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Karami M, Gorgani-Firouzjaee T, Chehrazi M. Prevalence of cutaneous Leishmaniasis in the Middle East: a systematic review and meta-analysis. Pathog Glob Health 2023; 117:356-365. [PMID: 36222473 PMCID: PMC10177677 DOI: 10.1080/20477724.2022.2133452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Cutaneous leishmaniasis (CL), caused by an obligate intracellular protozoan parasite from the genus Leishmania, imposing a significant burden on underdeveloped countries especially those located in the Middle East. Four electronic databases were searched to evaluate the prevalence of CL in the Middle East. The random effects model (95% confidence intervals (CI)) were applied to determine the overall and subgroup pooled prevalence. Heterogeneity was assessed by Cochran's Q test and I2 statistics. Among 2424 peer-reviewed papers, 37 datasets from 34 studies were included in the current meta-analysis. 285560 individuals were assessed across 9 Middle Eastern countries. The pooled prevalence of CL was estimated at 12% (95% CI 9-15 %; 10718/285560). The highest prevalence rate was observed in Syria (39%, 37-42%), and the lowest one was found in Iraq and Lebanon (0%, 0-1%). The prevalence of CL in studies that applied LST assays had the highest rate (48%, 17-80%). The infection rate in males was similar to females (7%, 4-10%). The prevalence of infection in individuals living in urban areas was higher than in rural areas (14%, 10-19%). The prevalence of CL in the age group 0-15 years was higher than in individuals 16-40 and >40 years (9%, 6-13%). Most of the lesions were found on the face, and single lesions were more prevalent than two and three ones. In conclusion, the occurrence of CL was considerable in Middle Eastern countries. Therefore, more efforts should be made to precisely report the CL in this region for developing appropriate preventive and controlling strategies. .
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Affiliation(s)
- Mohsen Karami
- Department of Mycology and Parasitology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Tahmineh Gorgani-Firouzjaee
- Department of Mycology and Parasitology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Mohammad Chehrazi
- Department of Biostatistics and Epidemiology, School of Health Science, Babol University of Medical Sciences, Babol, Iran
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2
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Sghaier RM, Benhnini F, Guerfali FZ, Attia H, Bali A, Zaatour A, Mkannez G, Gharbi A, Belhaj-Hamida N, Dridi H, Ben-Salah A, Dellagi K, Laouini D. Healed Lesions of Human Cutaneous Leishmaniasis Caused By Leishmania major Do Not Shelter Persistent Residual Parasites. Front Cell Infect Microbiol 2022; 12:839216. [PMID: 35967864 PMCID: PMC9363604 DOI: 10.3389/fcimb.2022.839216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 04/15/2022] [Indexed: 11/13/2022] Open
Abstract
In human cutaneous leishmaniasis (HCL) caused by Leishmania (L.) major, the cutaneous lesions heal spontaneously and induce a Th1-type immunity that confers solid protection against reinfection. The same holds true for the experimental leishmaniasis induced by L. major in C57BL/6 mice where residual parasites persist after spontaneous clinical cure and induce sustainable memory immune responses and resistance to reinfection. Whether residual parasites also persist in scars of cured HCL caused by L. major is still unknown. Cutaneous scars from 53 volunteers with healed HCL caused by L. major were biopsied and the tissue sample homogenates were analyzed for residual parasites by four methods: i) microscope detection of amastigotes, ii) parasite culture by inoculation on biphasic medium, iii) inoculation of tissue exctracts to the footpad of BALB/c mice, an inbred strain highly susceptible to L. major, and iv) amplification of parasite kDNA by a highly sensitive real-time PCR (RT-PCR). Our results show that the scars of healed lesions of HCL caused by L. major do not contain detectable residual parasites, suggesting that this form likely induces a sterile cure at least within the scars. This feature contrasts with other Leishmania species causing chronic, diffuse, or recidivating forms of leishmaniasis where parasites do persist in healed lesions. The possibility that alternative mechanisms to parasite persistence are needed to boost and maintain long-term immunity to L. major, should be taken into consideration in vaccine development against L. major infection.
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Affiliation(s)
- Rabiaa M. Sghaier
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Fouad Benhnini
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Fatma Z. Guerfali
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Hanène Attia
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Aymen Bali
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Amor Zaatour
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- Service of Medical Epidemiology, Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
| | - Ghada Mkannez
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Adel Gharbi
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- Service of Medical Epidemiology, Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
| | - Nabil Belhaj-Hamida
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- Service of Medical Epidemiology, Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
| | - Hichem Dridi
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- Service of Medical Epidemiology, Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
| | - Afif Ben-Salah
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- Service of Medical Epidemiology, Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Koussay Dellagi
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
| | - Dhafer Laouini
- LR16IPT02, Laboratory of Transmission, Control and Immunobiology of Infections (LTCII), Institut Pasteur de Tunis, Tunis-Belvédère, Tunisia
- Université Tunis El Manar, Tunis, Tunisia
- *Correspondence: Dhafer Laouini, ;
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Goonoo N, Laetitia Huët MA, Chummun I, Karuri N, Badu K, Gimié F, Bergrath J, Schulze M, Müller M, Bhaw-Luximon A. Nanomedicine-based strategies to improve treatment of cutaneous leishmaniasis. ROYAL SOCIETY OPEN SCIENCE 2022; 9:220058. [PMID: 35719886 PMCID: PMC9198523 DOI: 10.1098/rsos.220058] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/14/2022] [Indexed: 05/03/2023]
Abstract
Nanomedicine strategies were first adapted and successfully translated to clinical application for diseases, such as cancer and diabetes. These strategies would no doubt benefit unmet diseases needs as in the case of leishmaniasis. The latter causes skin sores in the cutaneous form and affects internal organs in the visceral form. Treatment of cutaneous leishmaniasis (CL) aims at accelerating wound healing, reducing scarring and cosmetic morbidity, preventing parasite transmission and relapse. Unfortunately, available treatments show only suboptimal effectiveness and none of them were designed specifically for this disease condition. Tissue regeneration using nano-based devices coupled with drug delivery are currently being used in clinic to address diabetic wounds. Thus, in this review, we analyse the current treatment options and attempt to critically analyse the use of nanomedicine-based strategies to address CL wounds in view of achieving scarless wound healing, targeting secondary bacterial infection and lowering drug toxicity.
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Affiliation(s)
- Nowsheen Goonoo
- Biomaterials, Drug Delivery and Nanotechnology Unit, Center for Biomedical and Biomaterials Research, University of Mauritius, Réduit 80837, Mauritius
| | - Marie Andrea Laetitia Huët
- Biomaterials, Drug Delivery and Nanotechnology Unit, Center for Biomedical and Biomaterials Research, University of Mauritius, Réduit 80837, Mauritius
| | - Itisha Chummun
- Biomaterials, Drug Delivery and Nanotechnology Unit, Center for Biomedical and Biomaterials Research, University of Mauritius, Réduit 80837, Mauritius
| | - Nancy Karuri
- Department of Chemical Engineering, Dedan Kimathi University of Technology, Private Bag 10143 – Dedan Kimathi, Nyeri, Kenya
| | - Kingsley Badu
- Vector-borne Infectious Disease Group, Theoretical and Applied Biology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Fanny Gimié
- Animalerie, Plateforme de recherche CYROI, 2 rue Maxime Rivière, 97490 Sainte Clotilde, Ile de La Réunion, France
| | - Jonas Bergrath
- Department of Natural Sciences, University of Applied Sciences Bonn-Rhein-Sieg, Heisenbergstrasse 16, D-53359 Rheinbach, Germany
| | - Margit Schulze
- Department of Natural Sciences, University of Applied Sciences Bonn-Rhein-Sieg, Heisenbergstrasse 16, D-53359 Rheinbach, Germany
| | - Mareike Müller
- Physical Chemistry I & Research Center of Micro- and Nanochemistry and (Bio)Technology (Cμ), Department of Chemistry and Biology, University of Siegen, Adolf-Reichwein-Strasse 2, 57076 Siegen, Germany
| | - Archana Bhaw-Luximon
- Biomaterials, Drug Delivery and Nanotechnology Unit, Center for Biomedical and Biomaterials Research, University of Mauritius, Réduit 80837, Mauritius
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Sharquie KE, Jabbar RI. Leishmania Recidivans Could Be Induced by Intralesional Infiltration of Cutaneous Leishmaniasis by Sodium Stibogluconate, with New Therapeutic Trial. JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2022. [DOI: 10.29333/jcei/11516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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5
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Hajjaran H, Saberi R, Borjian A, Fakhar M, Hosseini SA, Ghodrati S, Mohebali M. The Geographical Distribution of Human Cutaneous and Visceral Leishmania Species Identified by Molecular Methods in Iran: A Systematic Review With Meta-Analysis. Front Public Health 2021; 9:661674. [PMID: 34249836 PMCID: PMC8267797 DOI: 10.3389/fpubh.2021.661674] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/31/2021] [Indexed: 01/11/2023] Open
Abstract
Leishmaniasis is one of the most common vector-borne parasitic diseases in Iran. Leishmania species identification is necessary for epidemiological aspects, precise prognosis, control and treatment of the disease. We systematically searched all the studies, reports, and documentation related to species identification and geographical distribution of causative agents of cutaneous (CL), mucosal (ML), and visceral leishmaniasis (VL) using DNA-based molecular diagnostic techniques in Iran. International databases including PubMed, ScienceDirect, Embase, Google Scholar, Scopus, and Web of Science were systemically searched for English articles and Iran's databases including SID, IranMedex and Magiran were searched for Persian reports and articles. Searches were performed from 1999 to 2019 (20 years). The current review was conducted using the keywords: cutaneous leishmaniasis, visceral leishmaniasis, Leishmania species, Human, Molecular, PCR, and Iran. The study quality was evaluated using the NOS checklist. This meta-analysis procedure was accomplished using STATA, version 2.7.9. Of the 3,426 records identified in the initial search, 154 articles met inclusion criteria and qualified for the systematic review and meta-analysis. In subgroup analysis, the pooled frequency of causative agents of CL isolates was 67.3% (95% CI: 59.51–74.67%) for L. major and 32.1% (95% CI: 24.72–39.87%) for L. tropica. In addition, the pooled frequency of causative agents of VL isolates was 97.1% (95% CI: 94.6–98.8%) for L. infantum and 2.9% (95% CI: 1.12–5.37%) for L. tropica. The findings of this study showed that the main causative agents of CL and VL in Iran are L. major and L. infantum, respectively. Moreover, kinetoplast DNA (kDNA) and internal transcriber spacer (ITS) were the most used markers for identifying Leishmania species. The current study provides valuable data to encourage and direct researchers as well as public health managers in the comprehensive leishmaniasis control and prevention planning in Iran.
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Affiliation(s)
- Homa Hajjaran
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Saberi
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Alireza Borjian
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Seyed Abdollah Hosseini
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis and Toxoplasmosis, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sajjad Ghodrati
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohebali
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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6
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Volpedo G, Pacheco-Fernandez T, Holcomb EA, Cipriano N, Cox B, Satoskar AR. Mechanisms of Immunopathogenesis in Cutaneous Leishmaniasis And Post Kala-azar Dermal Leishmaniasis (PKDL). Front Cell Infect Microbiol 2021; 11:685296. [PMID: 34169006 PMCID: PMC8217655 DOI: 10.3389/fcimb.2021.685296] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/24/2021] [Indexed: 12/18/2022] Open
Abstract
Leishmaniasis is a neglected tropical disease that affects 12 million people worldwide. The disease has high morbidity and mortality rates and is prevalent in over 80 countries, leaving more than 300 million people at risk of infection. Of all of the manifestations of this disease, cutaneous leishmaniasis (CL) is the most common form and it presents as ulcerating skin lesions that can self-heal or become chronic, leading to disfiguring scars. This review focuses on the different pathologies and disease manifestations of CL, as well as their varying degrees of severity. In particular, this review will discuss self-healing localized cutaneous leishmaniasis (LCL), leishmaniasis recidivans (LR), mucocutaneous leishmaniasis (MCL), anergic diffuse cutaneous leishmaniasis (ADCL), disseminated leishmaniasis (DL), and Post Kala-azar Dermal Leishmaniasis (PKDL), which is a cutaneous manifestation observed in some visceral leishmaniasis (VL) patients after successful treatment. The different clinical manifestations of CL are determined by a variety of factors including the species of the parasites and the host's immune response. Specifically, the balance between the pro and anti-inflammatory mediators plays a vital role in the clinical presentation and outcome of the disease. Depending upon the immune response, Leishmania infection can also transition from one form of the disease to another. In this review, different forms of cutaneous Leishmania infections and their immunology are described.
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Affiliation(s)
- Greta Volpedo
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Department of Microbiology, College of Arts and Sciences, The Ohio State University, Columbus, OH, United States
| | - Thalia Pacheco-Fernandez
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Erin A. Holcomb
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Natalie Cipriano
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Blake Cox
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Abhay R. Satoskar
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Department of Microbiology, College of Arts and Sciences, The Ohio State University, Columbus, OH, United States
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7
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Bamorovat M, Sharifi I, Tavakoli Oliaee R, Jafarzadeh A, Khosravi A. Determinants of Unresponsiveness to Treatment in Cutaneous Leishmaniasis: A Focus on Anthroponotic Form Due to Leishmania tropica. Front Microbiol 2021; 12:638957. [PMID: 34140933 PMCID: PMC8203913 DOI: 10.3389/fmicb.2021.638957] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
Cutaneous leishmaniasis (CL) is a curable disease; however, due to various risk factors, unresponsiveness to CL treatments is inevitable. The treatment of CL has been firmly correlated with multiple determinants, such as demographical, clinical, and environmental factors, the host’s immune response, poor treatment adherence, the parasite’s genetic make-up, and Leishmania RNA virus. This study primarily focuses on the risk factors associated with different therapeutic outcomes following meglumine antimoniate (MA; Glucantime®) treatment and policy approaches to prevent unresponsiveness in CL patients with a focus on anthroponotic form (ACL). Findings suggest that effective preventive and therapeutic measures should be more vigorously implemented, particularly in endemic areas. Accordingly, extensive training is essential to monitor drug unresponsiveness regularly, especially in tropical regions where the disease is prevalent. Since humans are the fundamental reservoir host of ACL due to L. tropica, prompt detection, early diagnosis, and timely and effective treatment could help control this disease. Furthermore, major challenges and gaps remain: efficacious vaccine, new tools, and expert staff are crucial before CL can be definitively controlled.
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Affiliation(s)
- Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Abdollah Jafarzadeh
- Department of Immunology, Medical School, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Khosravi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
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8
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Rassi Y, Ebrahimi S, Abai MR, Vatandoost H, Akhavan AA, Afshar AA. Comparative Testing of Susceptibility Levels of Phlebotomus sergenti, the Main Vector of Anthroponotic Cutaneous Leishmaniasis, to Conventional Insecticides Using Two Capture Methods in Kerman City, Southeastern Iran. J Arthropod Borne Dis 2021; 15:82-96. [PMID: 34277858 PMCID: PMC8271233 DOI: 10.18502/jad.v15i1.6488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 03/13/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Collecting live sand flies from indoor sites is a major challenge for researchers in large cities due to the reluctance of families to survey their homes. This study was conducted to assess the efficacy of two methods for collecting sand flies for use in susceptibility tests in the urban area of Kerman, southeastern Iran. Methods: Sandflies were mainly collected using both baited traps and hand catch methods from outdoor and indoor sites. Susceptibility tests were separately done according to the standard World Health Organization testing protocol on Phlebotomus sergenti, including 60-minute exposure to DDT 4.0%, propoxur 0.1%, deltamethrin 0.05%, and malathion 5.0%. Results: During this research, the natural habitats and suitable indoor sites were selected to predict the density of live sand fly with perfect accuracy. The number of live Ph. sergenti caught by hand catch and baited traps methods was 42 and 361 in indoor and outdoor sites, respectively. The mortality rate of Ph. sergenti exposed to DDT 4%, deltamethrin 0.05, malathion 5%, and propoxur was 100%. Conclusion The baited traps showed a significant efficiency compared to hand catch for collecting live Ph. sergenti for use in susceptibility tests in urban areas. The Ph. sergenti collected from both indoor and outdoor sites were susceptible to all insecticides.
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Affiliation(s)
- Yavar Rassi
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahla Ebrahimi
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Abai
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Environmental Chemical Pollutants and Pesticides, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Vatandoost
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Environmental Chemical Pollutants and Pesticides, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ahmad Akhavan
- Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Environmental Chemical Pollutants and Pesticides, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Abass Aghaie Afshar
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Karimi T, Sharifi I, Aflatoonian MR, Aflatoonian B, Mohammadi MA, Salarkia E, Babaei Z, Zarinkar F, Sharifi F, Hatami N, Khosravi A, Eskandari A, Solimani E, Shafiee M, Mozaffari M, Heshmatkhah A, Amiri R, Farajzadeh S, Kyhani A, Aghaei Afshar A, Jafarzadeh A, Bamorovat M. A long-lasting emerging epidemic of anthroponotic cutaneous leishmaniasis in southeastern Iran: population movement and peri-urban settlements as a major risk factor. Parasit Vectors 2021; 14:122. [PMID: 33627184 PMCID: PMC7903377 DOI: 10.1186/s13071-021-04619-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 02/01/2021] [Indexed: 01/18/2023] Open
Abstract
Background Epidemics of cutaneous leishmaniasis (CL) are occurring more frequently and spreading faster and farther than before in many areas of the world. The present study aimed to assess a long-lasting emerging epidemic (2005–2019) of 5532 cases with anthroponotic CL (ACL) in peri-urban areas of Kerman city in southeastern Iran. Methods This descriptive-analytical study was carried out for 15 years in Kerman province, southeastern Iran. The data were passively obtained through the health surveillance system and the Kerman Leishmaniasis Research Center. Every subject was diagnosed using direct smear microscopy. The representative causative agent was further examined by ITS1-PCR, PCR-RFLP, 7SL RNA gene sequencing and phylogenetic analyses. For each subject, a case report form designating demographic and clinical data was recorded. Results A different pattern of ACL incidence was found in peri-urban areas compared to that in the city of Kerman. The incidence rate of ACL cases has significantly increased (P < 0.001) from 2005 to 2016 in new settlements with a gradual decline after that. The overall average risk of contracting the disease was 7.6 times higher in peri-urban areas compared to Kerman city, an old endemic focus. All isolates consisting of six variants were confirmed to be Leishmania tropica. The overall pattern of the ACL infection indicates that the etiological agent of ACL is propagated and transmitted by the bite of female Phlebotomus sergenti sandflies from person to person from dissimilar clones as reflected by the complexity of the migrants’ backgrounds in the province. Conclusions The movement of populations and establishment of new settlements in peri-urban areas close to endemic areas are major risk factors for and are directly linked to CL. The underlying factors of this emerging ACL epidemic caused by L. tropica were disasters and droughts, among others. A robust commitment to a multilateral approach is crucial to make improvements in this area. This will require decisive coordinated actions through all governmental factions and non-governmental organizations. Furthermore, active and passive case detection strategies, early diagnosis, and effective treatment could help control the disease. ![]()
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Affiliation(s)
- Taiebeh Karimi
- Department of Medical Parasitology and Mycology, Kerman University of Medical Sciences, Kerman, Iran
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran.
| | - Mohammad Reza Aflatoonian
- Research Center for Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran.
| | - Behnaz Aflatoonian
- Research Center for Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Ali Mohammadi
- Research Center for Hydatid Disease in Iran, Kerman University of Medical Sciences, Kerman, Iran
| | - Ehsan Salarkia
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Babaei
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Farzaneh Zarinkar
- Department of Medical Parasitology and Mycology, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sharifi
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Nima Hatami
- Department of Endodontic, Faculty of Dentistry, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Khosravi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Arsalan Eskandari
- County Health System Services, Kerman University of Medical Sciences, Kerman, Iran
| | - Elyas Solimani
- Provincial Health System Services, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Shafiee
- Provincial Health System Services, Kerman University of Medical Sciences, Kerman, Iran
| | - Masoumeh Mozaffari
- Provincial Health System Services, Kerman University of Medical Sciences, Kerman, Iran
| | - Amireh Heshmatkhah
- Shahid Dadbin Clinic, Kerman University of Medical Sciences, Kerman, Iran
| | - Rezvan Amiri
- Department of Dermatology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Saeideh Farajzadeh
- Department of Dermatology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Alireza Kyhani
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Abbas Aghaei Afshar
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Abdollah Jafarzadeh
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Bamorovat M, Sharifi I, Dabiri S, Shamsi Meymandi S, Karamoozian A, Amiri R, Heshmatkhah A, Borhani Zarandi M, Aflatoonian MR, Sharifi F, Kheirandish R, Hassanzadeh S. Major risk factors and histopathological profile of treatment failure, relapse and chronic patients with anthroponotic cutaneous leishmaniasis: A prospective case-control study on treatment outcome and their medical importance. PLoS Negl Trop Dis 2021; 15:e0009089. [PMID: 33507940 PMCID: PMC7872302 DOI: 10.1371/journal.pntd.0009089] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 02/09/2021] [Accepted: 12/30/2020] [Indexed: 11/19/2022] Open
Abstract
Over the last years, there has been a remarkable increase in the number of unresponsive patients with anthroponotic cutaneous leishmaniasis (ACL) reported worldwide. The primary objective of this study was to explore the role of demographic, clinical and environmental risk related-factors in the development of treatment failure, relapse and chronic cases compared to responsive patients with ACL. Moreover, molecular, histopathological and immunohistochemical (IHC) findings between these forms were explored. This work was undertaken as a prospective and case-control study in southeastern Iran. Culture media and nested PCR were used to identify the causative agent. Univariate multinomial and multiple multinomial logistic regression models and the backward elimination stepwise method were applied to analyze the data. A P<0.05 was defined as significant. Also, for different groups, skin punch biopsies were used to study the histopathological and immunohistochemical (IHC) profile. All samples showed that L. tropica was the only etiological agent in all unresponsive and responsive patients with ACL. Data analysis represented that 8 major risk factors including nationality, age groups, occupation, marital status, history of chronic diseases, duration of the lesion, the lesion on face and presence of domestic animals in the house were significantly associated with the induction of unresponsive forms. The histopathological and immunohistochemical findings were different from one form to another. The present findings clearly demonstrated a positive relation between ACL and distinct demographic, clinical and environmental risk determinants. Knowledge of the main risk factors for ACL infection is crucial in improving clinical and public health strategies and monitor such perplexing factors. Negligible data are present related to anthroponotic cutaneous leishmaniasis (ACL) treatment outcome and resultant unresponsiveness risk determinants. The role of demographic, clinical, and environmental risk associated-factors in the development of treatment failure, relapse, and chronic forms of ACL has not been studied. We carried out a case-control study for a period of 4 years (2015–2019) using culture media and nested PCR to identify the causative agent. Afterward, we analyzed the data by univariate multinomial and multiple multinomial logistic regression models and the backward elimination stepwise method. Also, we examined skin punch biopsies to study the histopathological and immunohistochemical (IHC) profile for different comparative groups. The findings identified 8 major risk factors were significantly associated with the creation of unresponsive forms. Clinical practitioners and health surveillance systems should be aware of and monitor such perplexing factors. Awareness of the major determinants for unresponsiveness to the treatment of ACL is critical to improving clinical strategies and public health measures. These multidisciplinary approaches need to address specific barriers that directly affect the treatment outcome.
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Affiliation(s)
- Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman Univeprsity of Medical Sciences, Kerman, Iran
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman Univeprsity of Medical Sciences, Kerman, Iran
- * E-mail:
| | - Shahriar Dabiri
- Department of Pathology, Afzalipour Hospital, Pathology and Stem Cell Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Simin Shamsi Meymandi
- Department of Dermatology, Pathology and Stem Cell Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Karamoozian
- Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Rezvan Amiri
- Department of Dermatology, Afzalipour Hospital, Kerman University of Medical Sciences, Kerman, Iran
| | - Amireh Heshmatkhah
- Dadbin Health Clinic, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Borhani Zarandi
- Research Center for Hydatid Disease in Iran, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Reza Aflatoonian
- Research Center for Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sharifi
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Kheirandish
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
| | - Saeid Hassanzadeh
- Department of Pathobiology, Faculty of Veterinary Medicine, Shahid Bahonar University of Kerman, Kerman, Iran
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11
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Ziaei Hezarjaribi H, Karamian M, Geran Orimi T, Pagheh AS, Emadi SN, Fakhar M, Derakhshani-Niya M. Phylogenetic position of Leishmania tropica isolates from an old endemic focus in south-eastern Iran; relying on atypical cutaneous leishmaniasis. Transbound Emerg Dis 2020; 68:1493-1503. [PMID: 32881318 DOI: 10.1111/tbed.13818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 08/23/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023]
Abstract
Cutaneous leishmaniasis (CL) is a major health problem in Iran, with a heavy burden on human health and society. There is little knowledge about the molecular epidemiology of the disease, as well as phylogenetic relationship of causative agents in south-eastern Iran. The aim of the present study was to investigate the molecular aspects of CL, especially atypical CL in the Bam district, Kerman province, south-eastern Iran, as an endemic region of CL in Iran. The smears were collected from lesion samples of 353 patients clinically suspected to CL, who attended local health centres in the Bam district during 2016-2017. Direct smears were examined for Leishmania parasites using the Giemsa staining technique. Amplification of kinetoplast DNA (kDNA) and the ribosomal internal transcribed spacer 1(ITS-1) gene were carried out using polymerase chain reaction (PCR). Then, the ITS1-PCR products were sequenced for phylogenetic analysis. Overall, 278 cases were confirmed as CL by microscopic examination of Giemsa-stained slides. Clinical presentation of the lesions was basically of two types: (a) typical lesions and (b) atypical including lupoid ulcers, sporotrichoid, nodular and exudative lesions. The PCR assay on all specimens of skin lesions proved L. tropica as the main pathogenic agent. Phylogenic analysis revealed high similarity among isolates from the Bam district in the south-east with isolates from Birjand in eastern Iran, as well as with isolates from Herat province in western Afghanistan. The study provided valuable information concerning the genetic diversity of the parasite as one of the factors influencing the clinical manifestations in CL in south-eastern Iran, which could be the basis for planning future control strategies.
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Affiliation(s)
- Hajar Ziaei Hezarjaribi
- Molecular and Cell Biology Research Center, Department of Parasitology, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.,Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis (INRCL) and Toxoplasmosis (INRCT), Department of Parasitolgy, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mehdi Karamian
- Department of Parasitology and Mycology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Tahmineh Geran Orimi
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis (INRCL) and Toxoplasmosis (INRCT), Department of Parasitolgy, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Abdol Sattar Pagheh
- Infectious Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Seyed Naser Emadi
- Skin Research Center, Razi and Imam Khomeini Hospitals, Department of Dermatology, Faculty of Medicine, Tehran University of Medical Sciences, and Iranian Red Crescent, Tehran, Iran
| | - Mahdi Fakhar
- Toxoplasmosis Research Center, Communicable Diseases Institute, Iranian National Registry Center for Lophomoniasis (INRCL) and Toxoplasmosis (INRCT), Department of Parasitolgy, School of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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12
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Ghatee MA, Taylor WR, Karamian M. The Geographical Distribution of Cutaneous Leishmaniasis Causative Agents in Iran and Its Neighboring Countries, A Review. Front Public Health 2020; 8:11. [PMID: 32133334 PMCID: PMC7039857 DOI: 10.3389/fpubh.2020.00011] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/14/2020] [Indexed: 12/15/2022] Open
Abstract
Leishmania tropica and Leishmania major are both the main cause of anthroponotic (ACL) and zoonotic cutaneous leishmaniasis (ZCL), respectively, in the Old World. Leishmania infantum and Leishmania donovani, which are important causes of visceral leishmaniasis, have also occasionally been reported in CL patients. The present study investigates the current distribution of causative species of CL in Iran and neighboring countries in the Middle East. There has been expansion of L. tropica into new urban and rural foci in Iran, with well-documented cases of visceralization, a substantial increase of CL in Syria, and the emergence of new foci and outbreaks in Turkey and Iraq, especially due to L. major. Civil war in Syria and Iraq, population movement, poverty, and climatic change play important roles in the changing CL distribution in this region. Control programs should adopt a multidisciplinary approach based on active surveillance and case finding, especially in vulnerable refugee populations, determination of hazard maps for CL hot points using GIS and other advanced technology, the free distribution of drugs, rodent control, and greater community engagement in poor and marginalized populations. Comprehensive molecular studies that could show the species and strains of Leishmania in different areas of each country can give a better view from the distribution of CL in this region.
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Affiliation(s)
- Mohammad Amin Ghatee
- Cellular and Molecular Research Center, Yasuj University of Medical Sciences, Yasuj, Iran.,Department of Parasitology, School of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
| | - Walter R Taylor
- Clinical Therapeutics Unit, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Mehdi Karamian
- Infectious Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
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Firooz A, Mortazavi H, Khamesipour A, Ghiasi M, Abedini R, Balighi K, Esmaili N, Nassiri-Kashani M, Eskandari SE, Mohebali M, Mir Amin Mohammadi A, Dowlati Y. Old world cutaneous leishmaniasis in Iran: clinical variants and treatments. J DERMATOL TREAT 2020; 32:673-683. [DOI: 10.1080/09546634.2019.1704214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alireza Firooz
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Mortazavi
- Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
| | - Ali Khamesipour
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ghiasi
- Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
| | - Robabeh Abedini
- Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
| | - Kamran Balighi
- Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
| | - Nafiseh Esmaili
- Department of Dermatology, Tehran University of Medical Sciences, Razi Hospital, Tehran, Iran
| | - Mansour Nassiri-Kashani
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - S. Ebrahim Eskandari
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohebali
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Mir Amin Mohammadi
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Yahya Dowlati
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Baghad B, Riyad M, Razanapinaritra R, Maksouri H, Ben Errais H, Chiheb S. [Pediatric cutaneous leishmaniasis in Morocco: Clinical and epidemiological features]. Ann Dermatol Venereol 2019; 147:106-112. [PMID: 31843225 DOI: 10.1016/j.annder.2019.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 04/03/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Cutaneous leishmaniasis (CL) is a parasitic disease caused by a flagellate protozoa of the genus Leishmania and is a public health problem throughout the world. In Morocco, CL may be sporadic or endemic depending on the species of Leishmania and the region involved. Casablanca is a non-endemic city but many children with CL come from elsewhere in the country. The aim of our study is to describe the clinical and epidemiological particularities of CL diagnosed in children at the Casablanca University Hospital. MATERIALS AND METHODS A cross-sectional study was conducted between 2010 and 2016. All patients with one or more skin lesions suggestive of CL underwent parasitological and molecular investigation. Epidemiological and clinical data from patients with positive genotyping were collected and analyzed. A comparative study was made of epidemiological and clinical variables between children and adults and between different species found in children. RESULTS One hundred and six cases of CL were diagnosed, of which 40 in children (37.7%): 29 due to L. tropica (72.5%), 7 due to L. major (17.5%), and 4 due to L. infantum (10%). CL caused by L. tropica was significantly associated with children (P=0.009) and was distinguished by the predominance of the nodular form (P=0.04) and a facial location (P=0.007). Compared to adults, childhood CL lesions were characterized by their small size (P=0.001) and facial location (P=0.003). Children were treated mainly with pentavalent antimonials, with good safety and clinical response. CONCLUSION In our series, CL due to L. tropica was predominant in children, reflecting the epidemic nature and wide geographical distribution of this species in Morocco. CL due to L. tropica was significantly associated with facial location and nodular form in children.
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Affiliation(s)
- B Baghad
- Service de dermatologie et vénéréologie, CHU Ibn Rochd, Casablanca, Maroc; Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc.
| | - M Riyad
- Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc; Laboratoire de parasitologie, faculté de médecine et pharmacie, université Hassan II de Casablanca, Maroc
| | - R Razanapinaritra
- Service de dermatologie et vénéréologie, CHU Ibn Rochd, Casablanca, Maroc; Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc
| | - H Maksouri
- Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc; Laboratoire de parasitologie, faculté de médecine et pharmacie, université Hassan II de Casablanca, Maroc
| | - H Ben Errais
- Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc
| | - S Chiheb
- Service de dermatologie et vénéréologie, CHU Ibn Rochd, Casablanca, Maroc; Équipe de recherche, immunopathologie des maladies infectieuses et de système, faculté de médecine et de pharmacie, université Hassan II de Casablanca, Maroc
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15
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Mohebali M, Nadim A, Khamesipour A. An overview of leishmanization experience: A successful control measure and a tool to evaluate candidate vaccines. Acta Trop 2019; 200:105173. [PMID: 31525323 DOI: 10.1016/j.actatropica.2019.105173] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/17/2019] [Accepted: 09/12/2019] [Indexed: 12/11/2022]
Abstract
Leishmanization (LZ) is an intradermal inoculation of live Leishmania to induce an artificial cutaneous leishmaniasis (CL) lesion in a covered part of the body to protect against further natural CL lesion development. Leishmanization has been used from ancient times and when NNN medium was developed continued with using Leishmania from culture media. The objective of this study was to review LZ published experiences. This article is a review of LZ experiences and historical studies initiated since 1910 when Leishmania promastigotes were harvested from culture media and used for LZ. This review includes LZ experiences in Israel, some countries of Former Soviet Union and Iran. The results of LZ in Israel, some countries of Former Soviet Union and Iran showed that despite limitations, using this method significantly reduced the incidence rate of CL among leishmanized individuals in endemic areas. In conclusion, leishmanization using Leishmania major produced under GMP guideline is a valuable tool to protect against CL, there are limitations which need further study.
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Affiliation(s)
- Mehdi Mohebali
- Department of Medical Parasitology & Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Research Center for Endemic Parasites of Iran, Tehran University of Medical Sciences, Tehran, Iran
| | - Abolhassan Nadim
- Continuously member of Academy of Medical Sciences, Tehran, Iran
| | - Ali Khamesipour
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran 14166-13675, Iran.
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Comparison of Nested-PCR and Loop-Mediated Isothermal Amplification for Cutaneous Leishmaniasis Diagnosis. Jundishapur J Microbiol 2019. [DOI: 10.5812/jjm.94171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Sharifi I, Aflatoonian MR, Babaei Z, Sharifi F, Keyhani A, Salarkia E, Khosravi A, Khamesipour A, Mohebali M, Nadim A, Bamorovat M. Emerging Epidemics of Cutaneous Leishmaniasis in Iran: Operational Aspects, Management and Implemented Control Approaches. JOURNAL OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASES 2019. [DOI: 10.29252/jommid.7.3.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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18
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Aflatoonian MR, Sharifi I, Aflatoonian B, Bamorovat M, Heshmatkhah A, Babaei Z, Ghasemi Nejad Almani P, Mohammadi MA, Salarkia E, Aghaei Afshar A, Sharifi H, Sharifi F, Khosravi A, Khatami M, Arefinia N, Fekri A, Farajzadeh S, Khamesipour A, Mohebali M, Gouya MM, Shirzadi MR, Varma RS. Associated-risk determinants for anthroponotic cutaneous leishmaniasis treated with meglumine antimoniate: A cohort study in Iran. PLoS Negl Trop Dis 2019; 13:e0007423. [PMID: 31188834 PMCID: PMC6590833 DOI: 10.1371/journal.pntd.0007423] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/24/2019] [Accepted: 04/29/2019] [Indexed: 01/22/2023] Open
Abstract
Background The control of cutaneous leishmaniasis (CL) is facilitated by knowledge of factors associated with the treatment failures in endemic countries. The aim of this evaluation was to identify the potential risk determinants which might affect the significance of demographic and clinical characteristics for the patients with anthroponotic CL (ACL) and the outcome of meglumine antimoniate (MA) (Glucantime) treatment. Methodology/Principal findings This current was executed as a cohort spanning over a period of 5 years which centered in southeastern part of Iran. Altogether, 2,422 participants were evaluated and 1,391 eligible volunteer patients with ACL caused by Leishmania tropica were included. Overall, 1,116 (80.2%) patients received MA intraleisionally (IL), once a week for 12 weeks along with biweekly cryotherapy, while 275 (19.8%) patients received MA alone (20 mg/kg/day for 3 weeks) (intramuscular, IM). The treatment failure rate in ACL patients was 11% using IL combined with cryotherapy plus IM alone, whilst 9% and 18.5% by IL along with cryotherapy or IM alone, respectively. Multivariate logistic regression model predicted 5 major associated-risk determinants including male (odds ratio (OR) = 1.54, confidence interval (CI) = 1.079–2.22, p = 0.018), lesion on face (OR = 1.574, CI = 1.075–2.303, p = 0.02), multiple lesions (OR = 1.446, CI = 1.008–2.075, p = 0.045), poor treatment adherence (OR = 2.041, CI = 1.204–3.46, p = 0.008) and disease duration > 4 months (OR = 2.739, CI = 1.906–3.936, p≤0.001). Conclusions/Significance The present study is the original and largest cohort of ACL patients who treated with MA. A comprehensive intervention and coordinated action by the health authorities and policy-makers are crucial to make sure that patients strictly follow medical instructions. Early detection and effective therapy < 4 months following the onset of the lesion is critical for successful treatment of the patients. Since a significant number of patients are still refractory to MA, reducing man-vector exposure and development of new effective alternative drugs are essential measures against ACL due to L. tropica. Cutaneous leishmaniasis (CL) is a serious neglected tropical disease with social stigma and associated disfiguring with health burden, especially in poor endemic regions of the world. Iran is among the seven high burden CL-infected countries. Limited data are available in regarding to CL treatment and related risk determinants. Parasitologically confirmed ACL patients caused by Leishmania tropica were treated over a 5-year period (2012–2016), with IL meglumine antimoniate (MA) (Glucantime), combined with cryotherapy or with IM MA alone. The objective of this study was to identify the potential risk factors that are associated with response to treatment. The ensuing results with both therapeutic routes identified 5 major risk determinants namely male patients, lesion on face, multiple lesions, poor treatment regimen and disease duration >4 months. The extent to which medical instructions related to patients, therapy and the healthcare system should be seriously monitored. This requires multidisciplinary actions to address specific barriers which directly threaten the treatment outcome. Furthermore, early detection and prompt treatment <4 months following the disease duration together with implementations of public health education and prophylactic measures should receive priority in high risk areas.
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Affiliation(s)
- Mohammad Reza Aflatoonian
- Research Center of Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
- * E-mail: ,
| | - Behnaz Aflatoonian
- Research Center of Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Amireh Heshmatkhah
- Shahid Dadbin Clinic, Kerman University of Medical Sciences, Kerman, Iran
| | - Zahra Babaei
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Mohammad Ali Mohammadi
- Research Center for Hydatid Disease in Iran, Kerman University of Medical Sciences٫ Kerman, Iran
| | - Ehsan Salarkia
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Abbas Aghaei Afshar
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Sharifi
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Khosravi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mehrdad Khatami
- School of Medicine, Bam University of Medical Sciences, Bam, Iran
| | - Nasir Arefinia
- Shahid Dadbin Clinic, Kerman University of Medical Sciences, Kerman, Iran
| | - Alireza Fekri
- Department of Dermatology, Afzalipour Hospital, Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Saeideh Farajzadeh
- Department of Dermatology, Afzalipour Hospital, Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Khamesipour
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Mohebali
- Department of Medical Parasitology and Mycology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Rajender S. Varma
- Regional Centre of Advanced Technologies and Materials, Faculty of Science, Palacký University in Olomouc, Šlechtitelů 27, Czech Republic
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Abstract
Cutaneous leishmaniasis is a parasitic infection caused by a flagellated parasite belonging to the genus Leishmania. In most cases, it is a zoonotic disease transmitted via a bite by bloodsucking sand-flies of the genus Phlebotomus. The disease reservoirs consist of wild or semi-domesticated animals, generally rodents or dogs. The disease itself is distributed extensively worldwide in the Americas, Asia, Europe and Africa. Epidemiology is affected by environmental, migratory and climatic factors. Identification of the different types of leishmaniasis is based chiefly on the biochemical characteristics (isoenzymes) on which their classification is based. The offending parasites are dimorphic intracellular organisms within the phagosome of the host's immune cells, and a single-cell flagellated protozoan with a kinetoplast contained in the gut of the vector and in culture. Three major clinical forms are seen: cutaneous leishmaniasis, mucosal leishmaniasis and visceral leishmaniasis. The clinical presentation depends on factors associated with the virulence of the parasite, with individual immune response and with the site of lesions. Although each type of leishmaniasis may have its own specific cutaneous signs and endemic regions, the most common presentations are crusted, ulcerated nodules and plaques. The natural history of leishmaniasis must also be considered when formulating therapeutic strategies. Cutaneous leishmaniasis resolves spontaneously within between one month and six years. While numerous therapeutic options have been considered in recent decades, very few have shown proven efficacy and safety. Antimony compounds administered either directly to the lesion or parenterally remain the standard treatment and their toxicity calls for vigilance and monitoring of therapy.
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Affiliation(s)
- M Mokni
- Faculté de médecine de Tunis, université Al Manar 2, service de dermatologie, hôpital La Rabta, rue Jabbari-Bab Saadoun, 1007 Tunis, Tunisie.
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Gitari JW, Nzou SM, Wamunyokoli F, Kinyeru E, Fujii Y, Kaneko S, Mwau M. Leishmaniasis recidivans by Leishmania tropica in Central Rift Valley Region in Kenya. Int J Infect Dis 2018; 74:109-116. [PMID: 30017946 DOI: 10.1016/j.ijid.2018.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/05/2018] [Accepted: 07/05/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES This study sought to determine the endemic Leishmania species, the clinical features of cutaneous leishmaniasis (CL) in the Central Rift Valley in Kenya and to give an account on unresponsiveness to treatment in the region. METHODS Participants were clinically identified and grouped into untreated, classical and recidivate based on clinical manifestation and clinical data. Leishmaniasis recidivans lesions were scaly hyperemic papules that appeared before the classic lesion had healed or after healing. The demographics and socio-economic data were recorded and lesion scraping samples screened through microscopy and Internal Transcribed Spacer 1-PCR. Leishmania species were identified using Restriction Fragment Length Polymorphism. RESULTS A total of 52 participants were sampled, of which, 44.2% of the cases were recidivate and L. tropica the only species identified. All patients had been treated using sodium stibogluconate (SSG) which is the recommended first-line drug in Kenya. 60% of the patients experienced prolonged exposure to the drug (>30 days). CONCLUSION L. tropica is the endemic Leishmania species for CL leading to classical and leishmaniasis recidivans. Treatment of CL in the area is not effective hence, alternative measures/therapy should be considered to cope with the unresponsiveness.
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Affiliation(s)
- Joseph Wambugu Gitari
- Department of Molecular Biology and Biotechnology, Pan African University Institute of Basic Sciences, Technology and Innovation, Nairobi, Kenya
| | - Samson Muuo Nzou
- Center for Infectious Parasitic Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya; Nagasaki University, Institute of Tropical Medicine, Kenya Medical Research Institute Project (NUITM-KEMRI Project), Nairobi, Kenya.
| | - Fred Wamunyokoli
- Department of Molecular Biology and Biotechnology, Pan African University Institute of Basic Sciences, Technology and Innovation, Nairobi, Kenya
| | | | - Yoshito Fujii
- Institute of Tropical Medicine, Eco-epidemiology Department (NEKKEN), Nagasaki University, Japan
| | - Satoshi Kaneko
- Nagasaki University, Institute of Tropical Medicine, Kenya Medical Research Institute Project (NUITM-KEMRI Project), Nairobi, Kenya; Institute of Tropical Medicine, Eco-epidemiology Department (NEKKEN), Nagasaki University, Japan
| | - Matilu Mwau
- Center for Infectious Parasitic Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
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Heras‐Mosteiro J, Monge‐Maillo B, Pinart M, Lopez Pereira P, Reveiz L, Garcia‐Carrasco E, Campuzano Cuadrado P, Royuela A, Mendez Roman I, López‐Vélez R. Interventions for Old World cutaneous leishmaniasis. Cochrane Database Syst Rev 2017; 12:CD005067. [PMID: 29192424 PMCID: PMC6485999 DOI: 10.1002/14651858.cd005067.pub5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008. OBJECTIVES To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis. SEARCH METHODS We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE. SELECTION CRITERIA Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search. MAIN RESULTS We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons. AUTHORS' CONCLUSIONS There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.
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Affiliation(s)
- Julio Heras‐Mosteiro
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | - Begoña Monge‐Maillo
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
| | - Mariona Pinart
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UKNottinghamUK
| | - Patricia Lopez Pereira
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | | | - Emely Garcia‐Carrasco
- National Referral Centre for Tropical DiseasesInfectious Diseases DepartmentCtra Colmenar, Km 9,100.MadridSpain28034
| | - Pedro Campuzano Cuadrado
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Ana Royuela
- Biomedical Sciences Research Institute,Hospital Universitario Puerta de Hierro‐MajadahondaDepartment of BiostatisticsMajadahondaSpain28222
| | - Irene Mendez Roman
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamSpainNG7 2NR
| | - Rogelio López‐Vélez
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
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Heras‐Mosteiro J, Monge‐Maillo B, Pinart M, Lopez Pereira P, Garcia‐Carrasco E, Campuzano Cuadrado P, Royuela A, Mendez Roman I, López‐Vélez R. Interventions for Old World cutaneous leishmaniasis. Cochrane Database Syst Rev 2017; 11:CD005067. [PMID: 29149474 PMCID: PMC6486265 DOI: 10.1002/14651858.cd005067.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008. OBJECTIVES To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis. SEARCH METHODS We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE. SELECTION CRITERIA Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search. MAIN RESULTS We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons. AUTHORS' CONCLUSIONS There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.
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Affiliation(s)
| | - Begoña Monge‐Maillo
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
| | - Mariona Pinart
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UKNottinghamUK
| | - Patricia Lopez Pereira
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | - Emely Garcia‐Carrasco
- National Referral Centre for Tropical DiseasesInfectious Diseases DepartmentCtra Colmenar, Km 9,100.MadridSpain28034
| | - Pedro Campuzano Cuadrado
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Ana Royuela
- Biomedical Sciences Research Institute,Hospital Universitario Puerta de Hierro‐MajadahondaDepartment of BiostatisticsMajadahondaSpain28222
| | - Irene Mendez Roman
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamSpainNG7 2NR
| | - Rogelio López‐Vélez
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
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Abstract
The leishmaniases are diseases caused by pathogenic protozoan parasites of the genus Leishmania. Infections are initiated when a sand fly vector inoculates Leishmania parasites into the skin of a mammalian host. Leishmania causes a spectrum of inflammatory cutaneous disease manifestations. The type of cutaneous pathology is determined in part by the infecting Leishmania species, but also by a combination of inflammatory and anti-inflammatory host immune response factors resulting in different clinical outcomes. This review discusses the distinct cutaneous syndromes described in humans, and current knowledge of the inflammatory responses associated with divergent cutaneous pathologic responses to different Leishmania species. The contribution of key hematopoietic cells in experimental cutaneous leishmaniasis in mouse models are also reviewed and compared with those observed during human infection. We hypothesize that local skin events influence the ensuing adaptive immune response to Leishmania spp. infections, and that the balance between inflammatory and regulatory factors induced by infection are critical for determining cutaneous pathology and outcome of infection.
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Affiliation(s)
- Nurittin Ardic
- Department of Medical Microbiology, Faculty of Medicine, Baskent University, Ankara, Turkey Department of Dermatology, Special Lokman Physician Hospital, Van, Turkey Department of Pediatric, Faculty of Medicine, Hacettepe University, Ankara, Turkey School of Medicine, Gazi University, Ankara, Turkey
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Wound healing in cutaneous leishmaniasis: A double edged sword of IL-10 and TGF-β. Comp Immunol Microbiol Infect Dis 2017; 51:15-26. [PMID: 28504090 DOI: 10.1016/j.cimid.2017.02.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 01/16/2017] [Accepted: 02/08/2017] [Indexed: 01/05/2023]
Abstract
Immune responses have a crucial role during the wound healing process in cutaneous leishmaniasis (CL). However, there are several paradoxes in immunity against CL. On the one hand, regulatory cytokines interleukin (IL)-10 and transforming growth factor beta (TGF-β) increase susceptibility to CL through suppression of several proinflammatory cytokines that require for defense against CL. On the other hand, these cytokines play a pivotal role in the acceleration of wound healing process. This review discusses about the dual role of IL-10 and TGF-β during the wound healing process and immunity against CL to offer a new insight about wound healing in CL.
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Moafi M, Rezvan H, Sherkat R, Taleban R, Asilian A, Zarkesh Esfahani SH, Nilforoushzadeh MA, Jaffary F, Feizi A. Evaluation of IL-12RB1, IL-12B, CXCR-3 and IL-17a expression in cases affected by a non-healing form of cutaneous leishmaniasis: an observational study design. BMJ Open 2017; 7:e013006. [PMID: 28132002 PMCID: PMC5278291 DOI: 10.1136/bmjopen-2016-013006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Seldom cutaneous leishmaniasis (CL) may present as a lasting and active lesion(s), known as a non-healing form of CL (NHCL). Non-functional type 1 T helper (Th1) cells are assumed the most important factor in the outcome of the disease. The present study aims to assess some molecular defects that potentially contribute to Th1 impairment in NHCL. METHODS AND ANALYSIS This prospective observational study will be implemented among five groups. The first and second groups comprise patients afflicted with non-healing and healing forms of CL, respectively. The third group consists of those recovered participants who have scars as a result of CL. Those participants who have never lived or travelled to endemic areas of leishmaniasis will comprise the fourth group. The fifth group comprises participants living in hyperendemic areas for leishmaniasis, although none of them have been afflicted by CL. The aim is to recruit 10 NHCL cases and 30 participants in each of the other groups. A leishmanin skin test (LST) will be performed to assess in vivo immunity against the Leishmania infection. The cytokine profile (interleukin (IL)-12p70, interferon (IFN)-γ, C-X-C motif chemokine ligand (CXCL)-11 and IL-17a) of the isolated peripheral blood mononuclear cells (PBMCs) will be evaluated through ELISA. Real-time PCR will determine the C-X-C motif chemokine receptor (CXCR)-3 and IL-17a gene expression and expression of IL-12Rβ1 will be assessed by flow cytometry. Furthermore, IL-12B and IL-12RB1 mutation analysis will be performed. DISCUSSION It is anticipated that the outcome of the current study will identify IL-12B and IL-12RB1 mutations, which lead to persistent lesions of CL. Furthermore, our expected results will reveal an association between NHCL and pro-inflammatory cytokines (IL-12p70, IFN-γ IL-17a and CXCL-11), as well as CXCR-3 expression. ETHICS AND DISSEMINATION This study has been approved by a local ethical committee. The final results will be disseminated through peer-reviewed journals and scientific conferences.
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Affiliation(s)
- Mohammad Moafi
- Faculty of Veterinary Science, Department of Pathobiology, Bu-Ali Sina University, Hamedan, Iran
| | - Hossein Rezvan
- Faculty of Veterinary Science, Department of Pathobiology, Bu-Ali Sina University, Hamedan, Iran
| | - Roya Sherkat
- Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roya Taleban
- Acquired Immunodeficiency Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Asilian
- Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | - Fariba Jaffary
- Skin Diseases and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- Department of Epidemiology and Biostatistics, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran
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Lupoid leishmaniasis among the known cases of cutaneous leishmaniasis in Herat Province, western Afghanistan. J Infect Public Health 2016; 9:557-63. [DOI: 10.1016/j.jiph.2015.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 11/20/2015] [Accepted: 12/11/2015] [Indexed: 11/23/2022] Open
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Solomon M, Greenberger S, Baum S, Pavlotsky F, Barzilai A, Schwartz E. Unusual forms of cutaneous leishmaniasis due to Leishmania major. J Eur Acad Dermatol Venereol 2015; 30:1171-5. [PMID: 26347371 DOI: 10.1111/jdv.13220] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) due to Leishmania major (L. major) is common in the Middle East; however, this skin infection may be under-diagnosed when it presents atypically. OBJECTIVE To highlight the occurrence of uncommon presentations of CL that may elude diagnosis. MATERIALS AND METHODS A retrospective study was performed among patients who presented at The Sheba Medical Center between 2005 and 2014 with atypical clinical presentations of CL due to L. major. RESULTS Twelve patients with unusual clinical presentations of L. major CL were identified. All infections were acquired in L. major - endemic areas of Israel. The average age was 37 years. The average number of lesions was 2. Nine patients presented with a form that mimicked other forms of CL, such as lupoid, giant ulcer, sporotrichoid and recidivans, and three had a variant resembling other infectious skin diseases, such as erysipeloid and verruciform. All patients required systemic therapy. CONCLUSION Cutaneous leishmaniasis due to L. major can masquerade as many other infectious and inflammatory diseases. In addition, it can mimic clinical forms of New World CL. We suggest that in endemic countries or in travellers returning from countries where L. major is endemic, polymerase chain reaction (PCR) for Leishmania-specific DNA should be performed routinely in cases of unusual presentations of dermatitis with a single or a few lesions, even if a diagnosis of CL was not considered by the referring clinician.
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Affiliation(s)
- M Solomon
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Greenberger
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Baum
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - F Pavlotsky
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Barzilai
- Department of Dermatology, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Schwartz
- Center for Geographic Medicine and Tropical Diseases, Chaim Sheba Medical Center, Tel Hashomer, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Crowe A, Slavin J, Stark D, Aboltins C. A case of imported Leishmania infantum cutaneous leishmaniasis; an unusual presentation occurring 19 years after travel. BMC Infect Dis 2014; 14:597. [PMID: 25428722 PMCID: PMC4262283 DOI: 10.1186/s12879-014-0597-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 10/29/2014] [Indexed: 11/21/2022] Open
Abstract
Background Leishmania infantum is a flagellated protozoan parasite that is able to parasitize blood and tissue. Leishmania species cause a spectrum of clinical disease with cutaneous, visceral or mucosal involvement. L. infantum is recognised as a cause of visceral leishmaniasis (VL) and is less commonly reported as a cause of cutaneous leishmaniasis (CL) from countries around the Mediterranean basin. This is the first report of imported L. infantum CL to Australia and is remarkable for a 19 year period between the patient's exposure to an endemic region, and the manifestation of symptoms. Case presentation A 76 year old Italian-born man presented to our institution with a non-healing lesion over his upper lip, abutting his nasal mucosa. The patient had travelled to Italy, an endemic area for L. infantum 19 years earlier but had resided in Australia, a non-endemic area since. Histopathology performed on a biopsy of the lesion demonstrated findings consistent with CL. A species specific polymerase chain reaction (PCR) performed on the tissue detected L. infantum. The patient had complete clinical recovery following treatment with Liposomal amphotericin B at a dose of 3 mg/kg for five days followed by a subsequent 3 mg/kg dose at day ten. Conclusions L. infantum should be recognised as a cause of imported CL in returned travellers from the Mediterranean. In this case, the incubation period for L. infantum CL was at least 19 years. This case adds to the described spectrum of clinical presentations of leishmaniasis and supports the theory of parasite persistence underlying natural immunity and recurrence of disease. Clinicians should consider L. infantum CL in the differential diagnosis of a non-healing skin lesion in any patient who reports travel to the Mediterranean, even when travel occurred several years before clinical presentation. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0597-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amy Crowe
- Department of Infectious Diseases, St Vincent's Hospital, Melbourne, Australia.
| | - John Slavin
- Department of Pathology, St Vincent's Hospital, Melbourne, Australia.
| | - Damien Stark
- Department of Microbiology, SydPath, St Vincent's Hospital, Darlinghurst, New South Wales, Australia.
| | - Craig Aboltins
- Department of Infectious Diseases, St Vincent's Hospital, Melbourne, Australia. .,Department of Infectious Diseases, Northwest Academic Centre, The University of Melbourne, Epping, Victoria, Australia.
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Mashayekhi Goyonlo V, Elnour H, Nordlind K. Interleukin-2 expression in lupoid and usual types of old world cutaneous leishmaniasis. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e5410. [PMID: 25763226 PMCID: PMC4329931 DOI: 10.5812/ircmj.5410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Revised: 11/12/2013] [Accepted: 10/06/2014] [Indexed: 12/02/2022]
Abstract
Background: Interleukin (IL)-2 plays a central role in T cell-dependent immune responses. Objectives: We conducted this study to determine and compare IL-2 expression in lupoid and usual types of Old World Cutaneous Leishmaniasis (OWCL), using immunohistochemistry. Patients and Methods: Thirteen paraffin-embedded specimens of lupoid and 12 specimens of usual types of OWCL were used. A mouse monoclonal anti IL-2 antibody was used for staining by the envision technique. Results: There were strongly stained discrete foci of staining through inflammatory infiltrates of dermis and also in basal layers of epidermis and adnexal structures, with a distinctive pattern of hot spot activity foci (mean of 9.31 ± 6.4 versus 8.17 ± 6.9 foci per HPF for lupoid and usual types, respectively). The expression of IL-2 had no correlation with the pattern of granulomatous inflammation (tuberculoid, sarcoidal or mixed suppurative). Conclusions: Interleukin-2 takes part in the immunological response of the granulomatous reaction of OWCL and is not statistically different between lupoid and usual types (P = 0.674).
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Affiliation(s)
- Vahid Mashayekhi Goyonlo
- Department of Dermatology, Faculty of Medicine, Rsearch Center for Skin Disease and Cutaneous Leishmaniasis, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding Author: Vahid Mashayekhi Goyonlo, Department of Dermatology, Faculty of Medicine, Rsearch Center for Skin Disease and Cutaneous Leishmaniasis, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel: +98-5118022490, E-mail:
| | - Hesameldin Elnour
- Department of Medicine, Unit of Dermatology and Venereology, Solna, Karolinska Instititutet, Stockholm, Sweden
| | - Klas Nordlind
- Department of Medicine, Unit of Dermatology and Venereology, Solna, Karolinska Instititutet, Stockholm, Sweden
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Gomes CM, Cesetti MV, de Morais OO, Mendes MST, Roselino AM, Sampaio RNR. The influence of treatment on the development of leishmaniasis recidiva cutis: a 17-year case-control study in Midwestern Brazil. J Eur Acad Dermatol Venereol 2014; 29:109-14. [PMID: 24655077 DOI: 10.1111/jdv.12473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 02/18/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The recurrence of American cutaneous leishmaniasis (ACL) in patients experiencing a long-term cure is often called leishmaniasis recidiva cutis (LRC). LRC is considered an unusual form of ACL. OBJECTIVE This study aims to estimate the incidence of LRC in ACL patients evaluated at a tertiary dermatologic centre in Midwestern Brazil. We also aim to evaluate the association between various treatment regimens and the development of LRC using multivariate analysis in a case-control study. METHODS We performed a 17-year epidemiological study using data from patients treated at our dermatologic centre from July 1994 to December 2011. A retrospective analysis was then performed to estimate risk and protective factors related to clinical presentation. We also assessed the influence of treatment regimens in the development of LRC. RESULTS The incidence of LRC among ACL patients was 1.34%. The analysis included 105 patients; 82 patients (78%) were in the control group, and 23 patients (22%) were in the LRC case group. The data analysis indicated that the standard treatment N-methylglucamine antimoniate (N-MA) reduced the development of LRC in bivariate (odds ratio (OR) = 0.34; 95% CI = 0.13-0.91) and multivariate analyses (OR = 0.16; 95% CI = 0.03-0.86; P = 0.03). However, no differences in LRC incidence were observed when the standard treatment N-MA and alternative drugs, such as pentamidine and amphotericin B, were considered (OR = 0.47; 95% CI = 0.16-1.35) CONCLUSION: We conclude that the standard treatment N-MA, as proposed by the Brazilian Ministry of Health, is effective in the prevention of LRC. Although other drugs have shown promising results in LRC, more scientific evidence is needed to assess their efficacy compared with N-MA.
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Affiliation(s)
- C M Gomes
- Department of Dermatology, Universidade de Brasília, Brasília, Brazil; Laboratório de Dermatomicologia, Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília Brazil
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Abbas AA, Hassan V, Iraj S, Yavar R, Reza AM, Ali OM, Reza YEM, Sina R. First determination of impact and outcome indicators following indoor residual spraying (IRS) with deltamethrin in a new focus of anthroponotic cutaneous leishmaniasis (ACL) in Iran. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2013. [DOI: 10.1016/s2222-1808(13)60002-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nylén S, Eidsmo L. Tissue damage and immunity in cutaneous leishmaniasis. Parasite Immunol 2012; 34:551-61. [DOI: 10.1111/pim.12007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 09/17/2012] [Indexed: 12/21/2022]
Affiliation(s)
- S. Nylén
- Department of Microbiology; Tumor and Cell Biology; Karolinska Institutet; Stockholm; Sweden
| | - L. Eidsmo
- Molecular Dermatology; Department of Medicine Solna; Karolinska Institutet; Stockholm; Sweden
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Shokri A, Sharifi I, Khamesipour A, Nakhaee N, Fasihi Harandi M, Nosratabadi J, Hakimi Parizi M, Barati M. The effect of verapamil on in vitro susceptibility of promastigote and amastigote stages of Leishmania tropica to meglumine antimoniate. Parasitol Res 2011; 110:1113-7. [DOI: 10.1007/s00436-011-2599-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2011] [Accepted: 08/03/2011] [Indexed: 10/17/2022]
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Sharifi I, Poursmaelian S, Aflatoonian MR, Ardakani RF, Mirzaei M, Fekri AR, Khamesipour A, Parizi MH, Harandi MF. Emergence of a new focus of anthroponotic cutaneous leishmaniasis due to Leishmania tropica in rural communities of Bam district after the earthquake, Iran. Trop Med Int Health 2011; 16:510-3. [PMID: 21255206 DOI: 10.1111/j.1365-3156.2011.02729.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe a new emerging focus of anthroponotic cutaneous leishmaniasis (ACL) due to Leishmania tropica in rural areas of Dehbakry county, south-eastern Iran, after the earthquake of 2003. METHODS House-to-house survey of 3884 inhabitants for active leishmaniasis lesions or scars. The diagnosis was confirmed by smears, cultures and identification of the parasite by polymerase chain reaction (PCR). RESULTS All age groups were affected, although patients ≤10 years of age showed the highest rate of infection (P = 0.0001). The overall prevalence rate was 5.3%; 6.3% in females and 4.3% in males. Of 204 cases, 1.8% had active sores and 3.5% had scars, with a significant difference between the sexes (P = 0.005). 47% of the lesions were on the face and 77.9% had one lesion. The incidence rose gradually 2004-2005, but grew exponentially 2006-2008. Electrophoresis of PCR products indicated that L. tropica was the causative agent. CONCLUSIONS The current emergence was unexpected in this rural locality, where no previous history of CL was recorded. According to our knowledge this is the first report of a gradually establishing new ACL focus in rural communities after the 2003 earthquake.
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Affiliation(s)
- Iraj Sharifi
- Dermatology and Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran.
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