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Madu SJ, Wang K, Chirumamilla SK, Turner DB, Steel PG, Li M. Assessing Dose-Exposure-Response Relationships of Miltefosine in Adults and Children using Physiologically-Based Pharmacokinetic Modeling Approach. Pharm Res 2023; 40:2983-3000. [PMID: 37816929 PMCID: PMC10746618 DOI: 10.1007/s11095-023-03610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/18/2023] [Indexed: 10/12/2023]
Abstract
OBJECTIVES Miltefosine is the first and only oral medication to be successfully utilized as an antileishmanial agent. However, the drug is associated with differences in exposure patterns and cure rates among different population groups e.g. ethnicity and age (i.e., children v adults) in clinical trials. In this work, mechanistic population physiologically-based pharmacokinetic (PBPK) models have been developed to study the dose-exposure-response relationship of miltefosine in in silico clinical trials and evaluate the differences in population groups, particularly children and adults. METHODS The Simcyp population pharmacokinetics platform was employed to predict miltefosine exposure in plasma and peripheral blood mononuclear cells (PBMCs) in a virtual population under different dosing regimens. The cure rate of a simulation was based on the percentage of number of the individual virtual subjects with AUCd0-28 > 535 µg⋅day/mL in the virtual population. RESULTS It is shown that both adult and paediatric PBPK models of miltefosine can be developed to predict the PK data of the clinical trials accurately. There was no significant difference in the predicted dose-exposure-response of the miltefosine treatment for different simulated ethnicities under the same dose regime and the dose-selection strategies determined the clinical outcome of the miltefosine treatment. A lower cure rate of the miltefosine treatment in paediatrics was predicted because a lower exposure of miltefosine was simulated in virtual paediatric in comparison with adult virtual populations when they received the same dose of the treatment. CONCLUSIONS The mechanistic PBPK model suggested that the higher fraction of unbound miltefosine in plasma was responsible for a higher probability of failure in paediatrics because of the difference in the distribution of plasma proteins between adults and paediatrics. The developed PBPK models could be used to determine an optimal miltefosine dose regime in future clinical trials.
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Affiliation(s)
- Shadrack J Madu
- School of Pharmacy, De Montfort University, Leicester, LE1 9BH, UK
| | - Ke Wang
- School of Pharmacy, De Montfort University, Leicester, LE1 9BH, UK
| | | | - David B Turner
- Certara UK Limited, Simcyp Division, Sheffield, S1 2BJ, UK
| | - Patrick G Steel
- Department of Chemistry, Durham University, Durham, DH1 3LE, UK
| | - Mingzhong Li
- School of Pharmacy, De Montfort University, Leicester, LE1 9BH, UK.
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Miltefosine and Nifuratel Combination: A Promising Therapy for the Treatment of Leishmania donovani Visceral Leishmaniasis. Int J Mol Sci 2023; 24:ijms24021635. [PMID: 36675150 PMCID: PMC9865052 DOI: 10.3390/ijms24021635] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Visceral leishmaniasis is a neglected vector-borne tropical disease caused by Leishmania donovani and Leishmania infantum that is endemic not only in East African countries, but also in Asia, regions of South America and the Mediterranean Basin. For the pharmacological control of this disease, there is a limited number of old and, in general, poorly adherent drugs, with a multitude of adverse effects and low oral bioavailability, which favor the emergence of resistant pathogens. Pentavalent antimonials are the first-line drugs, but due to their misuse, resistant Leishmania strains have emerged worldwide. Although these drugs have saved many lives, it is recommended to reduce their use as much as possible and replace them with novel and more friendly drugs. From a commercial collection of anti-infective drugs, we have recently identified nifuratel-a nitrofurantoin used against vaginal infections-as a promising repurposing drug against a mouse model of visceral leishmaniasis. In the present work, we have tested combinations of miltefosine-the only oral drug currently used against leishmaniasis-with nifuratel in different proportions, both in axenic amastigotes from bone marrow and in intracellular amastigotes from infected Balb/c mouse spleen macrophages, finding a potent synergy in both cases. In vivo evaluation of oral miltefosine/nifuratel combinations using a bioimaging platform has revealed the potential of these combinations for the treatment of this disease.
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Cutaneous Leishmaniasis: A 2022 Updated Narrative Review into Diagnosis and Management Developments. Am J Clin Dermatol 2022; 23:823-840. [PMID: 36103050 PMCID: PMC9472198 DOI: 10.1007/s40257-022-00726-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2022] [Indexed: 01/10/2023]
Abstract
This review is an update of an earlier narrative review published in 2015 on developments in the clinical management of cutaneous leishmaniasis (CL) including diagnosis, treatment, prevention and control measurements. CL is a vector-borne infection caused by the protozoan parasite Leishmania. The vector is the female sandfly. Globally, CL affects 12 million cases and annually 2 million new cases occur. CL is endemic in almost 100 countries and the total risk population is approximately 350 million people. WHO lists CL an emerging and uncontrolled disease and a neglected tropical disease. Local experience-based evidence remains the mainstay for the management of CL. Whereas intralesional therapeutic options are the first treatment option for most CL patients, those with mucocutaneous and disseminated involvement require a systemic therapeutic approach. Moreover, different Leishmania species can vary in their treatment outcomes. Therefore, species determination is critical for optimal CL clinical management. New DNA techniques allow for relatively easy Leishmania species determination, yet they are not easily implemented in resource-limited settings. There is a desperate need for novel, less toxic, and less painful treatment options, especially for children with CL. Yet, the large and well conducted studies required to provide the necessary evidence are lacking. To further control and potentially eliminate CL, we urgently need to improve vector control, and diagnostics, and we require efficient and safe vaccines. Alas, since CL primarily affects poor people, biotechnical companies dedicate little investment into the research programs that could lead to diagnostic, pharmaceutical, and vaccine innovations.
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Non-Endemic Leishmaniases Reported Globally in Humans between 2000 and 2021—A Comprehensive Review. Pathogens 2022; 11:pathogens11080921. [PMID: 36015042 PMCID: PMC9415673 DOI: 10.3390/pathogens11080921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Leishmaniases are human and animal parasitic diseases transmitted by phlebotomine sand flies. Globalization is an important driver of the burden and in the current dynamics of these diseases. A systematic review of articles published between 2000 and 2021 was conducted using the PubMed search engine to identify the epidemiology and clinical management of imported human leishmaniases as a fundamental step to better manage individual cases and traveler and migrant health from a global perspective. A total of 275 articles were selected, representing 10,341 human imported cases. Identified drivers of changing patterns in epidemiology include conflict and war, as well as host factors, such as immunosuppression, natural and iatrogenic. Leishmania species diversity associated with different clinical presentations implies diagnostic and treatment strategies often complex to select and apply, especially in non-endemic settings. Thus, diagnostic and management algorithms for medical clinical decision support are proposed. Increased surveillance of non-endemic cases, whether in vulnerable populations such as refugees/migrants and immunocompromised individuals or travelers, could improve individual health and mitigate the public health risk of introducing Leishmania species into new areas.
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Treatment outcome of imported cutaneous leishmaniasis among travellers and migrants infected with Leishmania major and Leishmania tropica: a retrospective study in European centres 2013 to 2019. Int J Infect Dis 2022; 122:375-381. [PMID: 35728749 DOI: 10.1016/j.ijid.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Cutaneous leishmaniasis (CL) in Asia, Northern and Sub-Saharan Africa is mainly caused by Leishmania major and Leishmania tropica. We describe and evaluate the treatment outcome of CL among travellers and migrants in Europe. METHODS A retrospective study of parasitological confirmed CL cases caused by L. major and L. tropica during 2013-2019 in Europe. Data were collected from medical records and databases within the LeishMan network. RESULTS Out of 206 included cases of CL, seventy-five were identified as L. major and 131 as L. tropica. Eighty percent of the patients with L. tropica infection were migrants, whereas 53 % of patients with L. major infection had been visiting friends and relatives. Among patients with L. tropica, 48 %, were younger than 15. Pentavalent antimony cured 73 % (L. major) and 78 % (L. tropica). Intralesional administration had a cure rate, 86 % and systemic, 67%, on L. tropica. Liposomal amphotericin B had a cure rate of 44-63 %. CONCLUSION L. major infections were mostly found in individuals visiting friends and relatives, whereas L. tropica were mainly identified in migrants. No patients with L. major relapsed. Pentavalent antimony, liposomal amphotericin B and cryotherapy had cure rates in accordance with previous studies.
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Ubals M, Bosch-Nicolau P, Sánchez-Montalvá A, Salvador F, Aparicio-Español G, Sulleiro E, Silgado A, Soriano-Arandes A, Espiau M, Ferrer B, Pou D, Treviño B, Molina I, García-Patos V. Treatment of Complex Cutaneous Leishmaniasis with Liposomal Amphotericin B. Pathogens 2021; 10:1253. [PMID: 34684202 PMCID: PMC8537943 DOI: 10.3390/pathogens10101253] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 09/10/2021] [Accepted: 09/25/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There is no consensus for the best treatment of complex cutaneous leishmaniasis (CL). We aimed to describe a cohort of CL, focusing on liposomal amphotericin B (L-AmB) treatment outcome. METHODS We performed a retrospective study in Vall d'Hebron University Hospital (Barcelona, Spain). All patients with parasitologically proven CL diagnosed from 2012 to 2018 were included. RESULTS The analysis included 41 patients with CL. The median age was 39 years (IQR 12- 66); 12 (29%) were children, and 29 (71%) were men. Regarding treatment, 24 (59%) received local treatment, whereas 17 (41%) had complex CL and were offered intravenous systemic treatment. Sixteen patients received L-AmB; eight (50%) had adverse events, and three (19%) discontinued treatment for safety reasons. All cases were considered cured within the first year post-treatment. CONCLUSIONS L-AmB for complex CL showed no treatment failures, offering an alternative treatment option for patients with complex CL. Clinicians should pay close attention to the potential adverse events of L-AmB and adopt an active drug safety surveillance scheme to rapidly detect reversible side effects.
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Affiliation(s)
- Maria Ubals
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (M.U.); (G.A.-E.); (V.G.-P.)
- Doctoral Programme in Medicine and Translational Research: International Health Track, Facultat de Medicina, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Pau Bosch-Nicolau
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.B.-N.); (F.S.); (I.M.)
| | - Adrián Sánchez-Montalvá
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.B.-N.); (F.S.); (I.M.)
| | - Fernando Salvador
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.B.-N.); (F.S.); (I.M.)
| | - Gloria Aparicio-Español
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (M.U.); (G.A.-E.); (V.G.-P.)
- Facultat de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Elena Sulleiro
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (E.S.); (A.S.)
| | - Aroa Silgado
- Department of Clinical Microbiology, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (E.S.); (A.S.)
| | - Antoni Soriano-Arandes
- Department of Paediatrics, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (A.S.-A.); (M.E.)
| | - Maria Espiau
- Department of Paediatrics, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (A.S.-A.); (M.E.)
| | - Berta Ferrer
- Department of Pathology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain;
| | - Diana Pou
- Tropical Medicine and International Health Unit, Drassanes-Vall d’Hebron, PROSICS Barcelona, 08035 Barcelona, Spain; (D.P.); (B.T.)
| | - Begoña Treviño
- Tropical Medicine and International Health Unit, Drassanes-Vall d’Hebron, PROSICS Barcelona, 08035 Barcelona, Spain; (D.P.); (B.T.)
| | - Israel Molina
- Department of Infectious Diseases, Hospital Universitari Vall d’Hebron, PROSICS Barcelona, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (P.B.-N.); (F.S.); (I.M.)
| | - Vicente García-Patos
- Department of Dermatology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (M.U.); (G.A.-E.); (V.G.-P.)
- Facultat de Medicina, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
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Spinicci M, Zammarchi L, Gramiccia M, Di Muccio T, Bartolozzi D, Corsi P, Trotta M, Bartoloni A. Effective meglumine antimoniate intralesional therapy for Chiclero's ulcer refractory to systemic liposomal amphotericin B. J Travel Med 2021; 28:5904797. [PMID: 32918547 DOI: 10.1093/jtm/taaa169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Michele Spinicci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Lorenzo Zammarchi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Marina Gramiccia
- Unit of Vector-Borne Diseases, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Trentina Di Muccio
- Unit of Vector-Borne Diseases, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Dario Bartolozzi
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Paola Corsi
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Michele Trotta
- Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Infectious and Tropical Diseases Unit, Careggi University Hospital, Florence, Italy
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Kämink S, Masih B, Ali N, Ullah A, Khan SJ, Ashraf S, Pylypenko T, Grobusch MP, Fernhout J, den Boer M, Ritmeijer K. Effectiveness of miltefosine in cutaneous leishmaniasis caused by Leishmania tropica in Pakistan after antimonial treatment failure or contraindications to first line therapy-A retrospective analysis. PLoS Negl Trop Dis 2021; 15:e0008988. [PMID: 33507944 PMCID: PMC7872246 DOI: 10.1371/journal.pntd.0008988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/09/2021] [Accepted: 11/17/2020] [Indexed: 12/15/2022] Open
Abstract
Background Cutaneous leishmaniasis (CL) is a neglected tropical skin disease, caused by Leishmania protozoa. In Pakistan, where CL caused by L. tropica is highly endemic, therapy with pentavalent antimonials is the standard of care, but has significant toxicity when used in systemic therapy, while are no evidence-based safer alternative treatment options for L. tropica. The efficacy of oral miltefosine has not been studied in CL caused by L. tropica. We evaluated effectiveness and tolerability of miltefosine in patients with previous treatment failure or with contraindications to systemic antimonial treatment. Methods A retrospective review was conducted of a cohort of CL patients who were treated with a 28-day course of miltefosine between December 2017 and August 2019, in urban Quetta, Pakistan, an area endemic for L. tropica. Descriptive analyses were performed, and effectiveness was assessed by initial response after treatment, and final cure at routine follow up visits, six weeks to three months post-treatment. Tolerability was assessed by routinely reported adverse events. Results Of the 76 CL patients in the cohort, 42 (55%) had contraindications to systemic antimonial treatment, and 34 (45%) had failure or relapse after antimonial treatment. Twelve patients defaulted during treatment and 12 patients were lost to follow up. In the remaining 52 patients, final cure rate was 77% (40/52). In those with contraindications to systemic antimonial treatment the final cure rate was 83% (24/29) and in the failure and relapse group 70% (16/23). Twenty-eight patients (40.0%) reported 39 mild to moderate adverse events with the main complaints being nausea (41.0%), general malaise (25.6%), and stomach pain (12.8%). Conclusion Results indicate that miltefosine is an effective second line treatment in CL in areas endemic for L. tropica. Prospective studies with systematic follow up are needed to obtain definitive evidence of effectiveness and tolerability, including identification of risk factors for miltefosine treatment failure. Cutaneous Leishmaniasis (CL) is a neglected tropical skin disease, which globally affects an estimated 0.6 to 1 million people. The skin disease is caused by the protozoa Leishmania and is transmitted by phlebotomine sandflies in Old World CL (OWCL). In Pakistan, CL is highly endemic, especially in the provinces Balochistan and Khyber Pashtunkwa, where L. tropica is the main causative species. In this context, untreated CL often leads to stigmatisation and severe (psycho)social suffering, due to the disfiguring ulcerating wounds and scars. The mainstay treatment is with pentavalent antimonials, and evidence for efficacy of alternative treatments for L. tropica is lacking. Médecins sans Frontières (MSF) has specialised treatment centres in Balochistan (Quetta and Kuchlak), where in December 2017 miltefosine was introduced for patients who did not respond to, or had contraindications for antimonials. In this study, we showed favourable outcomes of miltefosine as second-line treatment for these CL patients.
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Affiliation(s)
- Suzette Kämink
- Médecins Sans Frontières, Quetta, Pakistan
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Amsterdam Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | | | - Noor Ali
- Médecins Sans Frontières, Quetta, Pakistan
| | - Aman Ullah
- Médecins Sans Frontières, Quetta, Pakistan
| | | | - Shakil Ashraf
- Mohtarma Shaheed Benazir Bhutto General Hospital,Quetta, Pakistan
| | | | - Martin P. Grobusch
- Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Amsterdam Infection and Immunity, University of Amsterdam, Amsterdam, The Netherlands
| | - Jena Fernhout
- Médecins Sans Frontières, Amsterdam, the Netherlands
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Lindner AK, Richter J, Gertler M, Nikolaus M, Equihua Martinez G, Müller K, Harms G. Cutaneous leishmaniasis in refugees from Syria: complex cases in Berlin 2015-2020. J Travel Med 2020; 27:5905945. [PMID: 33057714 DOI: 10.1093/jtm/taaa161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/03/2020] [Accepted: 09/06/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Syrian conflict has led to a dramatic increase of Old World cutaneous leishmaniasis (CL), triggered by continuous population displacements, disrupted control programmes, poor shelter and sanitation. METHODS A retrospective patient record study was conducted at the Institute of Tropical Medicine and International Health in Berlin. Records of all refugees from Syria treated for CL between January 2015 and March 2020 were reviewed. RESULTS Twenty refugees from Syria were treated. Seventeen refugees (85%) had complex lesions, mainly due to previous therapy failure or localization on the face. A long disease duration (50% > 1 year), pronounced facial scarring (20%), recurrences (20%), or worsening of existing lesions (20%) were observed. Nine patients (45%) had been pretreated in Syria. Complete remission was achieved in 10 of 16 patients (63%) treated with perilesional antimony. Eight patients (40%) required systemic treatment, thereof four (20%) repeated systemic treatment. Eight patients (40%) reported a delay of therapy ≥3 months in Germany, thereof one patient with a delay of 12 months and one patient with a delay of 32 months. CONCLUSION Between 2015 and 2020, Syrian refugees presented with severe morbidities of CL frequently requiring systemic and even consecutive systemic treatments. We assume a combination of socioeconomic and environmental factors associated with the ongoing Syrian conflict and migration to be responsible for the complex clinical presentations in this case series. More attention should be drawn to the situation of Syrian refugees with CL in countries where they are displaced to.
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Affiliation(s)
- Andreas K Lindner
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Joachim Richter
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Maximilian Gertler
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Marc Nikolaus
- Department of Paediatrics, Division of Pneumology, Immunology and Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Gabriela Equihua Martinez
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Kirsten Müller
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Gundel Harms
- Institute of Tropical Medicine and International Health, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353 Berlin, Germany
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10
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Misra P, Singh S. Site specific microbiome of Leishmania parasite and its cross-talk with immune milieu. Immunol Lett 2019; 216:79-88. [PMID: 31678358 DOI: 10.1016/j.imlet.2019.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 12/12/2022]
Abstract
Microbiota consists of commensal, symbiotic and pathogenic microorganisms found in all multicellular organisms. These micro-organisms are found in or on many parts of the body, including the intestinal tract, skin, mouth, and the reproductive tract. This review focuses on interplay of site specific microbiota, vector microbiota along with immune response and severity of Leishmaniasis. Herein, we have reviewed and summarized the counter effect of microbiome post infection with the Leishmania parasite. We have studied skin microbiome along with the gut microbiome of sand-fly which is the vector for transmission of this disease. Our major focus was to understand the skin and gut microbiome during Leishmania infection,their interaction and effect on immunological responses generated during the infection.Moreover, systems biology approach is envisioned to enumerate bacterial species in skin microbiota and Phlebotmus gut microbiota during Leishmania infection.
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Affiliation(s)
- Pragya Misra
- National Centre for Cell Science, NCCS Complex, Ganeshkhind, SP Pune University Campus, Pune 411007, India
| | - Shailza Singh
- National Centre for Cell Science, NCCS Complex, Ganeshkhind, SP Pune University Campus, Pune 411007, India.
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11
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Route map for the discovery and pre-clinical development of new drugs and treatments for cutaneous leishmaniasis. INTERNATIONAL JOURNAL FOR PARASITOLOGY-DRUGS AND DRUG RESISTANCE 2019; 11:106-117. [PMID: 31320296 PMCID: PMC6904839 DOI: 10.1016/j.ijpddr.2019.06.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 12/11/2022]
Abstract
Although there have been significant advances in the treatment of visceral leishmaniasis (VL) and several novel compounds are currently in pre-clinical and clinical development for this manifestation of leishmaniasis, there have been limited advances in drug research and development (R & D) for cutaneous leishmaniasis (CL). Here we review the need for new treatments for CL, describe in vitro and in vivo assays, models and approaches taken over the past decade to establish a pathway for the discovery, and pre-clinical development of new drugs for CL. These recent advances include novel mouse models of infection using bioluminescent Leishmania, the introduction of PK/PD approaches to skin infection, and defined pre-clinical candidate profiles.
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Eissa MM, Amer EI, Mossallam SF, Gomaa MM, Baddour NM. Miltefosine for Old World cutaneous leishmaniasis: An experimental study on Leishmania major infected mice. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Maha M. Eissa
- Department of Medical Parasitology, Faculty of Medicine , Alexandria University, Alexandria, Egypt
| | - Eglal I. Amer
- Department of Medical Parasitology, Faculty of Medicine , Alexandria University, Alexandria, Egypt
| | - Shereen F. Mossallam
- Department of Medical Parasitology, Faculty of Medicine , Alexandria University, Alexandria, Egypt
| | - Maha M. Gomaa
- Department of Medical Parasitology, Faculty of Medicine , Alexandria University, Alexandria, Egypt
| | - Nahed M. Baddour
- Department of Pathology, Faculty of Medicine , Alexandria University, Alexandria, Egypt
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13
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Iranpour S, Hosseinzadeh A, Alipour A. Efficacy of miltefosine compared with glucantime for the treatment of cutaneous leishmaniasis: a systematic review and meta-analysis. Epidemiol Health 2019; 41:e2019011. [PMID: 30999735 PMCID: PMC6635659 DOI: 10.4178/epih.e2019011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/31/2019] [Indexed: 11/09/2022] Open
Abstract
Cutaneous leishmaniasis (CL) is most common form of leishmaniasis and is characterized by ulcerative skin lesions. The objective of this study was to conduct a systematic review and meta-analysis of clinical trials that compared the efficacy of miltefosine and glucantime for the treatment of CL. We searched the following databases: Cochrane, PubMed, Embase, Scopus, Web of Science, ProQuest, Cochrane Central Register of Controlled Trials, International Clinical Trials Registry Platform search portal of World Health Organization, Sid, Irandoc, Magiran, and clinicaltrials.gov. We used keywords including “miltefosine,” “glucantime,” and “Leishmania.” The quality of studies was assessed using the Cochrane risk of bias tool. A random-effects model was employed for the analysis. We assessed heterogeneity by the chi-square test and the I2 index statistic. When heterogeneity was present, meta-regression analyses were performed. The Egger method was used to assess publication bias; when it was significant, the trim-and-fill method was used to test and adjust for publication bias. A total of 1,570 reports were identified, of which 10 studies were included in the meta-analysis. In the meta-analysis, there was no significant difference between the efficacy of miltefosine and glucantime; however, subgroup analysis showed that, regarding parasite species other than Leishmania braziliensis, miltefosine was significantly superior to glucantime (intention to treat; relative risk, 1.15; 95% confidence interval, 1.01 to 1.32). In the meta-regression, only the glucantime injection type was significant at the p=0.1 level. The Egger test found statistically significant publication bias; however, including the 3 missing studies in the trim-and-fill analysis did not change the results. This meta-analysis found that miltefosine seems to be more effective than glucantime, at least in species other than L. braziliensis, for treating CL.
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Affiliation(s)
- Sohrab Iranpour
- Student Research Committee, Department of Epidemiology, Faculty of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Community Medicine, Faculty of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Ali Hosseinzadeh
- Research Center for Modeling in Health, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Abbas Alipour
- Department of Community Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Mazandaran, Iran
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Pijpers J, den Boer ML, Essink DR, Ritmeijer K. The safety and efficacy of miltefosine in the long-term treatment of post-kala-azar dermal leishmaniasis in South Asia - A review and meta-analysis. PLoS Negl Trop Dis 2019; 13:e0007173. [PMID: 30742620 PMCID: PMC6386412 DOI: 10.1371/journal.pntd.0007173] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/22/2019] [Accepted: 01/20/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Miltefosine (MF) is the only oral drug available for treatment of visceral leishmaniasis (VL) and post-kala-azar dermal leishmaniasis (PKDL). Although the drug is effective and well tolerated in treatment of VL, the efficacy and safety of MF for longer treatment durations (>28 days) in PKDL remains unclear. This study provides an overview of the current knowledge about safety and efficacy of long treatment courses with MF in PKDL, as a strategy in the VL elimination in South Asia. METHODOLOGY/PRINCIPAL FINDINGS Literature was searched systematically for articles investigating MF treatment in PKDL. A meta-analysis included eight studies (total 324 PKDL patients) to estimate the efficacy of MF in longer treatment regimens (range 6-16 weeks). We found a per-protocol (PP) initial cure rate of 95.2% (95%CI 89.6-100.8) and a PP definite cure rate of 90% (95%CI 81.6-96.3). Descriptive analysis showed that 20% of patients experienced adverse events, which mostly had an onset in the first week of treatment and were likely to get more severe after four weeks of treatment. Gastrointestinal (GI) side effects such as vomiting, nausea, diarrhoea, and abdominal pain were most common. CONCLUSIONS/SIGNIFICANCE Longer treatment regimens with MF are effective in PKDL patients in India, however with the caveat that the efficacy has recently been observed to decline. GI side effects are frequent, although mostly mild or moderate. However, on the basis of limited data, we cannot conclude that longer MF treatment regimens are safe. Moreover, VL and PKDL pharmacovigilance studies indicate a risk for serious adverse events, questioning the safety of MF. The provision of safer treatment regimens for PKDL patients are therefore recommended. Until these regimens are identified, it should be considered to halt the use of MF monotherapy for PKDL in order to preserve the drug's efficacy.
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Affiliation(s)
- Joyce Pijpers
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | | | - Dirk R. Essink
- Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Koert Ritmeijer
- Public Health Department, Médecins Sans Frontières, Amsterdam, The Netherlands
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15
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Ganjaei KG, Lawton K, Gaur S. Cutaneous Leishmaniasis in an American Adolescent Returning From Israel. J Pediatric Infect Dis Soc 2018; 7:e178-e181. [PMID: 29878238 DOI: 10.1093/jpids/piy045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 04/28/2018] [Indexed: 11/12/2022]
Abstract
We present here the case of a healthy 16-year-old American girl who returned from an organized trip to Israel with cutaneous leishmaniasis caused by Leishmania major; the infection was treated successfully with paromomycin-gentamicin ointment. She was initially misdiagnosed with staphylococcal and pseudomonal cellulitis. Although cutaneous leishmaniasis is seen only rarely in the United States, it should be considered when diagnosing new skin lesions after travel to affected countries.
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Affiliation(s)
- Kimia G Ganjaei
- Rutgers-Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - Kira Lawton
- Rutgers-Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Sunanda Gaur
- Robert Wood Johnson AIDS Program, Pediatric Infectious Diseases, Bristol-Myers Squibb Children's Hospital at Robert Wood Johnson University Hospital, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
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16
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Patel TA, Scadding GK, Phillips DE, Lockwood DN. Case Report: Old World Mucosal Leishmaniasis: Report of Five Imported Cases to the Hospital for Tropical Diseases, London, United Kingdom. Am J Trop Med Hyg 2017; 97:1116-1119. [PMID: 29031288 PMCID: PMC5637608 DOI: 10.4269/ajtmh.17-0162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/10/2017] [Indexed: 11/07/2022] Open
Abstract
Old World species of Leishmania typically cause visceral and cutaneous leishmaniasis. Mucosal involvement is typically seen with infection by Leishmania species found in South America, usually after the healing of cutaneous leishmaniasis. We present five imported cases of mucosal leishmaniasis caused by Old World Mediterranean Leishmania infantum exclusively affecting the nasal mucosa or vocal cord. In only one case was there a recollection of a preceding cutaneous lesion compatible with cutaneous Leishmaniasis. Of significance was that four out of five cases were receiving local corticosteroids for chronic lung disorders and four were systemically immunosuppressed. This report highlights the importance of considering mucosal leishmaniasis in the differential diagnosis in those presenting with upper respiratory tract mucosal lesions with a relevant travel history to the Mediterranean and in whom malignancy has been excluded.
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Affiliation(s)
- Trupti A. Patel
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Glenis K. Scadding
- Royal National Throat, Nose and Ear Hospital, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - David E. Phillips
- Department of Ear, Nose and Throat Surgery, Warwick Hospital, Warwick, United Kingdom
| | - Diana N. Lockwood
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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17
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Aronson N, Herwaldt BL, Libman M, Pearson R, Lopez-Velez R, Weina P, Carvalho EM, Ephros M, Jeronimo S, Magill A. Diagnosis and Treatment of Leishmaniasis: Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH). Clin Infect Dis 2016; 63:e202-e264. [PMID: 27941151 DOI: 10.1093/cid/ciw670] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 09/22/2016] [Indexed: 12/25/2022] Open
Abstract
It is important to realize that leishmaniasis guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The IDSA and ASTMH consider adherence to these guidelines to be voluntary, with the ultimate determinations regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
- Naomi Aronson
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Michael Libman
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Peter Weina
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | - Selma Jeronimo
- Federal University of Rio Grande do Norte, Natal, Brazil
| | - Alan Magill
- Bill and Melinda Gates Foundation, Seattle, Washington
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18
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Mosimann V, Blazek C, Grob H, Chaney M, Neumayr A, Blum J. Miltefosine for Mucosal and Complicated Cutaneous Old World Leishmaniasis: A Case Series and Review of the Literature. Open Forum Infect Dis 2016; 3:ofw008. [PMID: 27042675 PMCID: PMC4810230 DOI: 10.1093/ofid/ofw008] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/19/2016] [Indexed: 02/03/2023] Open
Abstract
Complicated Old World cutaneous leishmaniasis (OWCL) and Old World mucosal leishmaniasis (OWML) constitute an indication for systemic treatment. To date, there no controlled clinical studies that compare treatment options for these diseases. We compiled a case series of 24 cases successfully treated with miltefosine. We conclude that oral miltefosine is an effective treatment option for both OWCL and OWML.
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Affiliation(s)
- Vincent Mosimann
- Swiss Tropical and Public Health Institute, Basel; University of Basel; Department of Medicine, University Hospital Basel
| | | | - Heini Grob
- Praxis Reinacherhof , Reinach , Switzerland
| | | | - Andreas Neumayr
- Swiss Tropical and Public Health Institute, Basel; University of Basel
| | - Johannes Blum
- Swiss Tropical and Public Health Institute, Basel; University of Basel
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19
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Cutaneous leishmaniasis in travellers: a focus on epidemiology and treatment in 2015. Curr Infect Dis Rep 2015; 17:489. [PMID: 26031962 DOI: 10.1007/s11908-015-0489-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Imported cutaneous leishmaniasis (CL) is a growing problem with increasing global travel to endemic areas. Returned travellers seeking care encounter significant barriers to treatment, including diagnostic delays and difficult access to anti-leishmanial drugs. Treatment recommendations in non-endemic settings are a moving target, reflecting recent developments in Leishmania diagnostics and therapeutics. Accumulating experience with molecular-based species identification has enabled species-directed therapy. Clinicians are reevaluating more toxic traditional regimens in light of newly approved therapeutic agents and emerging data on local cutaneous treatments. Referral centers are implementing treatment decision algorithms designed to maximize efficacy while minimizing adverse events. Although management strategies continue to evolve, treatment of CL in non-endemic settings remains controversial. Persistent reliance on expert opinion reflects lack of research focused on travellers and limited randomized controlled trial evidence. We herein review the current epidemiology of cutaneous leishmaniasis in travellers and species-specific evidence for available therapies.
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20
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de Vries HJC, Reedijk SH, Schallig HDFH. Cutaneous leishmaniasis: recent developments in diagnosis and management. Am J Clin Dermatol 2015; 16:99-109. [PMID: 25687688 PMCID: PMC4363483 DOI: 10.1007/s40257-015-0114-z] [Citation(s) in RCA: 234] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This review focuses on recent developments in the diagnosis, treatment, management, and strategies for the prevention and control of cutaneous leishmaniasis (CL) caused by both Old and New World Leishmania species. CL is caused by the vector-borne protozoan parasite Leishmania and is transmitted via infected female sandflies. The disease is endemic in more than 98 countries and an estimated 350 million people are at risk. The overall prevalence is 12 million cases and the annual incidence is 2–2.5 million. The World Health Organization considers CL a severely neglected disease and a category 1 emerging and uncontrolled disease. The management of CL differs from region to region and is primarily based on local experience-based evidence. Most CL patients can be treated with topical treatments, but some Leishmania species can cause mucocutaneous involvement requiring a systemic therapeutic approach. Moreover, Leishmania species can vary in their sensitivity to available therapeutic options. This makes species determination critical for the choice of treatment and the clinical outcome of CL. Identification of the infecting parasite used to be laborious, but now the Leishmania species can be identified relatively easy with new DNA techniques that enable a more rational therapy choice. Current treatment guidelines for CL are based on poorly designed and reported trials. There is a lack of evidence for potentially beneficial treatments, a desperate need for large well-conducted studies, and standardization of future trials. Moreover, intensified research programs to improve vector control, diagnostics, and the therapeutic arsenal to contain further incidence and morbidity are needed.
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Affiliation(s)
- Henry J C de Vries
- Department of Dermatology, Academic Medical Center (AMC), University of Amsterdam, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands,
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21
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Monge-Maillo B, López-Vélez R. Miltefosine for visceral and cutaneous leishmaniasis: drug characteristics and evidence-based treatment recommendations. Clin Infect Dis 2015; 60:1398-404. [PMID: 25601455 DOI: 10.1093/cid/civ004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/23/2014] [Indexed: 12/25/2022] Open
Abstract
Miltefosine is the only recognized oral agent with potential to treat leishmaniasis. Miltefosine had demonstrated very good cure rates for visceral leishmaniasis (VL) in India, Nepal, and Bangladesh, but high rates of clinical failures have been recently reported. Moderate efficacy has been observed for VL in East Africa, whereas data from Mediterranean countries and Latin America are scarce. Results have not been very promising for patients coinfected with VL and human immunodeficiency virus. However, miltefosine's long half-life and its oral administration could make it a good option for maintenance prophylaxis. Good evidence of efficacy has been documented in Old World cutaneous leishmaniasis (CL), and different cure rates among New World CL have been obtained depending on the geographical areas and species involved. Appropriate regimens for New World mucocutaneous leishmaniasis need to be established, although longer treatment duration seems to confer better results. Strategies to prevent the development and spread of miltefosine resistance are urgently needed.
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Affiliation(s)
- Begoña Monge-Maillo
- Tropical Medicine Centre, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain
| | - Rogelio López-Vélez
- Tropical Medicine Centre, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain
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22
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[Cutaneous leishmaniasis. Diagnosis and therapy in northern Afghanistan]. DER HAUTARZT 2014; 65:125-9. [PMID: 24337239 DOI: 10.1007/s00105-013-2725-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The German S1 guidelines from 2009 contain a variety of recommendations for the treatment of cutaneous leishmaniasis. PATIENTS AND METHODS We report the results of our diagnostic procedures and treatment of 32 international patients in autumn 2010 in northern Afghanistan. RESULTS Giemsa stain confirmed the clinical diagnosis within 24 hours. Eleven simple lesions and one larger ulcer responded well to cryotherapy and intralesional sodium stibogluconate. More complex lesions in 19 patients responded well to oral miltefosine. One patient refused outpatient therapy. CONCLUSIONS Cryotherapy and intralesional antimony compounds showed good results in early lesions of cutaneous leishmaniasis in northern Afghanistan. Outpatient treatment of complex lesions with miltefosine was successful in all cases.
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Sodji Q, Patil V, Jain S, Kornacki JR, Mrksich M, Tekwani BL, Oyelere AK. The antileishmanial activity of isoforms 6- and 8-selective histone deacetylase inhibitors. Bioorg Med Chem Lett 2014; 24:4826-30. [PMID: 25240614 PMCID: PMC4225773 DOI: 10.1016/j.bmcl.2014.08.060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/27/2014] [Indexed: 11/23/2022]
Abstract
Histone deacetylase inhibitors (HDACi) pleiotropy is largely due to their nonselective inhibition of various cellular HDAC isoforms. Connecting inhibition of a specific isoform to biological responses and/or phenotypes is essential toward deconvoluting HDACi pleiotropy. The contribution of classes I and II HDACs to the antileishmanial activity of HDACi was investigated using the amastigote and promastigote forms of Leishmania donovani. We observed that the antileishmanial activities of HDACi are largely due to the inhibition of HDAC6-like activity. This observation could facilitate the development of HDACi as antileishmanial agents.
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Affiliation(s)
- Quaovi Sodji
- School of Chemistry and Biochemistry, Parker H. Petit for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA 30332-0400, USA
| | - Vishal Patil
- School of Chemistry and Biochemistry, Parker H. Petit for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA 30332-0400, USA
| | - Surendra Jain
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA
| | - James R Kornacki
- Department of Chemistry and Biomedical Engineering, Northwestern University, 2145 Sheridan Rd, Evanston, IL 60208-3113, USA
| | - Milan Mrksich
- Department of Chemistry and Biomedical Engineering, Northwestern University, 2145 Sheridan Rd, Evanston, IL 60208-3113, USA
| | - Babu L Tekwani
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS 38677-1848, USA.
| | - Adegboyega K Oyelere
- School of Chemistry and Biochemistry, Parker H. Petit for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA 30332-0400, USA.
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Species-directed therapy for leishmaniasis in returning travellers: a comprehensive guide. PLoS Negl Trop Dis 2014; 8:e2832. [PMID: 24787001 PMCID: PMC4006727 DOI: 10.1371/journal.pntd.0002832] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/14/2014] [Indexed: 02/06/2023] Open
Abstract
Background Leishmaniasis is increasingly reported among travellers. Leishmania species vary in sensitivity to available therapies. Fast and reliable molecular techniques have made species-directed treatment feasible. Many treatment trials have been designed poorly, thus developing evidence-based guidelines for species-directed treatment is difficult. Published guidelines on leishmaniasis in travellers do not aim to be comprehensive or do not quantify overall treatment success for available therapies. We aimed at providing comprehensive species-directed treatment guidelines. Methodology/Principal Findings English literature was searched using PubMed. Trials and observational studies were included if all cases were parasitologically confirmed, the Leishmania species was known, clear clinical end-points and time points for evaluation of treatment success were defined, duration of follow-up was adequate and loss to follow-up was acceptable. The proportion of successful treatment responses was pooled using mixed effects methods to estimate the efficacy of specific therapies. Final ranking of treatment options was done by an expert panel based on pooled efficacy estimates and practical considerations. 168 studies were included, with 287 treatment arms. Based on Leishmania species, symptoms and geography, 25 clinical categories were defined and therapy options ranked. In 12/25 categories, proposed treatment agreed with highest efficacy data from literature. For 5/25 categories no literature was found, and in 8/25 categories treatment advise differed from literature evidence. For uncomplicated cutaneous leishmaniasis, combination of intralesional antimony with cryotherapy is advised, except for L. guyanensis and L. braziliensis infections, for which systemic treatment is preferred. Treatment of complicated (muco)cutaneous leishmaniasis differs per species. For visceral leishmaniasis, liposomal amphotericin B is treatment of choice. Conclusions/Significance Our study highlights current knowledge about species-directed therapy of leishmaniasis in returning travellers and also demonstrates lack of evidence for treatment of several clinical categories. New data can easily be incorporated in the presented overview. Updates will be of use for clinical decision making and for defining further research. Human leishmaniasis is caused by unicellular parasites that are injected into the skin by sand-flies, small, flying insects. Many different Leishmania species cause various manifestations of disease, both of the skin and internal organs. Leishmaniasis is a curable disease but clear guidelines on the best available treatment are lacking. Leishmania species differ in sensitivity to available drugs. Until recently, identification of the infecting Leishmania parasite was laborious, thus therapy could not precisely be targeted to the infecting species, in contrast to many other infectious diseases. Nowadays, Leishmania parasites can be identified relatively easily with new DNA techniques. We studied efficacy of therapies for diseases due to different Leishmania species, limited to the English literature. Efficacy was summarized and presented in an easy to read format. Because of difficulties with identification of parasite species in earlier studies, quality of evidence was often limited. Our findings are a major help for clinicians to easily find optimal treatment for specific patients. Moreover, our results demonstrate where additional research is needed to further improve treatment of leishmaniasis.
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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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Moriarty P, Burke C, McCrossin D, Campbell R, Cherian S, Shahab MS, Visvesvara GS, Nourse C. Balamuthia mandrillaris Encephalitis: Survival of a Child With Severe Meningoencephalitis and Review of the Literature. J Pediatric Infect Dis Soc 2014; 3:e4-9. [PMID: 26624913 DOI: 10.1093/jpids/pit033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/21/2013] [Indexed: 12/23/2022]
Abstract
Balamuthia mandrillaris causes granulomatous amoebic encephalitis, which is frequently fatal. There are few reports of survival in children. A 4-year-old child developed severe meningoencephalitis with multiple intracranial ring-enhancing lesions. Empiric therapy was commenced after a biopsy was performed, and the patient had a good clinical response. Molecular testing and indirect immunofluorescence later confirmed the diagnosis of Balamuthia encephalitis. Diagnosis of Balamuthia encephalitis is often delayed. The literature is reviewed with particular reference to reported survival. Prompt tissue diagnosis and initiation of therapy are common features among survivors. In previous reports, miltefosine was not used to treat children, but it was well tolerated in this case and should be considered as a therapeutic option.
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Affiliation(s)
| | | | | | | | - Sarah Cherian
- Department of Sullivan and Nicolaides Pathology, and
| | | | - Govinda S Visvesvara
- Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Clare Nourse
- Department of Paediatrics University of Queensland, Brisbane, Australia
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Jebran AF, Schleicher U, Steiner R, Wentker P, Mahfuz F, Stahl HC, Amin FM, Bogdan C, Stahl KW. Rapid healing of cutaneous leishmaniasis by high-frequency electrocauterization and hydrogel wound care with or without DAC N-055: a randomized controlled phase IIa trial in Kabul. PLoS Negl Trop Dis 2014; 8:e2694. [PMID: 24551257 PMCID: PMC3923720 DOI: 10.1371/journal.pntd.0002694] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 12/29/2013] [Indexed: 12/30/2022] Open
Abstract
Background Anthroponotic cutaneous leishmaniasis (CL) due to Leishmania (L.) tropica infection is a chronic, frequently disfiguring skin disease with limited therapeutic options. In endemic countries healing of ulcerative lesions is often delayed by bacterial and/or fungal infections. Here, we studied a novel therapeutic concept to prevent superinfections, accelerate wound closure, and improve the cosmetic outcome of ACL. Methodology/Principal Findings From 2004 to 2008 we performed a two-armed, randomized, double-blinded, phase IIa trial in Kabul, Afghanistan, with patients suffering from L. tropica CL. The skin lesions were treated with bipolar high-frequency electrocauterization (EC) followed by daily moist-wound-treatment (MWT) with polyacrylate hydrogel with (group I) or without (group II) pharmaceutical sodium chlorite (DAC N-055). Patients below age 5, with facial lesions, pregnancy, or serious comorbidities were excluded. The primary, photodocumented outcome was the time needed for complete lesion epithelialization. Biopsies for parasitological and (immuno)histopathological analyses were taken prior to EC (1st), after wound closure (2nd) and after 6 months (3rd). The mean duration for complete wound closure was short and indifferent in group I (59 patients, 43.1 d) and II (54 patients, 42 d; p = 0.83). In patients with Leishmania-positive 2nd biopsies DAC N-055 caused a more rapid wound epithelialization (37.2 d vs. 58.3 d; p = 0.08). Superinfections occurred in both groups at the same rate (8.8%). Except for one patient, reulcerations (10.2% in group I, 18.5% in group II; p = 0.158) were confined to cases with persistent high parasite loads after healing. In vitro, DAC N-055 showed a leishmanicidal effect on pro- and amastigotes. Conclusions/Significance Compared to previous results with intralesional antimony injections, the EC plus MWT protocol led to more rapid wound closure. The tentatively lower rate of relapses and the acceleration of wound closure in a subgroup of patients with parasite persistence warrant future studies on the activity of DAC N-055. Trial Registration ClinicalTrails.gov NCT00947362 In many countries of the Middle East such as Afghanistan, cutaneous leishmaniasis is a highly prevalent, chronic and stigmatizing skin disease. Poor hygiene conditions frequently aggravate the lesions due to bacterial and fungal superinfections. Classical treatments with injections of pentavalent antimony are hampered by costs, side effects, resistance development, supply and manufactural quality problems. In the present study on Afghan patients with Leishmania tropica-induced skin lesions we evaluated the clinical effect of an initial removal of lesion tissue by electrocoagulation using a bipolar high-frequency electrosurgery instrument, followed by daily moist wound treatment with or without a preparation of pharmaceutical sodium chlorite (DAC N-055). DAC N-055 is a compound with anti-infective, immunomodulatory and tissue repair-promoting effects. Our analysis revealed that the carefully performed moist wound treatment led to a rapid healing of the wounds within an average period of 6 weeks, even in the absence of the sodium chlorite preparation. This is considerably faster than the time spans previously reported for local or systemic antimony treatment. We believe that the current standard for local care of chronic wounds should also be applied to Leishmania skin lesions. If combined with an initial single high-frequency electrocoagulation, it is a highly effective, inexpensive and well-tolerated treatment option for cutaneous leishmaniasis.
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Affiliation(s)
- Ahmad Fawad Jebran
- Mikrobiologisches Institut – Klinische Mikrobiologie, Immunologie und Hygiene, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Ulrike Schleicher
- Mikrobiologisches Institut – Klinische Mikrobiologie, Immunologie und Hygiene, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Reto Steiner
- Leishmania Clinic, German Medical Service (NGO), Darwaze-e-Lahory, Kabul, Afghanistan
| | - Pia Wentker
- Mikrobiologisches Institut – Klinische Mikrobiologie, Immunologie und Hygiene, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Farouq Mahfuz
- Leishmania Clinic, German Medical Service (NGO), Darwaze-e-Lahory, Kabul, Afghanistan
| | - Hans-Christian Stahl
- Waisenmedizin e.V. Promoting Access to Care with Essential Medicine, Non-Profit Organization, Freiburg, Germany
| | - Faquir Mohammad Amin
- Leishmania Clinic, German Medical Service (NGO), Darwaze-e-Lahory, Kabul, Afghanistan
| | - Christian Bogdan
- Mikrobiologisches Institut – Klinische Mikrobiologie, Immunologie und Hygiene, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
- * E-mail: (CB); (KWS)
| | - Kurt-Wilhelm Stahl
- Waisenmedizin e.V. Promoting Access to Care with Essential Medicine, Non-Profit Organization, Freiburg, Germany
- * E-mail: (CB); (KWS)
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Bottieau E, Vekemans M, Van Gompel A. Therapy of vector-borne protozoan infections in nonendemic settings. Expert Rev Anti Infect Ther 2014; 9:583-608. [DOI: 10.1586/eri.11.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Blum J, Lockwood DNJ, Visser L, Harms G, Bailey MS, Caumes E, Clerinx J, van Thiel PPAM, Morizot G, Hatz C, Buffet P. Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis. Int Health 2013; 4:153-63. [PMID: 24029394 DOI: 10.1016/j.inhe.2012.06.004] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm(2)), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.
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Affiliation(s)
- Johannes Blum
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland
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Bart A, van Thiel PPAM, de Vries HJC, Hodiamont CJ, Van Gool T. Imported leishmaniasis in the Netherlands from 2005 to 2012: epidemiology, diagnostic techniques and sequence-based species typing from 195 patients. Euro Surveill 2013; 18:20544. [DOI: 10.2807/1560-7917.es2013.18.30.20544] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Leishmaniasis is an imported disease in the Netherlands. We report data for the period between 2005 and 2012, on clinical presentation, country where leishmaniasis was acquired, and causative species, for 195 civilian and military patients who had travelled abroad. Most patients were affected by cutaneous leishmaniasis (CL) (n=185 patients), while visceral leishmaniasis (VL) (n=8 patients) and mucocutaneous leishmaniasis (n=2 patients) were less frequently observed. All VL patients had been infected in Europe. CL was mainly acquired in Afghanistan, Surinam, Morocco and Spain. The majority of CL patients consisted of military personnel (55%, 102/185), 78 of whom had been infected during an outbreak in Afghanistan. Parasitological diagnosis was made by a combination of polymerase chain reaction (PCR), microscopy and culture. Compared to a standard of parasitological proof by any method other than the one under consideration, sensitivities of the individual methods ranged from 73% to 98%. Microscopy was least sensitive, but is fast and cheap. Mini-exon repeat PCR combines high sensitivity and specificity, and allows differentiation between species by sequencing of the PCR product. Eight different species or species complexes were identified, allowing species-specific therapy. Four patients proved infected with Leishmania naiffi, a hitherto rarely described cause of leishmaniasis. In comparison to previous decennia, an increase in cutaneous leishmaniasis was observed in our hospital, both in civilian and military patients who had travelled abroad. This calls for increased awareness among clinicians, availability of diagnostic tests and species-specific treatment guidelines in non-endemic countries.
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Affiliation(s)
- A Bart
- Department of Medical Microbiology, section of Parasitology, Academic Medical Center, Amsterdam, the Netherlands
| | - P PAM van Thiel
- Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, Amsterdam, the Netherlands
| | - H JC de Vries
- Department of Dermatology, Academic Medical Center, Amsterdam, the Netherlands
| | - C J Hodiamont
- Department of Medical Microbiology, section of Parasitology, Academic Medical Center, Amsterdam, the Netherlands
| | - T Van Gool
- Department of Medical Microbiology, section of Parasitology, Academic Medical Center, Amsterdam, the Netherlands
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Bailey MS, Caddy AJ, McKinnon KA, Fogg LF, Roscoe M, Bailey JW, O’Dempsey TJ, Beeching NJ. Outbreak of Zoonotic Cutaneous Leishmaniasis with Local Dissemination in Balkh, Afghanistan. J ROY ARMY MED CORPS 2012; 158:225-8. [DOI: 10.1136/jramc-158-03-16] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dorlo TPC, Balasegaram M, Beijnen JH, de Vries PJ. Miltefosine: a review of its pharmacology and therapeutic efficacy in the treatment of leishmaniasis. J Antimicrob Chemother 2012; 67:2576-97. [PMID: 22833634 DOI: 10.1093/jac/dks275] [Citation(s) in RCA: 487] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Miltefosine is an alkylphosphocholine drug with demonstrated activity against various parasite species and cancer cells as well as some pathogenic bacteria and fungi. For 10 years it has been licensed in India for the treatment of visceral leishmaniasis (VL), a fatal neglected parasitic disease. It is the first and still the only oral drug that can be used to treat VL and cutaneous leishmaniasis (CL). The standard 28 day miltefosine monotherapy regimen is well tolerated, except for mild gastrointestinal side effects, although its teratogenic potential severely hampers its general use in the clinic and roll-out in national elimination programmes. The pharmacokinetics of miltefosine are mainly characterized by its long residence time in the body, resulting in extensive drug accumulation during treatment and long elimination half-lives. At the moment, different combination therapy strategies encompassing miltefosine are being tested in multiple controlled clinical trials in various geographical areas of endemicity, both in South Asia and East Africa. We here review the most salient pre-clinical and clinical pharmacological aspects of miltefosine, its mechanism of action against Leishmania parasites and other pathogens, and provide a systematic overview of the efficacy and safety data from all clinical trials of miltefosine, either alone or in combination, in the treatment of VL and CL.
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Affiliation(s)
- Thomas P C Dorlo
- Center for Tropical Medicine and Travel Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Optimal dosing of miltefosine in children and adults with visceral leishmaniasis. Antimicrob Agents Chemother 2012; 56:3864-72. [PMID: 22585212 DOI: 10.1128/aac.00292-12] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Only anecdotal data are available on the pharmacokinetics (PK) of miltefosine in children suffering from visceral leishmaniasis (VL). While failure rates were higher in children with VL, steady-state concentrations appeared lower than those seen with adults. We hypothesized that the current linear dosage (in milligrams per kilogram of body weight) is too low for children and that a new dosing algorithm based on an appropriate body size model would result in an optimal exposure. A population PK analysis was performed on three historic pooled data sets, including Indian children, Indian adults, and European adults. Linear and allometric scaling of PK parameters by either body weight or fat-free mass (FFM) was evaluated for body size models. Based on the developed PK model, a dosing algorithm for miltefosine in children and adults was proposed and evaluated in silico. The population PK model employing allometric scaling fitted best to the pooled miltefosine data. Allometric scaling by FFM reduced between-subject variability, e.g., for drug clearance, from 49.6% to 32.1%. A new allometric miltefosine dosing algorithm was proposed. Exposure to miltefosine was lower in children than adults receiving 2.5 mg/kg/day: a C(max) of 18.8 μg/ml was reached by 90% of adults and 66.7% of children. The allometric daily dose resulted in similar levels of exposure to miltefosine for adults and children. The use of a new allometric dosing algorithm for miltefosine in VL patients results in optimal exposure to miltefosine in both adults and children and might improve clinical outcome in children.
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Dorlo TPC, Balasegaram M, Lima MA, de Vries PJ, Beijnen JH, Huitema ADR. Translational pharmacokinetic modelling and simulation for the assessment of duration of contraceptive use after treatment with miltefosine. J Antimicrob Chemother 2012; 67:1996-2004. [DOI: 10.1093/jac/dks164] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
PURPOSE OF REVIEW Miltefosine is a new oral treatment against leishmaniasis. The evidence about its use in New and Old World cutaneous leishmaniasis is presented and discussed. RECENT FINDINGS Miltefosine is being tested with small clinical trials mainly in endemic cutaneous leishmaniasis regions of South America and Iran. Severe cutaneous leishmaniasis forms successfully treated with miltefosine are reported. SUMMARY The use of miltefosine in cutaneous leishmaniasis has been addressed in a few clinical trials. An important advantage of this drug is its oral administration when compared with the standard parenteral drugs in the context of a large-scale use in the inner regions of the endemic countries. Miltefosine also shows activity in severe or refractory cases. However, this review points out the need for further investment on clinical research into cutaneous leishmaniasis treatment.
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Abstract
Although civilian physicians in the United States seldom encounter patients with leishmaniasis, therapeutic advances in endemic regions have opened the door to approaches that can be applied in this country. Advances revolve around the use of oral miltefosine in all forms of leishmaniasis and the use of short-course intravenous liposomal amphotericin B in visceral and possibly cutaneous infection. Lengthy, traditional intravenous treatment with pentavalent antimony (sodium stibogluconate) still has a role in the United States; however, although expensive, miltefosine and liposomal amphotericin B are considerably more appealing selections for initial therapy.
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Affiliation(s)
- Henry W Murray
- Department of Medicine, Weill Cornell Medical College, New York, New York 10065, USA.
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Neumayr ALC, Walter C, Stoeckle M, Braendle N, Glatz K, Blum JA. Successful treatment of imported mucosal Leishmania infantum leishmaniasis with miltefosine after severe hypokalemia under meglumine antimoniate treatment. J Travel Med 2012; 19:124-6. [PMID: 22414039 DOI: 10.1111/j.1708-8305.2011.00572.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Old World mucosal leishmaniasis is a rare but regularly reported disease in Southern Europe. We report the case of a 64-year-old woman who developed severe hypokalemia under meglumine antimoniate treatment and was successfully treated under second line therapy with miltefosine.
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Plourde M, Coelho A, Keynan Y, Larios OE, Ndao M, Ruest A, Roy G, Rubinstein E, Ouellette M. Genetic polymorphisms and drug susceptibility in four isolates of Leishmania tropica obtained from Canadian soldiers returning from Afghanistan. PLoS Negl Trop Dis 2012; 6:e1463. [PMID: 22272366 PMCID: PMC3260320 DOI: 10.1371/journal.pntd.0001463] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Accepted: 11/18/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) is a vector-borne parasitic disease characterized by the presence of one or more lesions on the skin that usually heal spontaneously after a few months. Most cases of CL worldwide occur in Southwest Asia, Africa and South America, and a number of cases have been reported among troops deployed to Afghanistan. No vaccines are available against this disease, and its treatment relies on chemotherapy. The aim of this study was to characterize parasites isolated from Canadian soldiers at the molecular level and to determine their susceptibility profile against a panel of antileishmanials to identify appropriate therapies. METHODOLOGY/PRINCIPAL FINDINGS Parasites were isolated from skin lesions and characterized as Leishmania tropica based on their pulsed field gel electrophoresis profiles and pteridine reductase 1 (PTR1) sequences. Unusually high allelic polymorphisms were observed at several genetic loci for the L. tropica isolates that were characterized. The drug susceptibility profile of intracellular amastigote parasites was determined using an established macrophage assay. All isolates were sensitive to miltefosine, amphotericin B, sodium stibogluconate (Pentostam) and paromomycin, but were not susceptible to fluconazole. Variable levels of susceptibility were observed for the antimalarial agent atovaquone/proguanil (Malarone). Three Canadian soldiers from this study were successfully treated with miltefosine. CONCLUSIONS/SIGNIFICANCE This study shows high heterogeneity between the two L. tropica allelic versions of a gene but despite this, L. tropica isolated from Afghanistan are susceptible to several of the antileishmanial drugs available.
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Affiliation(s)
- Marie Plourde
- Centre de Recherche en Infectiologie du Centre de Recherche du CHUQ and Département de Microbiologie, Immunologie et Infectiologie, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Adriano Coelho
- Centre de Recherche en Infectiologie du Centre de Recherche du CHUQ and Département de Microbiologie, Immunologie et Infectiologie, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Yoav Keynan
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Oscar E. Larios
- Department of Medicine and Laboratory Medicine, Divisions of Infectious Diseases and Microbiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Momar Ndao
- National Reference Center for Parasitology, McGill University, Montreal General Hospital/Research Institute, Montréal, Québec, Canada
| | | | - Gaétan Roy
- Centre de Recherche en Infectiologie du Centre de Recherche du CHUQ and Département de Microbiologie, Immunologie et Infectiologie, Faculté de Médecine, Université Laval, Québec, Québec, Canada
| | - Ethan Rubinstein
- Laboratory of Viral Immunology, Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marc Ouellette
- Centre de Recherche en Infectiologie du Centre de Recherche du CHUQ and Département de Microbiologie, Immunologie et Infectiologie, Faculté de Médecine, Université Laval, Québec, Québec, Canada
- * E-mail:
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Rubiano LC, Miranda MC, Muvdi Arenas S, Montero LM, Rodríguez-Barraquer I, Garcerant D, Prager M, Osorio L, Rojas MX, Pérez M, Nicholls RS, Gore Saravia N. Noninferiority of miltefosine versus meglumine antimoniate for cutaneous leishmaniasis in children. J Infect Dis 2012; 205:684-92. [PMID: 22238470 DOI: 10.1093/infdis/jir816] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Children have a lower response rate to antimonial drugs and higher elimination rate of antimony (Sb) than adults. Oral miltefosine has not been evaluated for pediatric cutaneous leishmaniasis. METHODS A randomized, noninferiority clinical trial with masked evaluation was conducted at 3 locations in Colombia where Leishmania panamensis and Leishmania guyanensis predominated. One hundred sixteen children aged 2-12 years with parasitologically confirmed cutaneous leishmaniasis were randomized to directly observed treatment with meglumine antimoniate (20 mg Sb/kg/d for 20 days; intramuscular) (n = 58) or miltefosine (1.8-2.5 mg/kg/d for 28 days; by mouth) (n = 58). Primary outcome was treatment failure at or before week 26 after initiation of treatment. Miltefosine was noninferior if the proportion of treatment failures was ≤15% higher than achieved with meglumine antimoniate (1-sided test, α = .05). RESULTS Ninety-five percent of children (111/116) completed follow-up evaluation. By intention-to-treat analysis, failure rate was 17.2% (98% confidence interval [CI], 5.7%-28.7%) for miltefosine and 31% (98% CI, 16.9%-45.2%) for meglumine antimoniate. The difference between treatment groups was 13.8%, (98% CI, -4.5% to 32%) (P = .04). Adverse events were mild for both treatments. CONCLUSIONS Miltefosine is noninferior to meglumine antimoniate for treatment of pediatric cutaneous leishmaniasis caused by Leishmania (Viannia) species. Advantages of oral administration and low toxicity favor use of miltefosine in children. CLINICAL TRIAL REGISTRATION NCT00487253.
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Affiliation(s)
- Luisa Consuelo Rubiano
- Centro Internacional De Entrenamiento E Investigaciones Médicas (CIDEIM), Cali, Colombia
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Dorlo TPC, van Thiel PPAM, Schoone GJ, Stienstra Y, van Vugt M, Beijnen JH, de Vries PJ. Dynamics of parasite clearance in cutaneous leishmaniasis patients treated with miltefosine. PLoS Negl Trop Dis 2011; 5:e1436. [PMID: 22180803 PMCID: PMC3236732 DOI: 10.1371/journal.pntd.0001436] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 11/04/2011] [Indexed: 11/18/2022] Open
Abstract
Parasite loads were quantified in repeated skin biopsies from lesions of 2 patients with Old-World cutaneous leishmaniasis (CL) caused by Leishmania major and L. infantum during and after treatment with miltefosine. Miltefosine induced a rapid therapeutic effect on both infections with an initial decline of parasites of ∼1 log/week for the L. major infection. These observations illustrate the usability of quantifying parasite loads in skin lesions as a pharmacodynamic measure and quantitative descriptor of drug effect for CL supporting clinical assessment.
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Affiliation(s)
- Thomas P C Dorlo
- Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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van Thiel PPAM, van Gool T, Faber WR, Leenstra T, Kager PA, Bart A. Variation in clinical presentation and genotype of causative Leishmania major strain in cutaneous leishmaniasis in north and south Afghanistan. Am J Trop Med Hyg 2011; 85:60-3. [PMID: 21734125 DOI: 10.4269/ajtmh.2011.10-0531] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A different clinical picture and therapeutic response were observed when data from Leishmania major-infected Dutch military personnel stationed in southern (N = 8) and northern (N = 169) Afghanistan were analyzed. Clinical presentation of cutaneous leishmaniasis in personnel in the south was milder and seemed to respond better to antileishmanial treatment; molecular analyses of parasite isolates seem to indicate that these differences may be genetic.
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Affiliation(s)
- Pieter-Paul A M van Thiel
- Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS and Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Parasitic diseases affect more than 2 billion people globally and cause substantial morbidity and mortality, particularly among the world's poorest people. This overview focuses on the treatment of the major protozoan and helminth infections in humans. Recent developments in antiparasitic therapy include the expansion of artemisinin-based therapies for malaria, new drugs for soil-transmitted helminths and intestinal protozoa, expansion of the indications for antiparasitic drug treatment in patients with Chagas disease, and the use of combination therapy for leishmaniasis and human African trypanosomiasis.
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Affiliation(s)
| | | | - Brian G. Blackburn
- Address correspondence to Brian G. Blackburn, MD, Stanford University School of Medicine, Division of Infectious Diseases and Geographic Medicine, 300 Pasteur Dr, Grant Bldg, Room S-101, Stanford, CA 94305-5107 (). Individual reprints of this article and a bound reprint of the entire Symposium on Antimicrobial Therapy will be available for purchase from our Web site www.mayoclinicproceedings.com
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Leishmaniasis: new insights from an old and neglected disease. Eur J Clin Microbiol Infect Dis 2011; 31:109-18. [PMID: 21533874 DOI: 10.1007/s10096-011-1276-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 04/12/2011] [Indexed: 02/06/2023]
Abstract
Leishmaniases are a clinically heterogeneous group of diseases caused by protozoa of the genus Leishmania. There is growing evidence that the true incidence of the disease is underestimated, especially in hyperendemic regions. Moreover, climate changes together with the increasing movement of humans and animals raise concerns about the possible introduction of Leishmania infection in previously spared areas. The disease is emerging in immunocompromised patients undergoing bone marrow or solid organ transplantation or treatment with biologic drugs. Furthermore, the deployment of military troops and travel to endemic areas are associated with the observation of a growing number of patients with cutaneous disease. Improvement in diagnostic methods, both in the field and in specialized laboratories, has been obtained through the implementation of molecular amplification methods and using the rK39 antigen as the substrate. Finally, new therapeutic approaches are gaining attention, such as the use of miltefosine for cutaneous leishmaniasis and paromomycin for visceral leishmaniasis, as well as the use of various antileishmanial drugs in combination.
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Roelfsema JH, Nozari N, Herremans T, Kortbeek LM, Pinelli E. Evaluation and improvement of two PCR targets in molecular typing of clinical samples of Leishmania patients. Exp Parasitol 2011; 127:36-41. [DOI: 10.1016/j.exppara.2010.06.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 06/15/2010] [Accepted: 06/16/2010] [Indexed: 10/19/2022]
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van Thiel PP, Leenstra T, de Vries HJ, van der Sluis A, van Gool T, Krull AC, van Vugt M, de Vries PJ, Zeegelaar JE, Bart A, van der Meide WF, Schallig HDFH, Faber WR, Kager PA. Cutaneous leishmaniasis (Leishmania major infection) in Dutch troops deployed in northern Afghanistan: epidemiology, clinical aspects, and treatment. Am J Trop Med Hyg 2010; 83:1295-300. [PMID: 21118937 PMCID: PMC2990047 DOI: 10.4269/ajtmh.2010.10-0143] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 07/14/2010] [Indexed: 11/07/2022] Open
Abstract
Cutaneous leishmaniasis caused by Leishmania major infection affected 172 (18.3%) of 938 Dutch military troops deployed in northern Afghanistan in 2005. The high attack rate was a result of initial insufficient availability of means of prevention and insufficient adherence to preventive measures. At presentation, the lymphatic system was involved in 24.8%. Treatment with intralesional injections of antimony with or without cryotherapy was satisfactory, but 19.5% of patients received secondary treatment with miltefosine. Six months after treatment, 128 (77.1%) of 166 treated patients were cured, 16 (9.6%) were lost to follow-up, and 22 (13.3%) already experienced cure at six weeks but were not seen at six months. Natural evolution played a role in this observational study, which showed cure of all patients seen at six months. In general, management of cutaneous leishmaniasis was feasible under field conditions.
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Affiliation(s)
- Pieter-Paul van Thiel
- Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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46
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Jacobson RL. Leishmaniasis in an era of conflict in the Middle East. Vector Borne Zoonotic Dis 2010; 11:247-58. [PMID: 20846030 DOI: 10.1089/vbz.2010.0068] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Leishmaniasis is endemic in the Middle East, and both cutaneous and visceral forms are reported from the region ranging from the Levant to Afghanistan. The potential and proven phlebotomine sand fly vectors and reservoir hosts of the Leishmaniases species in Afghanistan, Iran, Iraq, Israel, Jordan, Lebanon, Saudi Arabia, Syria, Turkey, and Yemen are described. This region has seen a movement of populations across the area, due to both military and civilian strife. Refugees, armed forces, and multi-national contractors are particularly at risk to acquire this disease. There has been an upsurge in Leishmaniasis research, especially as new foci are exposed and the need to protect the naïve populations moving into endemic areas becomes a public health priority. New sand fly vectors and animal reservoirs have been discovered while novel control methods are being evaluated. Modern molecular techniques are now being used more routinely and revealing some unusual findings. The aim of this review is to collate the most recent data on the burden of the disease, diagnostic applications, eco-epidemiology of vectors, and reservoir hosts, and how the control projects have been developing in the Middle East.
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Affiliation(s)
- Raymond L Jacobson
- Department of Molecular Genetics and Microbiology, The Hebrew University-Hadassah Medical School, The Institute of Medical Research Canada-Israel, Jerusalem, Israel.
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