Meglumine antimoniate was associated with a higher cure rate than liposomal amphotericin B in the treatment of American tegumentary leishmaniasis: A retrospective cohort study from a Leishmania braziliensis-endemic area

Background

Pentavalent antimonials (PAs) are the primary therapeutic option for American tegumentary leishmaniasis (ATL). However, the use of these drugs is complicated by adverse events (AEs), resistance and contraindications. Alternative therapies relative effectiveness is not well established.

Objective

This study compared the effectiveness of liposomal amphotericin B (LAB) with intravenous meglumine antimoniate (NMG) in the treatment of ATL. We also analysed and compared associated AEs and treatment interruption rates.

Methods

This was a retrospective cohort study from Brazil. The potential risk factors for the primary outcome were age, sex, total cutaneous lesion area, presence of mucosal lesions, AEs and treatment interruption. The primary outcome was lesion healing within 6 months of treatment. AEs and treatment interruption were also analysed. Multiple analytic strategies were employed to evaluate the reliability of the results.

Results

Before propensity score (PS) matching, patients in the LAB group were older and had a higher frequency of mucosal lesions. The NMG group had a higher cure rate than the LAB group (cure rate 88% versus 55% respectively) in the adjusted analysis (relative risk (RR)=1.55 95% CI: 1.19 - 2.02) and after PS matching (RR=1.63 95% CI: 1.20 - 2.21). NMG group had a higher AE rate (event rate 52% versus 44%) in the adjusted analysis (RR= 1.61, 95% CI: 1.06 - 2.43, p=0.02), but this result was not observed after PS matching (RR= 0.87, 95% CI: 0.49 -1.52, p= 0.61).

Conclusions

We observed that the NMG group had a higher cure rate than the LAB group, with an equivocally higher EV rate in the adjusted analysis.

The Presence of Leishmania braziliensis DNA in the Nasal Mucosa of Cutaneous Leishmaniasis Patients and the Search for Possible Clinical and Immunological Patterns of Disease Progression: A Cross Sectional Study

Leishmania braziliensis is the most important causal agent of American tegumentary leishmaniasis (ATL), and 3 to 5% of patients develop mucosal lesions. The mechanisms related to parasite and host immune interactions and the parasite life cycle that lead to dissemination to the mucosa are poorly understood. We aimed to detect L. braziliensis DNA in the nasal mucosa of cutaneous leishmaniasis (CL) patients with early mucous dissemination and to relate those findings to specific inflammatory responses. Nasal swabs were collected from patients with the cutaneous form of ATL. L. braziliensis DNA was investigated using TaqMan-based real-time PCR. The levels of serum cytokines (IL-12, IL-6, TNF-α, IL-10, IL-1β and IL-8) were measured by a multiplex cytometric array. A Poisson regression model was used to test prevalence ratios (PRs) and multivariate interactions of clinical and laboratory characteristics. Of the 79 CL patients, 24 (30%) had L. braziliensis DNA in the nasal mucosa. In the multivariate model, parasite DNA presence in mucosa was associated with a reduction in IL-12 levels (PR = 0.440; p=0.034), increased IL-6 levels (PR = 1.001; p=0.002) and a higher number of affected body segments (PR = 1.65; p<0.001). In this study, we observed a higher rate of early dissemination to the nasal mucosa than what was previously described. We suggest that an enhanced Th1 profile characterized by higher IL-12 is important for preventing dissemination of L. braziliensis to the mucosa. Further evaluation of parasite-related interactions with the host immunological response is necessary to elucidate the dissemination mechanisms of Leishmania.

Successful treatment of diffuse cutaneous leishmaniasis caused by Leishmania amazonensis

Diffuse cutaneous leishmaniasis is a rare universal disease associated with an inadequate host cell immune response, caused by different species: infantum, aethiopica, major, mexicana, and others, which presents the challenge of a poor therapeutic response. In Brazil, it is caused by L. amazonensis. A case confirmed by histopathology with an abundance of vacuolated macrophages full of amastigotes and lymphocyte scarcity, identified by RFLP-ITS1PCR and in vitro decrease and exhaustion of the host cell immune response to L. amazonensis antigen, was treated early (3 months after the onset) with Glucantime (2 months) and allopurinol (29 months) with clinical cure, after a follow-up for 30 months after treatment.

A Pilot Randomized Clinical Trial: Oral Miltefosine and Pentavalent Antimonials Associated With Pentoxifylline for the Treatment of American Tegumentary Leishmaniasis

Introduction

American tegumentary leishmaniasis (ATL), which can present as either cutaneous (CL) or mucosal leishmaniasis (ML), is endemic in South America, and first-line antimonial treatments are known for their wide range of adverse effects (AEs). Growing reports of drug resistance increase the urgency of the need for better treatment options. The objective of this pilot clinical trial was to assess the efficacy of and AEs associated with the oral combination of miltefosine and pentoxifylline based on a post hoc analysis.

Methods

A pilot, randomized, open-label clinical trial was performed. The experimental group (M+P) received 50 mg twice a day (BID) miltefosine and 400 mg three times a day (TID) pentoxifylline, and the control group (A+P) received 20 mg Sb+V/kg/day intravenously and 400 mg TID pentoxifylline. Patients with ML received treatment for 28 days, and patients with CL received treatment for 20 days.

Results

Forty-three patients were included: 25 with ML and 18 with CL caused by L.(V.) braziliensis. AEs were more frequent in the A+P group (p=0.322), and there was a need for treatment interruption due to severe AEs (p=0.027). Patients with CL had a higher chance of achieving a cure (p=0.042) and a higher risk of AEs (p=0.033). There was no difference in the chance of a cure based on the treatment (p=0.058).

Conclusion

In this pilot randomized clinical trial, M+P treatment and A+P treatment yielded similar cure rates, and the former was associated with a lower risk of AEs. Future studies with more patients and longer follow-up are recommended.

Leprosy detection rate in patients under immunosuppression for the treatment of dermatological, rheumatological, and gastroenterological diseases: a systematic review of the literature and meta-analysis

Background

Recently developed immunosuppressive drugs, especially TNF antagonists, may enhance the risk of granulomatous infections, including leprosy. We aimed to evaluate the leprosy detection rate in patients under immunosuppression due to rheumatological, dermatological and gastroenterological diseases.

Methods

We performed a systematic review of the literature by searching the PubMed, EMBASE, LILACS, Web of Science and Scielo databases through 2018. No date or language restrictions were applied. We included all articles that reported the occurrence of leprosy in patients under medication-induced immunosuppression.

Results

The search strategy resulted in 15,103 articles; finally, 20 articles were included, with 4 reporting longitudinal designs. The detection rate of leprosy ranged from 0.13 to 116.18 per 100,000 patients/year in the USA and Brazil, respectively. In the meta-analysis, the detection rate of cases of leprosy per 100,000 immunosuppressed patients with rheumatic diseases was 84 (detection rate = 0.00084; 95% CI = 0.0000–0.00266; I² = 0%, p = 0.55).

Conclusion

Our analysis showed that leprosy was relatively frequently detected in medication-induced immunosuppressed patients suffering from rheumatological diseases, and further studies are needed. The lack of an active search for leprosy in the included articles precluded more precise conclusions.

Trial registration

This review is registered in PROSPERO with the registry number CRD42018116275.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06041-7.

A retrospective cohort study of the effectiveness and adverse events of intralesional pentavalent antimonials in the treatment of cutaneous leishmaniasis

Introduction

The standard therapy for American cutaneous leishmaniasis (ACL) is intravenous meglumine antimoniate (IV-MA). However, treatment interruptions due to adverse events (AEs) and non-adherence are frequent. Consequently, intralesional MA (IL-MA) was proposed.

Objective

This study examined the effectiveness of and AEs associated with IL-MA.

Methods

We performed a retrospective cohort study of 240 patients with ACL. We excluded patients with mucous lesions and disseminated leishmaniasis and those who received treatment in the previous 6 months. We considered protocol treatments as the main risk factors. IL-MA was performed using a subcutaneous injection of MA in a volume sufficient to elevate the lesion base (approximately 1 mL/cm² of lesion area) once weekly for 1–8 weeks. IV-MA was performed via intravenous injections of MA at a dosage of 10–20 mg Sb⁵⁺/kg/day for 20 days. The primary outcome was defined as a lesion cure 3 months after treatment, and AEs were secondary outcomes.

Results

Seventy-three patients were included. The IL-MA group consisted of 21 patients, and the IV-MA group consisted of 52 patients. The IL-MA group was older, had more comorbidities and more previous unsuccessful treatment of ACL. The antimonial dose was significantly lower in this group. The cure rate for IL-MA was 66.7%, which was lower than that in the IV-MA group (relative risk (RR) = 0.68, 95% CI: 0.50–0.92, p < 0.001), while the rate of AEs was similar. Female sex (RR = 1.16, 95% CI: 1.02–1.33), lesion diameter ≤1 cm (RR = 1.25, 95% CI: 1.00–1.56) and treatment with IV-MA (RR = 1.43, 95% CI: 1.06–1.93) were independently associated with achieving a cure. Comorbidities (RR = 1.7, 95% CI: 1.06–2.98) were independently associated with AEs.

Conclusions

Patients of IL-MA group were older, had more comorbidities and more previous unsuccessful treatment of ACL. Nevertheless, IL-MA had a cure rate of 66.7%, and it was useful in this context. A prospective randomized trial is recommended.

•

Intralesional antimonials (IL-MA) had a 66.7% lower cure compared to systemic.

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IL-MA group was older, had more comorbidities and unsuccessful previous treatment.

•

IL-MA was useful in this group, where worse clinical responses are expected.

•

Lesions larger than 3 cm did not have more chance of failure with IL-MA.

•

There was no mucous recurrence after IL-MA in an area of New World Leishmaniasis.

The interference of polypharmacy and the importance of clinical pharmacy advice in the treatment of leprosy: a case-control study

INTRODUCTION:

Although supervised doses are essential for reducing leprosy treatment failure, the impact of specific drug interactions has rarely been assessed. This study aimed to estimate the risk of leprosy treatment suspension in patients receiving polypharmacy.

METHODS

We performed this case-control study in which the primary outcome was defined as the need to discontinue multibacillary leprosy treatment for at least one supervised dose, and the main risk factor was the detection of polypharmacy. Multivariate analysis by logistic regression was used for calculating odds ratio (OR).

RESULTS:

This study included 103 patients, of whom 43 needed to discontinue leprosy treatment (hemolysis = 26, hepatitis = 2, hemolysis associated with hepatitis = 6, and suspected treatment resistance = 9) and the rest did not. The severity of drug interactions had no effect on treatment discontinuation. Patients who used five or more drugs in addition to leprosy treatment had almost a 4-fold greater risk of treatment suspension (OR, 3.88; 95% confidence interval: 1.79-9.12; p < 0.001). The number of drugs used also positively influenced the occurrence of hemolysis (p < 0.001). No patient presented evidence of molecular resistance to rifampicin, dapsone, or ofloxacin treatment, as evidenced by genetic sequencing detection of rpoB, folp1, and gyrA mutations.

CONCLUSIONS:

Polypharmacy has deleterious effects on the already difficult-to-adhere-to treatment of leprosy and polypharmacy induces hemolysis. Additional measures must be taken to avoid the undesirable effects of inadequate polypharmacy.

A comprehensive systematic review of leishmaniasis in patients undergoing drug-induced immunosuppression for the treatment of dermatological, rheumatological and gastroenterological diseases

Immunosuppression is an important risk factor for leishmaniasis. We assessed the clinical profile, geographic distribution and prevalence of leishmaniasis in patients undergoing immunosuppressive therapy for dermatological, rheumatological or gastroenterological autoimmune diseases. We identified relevant studies in PubMed, EMBASE, Scopus, Web of Science and LILACS on July 3rd, 2018. We included articles that reported at least one case of leishmaniasis in patients undergoing immunosuppressive treatment for dermatological, rheumatological or gastroenterological diseases. Our protocol was registered in PROSPERO (CRD42018103050). We assessed the quality of the included studies with the Joanna Briggs Institute Critical Appraisal Tool. After the removal of duplicates, 5,431 articles were collected and screened. We included 138 articles; the prevalence of leishmaniasis in six methodologically similar studies varied from three to 1,282 cases per 100,000 patients using anti-TNFα drugs, but the results were significantly heterogeneous . Leishmaniasis in patients treated with immunosuppressive drugs is a health problem mostly reported in European countries bordering the Mediterranean Sea; sporadic activities, such as travelling, seem not to be associated with a significant risk of leishmaniasis, although effective control measures must always be observed.

The accuracy of the Montenegro skin test for leishmaniasis in PCR-negative patients

INTRODUCTION

As highly specific molecular biology-based techniques may not be sensitive enough for the diagnosis of American tegumentary leishmaniasis (ATL), clinicians frequently rely on immunological tests before treatment initiation. Hence, the correct combination of diagnostic tests is imperative for ATL diagnosis. We aimed to evaluate the accuracy of the Montenegro (Leishmanin) skin test (MST) in polymerase chain reaction (PCR)-negative patients to accurately detect ATL.

METHODS

Patients with a clinical picture compatible with ATL were divided into ATL (confirmed by lesion smear, culture indirect immunofluorescence, and/or histopathology) and no-ATL (diseases that can mimic leishmaniasis) groups. Conventional PCR for the minicircle kDNA of Leishmania was performed, and the MST was carried out for PCR-negative patients.

RESULTS

Ninety-nine patients were included in this study, including 79 diagnosed with ATL (6 with mucocutaneous leishmaniasis) and 20 without ATL (no-ATL group). The MST showed a high sensitivity of 90.0% (95% confidence interval [CI] = 69.90-97.21) in PCR-negative patients that was 10% higher than the sensitivity reported in PCR-positive population (79.66%; 95% CI = 67.73-87.96).

CONCLUSIONS

One of the most important reasons for PCR negativity among patients with active ATL is the presence of a strong cellular immunological response, especially in chronic and mucocutaneous leishmaniasis. This reinforces the considerable utility of the tests that detect cellular responses against Leishmania antigens such as the MST in PCR-negative patients when the performance in screening situations is questionable.

Study of the efficacy of N-methyl glucamine antimoniate (SbV) associated with photodynamic therapy using liposomal chloroaluminium phthalocyanine in the treatment of cutaneous leishmaniasis caused by Leishmania (L.) amazonensis in C57BL6 mice

BACKGROUND

Pentavalent antimonials remain first-line drugs in the treatment of cutaneous leishmaniasis (CL); however, adverse effects and drug resistance have led to the search for less toxic and more effective treatments. As an alternative, topical phthalocyanine has been studied and its efficacy and low toxicity demonstrated. We aimed to study the in vivo efficacy of N-methyl glucamine antimoniate (NMG) associated with photodynamic therapy (PDT) with topical liposomal chloroaluminium phthalocyanine (AlClPC) in the treatment of experimental CL by L. amazonensis.

METHODS

Experimental study with 54 C57BL6 isogenic mice divided into 9 groups including uninfected control, untreated control, PDT with AlClPC + NMG at doses of 10 and 20 mgSb^V/Kg/day. The criteria to evaluate the treatment efficacy were: paw diameter, amastigote count, culture, viability test and parasite counts using MTT (3-bromo-4,5-dimethylthiazol-2,5-diphenyl-tetrazolium bromide).

RESULTS

Treatment of CL with the association of NMG20 + PDT with AlClPC showed significant reduction of paw diameter, amastigote count, cultures, viability test and parasite counts. Parasite reduction occurred at the 10th and 20th days of treatment and 60 days after treatment ended, indicating that parasites did not multiply again. The NMG10 + PDT group with AlClPC presented results equivalent to gold-standard treatment (20 mgSb^V/kg/day). Biochemical and histopathological evaluation showed minor changes.

CONCLUSION

Treatment of CL caused by L. amazonensis with NMG20 mgSb^V/kg/day + PDT with AlClPC was more effective than the traditional NMG20 mgSb^V/kg/day.

A randomized, open-label clinical trial comparing the long-term effects of miltefosine and meglumine antimoniate for mucosal leishmaniasis

INTRODUCTION

The treatment of mucosal leishmaniasis (ML) is difficult due to the toxicity and route of administration of standard drugs. Miltefosine is an oral agent used for leishmaniasis treatment; however, no data exist regarding its use for ML in Brazil. In this study, we aimed to evaluate the efficacy of miltefosine for ML treatment compared to that of pentavalent antimonial in a pilot study.

METHODS

We performed a randomized clinical trial with two parallel groups. The tested intervention consisted of miltefosine 1.3-2 mg/kg/day (two capsules) for 28 days or intravenous 20 mg SbV/kg/day of meglumine antimoniate (N-MA) for 30 days. The final endpoint was defined as complete healing of the lesion four years after treatment. We also analyzed an early endpoint at 90 days after treatment.

RESULTS

Forty patients were included in this study: each experimental group comprised 20 patients. Applying a multivariate model in an intention-to-treat analysis, we observed that patients treated with miltefosine had a cure probability 2.08 times greater (95% confidence interval [CI] = 1.03-4.18) than those treated with N-MA at 90 days after treatment. At the final endpoint, we observed no differences in cure probability between miltefosine and N-MA (relative risk = 0.66; 95% CI = 0.33-1.32). With respect to adverse reactions, significant differences between groups were related to gastrointestinal effects, which were more frequent in the miltefosine group.

CONCLUSIONS

Miltefosine may be an interesting alternative for treating ML because of its oral administration and cure rate after long-term follow-up.

PD-L1 May Mediate T-Cell Exhaustion in a Case of Early Diffuse Leishmaniasis Caused by Leishmania (L.) amazonensis

Introduction

Diffuse cutaneous leishmaniasis (DCL) is a rare disease form associated with Leishmania (L.) amazonensis in South America. It represents the “anergic” pole of American Tegumentary Leishmaniasis, and the explanation for its resistance to treatment remains elusive. We aimed to study some possible immunological mechanisms involved in the poor DCL treatment response by evaluating some cell surface molecules obtained from a patient with DCL by flow cytometry.

Case presentation

A 65-year-old DCL patient who initially failed to respond to the standard treatment for the disease showed vacuolated macrophages filled with amastigotes in lesion biopsy, and L. (L.) amazonensis was identified through ITS1PCR amplification. The Leishmania skin test and indirect immunofluorescence analysis revealed negative results. Peripheral blood from the patient was collected after a few months of treatment, when the patient presented with no lesion. Peripheral blood mononuclear cells were analyzed ex vivo and in vitro after 48 h of stimulation with soluble L. (L.) amazonensis antigen (SLA). Cell death, surface molecules, and intracellular molecules, such as IFN-γ and granzyme B, were analyzed in the cells using flow cytometry. Analysis of the surface markers showed an increased expression of the inhibitory molecule programmed death ligand 1 (PD-L1) in the monocytes restimulated with SLA (approximately 65%), whereas the negative controls were 35% positive for PD-L1. Conversely, compared with the negative controls, we observed a decrease in CD4⁺IFN-γ⁺ T cells (8.32 versus 1.7%) and CD8⁺IFN-γ⁺ T cells (14% versus 1%). We also observed a relevant decrease in the granzyme B levels in the CD8⁺ T cells, from 31% in the negative controls to 5% after SLA restimulation.

Conclusion

The dysfunctional activation of PD-L1 inhibitory pathway after Leishmania antigen stimulation and reduced levels of IFN-gamma and granzyme B-producing cells could be closely related to unresponssiveness to standard drug treatment of DCL patient.

Accuracy of qPCR for quantifying Leishmania kDNA in different skin layers of patients with American tegumentary leishmaniasis

OBJECTIVES

Superficial swab sampling of American tegumentary leishmaniasis (ATL) lesions shows higher amounts of Leishmania than those from biopsy. Subcutaneous involvement is also important in ATL, but parasite quantification according to lesion depth has not been evaluated. We aim to present the best depth at which sampling should be performed for molecular exams of ATL.

METHODS

Patients with a clinical presentation compatible with ATL were allocated to ATL and control groups. Qualitative and quantitative qPCR assays were performed using SYBR Green and primers amplifying the kDNA minicircle of Leishmania spp. in different skin layers, including the epidermis, the superior dermis, the inferior dermis, and the hypodermis.

RESULTS

Fifty-nine patients were included in this study, including 40 who had been diagnosed with ATL and 19 controls. The number of parasites was greater in samples of the epidermis and superior dermis (159.1 × 10⁶, range 4.0-781.7, and 75.4 × 10⁶, range 8.0-244.5, mean Leishmania parasite equivalents per μg of tissue DNA, respectively) than those in samples of the inferior dermis and hypodermis (54.6, range 8.0-256.6, and 16.8 × 10⁶, range 8.0-24.1, mean Leishmania parasite equivalents per μg of tissue DNA, respectively). The best diagnostic accuracy was achieved in the superior dermis (77.9%) and was significantly greater than that in the hypodermis (63.3%; p 0.039).

CONCLUSIONS

We conclude that superficial sampling can retrieve a greater quantity of parasites. Future studies of the role of transepidermal elimination as a mechanism of host defence in ATL must be performed as there is a considerable quantity of Leishmania kDNA in the epidermis.

Evaluation of the efficacy of systemic miltefosine associated with photodynamic therapy with liposomal chloroaluminium phthalocyanine in the treatment of cutaneous leishmaniasis caused by Leishmania (L.) amazonensis in C57BL/6 mice

BACKGROUND

The shortage of drugs is a concern and has become the object of studies to discover effective alternatives for cutaneous leishmaniasis (CL) treatment. A topical formulation has been sought due to its low toxicity. Development of alternative therapies, such as multimodal ones, is important in confronting drug resistance. This study aims to compare the in vivo efficacy of topical photodynamic therapy (PDT) using liposomal chloroaluminium phthalocyanine (AlClPC) in the treatment of CL, isolated and associated with systemic therapy with miltefosine.

METHODS

Five groups were adopted, each one with six isogenic adult female mice C57BL/6: (1) Negative Control-non-infected and non-treated; (2) Positive Control (PBS)-infected and non-treated; (3) Miltefosine-infected and treated with oral miltefosine 200 mg/kg/day; (4) Infected and treated with PDT with topical AlClPC (500 μL) on alternate days; (5) Oral Miltefosine 200 mg/kg/day and PDT with topical AlClPC (500 μL) on alternate days. Therapeutic schemes lasted 20 days. Infection was confirmed by culture in Nove-McNeal-Nicolle medium (NNN) of lymph collected from the animal paw, and animals were evaluated by paw measurement and parasitological criteria.

RESULTS

Miltefosine associated with PDT with AlClPC promoted a significant reduction in parasite number and viability when compared to the other infected groups, also returning the paw diameter to a size similar to the negative control group after 20 days of treatment.

CONCLUSIONS

Association of miltefosine with PDT mediated by topical AlClPC represents hopes for CL treatment, an increasing dermatological disease in some countries.

Complementary exams in the diagnosis of American tegumentary leishmaniasis

The diagnosis of American Tegumentary Leishmaniasis is a difficult but essential task when considering the high toxicity profile of the drugs available. Since the discovery of its etiologic agent, numerous diagnostic tests have been developed. None of the tests available today can be considered as the gold standard, since they do not add enough accuracy for the disease detection. Good epidemiological and clinical knowledge of the disease are fundamental precepts of the dermatology practice and precede the rational use of existing diagnostic tests. In this article we aim, through extensive literature review, to recall fundamental concepts of any diagnostic test. Subsequently, based on this information, we will weave important comments about the characteristics of existing diagnostic tests, including immunological tests such as Montenegro's skin test, serology and detection of parasites by direct examination, culture or histopathology. Finally we will discuss the new technologies and options for the diagnosis of Cutaneous Leishmaniasis. The molecular biology technique is considered a promising tool, promoting the rapid identification of the species involved. We also aim to educate dermatologists about a disease with high morbidity and assist in its difficult recognition.

Effectiveness of miltefosine-pentoxifylline compared to miltefosine in the treatment of cutaneous leishmaniasis in C57Bl/6 mice

INTRODUCTION

The treatment of leishmaniasis ischallenging, given the difficulties in drug administration and resistance. Therefore, we chose to test the efficacy of miltefosine combined with pentoxifylline.

METHODS

Twenty-seven isogenic C57Bl/6 mice were infected with Leishmania (Leishmania) amazonensis, and equally divided into three groups: miltefosine (200mg/kg/day), miltefosine (200mg/kg/day) with pentoxifylline (8mg/kg/day), and untreated. Response to treatment was evaluated using paw diameter and parasitological criteria.

RESULTS

The number of viable Leishmania reduced significantly within the miltefosine-pentoxifylline group (p < 0.05).

CONCLUSIONS

There is hope that a viable treatment exists for Leishmania infection.

Accuracy of mucocutaneous leishmaniasis diagnosis using polymerase chain reaction: systematic literature review and meta-analysis

The diagnosis of mucocutaneous leishmaniasis (MCL) is hampered by the absence of a gold standard. An accurate diagnosis is essential because of the high toxicity of the medications for the disease. This study aimed to assess the ability of polymerase chain reaction (PCR) to identify MCL and to compare these results with clinical research recently published by the authors. A systematic literature review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement was performed using comprehensive search criteria and communication with the authors. A meta-analysis considering the estimates of the univariate and bivariate models was performed. Specificity near 100% was common among the papers. The primary reason for accuracy differences was sensitivity. The meta-analysis, which was only possible for PCR samples of lesion fragments, revealed a sensitivity of 71% [95% confidence interval (CI) = 0.59; 0.81] and a specificity of 93% (95% CI = 0.83; 0.98) in the bivariate model. The search for measures that could increase the sensitivity of PCR should be encouraged. The quality of the collected material and the optimisation of the amplification of genetic material should be prioritised.

Recurrent cutaneous leishmaniasis

We present a case of an 18-year-old male patient who, after two years of inappropriate treatment for cutaneous leishmaniasis, began to show nodules arising at the edges of the former healing scar. He was immune competent and denied any trauma. The diagnosis of recurrent cutaneous leishmaniasis was made following positive culture of aspirate samples. The patient was treated with N-methylglucamine associated with pentoxifylline for 30 days. Similar cases require special attention mainly because of the challenges imposed by treatment.

Lutzomyia whitmani is the main vector of American Cutaneous Leishmaniasis in the Brazilian Federal District and the most prevalent species in residential areas of the Administrative Region of Sobradinho

Although cases of cutaneous Leishmaniasis have been reported in Brasilia - DF, its mode of transmission is still unknown. Center of Disease Control traps (CDC trap) placed around Sobradinho, a periurban area in the Brazilian Federal District, were able to capture a sample of phlebotomines composed of 89% Lutzomyia whitmani, 7% Lu. bacula, and 3% Lu. davisi specimens. Being of 77% of these specimens were captured in peridomiciliary. PCR analyses showed that the specimens were negative for Leishmania DNA. However, the high prevalence of Lu. Whitmani in the studied region suggests that it may be the main vector for the transmission of Leishmaniasis in peridomiciliary areas in the studied region.

The influence of treatment on the development of leishmaniasis recidiva cutis: a 17-year case-control study in Midwestern Brazil

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.

Periungual leishmaniasis

The vast majority of cases of cutaneous leishmaniasis are represented by limb injuries. A female patient, white, presented an ulcer with infiltrated borders located on the fourth finger of the left hand following occupational exposure in an area of native forest. Diagnosis of cutaneous leishmaniasis caused by Leishmania of the subgenus Viannia was confirmed. The patient failed to respond to treatment with antimony, but achieved clinical cure after this was associated with pentoxifylline. The case highlights the rarity of the periungual location of the leishmanial lesion and the difficulties encountered in therapy.

Meglumine antimonate treatment enhances phagocytosis and TNF-α production by monocytes in human cutaneous leishmaniasis

This work evaluated phagocytic function, hydrogen peroxide (H(2)O(2)), TNF-α and IL-10 production by monocytes and serum INF-γ levels in New World human cutaneous leishmaniasis and the influence of meglumine antimonate treatment on these immune functions. The phagocytic capacity of monocytes in untreated Leishmania-infected individuals was significantly (2.5 times) lower than that of healthy controls, and antimonial treatment increased the phagocytosis by monocytes by about five times at the end of therapy. The leishmaniasis patients showed 3.9 times higher H(2)O(2) production than controls and treatment with meglumine antimonate did not influence the production of H(2)O(2), which remained enhanced until the end of treatment. Individuals with leishmaniasis showed 6.3 times lower TNF-α production than healthy individuals and meglumine antimonate treatment caused a significant increment (11.9 times) in its production. INF-γ serum levels were higher in Leishmania-infected individuals than healthy controls, and the production of IL-10 by monocytes was not influenced by infection or antimonial treatment. Enhancement of monocyte functions by the antimonial treatment suggests that the immunomodulatory effects of the drug may also play a part in the way meglumine antimonate acts against the parasite in human leishmaniasis, by directly increasing phagocytosis and TNF-α production.

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.

Estudo da transmissão da leishmaniose tegumentar americana no Distrito Federal

O objetivo do estudo foi caracterizar a leishmaniose tegumentar em pacientes do Distrito Federal, investigar infecção subclínica nos moradores das localidades dos pacientes e identificar as espécies de flebotomíneos e leishmanias. Foram selecionados pacientes atendidos no Hospital Universitário de Brasília de agosto de 2006 a junho de 2007. Parentes e vizinhos dos mesmos foram submetidos à intradermorreação de Montenegro e imunofluorescência indireta. Foram capturados flebotomíneos nas localidades de origem dos pacientes e identificados quanto às espécies, bem como foram identificadas as espécies de leishmanias encontradas nos pacientes. Foram registrados 10 casos autóctones de leishmaniose tegumentar. Em 32 moradores, foi realizada intradermorreação, com positividade de 71,8%. Trinta e sete imunofluorescências realizadas foram negativas. Foram capturadas Lutzomyia whitmani, inclusive no domicílio/peridomicílio e Lutzomyia flaviscutellata. O percentual de positividade das intradermorreações de Montenegro sugere infecção subclínica dos moradores. A captura do vetor Lutzomyia whitmani no peri/intradomicílio sugere transmissão peri/intradomicíliar.

O uso da associação azitromicina e N-metil glucamina no tratamento da leishmaniose cutânea causada por Leishmania (Leishmania) amazonensis em camundongos C57BL6

FUNDAMENTOS: O tratamento de primeira escolha da leishmaniose tegumentar americana é a N-metil-glucamina que tem alta toxicidade, exige administração parenteral e nem sempre cura. A azitromicina mostrou ação in vitro e resultado contraditório na doença humana. OBJETIVO: Verificar se a associação N-metil-glucamina+azitromicina é mais eficaz do que N-metil-glucamina no tratamento da leishmaniose experimental. MÉTODOS: 25 camundongos inoculados com a cepa C57BL/6 de L. (L.) amazonensis foram divididos em dois grupos. Um foi tratado com 400mgSbV/kg/dia de N-metil-glucamina associado a 200mg/kg/dia de azitromicina durante 20 dias, e o outro com N-metil-glucamina, na mesma dose, durante o mesmo tempo. Foi feita avaliação clínica e parasitológica com análise estatística. RESULTADO: Na avaliação clínica, pesquisa de amastigotas e das culturas, não houve diferença estatística. Verificou-se, entretanto, diferença significante no resultado das culturas realizadas através de diluição limitante, que desfavoreceu a associação NMG+ azitromicina. CONCLUSÃO: A associação N-metil-glucamina e azitromicina não demonstrou mais eficácia do que o N-metil-glucamina em uso isolado.

Estudo comparativo entre miltefosina oral e antimoniato de N-metil glucamina parenteral no tratamento da leishmaniose experimental causada por Leishmania (Leishmania) amazonensis

Vinte e cinco camundongos infectados com Leishmania amazonensis foram tratados com antimoniato de N-metil glucamina e miltefosina oral. Critérios: medidas das patas, pesquisa de amastigotas e culturas após-tratamento. Miltefosina: 2,43mm e glucamina 3,46mm (p=0,05). Miltefosina: esfregaços e culturas negativos. Glucamina: 2 esfregaços positivos e culturas positivas (p<0,05). Concluímos que miltefosina foi semelhante à glucamina.

Tratamento da Leishmaniose Tegumentar Americana

A leishmaniose tegumentar americana é doença infecciosa da pele e mucosa, cujo agente etiológico é um protozoário do gênero Leishmania. Seu tratamento é desafio porque as drogas disponíveis apresentam elevada toxicidade, e nenhuma delas é bastante eficaz. A recidiva, a falha terapêutica em pacientes imunodeprimidos e a resistência ao tratamento são fatores que motivam a busca de uma droga ideal.

Leishmaniose mucosa fatal em criança

A leishmaniose tegumentar americana, doença endêmica e crescente no Brasil, pode manifestar-se por úlceras na pele e lesões nas mucosas nasal, oral e faringiana. O antimônio pentavalente é a droga de primeira escolha no tratamento, com resposta menos favorável nas formas mucosas. Destaca-se a dificuldade para diagnosticar e tratar um caso de leishmaniose mucosa em criança de cinco anos que teve exames parasitológicos, imunológicos e reação em cadeia da polimerase negativos. Somente após várias repetições o esfregaço foi positivo. A paciente apresentou infecção bacteriana secundária persistente das lesões e falta de resposta a drogas específicas e antibióticos, evoluindo para septicemia e óbito.

[In vivo Terbinafine inefficacy on cutaneous leishmaniasis caused by Leishmania (Leishmania) amazonensis in C57BL/6 mice]

The efficiency of terbinafine was tested in C57BL/6 mice inoculated with the Leishmania (Leishmania) amazonensis strain MHOM/BR/PH8. The mice were administered: terbinafine at a dose of 100mg/kg/d by via oral; 0.9% saline solution orally as the control; and subcutaneous sodium stibogluconate 400mg SbV/kg/d as gold standard, for 20 days. Terbinafine was demonstrated to be ineffective when compared to the controls, using clinical and parasitological parameters and the limiting dilution assay.

Estudo comparativo da eficácia de isotionato de pentamidina administrada em três doses durante uma semana e de N-metil-glucamina 20mgSbV/kg/dia durante 20 dias para o tratamento da forma cutânea da leishmaniose tegumentar americana

Setenta e nove pacientes com leishmaniose tegumentar americana, forma cutânea, foram divididos em dois grupos: o grupo experimental (I), formado por 38 pessoas que receberam isotionato de pentamidina, 4mg/kg/dia, três aplicações, IM, durante uma semana, e o grupo controle (II), formado por 41 doentes tratados com N-metilglucamina, 20mgSbV/kg/dia por 20 dias, EV. Foram identificados, por técnica de anticorpos monoclonais, 21 isolados com predominância de Leishmania (Viannia) braziliensis. Encontrou-se cura clínica em 71,05% do grupo experimental e 73,17% do grupo controle (p=0,47). Alterações de ECG foram mais freqüentes utilizando antimonial pentavalente, com significância (p<0,05). O tratamento com a pentamidina mostrou eficácia semelhante quando comparado ao antimonial e apresenta vantagens como duração reduzida de tratamento e baixa toxicidade cardiológica.

[A comparative study between the efficacy of pentamidine isothionate given in three doses for one week and N-methil-glucamine in a dose of 20mgSbV/day for 20 days to treat cutaneous leishmaniasis]

Seventy-nine patients with cutaneous leishmaniasis were included in this study. The experimental group (n = 38) was treated with pentamidine isothionate in a dose of 4mg/kg/day on alternate days, for one week. The control group (n = 41) was treated with N-methylglucamine in a dose of 20mgSbV/kg/day for 20 days. Twenty-one isolates were identified using monoclonal antibody technique. We characterized Leishmania (Viannia) braziliensis, most frequently. There was a cure rate of 71.05% of the patients in the experimental group and 73.17% in the control group (p = 0.47). We found a statistical significance regarding frequency of ECG alterations between the experimental and control group (p<0.05). In our study pentamidine was as effective as antimonial for the treatment of american cutaneous leishmaniasis. It proved to be a safer drug considering heart toxicity. Moreover, it requires less time to complete the treatment.

[American cutaneous leishmaniasis associated with HIV/AIDS: report of four clinical cases]

The co-infection American cutaneous leishmaniasis and AIDS has recently been described in the literature, observing differences between the clinical and immunological behavior of these patients. Four cases are reported here, attended at the Brasilia University Hospital, with diagnoses of infection by Leishmania species and immunodeficiency virus, with a view to illustrating the clinical presentations, course and therapeutic responses.

Estudo comparativo de técnicas de demonstração de amastigotas e isolamento de promastigotas no diagnóstico da leishmaniose tegumentar americana

FUNDAMENTOS: O PCR tem alta sensibilidade no diagnóstico da LTA, mas é caro e distante da prática. A cultura e o esfregaço são práticos, mas pouco sensíveis. OBJETIVO: O objetivo deste trabalho foi comparar os dois últimos métodos, buscando maior sensibilidade e menor custo. MÉTODOS:Foram comparados três meios de cultura no isolamento de leishmânia: Difco agar sangue + Schneider + soro bovino fetal (20%); Difco agar sangue + Schneider + urina humana (2%); Schneider + urina humana (2%). Foram comparadas, também, duas técnicas de pesquisa de amastigotas: esfregaço realizado com biópsia, ou raspado através de palito (matchstick). RESULTADOS: Os índices de positividade e contaminação (29 a 33% e 8 a 11%, respectivamente, p>0.05) foram semelhantes na comparação dos cultivos. Os esfregaços com biópsia, ou palito também não tiveram diferenças significativas (14 e 19%, respectivamente, p> 0,05). A Leishmania (Viannia) braziliensis predominou. CONCLUSÃO: No Brasil, a urina pode substituir o soro fetal bovino. Há vantagem na relação custo/benefício. A urina não tem custo enquanto 500ml de soro bovino fetal custa 185 dólares.