Treatment of cutaneous leishmaniasis in travelers 2009

Treatment outcome of imported cutaneous leishmaniasis among travellers and migrants infected with Leishmania major and Leishmania tropica: a retrospective study in European centres 2013 to 2019

OBJECTIVES

Cutaneous leishmaniasis (CL) in Asia, Northern and Sub-Saharan Africa is mainly caused by Leishmania major and Leishmania tropica. We describe and evaluate the treatment outcome of CL among travellers and migrants in Europe.

METHODS

A retrospective study of parasitological confirmed CL cases caused by L. major and L. tropica during 2013-2019 in Europe. Data were collected from medical records and databases within the LeishMan network.

RESULTS

Out of 206 included cases of CL, seventy-five were identified as L. major and 131 as L. tropica. Eighty percent of the patients with L. tropica infection were migrants, whereas 53 % of patients with L. major infection had been visiting friends and relatives. Among patients with L. tropica, 48 %, were younger than 15. Pentavalent antimony cured 73 % (L. major) and 78 % (L. tropica). Intralesional administration had a cure rate, 86 % and systemic, 67%, on L. tropica. Liposomal amphotericin B had a cure rate of 44-63 %.

CONCLUSION

L. major infections were mostly found in individuals visiting friends and relatives, whereas L. tropica were mainly identified in migrants. No patients with L. major relapsed. Pentavalent antimony, liposomal amphotericin B and cryotherapy had cure rates in accordance with previous studies.

Spatial variations in Leishmaniasis: A biogeographic approach to mapping the distribution of Leishmania species

Cutaneous Leishmaniasis (CL) is the most prevalent form of Leishmaniasis and is widely endemic in the Americas. Several species of Leishmania are responsible for CL, a severely neglected tropical disease and the treatment of CL vary according to the different species of Leishmania. We proposed to map the distribution of the Leishmania species reported in French Guiana (FG) using a biogeographic approach based on environmental predictors. We also measured species endemism i.e., the uniqueness of species to a defined geographic location. Our results show that the distribution patterns varied between Leishmania spp. and were spatially dependent on climatic covariates. The species distribution modelling of the eco-epidemiological spatial patterns of Leishmania spp. is the first to measure endemism based on bioclimatic factors in FG. The study also emphasizes the impact of tree cover loss and climate on the increasing distribution of L. (Viannia) braziliensis in the most anthropized regions. Detection of high-risk regions for the different between Leishmania spp. is essential for monitoring and active surveillance of the vector. As climate plays a major role in the spatial distribution of the vector and reservoir and the survival of the pathogen, climatic covariates should be included in the analysis and mapping of vector-borne diseases. This study underscores the significance of local land management and the urgency of considering the impact of climate change in the development of vector-borne disease management strategies at the global scale.

Molecular epidemiological survey of cutaneous leishmaniasis from Azad Jammu and Kashmir, Pakistan

Cutaneous leishmaniasis (CL) is an emerging neglected tropical disease in Azad Jammu and Kashmir which is an underdeveloped area. Prevalence and parasite species identification are the key factors to control disease in a particular population, which were the objectives of the present study. Due to a lack of previous data, we performed a district-based active CL surveillance in 2018. The data of CL, suspected (n = 20,000) cases were analyzed statistically and identified the parasite species in microscopic positive cases by ITS1-PCR RFLP and also obtained accession numbers MN891719-28 from gene Bank. The phylogenetic tree was constructed using MEGA6 software. Out of 20,000 CL, suspected cases the highest rate of 4.02% (135/3360) of CL in Mirpur and the lowest 1.58% (8/505) in Neelum was reported. The slide positivity rate, annual parasite incidence rate and annual blood examination rate were 2.27 per 1000 population, 0.08 and 0.34%. The males were more infected 58.12% (297/511) than females 41.88% (214/511) and the age group of 1-20 years were found highly infected 82.78% (423/511) than 21-40 years 13.89% (71/511) and 41-60 years 3.33% (17/511) in the studied population. The patients 56.36% (288/511) had a single lesion whereas 29.35% (150/511) had two, only 10.76% (31/288) and 8% (12/150) were using bed nets. The patients 14.29% (73/511) had three or more lesions were not using bed nets. Only 27.98% (143/511) patients had received treatment, while 72.02% (368/511) didn't. Microscopically positive cases were found to be 2.56% (511/20,000) and ITS1-PCR positive cases were found to be 91.39% (467/511). The RFLP assay confirmed the presence of Leishmania tropica in 467 samples.

The combination therapy of meglumine antimoniate and oxiranes (epoxy-α-lapachone and epoxymethyl-lawsone) enhance the leishmanicidal effect in mice infected by Leishmania (Leishmania) amazonensis

Current treatment of cutaneous leishmaniasis includes pentavalent antimonials as first-line drugs, but this therapy has shown severe adverse effects. An alternative to minimize this issue is based on combination therapy scheme with other drugs. In this study we analyzed the potential of the association of meglumine antimoniate (MA) with the oxiranes epoxy-α-lapachone (LAP) or epoxymethyl-lawsone (LAW). Results demonstrated that association between these drugs enhanced leishmanicidal activity on Leishmania (Leishmania) amazonensis infection. The compounds were tested in monotherapy or in combinations (3:1; 1:1 and 1:3) and reduced intracellular parasite numbers, measured by the endocytic index, in all tested conditions. The most effective combination regimens were MA/LAP or MA/LAW in 3:1 ratio, which achieved a reduction of 98.3% and 93.6% in the endocytic index, respectively. BALB/c mice challenged with L. (L.) amazonensis showed significant reduction in lesion size and parasite load in both footpad and lymph nodes, after four weeks of treatment. Although, MA, LAP or LAW monotherapy were able to control the evolution of lesions when compared to untreated animals (30%, 40% and 40% of reduction, respectively), the combination of MA/LAP and LAW in 3:1 ratio showed better results reducing 61.7 and 54.4%, respectively. The results indicate that the association of meglumine antimoniate to oxiranes lead to an increment in the antileishmanial activity and represent a promising approach for the cutaneous leishmaniasis treatment.

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Meglumine antimoniate with oxiranes enhanced effect against Leishmania infection.

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The most effective treatment in vitro infection was observed in a 3:1 ratio.

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Mice treatment with drugs caused reductions in lesion size and parasite load.

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Antimony-based combination has the potential for leishmaniasis treatment.

Cutaneous leishmaniasis: A neglected disfiguring disease for women

Leishmaniasis is one of eight neglected tropical diseases currently endemic in 102 countries/areas around the world. In recent years, cutaneous leishmaniasis (CL) has been increasingly observed among migrants, travelers, ecotourists, and military personnel. Because of its great capacity to mimic other dermatoses, CL is one of the great imitators and can mislead practitioners, which can result in untreated lesions that cause scars. CL is a disfiguring disease, especially for women, and often leaves scars on visible body sites, causing psychological, social, and economic problems. CS is a challenge, especially in nonendemic regions, such as Australia, because experience with diagnosis and management of the disease is limited.

The epidemiology of cutaneous leishmaniasis in Golestan Province, Iran: A cross-sectional study of 8-years

Background

Leishmaniasis occurs with an incidence of 0.5-1.5 million new cases annually, and is also endemic in 88 countries across the world.

Aim

Presently, we aimed to investigate the status of Cutaneous Leishmaniasis (CL) in Golestan Province in North of Iran.

Methods

A retrospective survey was conducted on existed data of 6873 patients with CL who attended to Health Centers in Golestan Province during 2010 to 2017 years. Data were collected using patient sheets and online registry form of CL. Descriptive statistical methods such as mean and standard deviation, and Chi-square test were employed to report and analyze results. p-Value <0.05 was considered significant.

Results

CL cases were more common in men 3885 (56.7%) than women 2965 (43.3%) (p = 0.001). The most and least cases was reported in 2017 and 2104 as 18 and 3 CL cases, accordingly. CL was mainly happen in the November (3816 cases), December (2832 cases) months. Presently, CL gradually increases in the last three years from 2014 to 2017 years.

Conclusion

Decrease of exposurement, improve the nutrition and child's immunity can be more beneficial.

Cutaneous, mucocutaneous and visceral leishmaniasis in Sweden from 1996-2016: a retrospective study of clinical characteristics, treatments and outcomes

Background

Leishmaniasis is a neglected and poorly reported parasitic infection transmitted by sand flies in tropical and subtropical regions. Knowledge about leishmaniasis has become important in non-endemic countries due to increased migration and travel. Few studies of the clinical management of cutaneous, mucocutaneous and visceral leishmaniasis in non-endemic regions have been published to date. In this study, we aimed to evaluate patient characteristics, clinical manifestations and treatments of leishmaniasis in Sweden, over a 20-year period.

Methods

A retrospective observational nationwide study was performed using medical records of patients diagnosed with leishmaniasis in Sweden from 1996 to 2016. Cases with culture and polymerase chain reaction verified leishmaniasis were identified at the Public Health Agency of Sweden.

Results

In total, 165 cases of leishmaniasis were diagnosed from 1996 to 2016. Medical records from 156 patients (95%) were available for review and included in the study. Cutaneous leishmaniasis was the dominant manifestation (n = 149, 96%), and in 66 patients (44%) cutaneous leishmaniasis was due to Leishmania tropica. Other manifestations were mucocutaneous (n = 4, 3%), visceral (n = 2, 1%) and post-kala-azar dermal leishmaniasis (n = 1, 1%). During this time period, the number of cases increased, especially after 2013. Most patients (n = 81, 52%) were migrants who were infected in their countries of origin (from 2013 to 2016, mainly Syria or Afghanistan). Other groups were Swedish tourists (25%) and returning workers (13%). The time from collection of the diagnostic sample to the start of treatment was less than one month in 81 (66%) patients and under three months in 124 patients (96%). Among the 149 patients with cutaneous leishmaniasis, 125 patients received antileishmanial treatment, and in 88 of these patients (70%) cure was achieved, regardless of treatment.

Conclusions

The number of leishmaniasis cases diagnosed in Sweden increased between 1996 and 2016, mainly in migrants from endemic countries. Although leishmaniasis is a rare disease in Sweden, patients appear to be diagnosed early and treated according to current European guidelines, resulting in an overall high cure rate.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3539-1) contains supplementary material, which is available to authorized users.

Meglumine antimoniate is more effective than sodium stibogluconate in the treatment of cutaneous leishmaniasis

Sodium stibogluconate (SSG, Pentostam) and meglumine antimoniate (MA, Glucantime) are two antimonials that are widely used to treat cutaneous leishmaniasis (CL), but the relative efficacies of these treatments are not clear. The aim of this study is to compare the efficacy of intralesional SSG with intralesional MA therapy in the treatment of CL. One month after completion of the therapy, 1431 of 1728 patients (82%) who received intralesional MA showed complete clinical cure compared to 1157 of 1728 patients (67%) in the SSG group. Patients who did not respond to the first round of therapy were re-administered the same treatment but with twice weekly injections. Following completion of the second course of therapy, 237 of 297 patients (80%) in the MA group and 407 of 561 patients (72%) in the SSG group healed their lesions by 1-month post-treatment. At both times, the differences in cure rates between MA and SSG groups were statistically significant (p < 0.05). Cure rates in the MA group were always significantly higher than SSG groups irrespective of other parameters including age, gender, lesion site and type of lesion. Intralesional MA is more effective than intralesional SSG in the treatment of CL.

Leishmaniasis in travelers: a literature review

Leishmaniasis is a vector-borne protozoan infection whose clinical spectrum ranges from asymptomatic infection to fatal visceral leishmaniasis. Over the last decades, an increase in imported leishmaniasis cases in developed, non-endemic countries, have been pointed-out from a review of the international literature. Among the possible causes are increasing international tourism, influx of immigrants from endemic regions and military operations. The main area for the acquisition of cutaneous leishmaniasis, especially for adventure travelers on long-term trips in highly-endemic forested areas, is represented from South America, whereas popular Mediterranean destinations are emerging as the main areas to acquire visceral variant. Leishmaniasis should be considered in the diagnostic assessment of patients presenting with a compatible clinical syndrome and a history of travel to an endemic area, even if this occurred several months or years before. Adventure travelers, researchers, military personnel, and other groups of travelers likely to be exposed to sand flies in endemic areas, should receive counseling regarding leishmaniasis and appropriate protective measures.

Easy identification of leishmania species by mass spectrometry

BACKGROUND

Cutaneous leishmaniasis is caused by several Leishmania species that are associated with variable outcomes before and after therapy. Optimal treatment decision is based on an accurate identification of the infecting species but current methods to type Leishmania isolates are relatively complex and/or slow. Therefore, the initial treatment decision is generally presumptive, the infecting species being suspected on epidemiological and clinical grounds. A simple method to type cultured isolates would facilitate disease management.

METHODOLOGY

We analyzed MALDI-TOF spectra of promastigote pellets from 46 strains cultured in monophasic medium, including 20 short-term cultured isolates from French travelers (19 with CL, 1 with VL). As per routine procedure, clinical isolates were analyzed in parallel with Multilocus Sequence Typing (MLST) at the National Reference Center for Leishmania.

PRINCIPAL FINDINGS

Automatic dendrogram analysis generated a classification of isolates consistent with reference determination of species based on MLST or hsp70 sequencing. A minute analysis of spectra based on a very simple, database-independent analysis of spectra based on the algorithm showed that the mutually exclusive presence of two pairs of peaks discriminated isolates considered by reference methods to belong either to the Viannia or Leishmania subgenus, and that within each subgenus presence or absence of a few peaks allowed discrimination to species complexes level.

CONCLUSIONS/SIGNIFICANCE

Analysis of cultured Leishmania isolates using mass spectrometry allows a rapid and simple classification to the species complex level consistent with reference methods, a potentially useful method to guide treatment decision in patients with cutaneous leishmaniasis.

Species-directed therapy for leishmaniasis in returning travellers: a comprehensive guide

Background

Leishmaniasis is increasingly reported among travellers. Leishmania species vary in sensitivity to available therapies. Fast and reliable molecular techniques have made species-directed treatment feasible. Many treatment trials have been designed poorly, thus developing evidence-based guidelines for species-directed treatment is difficult. Published guidelines on leishmaniasis in travellers do not aim to be comprehensive or do not quantify overall treatment success for available therapies. We aimed at providing comprehensive species-directed treatment guidelines.

Methodology/Principal Findings

English literature was searched using PubMed. Trials and observational studies were included if all cases were parasitologically confirmed, the Leishmania species was known, clear clinical end-points and time points for evaluation of treatment success were defined, duration of follow-up was adequate and loss to follow-up was acceptable. The proportion of successful treatment responses was pooled using mixed effects methods to estimate the efficacy of specific therapies. Final ranking of treatment options was done by an expert panel based on pooled efficacy estimates and practical considerations. 168 studies were included, with 287 treatment arms. Based on Leishmania species, symptoms and geography, 25 clinical categories were defined and therapy options ranked. In 12/25 categories, proposed treatment agreed with highest efficacy data from literature. For 5/25 categories no literature was found, and in 8/25 categories treatment advise differed from literature evidence. For uncomplicated cutaneous leishmaniasis, combination of intralesional antimony with cryotherapy is advised, except for L. guyanensis and L. braziliensis infections, for which systemic treatment is preferred. Treatment of complicated (muco)cutaneous leishmaniasis differs per species. For visceral leishmaniasis, liposomal amphotericin B is treatment of choice.

Conclusions/Significance

Our study highlights current knowledge about species-directed therapy of leishmaniasis in returning travellers and also demonstrates lack of evidence for treatment of several clinical categories. New data can easily be incorporated in the presented overview. Updates will be of use for clinical decision making and for defining further research.

Human leishmaniasis is caused by unicellular parasites that are injected into the skin by sand-flies, small, flying insects. Many different Leishmania species cause various manifestations of disease, both of the skin and internal organs. Leishmaniasis is a curable disease but clear guidelines on the best available treatment are lacking. Leishmania species differ in sensitivity to available drugs. Until recently, identification of the infecting Leishmania parasite was laborious, thus therapy could not precisely be targeted to the infecting species, in contrast to many other infectious diseases. Nowadays, Leishmania parasites can be identified relatively easily with new DNA techniques. We studied efficacy of therapies for diseases due to different Leishmania species, limited to the English literature. Efficacy was summarized and presented in an easy to read format. Because of difficulties with identification of parasite species in earlier studies, quality of evidence was often limited. Our findings are a major help for clinicians to easily find optimal treatment for specific patients. Moreover, our results demonstrate where additional research is needed to further improve treatment of leishmaniasis.

LeishMan recommendations for treatment of cutaneous and mucosal leishmaniasis in travelers, 2014

BACKGROUND

Treatment of cutaneous leishmaniasis (CL) and mucosal leishmaniasis (ML) in travelers is still controversial. Over the last decade, national and international consortia have published recommendations for treating CL in travelers. These guidelines harmonize many issues, but there are some discrepancies.

METHODS

Leishmania parasites causing CL can now be genotyped by polymerase chain reaction techniques for detecting Leishmania DNA. Therefore, treatment recommendations can now be species based rather than based on geographical exposure. To review the evidence on which the recommendations were based, "LeishMan" (Leishmaniasis Management), a group of experts from 13 institutions in eight European countries, performed a PubMed MEDLINE) literature search and considered unpublished evidence and the experts' own personal experiences. The Oxford evidence grading system was used to evaluate the information.

RESULTS AND CONCLUSION

In this article, the authors provide practical treatment recommendations for imported CL and ML in Europe, drawn up from the review by the European experts.

Cluster of zoonotic cutaneous leishmaniasis (Leishmania major) in European travelers returning from Turkmenistan

We report a cluster of cutaneous leishmaniasis due to Leishmania major in four immunocompetent travelers returning from Western Turkmenistan and having atypical and/or multiple lesions. Treatments with pentamidine or fluconazole were effective. Physicians should be aware that some virulent strains of L major currently circulate in Central Asia.

Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis

This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm(2)), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.

Treatment of mucosal leishmaniasis (L. infantum) with miltefosine in a patient with Good syndrome

We report on a 76-year old patient with recurrent mucosal leishmaniasis. Multiple treatment regimens were administered. After the second relapse, immunologic workup and review of the patient's history revealed the presence of Good syndrome, characterized by immunodeficiency in patients with thymoma. The third relapse was treated with oral miltefosine with complete resolution of the lesions. Miltefosine is an option for treating Old World leishmaniasis (Leishmania infantum) and immunodeficiency should be considered in patients with recurrent leishmaniasis.

Heat-shock protein 70 gene sequencing for Leishmania species typing in European tropical infectious disease clinics

We describe Leishmania species determination on clinical samples on the basis of partial sequencing of the heat-shock protein 70 gene (hsp70), without the need for parasite isolation. The method is especially suited for use in non-endemic infectious disease clinics dealing with relatively few cases on an annual basis, for which no fast high throughput diagnostic tests are needed. We show that the results obtained from this gene are in nearly perfect agreement with those from multilocus enzyme electrophoresis, which is still considered by many clinicians and the World Health Organization (WHO) as the gold standard in Leishmania species typing. Currently, 203 sequences are available that cover the entire hsp70 gene region analysed here, originating from a total of 41 leishmaniasis endemic countries, and representing 15 species and sub-species causing human disease. We also provide a detailed laboratory protocol that includes a step-by-step procedure of the typing methodology, to facilitate implementation in diagnostic laboratories.

Cutaneous leishmaniasis in Switzerland: first experience with species-specific treatment

BACKGROUND

Different species of the genus Leishmania can cause cutaneous (CL) and mucosal leishmaniasis (ML). PCR-based tests allow a rapid diagnosis and determination of the species, thereby enabling species-oriented treatment. Such treatment procedures have not been evaluated to date.

METHODS

Patients presenting with CL and ML between 1999 and 2011 were analysed retrospectively. PCR technology was used to diagnose the disease and identify the protozoan to the species level.

RESULTS

A total of 61 cases were reviewed, including 58 patients with CL and three patients with ML. Treatment was effective in most patients. Treatment failure was reported in six patients with L. panamensis (one fluconazole, one ketoconazole), L. infantum (one excision, one fluconazole), L. tropica (one paromomycin/methylbenzethonium), L. braziliensis (1 paromomycin/methylbenzethonium). In 11 (18 %) patients treatment had to be interrupted due to adverse events, and in eight patients (13 %) a second treatment had to be applied. Treatment with meglumine antimoniate had to be interrupted in six patients, with QTc prolongation the reason for the interruption in three patients.

CONCLUSIONS

Species-related, targeted treatment resulted in good responses in CL and ML lesions. Treatment recommendations for L. panamensis were changed from ketoconazole to miltefosine because of new evidence of treatment failures. Meglumine antimoniate should be restricted to species with poor response to alternative medications and should be used with caution in patients older than 60 years because of its toxicity. Treatment in immunosuppressed patients was successful, but relapses were observed when the immune system could not be restored. This is the first report on L. aethiopica from Egypt.

Clinical findings and management of imported cutaneous leishmaniasis: report of 14 cases from Austria

BACKGROUND

The management of cutaneous leishmaniasis in non-endemic countries is challenging due to the wide variety of clinical manifestations and little information available on treatment modalities for travellers.

METHODS

Retrospective analysis and follow-up investigation in patients with imported cutaneous leishmaniasis managed at the General Hospital Vienna from 2004 to 2010.

RESULTS

In total, 14 patients with cutaneous leishmaniasis were analyzed. The time to diagnosis ranged between weeks and several months and up to four consultations were necessary before diagnosis was accomplished. Histological investigations performed in all patients were diagnostic for CL in 8 (57%) patients. PCR analyses were performed in 12 patients and were positive in 10 (83%) patients. All six patients with negative histological results for CL tested positive in the PCR analysis. Treatment regimens applied included systemic therapy with liposomal amphotericin B, miltefosine, or fluconazole, and local therapy with cryotherapy, paromomycin ointment, photodynamic therapy, surgery, and various combinations.

CONCLUSIONS

The present analysis strongly suggests that awareness of CL among physicians and travellers remains low and highlights the need to harmonize diagnostic and treatment guidelines for cutaneous and mucosal leishmaniasis in European travellers. Diagnostic outcome can be improved by combining histology and PCR in patients with suspected cutaneous leishmaniasis.

Leishmaniasis in the United States: treatment in 2012

Although civilian physicians in the United States seldom encounter patients with leishmaniasis, therapeutic advances in endemic regions have opened the door to approaches that can be applied in this country. Advances revolve around the use of oral miltefosine in all forms of leishmaniasis and the use of short-course intravenous liposomal amphotericin B in visceral and possibly cutaneous infection. Lengthy, traditional intravenous treatment with pentavalent antimony (sodium stibogluconate) still has a role in the United States; however, although expensive, miltefosine and liposomal amphotericin B are considerably more appealing selections for initial therapy.

Treatment of imported New World cutaneous leishmaniasis in Germany

BACKGROUND

Cutaneous leishmaniasis (CL), a parasitic disease which represents a public health problem, particularly in Central and South America, has become a leading condition in travelers who return from tropical countries with skin disorders. Cutaneous leishmaniasis caused by Leishmania (Viannia) braziliensis, the most common causative agent, requires systemic treatment because it is potentially able to disseminate and to cause mucosal or mucocutaneous disease. Although several drugs are available for the systemic treatment of leishmaniases, a definitive treatment regimen for infection caused by species of the Viannia subgenus has yet to be established in many countries, including Germany.

METHODS

We analyzed treatment outcomes in 23 returnees from Central and South America who were diagnosed with L. (V.) braziliensis CL by polymerase chain reaction.

RESULTS

Complete cure within one month following treatment was observed in 18 patients (78%). Cure was achieved with liposomal amphotericin B in 11 of 13 patients, miltefosine in five of eight patients, and meglumine antimoniate in two (of two) patients. Of the five patients (22%) who failed to respond to initial therapy, four were cured with meglumine antimoniate and one with liposomal amphotericin B.

CONCLUSIONS

In this outcome evaluation of treatment of imported L. (V.) braziliensis infections, liposomal amphotericin B, miltefosine, and meglumine antimoniate proved to be effective. Conventional meglumine antimoniate showed high efficacy as a first-line treatment and cured lesions that failed to respond to the other two drugs. A multi-country study using standardized treatment protocols is needed to establish a definitive regimen.

Human African trypanosomiasis in endemic populations and travellers

Human African trypanosomiasis (HAT) or sleeping sickness is caused by the protozoan parasites Trypanosoma brucei (T.b.) gambiense (West African form) and T.b. rhodesiense (East African form) that are transmitted by the bite of the tsetse fly, Glossina spp.. Whereas most patients in endemic populations are infected with T.b. gambiense, most tourists are infected with T.b. rhodesiense. In endemic populations, T.b. gambiense HAT is characterized by chronic and intermittent fever, headache, pruritus, and lymphadenopathy in the first stage and by sleep disturbances and neuro-psychiatric disorders in the second stage. Recent descriptions of the clinical presentation of T.b. rhodesiense in endemic populations show a high variability in different foci. The symptomatology of travellers is markedly different from the usual textbook descriptions of African HAT patients. The onset of both infections is almost invariably an acute and febrile disease. Diagnosis and treatment are difficult and rely mostly on old methods and drugs. However, new molecular diagnostic technologies are under development. A promising new drug combination is currently evaluated in a phase 3 b study and further new drugs are under evaluation.

Case report: Successful treatment of cutaneous leishmaniasis caused by Leishmania aethiopica with liposomal amphothericin B in an immunocompromised traveler returning from Eritrea

Cutaneous leishmaniasis caused by Leishmania aethiopica is rarely encountered outside disease-endemic areas and there have been no clinical trials evaluating its pharmacotherapy. We describe the treatment of cutaneous leishmaniasis caused by L. aethiopica using liposomal amphothericin B in an immunocompromised traveler returning from Eritrea.

Systematic review of the adverse effects of cutaneous leishmaniasis treatment in the New World

Pentavalent antimonials are first-line drugs for the treatment of the cutaneous form of American tegumentary leishmaniasis. Second-line drugs include amphotericin B and pentamidine. Although these drugs have been used for decades, there are no systematic reviews about their safety. The objective of this review was to identify and classify the main adverse effects associated with these drugs and to estimate the frequency of these effects, whenever possible. Intervention studies, case series and case reports containing information regarding clinical, laboratory or electrocardiographic adverse effects of drugs used for the treatment of cutaneous leishmaniasis were systematically retrieved from 10 databases searched between August 13, 2008 and March 31, 2009. The 65 studies included in this review had treated a total of 4359 patients from 12 countries infected with eight different Leishmania species. Despite the small number of drugs used in these studies, a wide variability in the therapeutic regimens was observed. As a consequence, the adverse effects of pentavalent antimonials and pentamidine needed to be classified jointly according to system, irrespective of formulation, daily dose, duration of treatment, and route of administration. The frequencies of adverse effects were calculated based on the data of 32 articles involving 1866 patients. The most frequently reported clinical adverse effects of pentavalent antimonials and pentamidine were musculoskeletal pain, gastrointestinal disturbances, and mild to moderate headache. Electrocardiographic QTc interval prolongation and a mild to moderate increase in liver and pancreatic enzymes were additional adverse effects of pentavalent antimonials. Patients treated with liposomal amphotericin B had mild dyspnea and erythema. The adverse effects associated with miltefosine were vomiting, nausea, kinetosis, headache, diarrhea, and a mild to moderate increase in aminotransferases and creatinine. Although closer surveillance is needed for the treatment of cutaneous leishmaniasis, antileishmanial drugs are basically safe and severe side effects requiring the discontinuation of treatment are relatively uncommon.

A pilot study comparing low-dose liposomal amphotericin B with N-methyl glucamine for the treatment of American cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis is an infectious re-emerging disease that has increased in incidence worldwide. Antimony, a highly toxic drug, remains the first choice therapy to treat it. Liposomal amphotericin B is active against Leishmania and is less toxic than antimony.

OBJECTIVE

To compare low-dose liposomal amphotericin B with N-methyl glucamine for the treatment of American cutaneous leishmaniasis.

PATIENTS/METHODS

In a controlled open-label trial 35 patients with a localized form of American cutaneous leishmaniasis were included. They were allocated to a first group treated with 1.5 mg/kg/day of liposomal amphotericin B for 5 days, or to a second one treated with 20 mgSbV/kg/day of N-methyl glucamine for 20 days.

RESULTS

In the first group, 50% and 81% of patients experienced a clinical cure and clinical improvement respectively. There was a 100% clinical cure in the second group.

CONCLUSION

Liposomal amphotericin B seems to be promising and safe for the treatment of American cutaneous leishmaniasis.

Dermatologic presentations of tropical diseases in travelers

Dermatoses are one of the three most common presenting health care problems in returning travelers. The spectrum of travel-related dermatoses is broad, and includes tropical, cosmopolitan, and environmental skin diseases. Bacterial infections are the main cause of skin consultations in returning travelers. Most of these infections are not specific to the tropics and are the consequences of arthropod bites. Conversely, tropical skin infections are less commonly observed. Knowledge of imported dermatoses among Western physicians is limited, even though it is becoming increasingly important that doctors be able to recognize and differentiate between the diverse varieties of diseases. This review highlights the most recent developments regarding dermatologic presentations of tropical diseases in travelers in order to provide more effective pre-travel counseling and an up-to-date aid to post-travel diagnosis and treatment.

Successful treatment of Old World cutaneous leishmaniasis caused by Leishmania infantum with posaconazole

Old World cutaneous leishmaniasis is a widespread and potentially disfiguring protozoal infection that is endemic in the Mediterranean basin, Africa, and parts of Asia. Human infection is caused by several species of Leishmania parasites, such as Leishmania infantum. Available systemic and topical treatments vary in efficacy and are often unjustified due to their toxicity. We report on a case that was treated with posaconazole, a drug typically considered an antifungal agent but which also targets specific metabolic pathways of the parasite.

[Therapy of leishmaniasis in France: consensus on proposed guidelines]

Because it relies on potentially toxic, difficult-to-handle, or expensive compounds the therapy of leishmaniasis is still a complex issue in 2010, especially for visceral leishmaniasis in immuno-suppressed subjects, or in patients with cutaneous and mucosal involvement. This induces a wide diversity of observed therapeutic practices, some being sub-optimal. The Société de Pathologie Exotique organised a meeting dedicated to the therapy of leishmaniasis in France that led to the first consensus on therapeutic guidelines. Liposomal amphotericin B is the first-line option for visceral leishmaniasis both in immunocompetent, and immunosuppressed patients (cumulated doses of 20 mg/kg and 30-40 mg/kg, respectively). Secondary prophylaxis with either liposomal amphotericin B, pentamidine or meglumine antimoniate is proposed to patients with heavy immunosuppression until immunity has been restored for at least 6 months. While the efficacy of new topical formulations of paromomycin is being tested, patients with Old World cutaneous leishmaniasis may be left untreated, or be administered a combination of superficial cryotherapy plus intralesional antimony, or even--in complex situations--receive systemic therapy. The efficacy of a short course of pentamidine (L. guyanensis/L. panamensis) and a 20-day schedule of meglumine antimoniate (L. braziliensis) is solidly established. However, in well-defined situations, local therapy of New World cutaneous leishmaniasis is now considered acceptable.

Two cases of Old World cutaneous leishmaniasis in Australian travelers visiting Morocco

Two cases of Old World cutaneous leishmaniasis (OWCL) acquired by travelers to Morocco are described. In Australia, OWCL is more frequently seen in migrants rather than returned travelers. The patients were treated with sodium stibogluconate and fluconazole. Optimal treatment is not established, particularly in returned travelers, but identification of Leishmania species can help with the selection of appropriate therapy.