Blum
- Medical Department, Swiss Tropical Institute, Basel, Switzerland.
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Recent developments leading toward a paradigm switch in the diagnostic and therapeutic approach to human leishmaniasis. Curr Opin Infect Dis 2008; 21:483-8. [PMID: 18725797 DOI: 10.1097/qco.0b013e32830d0ee8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To identify recent papers showing how human and parasite genetics influence leishmaniasis, and how understanding of the immunopathology may be utilized in immunotherapy for these diseases. RECENT FINDINGS Progress has been made in recent years showing the complexity within populations of Leishmania spp. and indicating that different strains lead to diverse clinical pictures and responses to treatment. Thus detection of parasite genetic tags for the precise identification of infecting strains, and for predictive diagnosis of clinical and therapeutic fates seems now possible. Host genetic loci involved in disease outcome have been detected, which may also be explored for better case management. These developments in diagnosis will demand expanding the therapeutic arsenal to take their expected effect. This is starting to be fulfilled by immunotherapies successfully employed to treat cases refractory to standard first line drugs, as the result of a more profound comprehension of the immunopathology of the leishmaniases. SUMMARY The knowledge mounting has already helped explain why different patients present different forms of leishmaniasis and respond differently to treatment, and may be on the verge of catalyzing a major change in the already over a century old paradigm of diagnosing and managing these patients.
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Ribeiro de Jesus A, Luna T, Pacheco de Almeida R, Machado PRL, Carvalho EM. Pentoxifylline down modulate in vitro T cell responses and attenuate pathology in Leishmania and HTLV-I infections. Int Immunopharmacol 2008; 8:1344-53. [PMID: 18687297 DOI: 10.1016/j.intimp.2008.03.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Revised: 03/27/2008] [Accepted: 03/31/2008] [Indexed: 01/13/2023]
Abstract
Tumor necrosis factor-alpha (TNF-alpha) is known to have numerous biological properties relating to inflammation. This cytokine participates in the tissue damage of chronic inflammatory, autoimmune and infectious diseases. Pentoxifylline is a methylxanthine that inhibits phosphodiesterase IV, which inhibits the degradation of the cAMP and prostanoids. The increased intracellular concentration of the cAMP leads to a negative regulation of NF-kappaB and NF-AT transcription factors and suppresses TNF-alpha production. This review describes studies that support evidences that TNF-alpha is involved in the pathogenesis of HTLV-1 associated myelopathy and of cutaneous and mucosal leishmaniasis. Additionally, it demonstrates the effect of pentoxifylline in vitro in inhibiting TNF-alpha and IFN-gamma spontaneous production in PBMC from HTLV-1-infected patients, as well as its in vivo effect in inhibiting TNF-alpha in sera from mucosal leishmaniasis patients. Moreover, we review the results of clinical studies from the last 10 years using pentoxifylline to treat HTLV-1 associated myelopathy and cutaneous and mucosal leishmaniasis.
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Affiliation(s)
- Amelia Ribeiro de Jesus
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brazil
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Carvalho LP, Passos S, Bacellar O, Lessa M, Almeida RP, Magalhães A, Dutra WO, Gollob KJ, Machado P, de Jesus AR. Differential immune regulation of activated T cells between cutaneous and mucosal leishmaniasis as a model for pathogenesis. Parasite Immunol 2007; 29:251-8. [PMID: 17430548 PMCID: PMC2593461 DOI: 10.1111/j.1365-3024.2007.00940.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cutaneous (CL) and mucosal leishmaniasis (ML) are characterized by a predominant type 1 immune response (IFN-gamma and TNF-alpha production) and strong inflammatory response in the lesions with few parasites. This exacerbated type 1 response is more evident in ML as compared to CL. Our main hypothesis is that a differential immune regulation of T cell activation leads to over reactive T cells in ML. In the present study, we investigated immunological factors that could explain the mechanisms behind it by comparing some immune regulatory mechanisms between ML and CL patients: frequency of cells expressing co-stimulatory molecules, apoptotic markers, T cell activation markers; and ability of neutralizing antibodies to IL-2, IL-12 and IL-15 do down-regulate IFN-gamma production in leishmania antigen-stimulated peripheral blood mononuclear cells (PBMC). Interestingly, in CL anti-IL-2 and anti-IL-15 significantly suppressed antigen-specific IFN-gamma production, while in ML only anti-IL-2 suppressed IFN-gamma production. Finally, higher frequency of CD4+ T cells expressing CD28-, CD69+ and CD62L(low) were observed in ML as compared to CL. These data indicate that an exacerbated type 1 response in ML is differentially regulated and not appropriately down modulated, with increased frequencies of activated effectors T cells, maintaining the persistent inflammatory response and tissue damage observed in ML.
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Affiliation(s)
- L P Carvalho
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador, Bahia, Brazil
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Machado PRL, Lessa H, Lessa M, Guimarães LH, Bang H, Ho JL, Carvalho EM. Oral Pentoxifylline Combined with Pentavalent Antimony: A Randomized Trial for Mucosal Leishmaniasis. Clin Infect Dis 2007; 44:788-93. [PMID: 17304449 DOI: 10.1086/511643] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Accepted: 11/13/2006] [Indexed: 11/03/2022] Open
Abstract
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).
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Affiliation(s)
- Paulo R L Machado
- Serviço de Imunologia, Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia, Salvador-Bahia, Brazil
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Carvalho LP, Passos S, Dutra WO, Soto M, Alonso C, Gollob KJ, Carvalho EM, Ribeiro de Jesus A. Effect of LACK and KMP11 on IFN-gamma Production by Peripheral Blood Mononuclear Cells from Cutaneous and Mucosal Leishmaniasis Patients. Scand J Immunol 2005; 61:337-42. [PMID: 15853916 DOI: 10.1111/j.1365-3083.2005.01581.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The immune modulatory properties of recombinant antigens Kinetoplasmid membrane protein-11 (KMP11) and Leishmania homologue of receptors for activated C kinase (LACK) in cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML) patients were evaluated. The mean levels of interferon-gamma (IFN-gamma) in soluble leishmania antigen (SLA) stimulated peripheral blood mononuclear cells (PBMC) of ML and CL patients were 5625 +/- 2333 pg/ml and 4422 +/- 3665 pg/ml, respectively. IFN-gamma was not detected in cultures stimulated with KMP11 or LACK. Interleukin-10 (IL-10) concentration in SLA, KMP11 and LACK-stimulated PBMC of ML patients was 13 +/- 12 pg/ml, 285 +/- 388 pg/ml and 802 +/- 483 pg/ml, respectively. Addition of KMP11 or LACK to SLA-stimulated PBMC of CL and ML patients enhanced IL-10 production (P < 0.05). Addition of KMP11 decreased IFN-gamma levels by 52% in CL patients and by 19% in ML patients. Addition of LACK to SLA-stimulated cultures decreased IFN-gamma levels by 58% in CL patients and by 30% in ML patients. Neutralization of IL-10 abrogated the downregulatory effect of LACK and KMP11. The modulatory properties of LACK and KMP11 are due to induction of IL-10 production and may be helpful for attenuating chronic inflammatory diseases. However, in some clinical conditions, as demonstrated for ML, these molecules are not able to suppress the IFN-gamma response, even inducing IL-10 production.
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MESH Headings
- Adolescent
- Adult
- Animals
- Antigens, Protozoan/immunology
- Antigens, Protozoan/pharmacology
- Child
- Down-Regulation/drug effects
- Down-Regulation/immunology
- Humans
- Hypersensitivity, Immediate/drug therapy
- Hypersensitivity, Immediate/immunology
- Immunophenotyping
- Interferon-gamma/biosynthesis
- Interferon-gamma/blood
- Interferon-gamma/immunology
- Interleukin-10/biosynthesis
- Interleukin-10/blood
- Interleukin-10/metabolism
- Leishmania braziliensis/immunology
- Leishmaniasis, Cutaneous/blood
- Leishmaniasis, Cutaneous/immunology
- Leishmaniasis, Cutaneous/parasitology
- Leishmaniasis, Visceral/blood
- Leishmaniasis, Visceral/immunology
- Leishmaniasis, Visceral/parasitology
- Leukocytes, Mononuclear/immunology
- Leukocytes, Mononuclear/parasitology
- Male
- Membrane Glycoproteins/immunology
- Membrane Glycoproteins/pharmacology
- Middle Aged
- Protozoan Proteins/immunology
- Protozoan Proteins/pharmacology
- Recombinant Proteins/immunology
- Recombinant Proteins/pharmacology
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Affiliation(s)
- L P Carvalho
- Serviço de Imunologia, Hospital Universitário Prof Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brazil
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Murray HW. Clinical and experimental advances in treatment of visceral leishmaniasis. Antimicrob Agents Chemother 2001; 45:2185-97. [PMID: 11451673 PMCID: PMC90630 DOI: 10.1128/aac.45.8.2185-2197.2001] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- H W Murray
- Department of Medicine, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Abstract
There is an urgent need for a safe, effective, easily administered and cheap treatment for cutaneous leishmaniasis. Unfortunately it remains elusive. There have been a number of contributions during the last year, but none will change present day management. The diagnosis of cutaneous leishmaniasis is established on the basis of a typical lesion, a history of exposure and demonstration of the parasite. Molecular methods, usually based on kinetoplast DNA, are being developed and used increasingly to diagnose and type the infecting organism. Pentavalent antimonials remain the mainstay of treatment.
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Affiliation(s)
- N C Hepburn
- Department of Dermatology, County Hospital, Lincoln, UK.
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