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Leishmania species (Leishmaniasis)
Updated Sept, 2011
PARASITOLOGY Guided Medline Search Leishmaniasis is caused by protozoan parasites of the genus Leishmania. The genus has 2 subgenera: Leishmania and Viannia. In Europe, Africa and Asia (the "Old World") parasites belonging to the subgenus Leishmania are found; in America (the "New World") parasites belonging to both genera occur. About 20 species are known to cause disease in man. Human disease can be divided into three major clinical syndromes: 1. Visceral leishmaniasis, also called kala azar, caused by L. donovani, L. infantum, and L. chagasi 2. Cutaneous leishmaniasis, also known under many local names like oriental sore, Bagdad sore, chiclero, a.o., caused by L. major, L. tropica and L. aethiopica, and parasites belonging to the L. mexicana complex (L. mexicana, L. amazonensis and L. venezuelensis), the L. braziliensis complex (L. braziliensis and L. peruviana) and L. guyanensis complex (L. guyanensis and L. panamensis). Parasites of the mexicana complex belong to the subgenus Leishmania, those of the braziliensis and guyanensis complex to the Viannia subgenus. Parasites are generally indicated by genus and species (L. mexicana) and not the full name L. (L.) mexicana mexicana. 3. Mucocutaneous leishmaniasis, also known as espundia, caused by parasites of the L. braziliensis complex. Mucocutaneous leishmaniasis may also be caused by L. panamensis, L. amazonensis and, rarely, by L. guyanensis. Leishmania parasites are transmitted by the bite of female sandflies. In the human host parasites survive intracellularly in mononuclear cells, as amastigotes, rounded to oval bodies without a flagellum. In the vector and in culture media they grow and multiply as promastigotes, slender, elongated and flagellated organisms. Both amastigotes and promastigotes multiply asexually. EPIDEMIOLOGY Guided Medline Search
The leishmaniases occur in 88 countries; 350 million persons are at risk of
infection and at least 12 million experience disease. The yearly incidence of
cutaneous leishmaniasis is about one million and incidence of visceral
leishmaniasis is 500,000 cases (75). About 50% of the cases of visceral leishmaniasis occur in India, 90% of those in the state of Bihar
(288). Approximately 90% of cutaneous leishmaniasis patients occur in
Afghanistan, Iran, Saudi Arabia, Brazil and Peru (166).
CLINICAL MANIFESTATIONS Guided Medline Search Visceral Leishmaniasis After an incubation period of 3-4 months (with variation from 7 days to many years) disease develops that is characterized by fever, lymphadenopathy, hepato-splenomegaly, wasting, pancytopenia and ultimately secondary infection of the respiratory and gastro-intestinal tract, bleeding tendency, and death. In endemic areas disease generally extends over months to some years with initial periods of fever, then gradual enlargement of liver and spleen, and wasting. Laboratory features include pancytopenia, high ESR and CRP, low albumen and high gammaglobulin levels due to specific, but non protective and non-specific antibodies. Patients co-infected with HIV may present with atypical manifestations, especially lesions of the gastro-intestinal tract. Post-kala azar dermal leishmaniasis (PKDL), a condition of unknown pathogenesis, occurs during or after treatment of visceral leishmaniasis. Some cases are not known to have had clinical visceral leishmaniasis (337). In India, post-kala azar dermal leishmaniasis occurs in up to 10% of patients, generally after a long interval of several years after treatment (226,305). In East Africa it is more frequent (in East Sudan in some series up to 50% of cases) and occurs earlier, between 3 and 6 months after treatment (337). In Ethiopia, post-kala azar dermal leishmaniasis is rare (Hailu, personal communication). Macules, papules, nodules and infiltrative plaques develop (87). Post-kala azar dermal leishmaniasis plays a role in transmission (305). In endemic areas many persons become infected without developing clinical manifestations and disease; some may develop mild constitutional symptoms (24). Once (cellular) immunity wanes these persons may develop full-blown visceral leishmaniasis.
Immunocompromised patients with visceral leishmaniasis were known before the advent of HIV/AIDS.
These included, amongst others, patients with a renal transplant, lymphoma,
corticosteroid use (101, 224). HIV/AIDS has given a new dimension to this:
Leishmania/HIV co-infection became a particular problem in Spain, Portugal,
southern France and Italy, and is now rapidly increasing in Ethiopia.(234,
236)
Cases have been reported from all endemic countries (334). Cutaneous Leishmaniasis At the site of the sand fly bite a papule, subsequently a nodule develops, that ulcerates, forms a crust and heals after months to years, leaving a scar. Lesions may appear as indurated plaques, scaly nodules, or ulcers; they may be single or multiple and lymph vessels and lymph nodes may be involved. In the Old World, cutaneous leishmaniasis is caused by L. tropica, L. major and L. aethiopica. L. aethiopica causes simple cutaneous leishmaniasis and also diffuse cutaneous leishmaniasis in Ethiopia and Kenya. Occasionally L. donovani and L. infantum are isolated from skin lesions. L. tropica is related to urban leishmaniasis, is a disease of man and causes dry, crustated, single lesions that heal spontaneously in about one to 2 years. L. major, endemic in rural areas with a reservoir in rodents, causes exsudative, often large ulcers that may be multiple. Lymphnode involvement may occur. Spontaneous healing is within 6 to 12 months. After healing of cutaneous leishmaniasis there is strain specific immunity. In the New World, cutaneous leishmaniasis is caused by parasites of the L. mexicana complex, the L. guyanensis complex and L. braziliensis complex. Parasites of the L. mexicana complex generally produce chronic ulcers with a tendency to heal within 6 to 12 months. Parasites of the L. guyanensis complex may involve lymph vessels and lymph nodes and the parasites of the L. braziliensis complex have the reputation of not healing spontaneously. Spontaneous cure does occur however (60,116,128,169,170,202) but we do not know how often and under which circumstances. In 2-5% of cases of L. braziliensis infection, mucosal disease (South American mucocutaneous leishmaniasis, mucocutaneous leishmaniasis, mucocutaneous leishmaniasis) may follow (209). As mentioned, mucocutaneous leishmaniasis may also be caused by L. panamensis, L. amazonensis and L. guyanensis. Disseminated leishmaniasis is seen in Latin America and defined by ≥ 10 mixed-type lesions like acneiform, papular, nodular, and/or ulcerated lesions, located in ≥ 2 body parts (head, trunk, arms and legs). These patients have a strongly positive Leishmanin Skin Test (LST), a delayed type hypersensitivity reaction (318). Diffuse cutaneous leishmaniasis is a rare, anergic manifestation of cutaneous leishmaniasis related to L. aethiopica in East Africa, L. amazonensis or L. mexicana in Central and South America, or an unnamed Leishmania species in the Dominican Republic. The primary nodular lesion does not ulcerate but persists for months to years and spreads producing many nodules, plaques and hypopigmented macules. Leishmaniasis recidivans, also called relapsing or lupoid leishmaniasis, caused by L. tropica, is a chronic manifestation with slowly enlarging and or spreading lesions that heal centrally but continue to crop up as nodules that ulcerate, heal and reappear. Review Article: Cutaneous Leishmaniasis. Reithinger, R., Dujardin, J., Pirmez, C., Alexander, B. and Brooker, S. The LANCET Infectious Diseases 2007; Vol.7, Issue 9, 581-596. Mucocutaneous Leishmaniasis: In a minority of patients infected with L. braziliensis parasites the mucosa of nose, mouth, pharynx and larynx may get involved with granulomatous lesions that mutilate and may be so destructive as to cause death because of malnutrition, wasting, superinfections and aspiration pneumonia. Involvement of the naso-pharyngeal mucosa occurs months to years after healing of the primary cutaneous lesion, in the majority of cases within 2 years and often after inadequate or no treatment (209). However, concomitant early mucosal and cutaneous leishmaniasis does occur (42). LABORATORY DIAGNOSIS Guided Medline Search Leishmaniasis is diagnosed by demonstration of parasites in aspirates of spleen, lymph nodes or bone marrow in visceral leishmaniasis, of edges of ulcers in cutaneous leishmaniasis and biopsies of mucosa in mucocutaneous leishmaniasis. Aspirates and biopsies may be stained with stains according to Giemsa, Field or Wright and examined microscopically at 1000 x magnification. Parasites are seen intracellularly in macrophages, and extracellularly because of rupture of the macrophages during processing. Aspirates may be cultured in several media; mice and Syrian hamsters are suitable animals for isolation and culturing. In Leishmania/HIV co-infected patients, parasites are found in the blood (microscopy and culture) in as many as 50% (171). In mucocutaneous leishmaniasis, parasites are often difficult to demonstrate, and may not be found by direct methods. Many serological tests are available with variable sensitivity and specificity in different endemic areas, and different populations. In visceral leishmaniasis, subclinical infections and antibodies persisting long after cure, may confuse the interpretation. An ELISA and a dipstick test based on a recombinant (r) antigen rK39 which consists of 39 aminoacid repeats of a kinesin-like gene of L. chagasi proved very satisfactory in India, Brazil, the Mediterranean and Sudan (235). Serologic diagnosis is less reliable in HIV patients (242). In cutaneous leishmaniasis in the Old World, serology is generally not useful. In the New World ELISA and IFA with L. amazonensis antigen proved useful in L. braziliensis and L. guyanensis infections (241). In mucocutaneous leishmaniasis, diagnosis often has to rely on the clinical and histopathological picture together with results of serological tests and of the Leishmanin Skin Test (LST) also called Montenegro Skin Test (MNST), because of difficulties in demonstrating parasites. Nucleic acid hybridization and PCR technologies with genus- and species-specific probes can demonstrate and identify parasites in aspirates, biopsies and cultures and are major advances in diagnosis (197). A positive skin test is evidence of infection; it is negative during symptomatic visceral leishmaniasis. How many infected persons effectively clear parasites and thus will never develop disease is not known. Probably many remain infected without signs and symptoms but harboring parasites that may give rise to clinical leishmaniasis once immunity diminishes due to disease (e.g. HIV, lymphoma) or immunosuppressive treatment (corticosteroids). Pedras MJ, et al. Comparative evaluation of direct agglutination test, rK39 and soluble antigen ELISA and IFAT for the diagnosis of visceral leishmaniasis. Trans R Soc Trop Med Hyg. 2008 Feb;102(2):172-8. Epub 2007 Dec 26. PATHOGENESIS Guided Medline Search The outcome of infection with Leishmania parasites depends on the complex, only partially understood interaction between parasites and immune response of the host, the latter dominated by macrophage reaction and cellular and cytokine response. Studies in mice and man indicate that IFN-γ, IL-10 and IL-12 are important. In endemic areas many persons are infected without developing disease. Review Article: Cutaneous Leishmaniasis. Reithinger, R., Dujardin, J., Pirmez, C., Alexander, B. and Brooker, S. The LANCET Infectious Diseases 2007; Vol.7, Issue 9, 581-596.
SUSCEPTIBILITY IN VITRO AND IN VIVO Guided Medline Search In Vitro and In Vivo Data on in vitro and in vivo susceptibility and resistance to drugs, on minimum inhibitory concentrations (MIC’s) and on mechanisms of drug action and resistance are relatively limited. Reasons are: the complex nature of the parasite with different life stages as extracellular, free living promastigotes and intracellular amastigotes; the many different species and various clinical manifestations; and difficulties in obtaining field isolates in areas where the diseases are endemic. Methods to establish drug sensitivity and resistance are limited to research laboratories. Clinical impressions of reduced drug sensitivity can not easily be confirmed in the laboratory. Clinical studies of drug response are tedious because of the long duration of treatment and are hampered by the lack of a "test of cure". The combination of clinical, haematological and biochemical improvement, disappearance of parasites and no recurrence of disease and parasites during follow up of 6 to 12 months, indicates "cure". There is no single marker of cure (207). The systems to test drugs for leishmaniasis may not or only partly be adequate. Animal models for visceral leishmaniasis and cutaneous leishmaniasis exist and are useful but at best mimic the conditions in man. In vitro studies of promastigotes in culture and of amastigotes in cell lines have given important information but validation to what is actually happening in man is limited. Methods to assess drug activities available up to 1987 were reviewed by Neal who noted that promastigotes of L. donovani, L. tropica and L. braziliensis were not affected by antimonials but that amastigotes in macrophages were susceptible at clinically achievable concentrations (203). Development of the radiospirometric test (RAM) (131), the semi-automated microdilution technique (115), and models of macrophage and axenic amastigotes have given more insight (62, 92, 156). In France (98), India (156) and Colombia (239) a strong correlation was found between clinical response and Sb sensitivity in vitro in intracellular amastigotes. Mechanism of Action and Resistance Apoptosis: Apoptosis may play an important role in leishmanial infections and the antileishmanial drugs antimony, amphotericin B, pentamidine and miltefosine all induce apoptosis in leishmania parasites (326). Ca 2+ and cytosolic Ca 2+ are important in this process (259). Antimony: The mechanism of action of antimony involves activation of several components of the intracellular signalling pathway resulting first in Reactive Oxygen Species (ROS)- dependent killing of parasites and subsequently in strong Nitric oxide (NO)- dependent killing (30). It is likely that interaction with sulphhydryl groups of the parasite plays a role. More recently developed analytical methods of measurement of Sbv and SbIII and of intracellular antimony make comparison with older studies difficult. Trivalent antimony was shown to be more active against promastigotes and amastigotes than pentavalent antimony and macrophages were demonstrated to accumulate and retain antimony for at least 3 days after a 4-hour exposure which may give rise to an effect similar to the post-antibiotic effect (238). Moderate drug resistance may be present in nature and drug sensitivity decreases after subcurative treatment (113,115); Sb resistant promastigotes can be created in the laboratory by drug pressure and these promastigotes retain Sb resistance once transferred into amastigotes (38,92,114). A mechanism of development of resistance may be selection: patients are infected with several "strains" of parasites with different susceptibilities to the drug and parasites may survive suboptimal treatment. Amplification of P-glycoprotein genes does occur in Leishmania parasites but a role for these genes in antimony resistance is unlikely. Increased efflux of drug has been demonstrated in arsenite-resistant cells. Transfection experiments with L. major and the ltpgpA-gene which is associated with Sb-resistance in wild type L. tarentolae isolates, did not confer resistance. Until recently drug resistant clinical isolates had not been used in models of resistance of Leishmaniae (243); since then isolates of Indian, Sudanese and French patients have been used in such studies (156). Rojas et al.(239) in Colombia found primary resistance and demonstrated that even a single cycle of antimony treatment can select for resistant Leishmania parasites (secondary resistance) From Iran, primary antimony resistant L. tropica field isolates were reported (118). Complicating factors are the differences between batches of the commonly available antimonial drugs, both in actual Sb content and in percentage of SbIII. Sodium stibogluconate is supposed to be a 30-34% solution but often is 25-30% (131); it should contain 100 mg Sbv/ml but was shown to have 125 and 123 mg/ml in 2 samples, 12.5 respectively 15.4% of this being trivalent (102). Four lots in India, supposedly containing 100 mg/ml, actually contained between 114 and 121.5 mg/ml (283). Samples of glucamine antimonate, supposed to contain 85 mg Sbv/ml, contained 91.6 to 128.6 mg Sb/ml, 10.5 to 15.8% of the antimony being trivalent (102). Another complicating factor may be the preservative chlorocresol. In a promastigote system of L. panamensis the leishmanicidal activity of sodium stibogluconate appeared to be due to the preservative. Preservative free sodium stibogluconate had a very high IC50 of > 4000 mg Sb/mlbut in an amastigote-macrophage system sodium stibogluconate self showed antileishmanial activity at levels achievable in serum during treatment (92,237). Axenic L. donovani amastigotes and promastigotes were susceptible to chlorocresol. Resistance to Pentostam® was induced in promastigotes and this manifested itself as resistance to chlorocresol in promastigotes and amastigotes and as resistance to sodium stibogluconate in amastigotes (92). In the study in Colombia mentioned above that demonstrated primary and secondary resistance, preservative free antimony was used (239). The variability of commonly used drugs and the presence of variable amounts of trivalent antimony might at least in part be responsible for differences in treatment results and susceptibilities in different studies and these variabilities cast doubts on the comparability and generalizibility of in vitro- and in vivo-studies, to some extend also of pharmacokinetic studies. Mode of Action of Other Drug Miltefosine: An alkylphospholipid oral antineoplastic agent, showed promising activity in visceral leishmaniasis (135,236,287,290). Its mode of action is probably by perturbation of the alkyl-phospholipid metabolism and biosynthesis of alkyl-anchored glycolipids and glycoproteinsand by induction of apoptosis (62,326). Amphotericin B: Amphotericin B binds to ergosterol, the predominant membrane sterol of Leishmaniae. It induces apoptosis. Until recently its use in leishmaniasis was limited because of toxicity and the effectiveness of antimony. Because of increasing antimony resistance, especially in India, amphotericin B and its lipid formulations are now increasingly studied and used. There are no reports on resistance yet. Aminosidine (paromomycin): An aminoglycoside, has activity against Leishmania parasites but its mode of action is unknown. Different species have different sensitivities (61,204). Pentamidine: Pentamidine acts by damaging the kinetoplast-DNA-mitochondrial complex (44) and induces apoptosis. Results of in vitro and in vivo tests with pentamidine were disappointing; activity at high concentration was found against promastigotes but activity against amastigotes varied with the cell source. The human monocyte appeared to be the most susceptible model (203). Antifungal agents like ketoconazole, fluconazole and itraconazole inhibit ergosterole synthesis and are cytostatic in vitro (61). Allopurinol: An analogue of hypoxanthine, forms aberrant nucleotides and interferes in nucleic acid synthesis in vitro in several species of Leishmania and Trypanosoma cruzi (61). Sitamaquine: An oral 8-aminoquinoline, is in early stages of clinical evaluation. Its mode of action is unknown (61,62). Imiquimod: Imiquimod is an antiviral agent, an immunomodulator that stimulates local immune response at the site of application by inducing production of cytokines and nitric oxide in macrophages (61). New Agents: Studies of the biology, metabolism and biochemistry of parasites may lead to new compounds: polyamine analogues, phopholipids and the flavanoid licochalcone (61) and other compounds of plants (62).
ANTIPARASITIC THERAPY Guided Medline Search Smart search Visceral Leishmaniasis The treatment of visceral leishmaniasis in a particular area depends on the susceptibility for drugs of the parasites circulating locally. Pharmacokinetics play an important role in dose, interval and duration of treatment and are dealt with in a separate chapter. Pharmacodynamic studies are difficult to perform in leishmaniasis as they require assessment of disappearance of parasites from spleen or bone marrow (49). Studies have followed disappearance of parasites in weekly splenic aspirates during treatment (46,54,138,304) but as a rule pharmacodynamic studies do not play a role in the choice of treatment.
Treatment of visceral leishmaniasis is with pentavalent
Pentavalent antimonials are still widely used and often are first choice of the clinician. In Bihar antimony resistance has reached such a level that the drug should no longer be used (286) and in Nepal (233) and France (98) resistance is increasing. Also in other countries the position of antimony as first line treatment is challenged especially in patients with HIV coinfection (72,178,236). In Italy liposomal amphotericin B has replaced Sb (112). In Eastern Sudan the high post-kala azar dermal leishmaniasis rate (337) and relatively high relapse rate (214) suggest that Sb treatment is no longer satisfactory . Trivalent antimony, first used in 1912 in a case of mucocutaneous leishmaniasis was replaced by the much less toxic pentavalent compounds in the 1920s (108). Although trivalent antimony is probably responsible for the antileishmanial activity, trivalent compounds are of historical interest only. The presently available products, sodium stibogluconate (Pentostam®, Glaxo-Wellcome, UK) and meglumine antimonate (Glucantime®, Specia, France) were developed in the 1940s. In India and China sodium stibogluconate (SSG), also called sodium antimony gluconate (SAG) is produced by several companies. SSG, produced by Albert David Ltd, Calcutta, was tested for quality by the International Dispensary Association, IDA, Amsterdam, The Netherlands, who also inspected the manufacturing process. Randomized trials of generic SSG from this producer and branded sodium stibogluconate (Pentostam®) have been performed by Médecins sans Frontières (MSF) in Sudan (323), Ethiopia (234) and Kenya (190). Apart from these trials no formal comparisons have been made between the different products for effectivity and toxicity in visceral leishmaniasis patients. In South America l meglumine antimonate and generic products from China (SSG, BP 80®, ShadongXinhan, China) and India (SSG, Albert David Ltd, Calcutta) were compared in patients with cutaneous leishmaniasis (248, 274). Sodium stibogluconate and meglumine antimonate are complex compounds of pentavalent antimony (Sbv) complexed in carbohydrates, the exact structures of which are actually unknown. The solution consists of numerous moieties with molecular weights of 100 to 4,000 and an osmolarity of 800 mOsmol, a solution that may be described as "an unknown number of uncharacterised complexes of Sb with carbohydrates derived from gluconic acid" (35). Differences in osmolality (283), in Sbv and SbIII contents between batches have been mentioned already (102,131). Pharmacokinetics are dealt with in a separate chapter. Dose: Traditionally sodium stibogluconate was advised as an intramuscular injection of 10 mg Sbv per kg, once daily for 6-10 days and meglumine antimonate at 28 mg Sbv per kg per day for 12 to 15 days, to be repeated after 10 days rest (44). The clinical impression that meglumine antimonate was both more effective and more toxic may at least partly be explained by the much higher dose given. Based on randomised comparative studies of patients with visceral leishmaniasis in Kenya (116) and India (302,303), with cutaneous leishmaniasis in Panama (28) and with mucocutaneous leishmaniasis in Brazil (168) the dose of antimony was increased from 10 to 20 mg/kg/day with a maximum of 850 mg per day (333), a maximum later abolished (127); 20 mg/kg per day became the standard. Formal comparisons of a dosing schedule based on body surface area (45) for efficacy and toxicity are lacking and this advice is not followed. Sodium stibogluconate (Pentostam®) comes in vials of 100 ml with 100 mg Sbv per ml. Dosing is relatively easy: a person of 55, 60 or 65 kg receives 11, 12 respectively 13 ml. Meglumine antimonate (Glucantime®) comes in ampoules of 5 ml with 85 mg Sbv per ml, 425 mg Sb per ampoule. Dosing is more complicated: at 55 kg one should receive 2.6 ampoules, at 60 kg 2.8 and at 65 kg 3 ampoules. There might well be a tendency to give full ampoules thus under- or overdose (275). Duration: Based on clinical experience (138,332) and comparative studies (303) the duration of treatment was increased from the traditional 6 to 10 days to 30 days in Kenya, and 40 days in India (36,303). In the Mediterranean region dosages and duration of antimonial treatment varied from region to region, even among hospitals in the same region. Meglumine antimonate 18 to 30 mg/kg/d was used for 10 to 20 days, often repeated after a rest of 15 to 30 days (109,110). Fears of toxicity led to the practice of "courses of treatment" of 10 days with intervals which may have enhanced development of resistance. Like in the Mediterranean region, in South America randomized comparative treatment studies were lacking up to the 1990s. "Antimony-unresponsive" patients, cured after continuous Sb treatment up to 60 days together with γ-interferon, had received short courses of antimony up to 10 days, with intervals (25). In 1990 WHO advised antimony treatment for at least 20 consecutive days and a variation of duration in different endemic areas but treatment certainly to be continued for 2 weeks after apparent parasitological cure (333). Once Daily versus Multiple Daily Administration: Traditionally antimony is administered once per day. Because of the short elimination half life of about 2 h (53) twice or thrice daily administration would seem logical which, in fact already had been practiced in the past although to limited extend (44). Small studies on multiple daily dosing in Kenya showed quicker disappearance of parasites from splenic aspirates, and good tolerance but they were too small to address efficacy (50), Other studies were reported in conferences and referred to by Nyakundi (207). Thrice daily administration of antimony (20 mg/kg/dose) to patients with "antimony resistant" disease was helpful in a few (2/10 cured) but was too toxic (extreme lethargy, cardiotoxic death) to be recommended (46,52). Trivalent antimonials are much more potent than pentavalent compounds and macrophages accumulate antimony during a 4-h exposure and retained it for at least 3 days and amastigotes within macrophages have a higher Sb content 6 days after exposure then immediately after exposure, comparable with the so-called "post-antibiotic effect" (238). Clinically, Sb is effective at once daily dosing. The duration of exposure is better reflected by the terminal elimination half life of 76 h than the initial half life of 2 h. In more recent reviews (36,127,196) multiple dosing per day is not mentioned. Toxicity: In the treatment of visceral leishmaniasis toxicity of antimonials does not frequently lead to discontinuation of treatment (44,110,302,303). Toxicity did not limit treatment in severely debilitated patients in South Sudan (257). In visceral leishmaniasis, assessment of toxicity is difficult because abnormalities may be due to the disease, its treatment, or the interaction between the two. Treatment of cutaneous leishmaniasis may give a better view of toxicity of Sb, see below. In patients with Leishmania/HIV co-infection a high frequency of serious toxicity due to antimony is reported (48,72,152,236): acute pancreatitis, acute renal failure and leucopenia. Eight of 19 Leishmania/HIV co-infected patients discontinued Sb treatment because of toxicity (4 pancreatitis, 1 renal failure; 3 died) (152). Variable percentages of abnormalities in various degrees of severity are reported in several studies on toxicity in treatment of cutaneous leishmaniasis and mucocutaneous leishmaniasis (Table 2). These studies at best give an indication of toxicity because of differences in size, in populations, in disease syndromes, and collection of data. Frequently reported complaints are arthralgia and myalgia, generally in the second and third week of treatment, headache and abdominal pain (Table 2). Acute pancreatitis has been reported both in immunocompromised and immunocompetent patients (72,83,105,152,176). A systematic study of amylase and lipase levels during Sb treatment for visceral leishmaniasis, mucocutaneous leishmaniasis and cutaneous leishmaniasis revealed the common occurrence of "chemical pancreatitis" with or without abdominal pain but without the clinical syndrome of acute pancreatitis and without hypo- or hyperglycaemia (105). In patients treated with Sb, who experience abdominal pain or nausea and vomiting, amylase levels should be assessed and if found increased treatment should be interrupted. After a few days it can generally be resumed without further problems (18). In the largest series of patients (n=114) with cutaneous leishmaniasis treated with Sb 20 mg/kg/d for 20 days myalgia was experienced by 46 and 56% of those treated with Pentostam® and Glucantime® respectively, and 29% of those treated with SSG; abdominal pain was reported by 16, 25 and 4%, respectively. Mild to moderate levations of pancreatic enzymes were seen in 46% (SSG), 64% (Glucantime®) and 69% (Pentostam®); high elevations in 2, 8 and 19% respectively (274). The cardiotoxicity of trivalent antimony is well known (125). Long term exposure to Sbv with conversion of Sbv to SbIII may lead to increase in cardiac calcium currents and toxicity (149). High doses of pentavalent antimony are toxic: once daily 30 mg/kg or 3 x 20 mg/kg per day led to QT-prolongation, tachyarrhythmias and death (46). A dose of 20 mg/kg/day up to 30 days is considered safe (52) although ECG recording once or twice per week seems advisable. A dose of 3 x 10 mg/kg/day, toxic in India (299) was well tolerated in Kenya (50,167). In a recent series from India 32 patients (10%) treated with a standard course of Sb experienced cardiotoxicity, in 20 fatal (286). Severe cardiotoxicity, with mortality, was seen during treatment with generic products (SAG) from India (232,283). A generic SSG product from China also showed high toxicity (248). Again, the variability in Sbv and SbIII content of the different products and different lots, makes comparison difficult. Efficacy: General conclusions on efficacy are difficult to draw; the dose and duration have to be adapted to the region and to the sensitivity pattern of the local parasite. The dose and duration have increased over time with increasing "antimony resistance". When given in the proper dose and for a duration adequate for the area and the given parasite, antimony should be efficacious treatment with cure rates above 90% in areas where secondary resistance is not widespread. Rates of death, of non-response and of relapse should be low, a few percentages each (44). An overview of treatment results in the Mediterranean region up to 1995 mentions good treatment results with unresponsiveness and relapse in a few cases only (110) but in Italy, since 1995, meglumine antimonate was gradually replaced by lipid amphotericin B. Since 2001 almost all patients are treated with liposomal amphotericin B. Reasons were toxicity of antimony drugs, increase in failure rates, and cost-effectiveness of lipid amphotericin B, mainly because of much shorter hospitalization (112). In South Sudan where due to the war follow up was impossible, 2562 of 3076 (83.3 %) patients treated with Sb were "cured" at the end of treatment; 10.9 % (335) died and 79 (3 %) were known to have relapsed (257). Definite "cure" should probably be defined as clinical, haematological and biochemical response and no relapse at 6 months follow up. Post-kala azar dermal leishmaniasis complicates the matter. In Sudan, post-kala azar dermal leishmaniasis is seen frequently during or shortly after treatment. It often does not require treatment and generally is cleared in 6 months (337). In India, post-kala azar dermal leishmaniasis may occur many years after treatment of visceral leishmaniasis. It requires treatment, in the past with many courses of Sb but now, with increasing Sb resistance with alternative treatment (312). Arevalo J, et al. Influence of Leishmania (Vianna) Species on the Response to Antimonial Treatment in Patients with American Tegumentary Leishmaniasis. JID 2007;195:1846-1851. Summary: Pentavalent antimony is given as intramuscular or intravenous injection in a dose of 20 mg Sb per kg body weight once daily. The minimal duration should be 20 days in the Mediterranean region, elsewhere longer treatment up to 40 days is advised, without interruption (196,333). Weekly assessment of haematological and biochemical parameters (liver enzymes, amylase) and a weekly ECG are recommended. Treatment may have to be interrupted because of severe thrombocytopenia (very rare), increase of liver enzyme or amylase levels to more than 5 times normal values (rare), QTc prolongation and dysrhythmias (rare) or severe arthralgia. In immunocompetent patients in areas around the Mediterranean Sea where resistance is not yet a big problem, 90 - 95 % of patients are expected to be cured, a few die and a few relapse. Elsewhere the cure rate may be lower but firm data are lacking for many regions. At the end of the 20th century in Bihar 35% (95% Confidence Interval (CI) 28 to 42) of patients only were cured with Sb treatment; elsewhere in India antimony response was still 86% (95% CI 79 to 93) (286). In India up to 10 to 20 % develop post-kala azar dermal leishmaniasis after several years (305). In Sudan, post-kala azar dermal leishmaniasis occurs earlier and is more frequent (337). In Leishmania/HIV co-infected patients efficacy of Sb is less (around 50%), mortality during treatment is higher (up to 20%) and adverse events are more frequent and more severe than in immunocompetent patients. Review Article: Cutaneous Leishmaniasis. Reithinger, R., Dujardin, J., Pirmez, C., Alexander, B. and Brooker, S. The LANCET Infectious Diseases 2007; Vol.7, Issue 9, 581-596. Amphotericin B and Lipid Associated Amphotericin B: Amphotericin B deoxycholate is a polyene antibiotic used in systemic fungal infections It is very active in vitro and in vivo against Leishmania parasites. It binds to sterols in the plasma membrane of fungi and Leishmaniae. It has to be given by intravenous infusion and administration is often accompanied by adverse effects ranging from fever and chills to severe anaemia, hypokalaemia and renal failure (36,132). These can be reduced by adequate hydration and infusion over several, even 24 hours (93). Administration requires hospitalization. Until the early 1990s its use in leishmaniasis was almost exclusively restricted to mucocutaneous leishmaniasis (36,44) for which it is effective treatment (168). Because of the toxicity of antimony, the increase of antimony resistance and the relatively high toxicity and mortality rate in Leishmania/HIV co-infection, amphotericin B was increasingly studied and the advent of new formulations has accelerated these studies. In the early 2000s amphotericin B became first line treatment of visceral leishmaniasis in Bihar, India because of antimony resistance, failure and toxicity of pentamidine and non availability of alternatives (291). In search of less toxic, possibly more effective formulations, lipid associated formulations of amphotericin B were developed. Two products, liposomal amphotericin B (Ambisome®, Nextar, San Dimas, California, USA) and amphotericin B lipid complex (formerly ABLC, now Abelcet®, Liposome Company, Princeton, New Jersey, USA) have been studied relatively extensively; on a third preparation, amphotericin B colloidal (or cholesteryl) dispersion (formerly Amphocil®, now Amphotec® Intermune, Sequus Pharmaceuticals Menlo Park, California, USA) only few reports are available.Other preparations include liposomal amphotericin B produced in India and “heated amphotericin B (43, 196). Dose, Duration, Efficacy of Amphotericin B: Amphotericin B is very effective both in patients not yet treated and in those not cured after treatment with antimony or pentamidine. Cure rates of 98 - 100 % are obtained (133,182,183,306,310,313). A dose of 1 mg/kg bodyweight daily, infused in 2 h for 20 days or on alternate days for 30 days is recommended (291) also for children and pregnant women (313). Febrile reactions (80 - 100 %), loss of appetite (up to 30 %) and thrombophlebitis (up to 18 %) are frequent but severe toxicity is rare (133,182,183,306,310,313). The incidence of adverse reactions was not dose dependent (310) and not different in a daily or alternate day schedule (307). Incremental doses were not necessary (308). Several patients died of cardiac complications when amphotericin B was given immediately after a course of Sb, not when an interval of 10 days was allowed for (301). Dose, Duration, Efficacy of Lipid-Associated Amphotericin B: Liposomal amphotericin B (Ambisome®) has been shown to be effective and non toxic in the treatment of immunocompetent and immunocompromised patients (36,39,43,65,66,109,180,222, 288,291,311,315). Studies in Italy in 88 immunocompetent patients, 56 of these children, led to the recommendation of a total dose of liposomal amphotericin B of > 20 mg/kg, given in 5 doses of 3 - 4 mg/kg per dose over 10 days. Adverse reactions were not frequent and not serious (66). In cases of severe and complicated visceral leishmaniasis with cachexia and coexistent other infections, treatment of 14 days at 3 - 4 mg/kg/day is probably to be advised (256). WHO supported trials resulted in the recommendation that for India and Kenya, liposomal amphotericin B should be used at a dose of 2 mg/kg/d on days 1 - 4, and on day 10, and for Brazil at 2 mg/kg/day on days 1 - 10 (39). FDA approved liposomal amphotericin B for treatment of visceral leishmaniasis at a dose of 3 mg/kg/d on days 1 - 5, 14 and 21 (179) but 3-4 mg/kg/d on days 1 - 5 and 10 may suffice for European, African and Brazilian visceral leishmaniasis while in India a dose of 2 - 3 mg/kg/d is sufficient (37). So one might well advise on 3 mg/kg/d on days 1-5 and day 10 for all immunocompetent patients with visceral leishmaniasis. Infusion of liposomal amphotericin B, 10 mg/kg once per day for 2 days cured 40 of 41 children in Greece (296). In India an open randomized study comparing a single infusion of 5 mg liposomal amphotericin B (n=46) and 1 mg/kg per day for five days (n=45) showed "cure" at 6 months in respectively 42 (91%; 95% CI 79 - 98) and 42 (93%; 95%CI 82 - 99) patients (288). Locally produced liposomal amphotericin B and amphotericin B dissolved in Intralipid® solutions have been used in small numbers of patients (43,222,300,214). Amphotericin B lipid complex (Abelcet®) at 3 mg/kg/d, 5 days cured all patients in a study in India but it was economical to treat at 1 mg/kg/d for 5 days and to retreat those who relapsed (3 of 19 in the study) with 2 or 3 mg/kg/d, again for 5 days (279). Almost all patients treated with amphotericinB lipid complex experience fever and chills during the first infusion, despite use of paracetamol. During later infusions reactions were less frequent and less severe; 42% had no reaction at the 5th infusion (280). Studies comparing antimony and amphotericin B (183,306) and of pentamidine versus amphotericin B (182) have become of historical interest. Amphotericin B remained as the single effective agent (289) until the advent and availability of miltefosine (291). Head to head comparisons of amphotericin B and the different liposomal products are rare and unlikely to be performed in the future. Comparison of amphotericin B (group 1), liposomal amphotericin B (group 2) and amphotericin B lipid complex (group 3) showed comparable cure rates : 96% (85-100%) for groups 1 and 2 and 92% (80-98%) for group 3. In group 1, 2 patients died of severe anaemia and hypokalaemia and in this group all patients experienced fever and rigors during the infusion while in group 2 71% had no reactions and in group 3, 24% (291). Amphotericin B colloidal dispersion (ABCD, Amphocil®) 2 mg/kg/d for 7 days was used successfully in Brazil in small studies (77,78). Amphotercin B colloidal dispersion (ABCD) at a total dose of 7.5 mg/kg , 10 mg/kg or 15 mg/kg all given over 6 days gave similar cure rates of 97% (95%CI 92-99), 96% (90-98) and 97% (92, 93, 94, 95, 96, 97, 98,99) respectively in a randomized study of 405 patients in India (293) In the 2 high dose groups 2 patients discontinued treatment because of toxicity; fever and chills occurred in 56-68% in all groups. In an older study in Spain in Leishmania/HIV co-infected patients efficacy of amphotericin B deoxycholate and meglumine antimonate was similar (151) but both were highly toxic. In a more recent randomized multicentre trial ABLC 3 mg/kg/d, for 5 and 10 days and Sb 20 mg/kg/d for 28 d were compared (152). Parasitological cure rates were low: 33% (13-59%) for ABLC 5 d, 42% (16-62%) for ABLC 10 d and 37% (16-62%) for Sb. Treatment had to be discontinued in 8 of 19 Sb treated patients versus in 1 in the combined ABLC groups. Summary: Amphotericin B and lipid associated amphotericin B preparations are highly effective in the treatment of visceral leishmaniasis, both for newly diagnosed patients and for antimony and pentamidine resistant cases. Cure rates close to 100% are to be expected. The advised dose of amphotericin B is 1 mg/kg/d, infused over 2 h for 20 days on alternate days for 15 doses (291,313). Short courses of liposomal amphotericin B at a dose of 3 - 4 mg/kg/d on days 1 - 5 and day 10 (36,39) are effective and in India short courses of low dose liposomal amphotericin B at 5 mg/kg total dose, given as single infusion or as 5 day course cured > 91 % (95% CI 79- 99%) of 91 patients (288). Two infusions of liposomal amphotericin B (10 mg/kg) may be sufficient treatment for children with Mediterranean visceral leishmaniasis (296). Amphotericin B lipid complex, 1 - 3 mg/kg/d for 5 days may be equally effective (281) but comes with more side effects of fever and chills. Less data are available on amphotericin b colloidal dispersion but a recent study from India, also showed cure rates of about 96% (95%CI ~90-99) albeit also with high rates of fever and chills (about 60 to 70%) (293) Comparative studies of the different products and of different schedules are rare; a comparison of all 3 liposomal products is not available. Lipid associated amphotericin B is less toxic than amphotericin B and requires shorter hospitalization which may offset the high costs of the drug in countries where hospitalisation is expensive. Liposomal amphotericin B is the least toxic and might even be given on an outpatient basis or in a day care setting. Amphotericin B lipid complex probably requires a short course of 5 days at a low dose of 2 mg/kg/d, but has infusion related effects and may require hospitalization. Data on amphotericine colloidal dispersion are relatively limited. The frequent infusion related adverse events also require hospitalization. For Leishmania/HIV co-infected patients and immunocompromised patients in general, treatment should be extended to 14 days and longer as needed and “secondary prophylaxis” with bi-weekly or monthly doses is required until CD4 counts are 350 per mm3 and higher. Pentamidine: Pentamidine isethionate, a diamidine drug (Pentacarinat®, Aventis, France) damages the kinetoplast DNA-mitochondrial complex, blocks RNA and protein synthesis and leads to apoptosis (259). Its main use is now in the treatment of patients with African trypanosomiasis and in patients with HIV and Pneumocystis jiroveci infection. It is of limited importance in the treatment of visceral leishmaniasis when miltefosine, (lipid associated) amphotericin B, antimonials and aminosidine are available. It still has a place in the treatment of some manifestations of American cutaneous leishmaniasis. Toxicity: The toxicity of pentamidine precludes wide application. In up to 50% of the patients adverse effects occur. These include hypotension, phlebitis, pain at the injection site, abscess formation, cardiac effects with arrhythmias, ventricular tachycardia, anaemia, leukopenia and thrombocytopenia, increase in liver enzyme activity, nephrotoxic effects, kidney failure, pancreatitis, hypo- and hyperglycaemia (15-25% of patients), permanent diabetes mellitus in an unknown percentage of cases even coma and death (106, 251). Toxicity may be dose related (56, 329). Dose, Duration, Efficacy: In India, pentamidine has been used to some extent in the treatment of visceral leishmaniasis and in the early1980s cure rates with relatively short courses of 15 injections were 95 - 100%. In the late 80s,early 90s, however, long courses of 27 injections, followed by 20 daily Sb injections were required for Sb unresponsive cases; pentamidine monotherapy showed a cure rate of 78% only (304) Another study on Sb unresponsive patients showed a cure rate of 77% after 20 injections (182) Toxicity with these courses was considerable: 10% hyperglycaemia, 6% reversible, 4% irreversible, delayed hypoglycaemia in 8% and occasional cardiac deaths in those treated concomitantly with Sb. Children seemed to respond less rapidly than adults (304). Because of the increased ineffectiveness and the considerable toxicity pentamidine was considered not suitable for first line treatment (289). In Kenya pentamidine was not favored because of low cure rates, high relapse rates and toxicity (167,332). In a small study of 9 Sb-resistant patients, 2 were cured after prolonged treatment, the others with combinations of pentamidine and Sb or pentamidine plus allopurinol. Treatment was associated with considerable toxicity (nephritis, abscess formation, disturbance of glucose metabolism) (46). Summary: Because of its toxicity, the long treatment courses needed and dubious results, pentamidine is a reserve drug for the treatment of visceral leishmaniasis after miltefosine, (liposomal) amphotericin B, antimonials and aminosidine. Pentamidine deserves evaluation in the "secondary prophylaxis" in Leishmania/HIV co-infection, see below. Aminosidine: Aminosidine, an aminoglycoside antibiotic is identical to paromomycin. It is produced by another Streptomyces species. It is active against Leishmania in vitro and in animals. Highest activity was against L. major and L. tropica while of the New World species L. panamensis was most, and L. mexicana was least sensitive. L. donovani species showed variable sensitivity and combination of antimony and aminosidine had an additive effect in vivo in mice infected with Ethiopian L. donovani and variable synergy in vitro against Indian and Ethiopian L. donovani (62,204). Combination with miltefosine potentiates the activity of miltefosine (258). The mode of action is not known. Dose, Duration, Efficacy, Toxicity: Monotherapy at doses of 16 to 20 mg/kg/d for a duration of 21 days showed efficacy of 93-97% (55,134,314); combination with antimony was synergistic (255,309). Assessment of toxicity has been limited in these small studies. Aminosidine being an aminoglycoside has the potential of oto- and nephrotoxicity. Production of aminosidine was problematic but under the aegis of the Institute of One World Health (www.iowh.org) and Drugs for Neglected Diseases Initiative (DNDi, www.dndi.org) phase III trials are ongoing in India and East Africa (62,289). Summary: Aminosidine at a dose of 16-20 mg/kg/d for 21 days seems a safe and effective drug for the treatment of visceral leishmaniasis. It acts synergistically with Sb and may help delaying further development of Sb resistance. It is likely to be a good candidate for combination treatment with miltefosine. Sundar S, Jha TK, Thakur CP, Sinha PK, Bhattacharya SK. Injectable paromomycin for visceral leishmaniasis in India. New Engl J Med 2007;356:2571-2581. Sundar S, Chakravarty J, Rai VK, Agrawal N, Singh SP, Chauhan V, Murray HW. Amphotericin B Treatment for Indian Visceral Leishmaniasis: Response to 15 Daily versus Alternate-Day Infusions. Clin Infect Dis 2007;45:556-561. Miltefosine: Miltefosine (Impavido®), (Zentaris, Frankfurt am Main, Germany) hexadecylphosphocholine, was developed as an oral antineoplastic agent. It was found to have anti-leishmanial activity in vitro and in vivo (61,148,319). Its mode of action in leishmaniasis is not yet fully determined; induction of apoptosis seems plausible (326). Leishmania species show different sensitivities to miltefosine in the following order from very sensitive to least sensitive: L. donovani (infantum=chagasi), L aethiopica, L. tropica, L. panamensis, L. mexicana, L. major (95). L. donovani parasites from Nepalese patients were sensitive whereas L. braziliensis complex parasites from patients in Peru were insensitive with the exception of L. (V.) lainsoni parasites (336). Miltefosine is registered in India for the treatment of visceral leishmaniasis and in Germany and Colombia for treatment of visceral leishmaniasis and cutaneous leishmaniasis. Phase IV studies are ongoing in India. It is the first oral drug of proved efficacy against visceral leishmaniasis. Dose, Duration, Efficacy: From a pilot (282) and a phase II study (135) it transpired that miltefosine 100 mg/d for 4 weeks (meaning 2.5 mg/kg/d for a 40 kg patient, the mean weight of an adult patient in India) was efficient and practicable (miltefosine is dispensed as 50 mg capsules). In an open label, randomized phase III trial comparing miltefosine 2.5 mg/kg/d for 28 days (299 patients) and the standard treatment, amphotericin B 1 mg/kg/d on alternate days for 15 injections (99 patients), efficacy of miltefosine at 6 months was 94% (95%CI 91-97) and of amphotericin B 96% (91, 92, 93, 94, 95, 96, 97, 98, 99) in the intention to treat analysis, and respectively 97 and 96% in the per protocol analysis (290). Severely ill patients were excluded from this study. Patients were ≥ 12 year; those weighing < 25 kg received 50 mg/d, for those ≥ 25 kg it was 100 mg/d (actual dose in mg per kg, mean and range, not reported). There was no difference in results between those previously treated and those not yet treated. In the miltefosine group 9 discontinued treatment; 1 withdrew, 8 stopped because of intolerance or intercurrent disease, for 4 of these there was no follow up; of the other 4, 3 were cured at 6 months without further treatment. One had developed Stevens Johnson syndrome at d 6 of treatment, one high bilirubin at d 14 and 1 bleeding hemorrhoids at d 21. The 4th patient had discontinued treatment at d 10 because of rash and arthritis. This patient relapsed. Vomiting was common in the miltefosine treated patients (38%), diarrhea was reported in 20%, reversible ASAT and creatinine increase in respectively 17% and 16%. To the partners of the male patients treated with miltefosine 48 live infants without congenital abnormalities were later born. Of 80 Indian children treated with miltefosine one died of pneumonia during treatment, 79 were “cured” at the end of treatment but 3 relapsed at 6 months and 1 was lost. So the final cure rate was 75 of 78 (96%) evaluable patients, 93.8% on intention to treat analysis. Patients were 2-11 y old, not severely ill, with a mean weight of 18 +/- 4.4 kg, range 10-30 kg and reportedly treated at 2.5 mg/kg/d. How this actually worked out with capsules of 50 mg is not reported (41). In India miltefosine is first line treatment for visceral leishmaniasis and the drug is available in the public and private sector. Indications are that compliance and adherence to proper dose and duration of treatment is not ideal and that actual cure rates may be lower. With the potential of development of resistance because of the long half life of the drug (117), an appeal was made to restrict prescription to a supervised public sector distribution system, free of charge, like for tuberculosis (292). Another reason to restrict the distribution of this drug is its potential of fetal damage and teratogenicity. A patient with antimony unresponsive extensive post-kala azar dermal leishmaniasis was cured after 12 weeks of miltefosine treatment (294); an adult Dutch patient with Mediterranean visceral leishmaniasis was cured after 4 weeks of miltefosine at 1.87 mg/kg/d (76). Thirty nine Leishmania/HIV co-infected patients (38 European, 1 Indian) who had received various antileishmanial treatments, were treated with miltefosine 100 mg/d for a mean of 55 d. Mean weight was 59 +/- 11 kg, range 43-99 kg., thus the dose was relatively low. Thirty three also received HAART. After the “standard course” of 4 weeks, 16 were “cured” and 9 were improved. Most relapsed and needed further treatment. Twenty two received a second, 9 a third and 4 a fourth course. Some patients had prolonged, uninterrupted treatment up to > 2 years (further details not given) (265). In Ethiopia where incidence of Leishmania/HIV co-infection is increasing, miltefosine and generic SSG were compared in an open, randomized trial. 580 male patients were enrolled to receive miltefosine 100 mg/kg/d, 28 d (290 patients) or i.m. sodium stibogluconate (SSG) at 20 mgSb/kg/d, 30 d (290 patients). HIV seroprevalence was 29% in the 375 patients who consented in testing. The 34 patients who had already been treated with SSG were equally divided to the 2 treatment groups. There was no difference in initial cure rate: miltefosine 88.3%; 95%CI 84.0-91.7%, SSG 87.6%; 83.2-91.2%, but mortality was lower in the miltefosine group: 2.1% versus 9.7% in the SSG group (OR 0.20; p= .0002). Initial treatment failure (end of treatment) was more frequent in the miltefosine group: 7.9% versus 0.7% (OR 12.4; p, .0001). Failed and later relapsed patients were treated with SSG (30 d) and final cure rates were comparable: 68.3% miltefosine group and 66.2%, SSG group. HIV infection influenced the outcome: there were more initial failures in HIV infected patients (17.5% versus 4.6%; OR 4.41, p= .044) and there was a higher seroprevalence in those who failed than in those who were cured: 63.3% versus 26.0%;OR 4.89, p= .0001). Multivariate logistic regression showed that SSG treatment (OR 6.53; 2.53-16.89), HIV infection or unknown HIV status (OR 3.54; 1.25-10.06) and vomiting (OR 2.97; 1.28-6.87) were independent risk factors for death. Relapse was more common in the miltefosine group, 10.3% vs 2.4 %, OR 5.05;p = .0001. Excluding those who were lost to follow up (per protocol analysis) cure rates in non HIV infected patients were comparable: 93.4% (miltefosine) and 94.6% (SSG). Miltefosine was considered an acceptable alternative to SSG in this population with many severely ill patients with massive splenomegaly, anaemia, malnutrition, inability to walk unaided and HIV coinfection. The high death rate in this study is likely to be a reflection of the severity of disease in these patients. In the miltefosine studies in India severely ill patients and HIV infected patients were excluded, and the death rate was low, < 0.2%. It was concluded that miltefosine is equivalent to SSG in non HIV coinfected patients and probably safer, but less effective in HIV coinfected patients. However, a “standard” course of treatment for 28 days was followed; optimal dose and duration of miltefosine for African visceral leishmaniasis with and without HIV infection should still be established (236). Toxicity: Vomiting and diarrhea are frequent adverse events and are dose related. In dose finding pilot studies in India (282, 285) a dose of 200 mg/d (about 4 mg/kg/d) appeared to be the maximum tolerable dose; 1 of 5 patients treated with 250 mg/d died of nephrotoxicity on d 21. Four patients (1 of 5 receiving 200 mg/d and 3 of 5 receiving 250 mg/d) discontinued treatment because of vomiting In 2 more patients receiving 200 mg/d considerable increases in creatinine levels occurred (reversibility not reported). Of 45 patients treated with 100, 150 or 200 mg miltefosine per day, 28 days, 44 were cured (1 was lost). The patients who discontinued treatment from day 7 to 17 were also cured. Reasons to discontinue were vomiting (2), diarrhea (2) and hepatotoxicity (1,200 mg) and nefrotoxicity (1,200 mg). Thirty one had at least 1 episode of vomiting, mostly in weeks 1 and 2 and 24 experienced diarrhea also mostly in weeks 1 and 2. There was reversible nephrotoxicity in the first 3 weeks in 13 and mild rise of ASAT in the first week. There were no indications of ophthalmologic toxicity as seen in animal studies (285). Animal studies showed embryotoxic, fetotoxic and teratogenic effects and also reproductive toxicity in male rats. Pregnancy is a contraindication and women of reproductive age should use effective contraception up to 2 months after treatment. In the phase III trial in India 48 healthy babies were born to partners of 80 male patients (290). Spermiograms in Colombian patients treated with miltefosine for cutaneous leishmaniasis appeared normal so it was concluded that there was no concern for male reproductive toxicity (211). In the larger studies from India 26-38% of patients vomited, 20-25% had diarrhea and ASAT levels rose by 17-19% in the first week (41,290). In the Ethiopian study vomiting was common: 54.8 in the miltefosine group vs 32.15 in the SSG group (p = .0001). It was of longer duration in the miltefosine group but less severe, leading less often to interruption of treatment than in the SSG group. Incidence and duration of diarrhea were similar in both groups (about 50%), but diarrhea was more common in HIV infected patients. One patient discontinued miltefosine treatment on d 21 because of itchy rash; this patient was lost to follow-up (236). Summary: Miltefosine as the first available oral treatment of visceral leishmaniasis is a very promising development in the field of the Neglected Diseases. Toxicity (vomiting and diarrhea) is probably limiting the dose to a maximum of 200 mg per day; the duration is not well established, not even for India; several patients who stopped treatment before d 28 because of adverse events were cured without further treatment. Miltefosine is effective treatment of visceral leishmaniasis in immunocompetent patients in India at a dose of about 2.5 mg/kg/d and duration of treatment of 28 days. Dose and duration for visceral leishmaniasis in other areas and for immunocompromised patients have not yet been established. Toxicity may preclude daily doses higher than 150-200 mg; efficacy of doses < 2 mg/kg/d is not assessed. A total dose needed has not been established. Pharmacokinetic and pharmacodynamic studies are limited; they may help devising treatment schedules. Development of resistance is a threat, the long elimination half life may contribute to this. Regulation of distribution and prescription is urgently needed and combination treatment is advocated and should be studied. Aminosidine is likely to be a good candidate for this combination. Sitamaquine: Sitamaquine (WR 6026), an oral 8-aminoquinoline showed promising anti-leishmanial activity (4 of 8 patients cured at 1 mg/kg/d for 28 days) in a phase I/II efficacy trial in Kenya (264). A dose escalating study in Brazil showed that at 2 mg/kg/d for 28 days, 4 of 6 patients (67%) were cured but at 2.5 mg/kg, only 1 of 5 and the single patient treated with 3.25 mg/kg was not cured. Nephrotoxicity was seen in 2 of the 5 patients treated with 2.5 mg/kg/d and in the patient at 3.25 mg/kg. These results were surprising and puzzling because of the lack of increasing efficacy at higher doses and because of the nephrotoxicity that was not seen in animal studies and in the Kenyan study (79). Two phase II dose-ranging studies (1.5 kg/kg/d to 3.0 mg/kg/d) in Kenya and India showed reasonable cure rates overall (ITT analysis): 79 of 97 (81.4%) in Kenya and 92 of 120 (76.7%) in India. (330, resp.136). Severe renal toxicity was seen in the higher dosed groups (2 of 24 in Kenya, 5 of 28 in India), in 1 fatal, in 1 of unknown outcome and in the remaining patients reversible. Adverse events were common (> 40%) in the higher dose groups but also relatively common (10-20%) in the lower dose groups. Abdominal complaints of discomfort, pain, dyspepsia, diarrhea and headache were the commonest events. In the study in India methemoglobinaemia was assessed. An increase of at least 10 % was found in 33% of patients (136). A Leishmania/HIV co-infected Kenyan patient who did not respond to Sb treatment received sitamaquine 2.5 mg/kg/d for 28 days and was cured with a follow up of 6 months (227). Summary: Oral sitamaquine for 28 days showed a cure rate of about 80% in visceral leishmaniasis at various doses; the optimal dose is still to be established. Abdominal discomfort, pain, vomiting, diarrhea seem to be quite common. Nephrotoxicity, probably dose related, needs careful further study before sitamaquine can be used at some scale. Allopurinol: Allopurinol, an analogue of hypoxanthine is metabolized by Leishmania spp and Trypanosoma cruzi whereby aberrant nucleotides are formed that, incorporated into the RNA of the protozoa, interfere with normal protein synthesis (61). Allopurinol showed anti-leishmanial activity in in vitro cultures and in animal models but results in vivo have been variable, both in visceral and in cutaneous leishmaniasis. Most reports are about non-controlled trials, mostly in combination treatments with Sb of patients non responsive to standard Sb treatment (44,54,73,137,138,175) but also with the antifungal azole drugs keto-, flu, and itraconazole, in the treatment of visceral leishmaniasis and as secondary prophylaxis in patients co-infected with Leishmania/HIV (109,316). Its use in the latter condition before the advent of HAART, seemed reasonable and, in areas where HAART is not available, should be further studied. Dose, Duration: In the dose used in leishmaniasis, 7 mg/kg x 3 per day for prolonged periods of time, adverse effects are more likely than with the dose used for gout. Adverse effects include rash, itching, fever, eosinophilia, hepatic granulomas, interstitial nephritis and vasculitis, bone marrow depression and exfoliative dermatitis. There is no room for allopurinol monotherapy in visceral leishmaniasis. Its place in combination therapy remains undecided. The derivative allopurinol ribonucleoside, much more effective in vitro, has been used to limited extent in cutaneous leishmaniasis but is not further developed (245). Other Treatments: The antifungal azoles Ketoconazole , fluconazole and itraconazole, have shown variable results in the treatment of leishmaniasis, probably due to variation in sensitivity of species (36,61,63). Eleven of 21 Indian patients treated with fluconazole were initially cured but all relapsed within 8 weeks. Studies of adjustment of the dose and or duration and of combination therapy were suggested (280) but have not been reported. Study of a role in the secondary prophylaxis in HIV-infection seems warranted (36,109,284). Bryceson summarized data on other treatments, mostly of unproved value (44). Atovaquone showed some activity in experimental leishmaniasis (194). Its effects in vivo, both alone and in combination with fluconazole were limited but warrant further study in combination with other antileishmanials and in the secondary prophylaxis in Leishmania/HIV co-infection (284). Several plant products are in various stages of research and development: licochalcone A from the Chinese liquorice plant Glycyrrhiza, PX-6581 from the Vietnamese plant Maesa balansae (several quinolines, one from Galipea longiflora from Bolivia (62). Immunochemotherapy is studied in several models and experimental animals and includes induction or enhancement of IFN-γ or IL-12 production, T-cell stimulation to strengthen Th1 response or down regulate suppressive mechanisms, influencing prostaglandin mediated actions and granulomas, and other (195,196).
Cutaneous Leishmaniasis Assessment of treatment of cutaneous leishmaniasis is hampered by several factors in published reports: lack of parasite characterization; lack of, or difference in, diagnostic criteria and criteria of cure; lack of comparisons and of controls, especially of placebo treatment in a disease with spontaneous healing tendency. There are relatively few comparative, randomised trials, and these are rarely (double-) blind. Treatment of Cutaneous Leishmaniasis: Treatment options are: - no treatment, “ wait and see” - local treatment physical methods excision, curettage cryotherapy heat therapy topical treatment paromomycin other? imiquimod? intralesional treatment Sb other - systemic treatment oral agents imidazoles miltefosine other parenteral agents antimony amphotericin B aminosidine A decision to treat or not to treat will depend on - evolution (history) of the lesion (if already improving: wait for self-cure) - number of lesions (presence of ≥ 5 lesions is often reason to treat) - size of lesion(s) (small lesions, < 1cm diameter may be left alone; lesions ≥ 5 cm are generally indication for treatment) - site of lesion(s) (treatment indicated if on face and ears, near joints, hands, if troublesome for wearing clothes or shoes - species: L. braziliensis will be treated - immune status of the patient. Cutaneous Leishmaniasis of the Old World: No Treatment: Observational studies and placebo arms of comparative studies have shown that most- L. major and L.tropica lesions self cure within 6 to 12 respectively 12 to 24 months (7,19,33,85,200). Local Treatment: Physical Methods: Excision or curettage of small lesions (papules, nodules) is reported but not in comparative studies and data on successes and recurrences are unreliable. Generally not recommended because of high relapse rates (85). Cryotherapy has been applied by itself or combined with intralesional antimony (il Sb). Assessment of results of cryotherapy is difficult because of variations in techniques, numbers and intervals of applications, differences in follow-up and lack of reporting of parasite species. Reports of efficacy vary from 68% (86) to more than 90 % (21,22). One session of cryotherapy was sufficient in 90% of 461 cutaneous leishmaniasis patients (L. tropica area) in Turkey (320). Heat therapy with a radio frequency generator (Thermo Med 1.8; ThermoSurgery Technologies,) was compared with il Sb, 5 injections of 2-5 ml every 5 to 7 days and im Sb, 20 mg/kg/d for 21 days in a study on L. tropica lesions in Afghanistan. Thermotherapy cured 75 of 108 patients (69.4%), il Sb 70 of 93 (75.3%) and im Sb 20 of 58 (44.8%). Time to cure was significantly shorter in the thermotherapy group compared to both Sb groups (53 versus 75 (il) and 100 (im) days) and OR for cure of Thermotherapy versus im Sb was 2.80 (95%CI 1.45-5.41), not different versus il Sb and OR for cure of il Sb versus im Sb was 3.75 (1.86-7.54). Treatment of one lesion would lead to cure of untouched lesions in other parts of the body (229). Topical treatment with paromomycin 15% in methylbenzethonium 12% was used in observational and comparative studies. Results are variable, probably because of differences in parasites (not always characterized), in dose, duration and way of application. Efficacy is 70 to 87% (19,89,90,216). Because of skin irritation methylbenzethonium was replaced by urea 10% but several studies have shown that paromomycine in urea is not effective (33,96,130). Topical paromomycin treatment is now in further evaluation. Topical treatment with miltefosine (253) and ethanolic lipid amphotericin B (322) deserve formal study. Other, older studies on topical treatment are of historical interest only (145,154). Imiquimod and S-nitroso-N-acetylpenicillamine, immunemodulators, examined in American cutaneous leishmaniasis, see below, have apparently not been studied in cutaneous leishmaniasis of the Old World . Another nitric-oxide generating cream was not effective in Syrian patients with L. tropica lesions (67). Intralesional Treatment: Both sodium stibogluconate and meglumine antimonate have been studied for intralesional treatment (il Sb) in observational and comparative studies. About 0.5-1ml, up to 4 ml, Sb is injected in the wall of a lesion until "blanching" . Various schedules are applied: once a week for 3 up to 8 weeks or twice or thrice a week for 2 to 3 weeks. Cure rates from about 40 to 55 % (21,96) up to ≥ 75% and > 90% (4,20,99,249,297) are reported. Uzun et al report large series of patients treated with intralesional antimony: 2329 (320) and 1030 (321) patients with cure rates > 90 %. They gave weekly injections of 0.2-1 ml up to 20 injections, mean 11 and 8.5 respectively in the 2 reports. Adverse events were pain and transient erythema and edema. Combination of cryotherapy with il Sb was more effective in several comparative studies: il Sb alone 50%, combination therapy about 90% (20) and cryotherapy alone 57%, il Sb alone 55%, combination therapy 90% (21) Fears that il Sb might lead to increase of chronic cases and reduced sensitivity to Sb have been expressed but have not been substantiated (84). Intralesional and intramuscular antimony were equally effective in a study in Saudi Arabia (mainly L. major) (4) but in an area in Iran where L. major and L. tropica are found il Sb was less effective than ketoconazole (72 versus 89%, p<0.05) (249). There does not seem to be a good reason to treat L. major lesions with systemic antimony. A comparative study of intralesional Sb plus cryotherapy (15 patients), cryotherapy alone (14 patients) and intralesional Sb alone (15 patients) of probably, but not proved, L. tropica lesions, showed 100% cure in the first, 68% in the second and 44% in the third group, 3 months after completion of treatment (86). Triamcinolone, bleomycine, mepacrine, emetine and hypertonic sodium chloride (7%), have been applied intralesionally in open, non comparative trials (85,145). Intralesional hypertonic (7%) sodium chloride (88 lesions, 96% cure), il Sb (50 lesions, 96% cure) and control (20, no cure in 6 weeks) and il NaCl 7% (40 lesions, 85% cure), il zinc sulfate 2% (38 lesions, 94.8% cure) and il Sb (35 lesions, 88.6% cure) were compared in 2 studies in Iraq (261,263). Systemic Treatment: Oral Therapy: Fluconazole, 200 mg daily for 6 weeks was compared to placebo in a randomized double blind trial of 106 patients with L. major infection in Saudi Arabia (7). Time to healing was significantly less in the fluconazole group at 6 weeks and three months follow up. Sb treatment was offered when lesions progressed (14% in the fluconazole group versus 51% in the placebo group) . Because lesions caused by L. major will usually heal over time without any therapy, cost of the fluconazole is a consideration in its use. Ketoconazole was effective in L. major-, not in L. tropica- and L. aethiopica infection and itraconazole seemed promising, both in L. major - and in L. tropica infection (81,145,185,266). Itraconazole was not better than placebo in a randomized double-blind placebo-controlled clinical trial in Iran (L. major area) (200). Data on drug resorption and blood levels are lacking in these studies. Miltefosine was prescribed to 34 Dutch soldiers with L. major infection acquired in northern Afghanistan after failure of combined cryo- and il Sb therapy. They received 150 mg per day for 28 days (1.3-2.1 mg/kg/d, a relatively low dose, drug levels are pending). Six weeks after treatment three received a few Sb injections and 1 was treated with iv Sb for 28 days because of reactivation of lesions. At 6 months 31 were cured, results of 3 were pending. Treatment was well tolerated. (P.P. van Thiel, personal communication). As L. major is the least sensitive of tested parasites (95), this treatment needs further evaluation also as regards pharmacokinetics and –dynamics. Allopurinol, 20 mg/kg/d x 30 days has been used in 25 Iranian patients with leishmaniasis recidivans, a difficult to treat condition, in combination with Sb (20 mg/kg/d x 30 d); 24 were cured (184). Antibiotics and Chemotherapeutics: Many drugs have been tried. Dapsone, 2 x 100 mg/d for 6 weeks, proved effective in a double blind study of 120 patients in India (80). Rifampicin has given equivocal results (cure rates from 0 to 80%), addition of INH did not improve efficacy (144,145). Metronidazole and co-trimoxazole are probably not of use (145). Azithromycin, a macrolide antibiotic that concentrates in macrophages, showed activity against L. major in vitro and in vivo (BALBc mice) and deserves further study (147). Many antimalarial drugs have some antileishmanial activity in vitro but have not been shown to be of use in vivo, may be with the exception of cycloguanil (44) and atovaquone (194, 284). Paniz Mondolfi AE, et al. Successful Treatment of Old World Cutaneous Leishmaniasis Caused by Leishmania infantum with Posaconazole. Antimicrob Agents Chemother 2011;55:1174-1776.
Hervás JA, et al.
Old World Leishmania infantum Cutaneous Leishmaniasis
Unresponsive to Liposomal Amphotericin B Treated With Topical Imiquimod. Kim DH, et al. Is Paromomycin an Effective and Safe Treatment against Cutaneous Leishmaniasis? A Meta-Analysis of 14 Randomized Controlled Trials. PLoS Negl Trop Dis 2009;3(2): e381. Parenteral Therapy: Antimonials are not first line therapy for Old World cutaneous leishmaniasis because of the tendency to spontaneous cure, the costs, side effects and the parenteral administration. A placebo controlled study of L. major infections in Algeria showed no benefit of systemic antimony treatment (32) in contrast to an uncontrolled study in Sudan (91). In Kenya, 4 of 10 patients infected with L. tropica were not cured after 30 day Sb treatment at 20 mg/kg/d (177) but 3 with L. aethiopica infection were after 30 days of Sb, 2 x 20 mg/kg/d (51). Eight of 11 patients with cutaneous leishmaniasis (various species) treated with 3 intramuscular injections of pentamidine responded well (123). The comparative study of intralesional and intramuscular Sb treatment referred to above (4,20,21) are not in favor of intramuscular administration. If indicated, parenteral antimony is generally advised for 20 days. In American military personnel (38 patients) with cutaneous leishmaniasis, 1 with L. tropica, the others with American leishmaniasis 10 days Sb was as effective as 20 days and came with much less discomfort and less adverse events (335). In Turkey, in 1030 patients intramuscular Sb, 10-20 mg/kg/d 15-20 d, was used in 19 patients because of large lesions or mucosal involvement (321). Diffuse Cutaneous Leishmaniasis: Treatment studies in this condition are rare and evidence based treatment advice can not be given. Pentamidine, 3-4 mg/kg intramuscularly once weekly, 4 months longer than needed to eliminate parasites is the recommended treatment for diffuse cutaneous leishmaniasis caused by L. aethiopica (44). In a small double blind trial of itraconazole (200 mg/d for 4 weeks) versus placebo in 14 patients with L. aethiopica infection (4 diffuse, 10 localized leishmaniasis), itraconazole was not more effective than placebo (1). Immunotherapy with Il-2, liposomal amphotericin B and combined aminosidine-antimony treatment may be useful but need further study (2, 298). Leishmaniasis Recidivans: This condition is rare and comparative trials of its treatment are lacking. Up to 5% of patients with cutaneous leishmaniasis, especially due to L. tropica may develop recurrent leishmaniasis (84,184). Combination treatment with Sb (20 mg/kg/d x 15 d) and allopurinol (20 mg/kg/d x 30 d) cured 24 of 25 Iranian patients (184). Cutaneous Leishmaniasis of the New World: It is important to differentiate between parasites of the 3 complexes of L. braziliensis, L. mexicana and L. guyanensis because of the differences in natural history, healing tendency, drug sensitivity and possibility of mucosal involvement. Different species in the respective complexes have different sensitivity patterns to the available drugs (240). In many studies parasites are not characterized to the species level. Localized cutaneous leishmaniasis is characterized by a single or few lesions, a cellular immune response, spontaneous healing tendency and response to treatment. It may be caused by parasites of all 3 complexes. Diffuse cutaneous leishmaniasis is caused by parasites of the L. mexicana complex and shows numerous non ulcerating lesions, no manifestations of cellular immune response, no spontaneous healing tendency and unsatisfactory response to chemotherapy. Intermediate forms include mucocutaneous disease and patients with extensive lesions and verrucous and vegetative forms. There is exacerbated delayed type hypersensitivity but apparently incomplete protective immunity. It is associated with L. braziliensis infection. Disseminated leishmaniasis is characterized by ≥ 10 mixed-type lesions in at least 2 body parts. There is a strong cellular immune response (LST). Leishmania Mexicana Infections: Parasites of the L. mexicana complex usually cause solitary lesions without lymphatic involvement and without later mucosal spread. L. mexicana infections of the ear may involve the cartilage (“chiclero”) and become chronic. Treatment of L. mexicana Infection No treatment: It is generally held that simple L. mexicana lesions heal spontaneously in 3 to 6 months and do not need treatment (328) but this is disputed (324). In Guatemala 22 of 25 L. mexicana lesions completely re-epithelialized without treatment by 14 weeks (median) and 17 (68%) were cured when assessed 6 months later while only 7 (22%) of 32 L. braziliensis lesions re-epithelialized by 13 weeks (median) and 2 were definitely cured (128). Other studies have shown spontaneous cure rates from 38% (L. mexicana) (Guatemala) (202) to 75% (mainly L. braziliensis species) (Ecuador) (116). Thus simple L. mexicana lesions might be left alone to self cure, (116,128,202,328) a notion challenged in Mexico (324). Local Therapy: Heat Therapy: In a placebo-controlled study of local heat and systemic Sb treatment with 22 patients in all 3 groups, 16 patients (73%) were cured in both treatment groups and 27% in the placebo group. Fifty-three isolates were characterized: 40 were L. braziliensis and 13 L. mexicana. L. braziliensis results were: cure with Sb 11 of 14 (79%), heat 9 of 14 (64%) and placebo 0 of 11. For L. mexicana the numbers were small: cure with Sb1 of 4, with heat 2 of 2 and placebo 5 of 7 (201). Treatment with a newly developed device (Thermosurgery ®,prototype of ThermoMed®) of 201 patients with cutaneous leishmaniasis in Mexico resulted in 90% cure (191 patients seen 8 weeks after treatment) (324). Topical Therapy: Studies of topical treatment of proved L. mexicana lesions are rare. A study in Belize of 53 patients treated with paromomycin 15% in 12% methylbenzethonium (PMBCL) ointment showed a 74% cure rate after 2 months and no response in 26%. Parasites were not identified but L. braziliensis was the most frequent parasite in the area and L. mexicana was identified in about 25% of cases (331). In Guatemala 91.4% efficacy was reported in patients presumably infected with L. braziliensis and L. mexicana (14). In Honduras paromomycin 15% in urea 10% proved ineffective in L. mexicana and L. chagasi lesions (206). Another formulation, paromomycin in hydrophilic gel, proved useful in animal models of L. major, L. amazonensis and L. braziliensis infection (107). Oral Treatment: Imidazoles: Ketoconazole was effective in 8 of 9 (89%) of L. mexicana infections while Sb cured 4 of 7 (57%) (202). Miltefosine: In a study of miltefosine treatment in New World cutaneous leishmaniasis in Colombia and Guatemala of 14 confirmed L. mexicana infections, 9 (60%) were cured (272). Other Treatment: Antituberculous drugs (rifampicin, isoniazid and para-aminoslicylic acid) have no proven efficacy (145) although animal studies (221) and a case report on concurrent mucosal leishmaniasis and pulmonary tuberculosis treated and cured with antituberculous therapy alone suggest otherwise (94). Parenteral Treatment: Antimony treatment at 20 mg/kg/d for 20 days is effective but may be over-treatment in L. mexicana infections; 10 day treatment cured 90% and has less adverse events (13). Leishmania Braziliensis Infection Most infections due to parasites of the L. braziliensis complex (L. braziliensis and L. peruviana) lead to a single lesion or a limited number of skin lesions. Mucosal disease may develop in less than 3 to 5% of L. braziliensis infections, months to years after cure of the cutaneous lesion (168,208); concurrent cutaneous and mucosal disease does occur (42). It is generally held that L. braziliensis infections should be treated with systemic drugs because of the risk of later mucosal development and that placebo treatment or no treatment are unnecessary or unethical (44,145, 173, 245). The picture is complicated because the risk of mucosal disease depends on the species, may be even the strain involved and may be less than 3% (208). Moreover, L. braziliensis lesions, both cutaneous and mucosal, may heal spontaneously (60,169,170). Many trials lack controls and long follow up which makes drawing firm conclusions difficult. Treatment of L. braziliensis Infection No Treatment: As mentioned, both cutaneous and mucosal lesions due to L. braziliensis may heal spontaneously but treatment is advised (44,145, 173, 245). Local Therapy Cryotherapy: In his review, Bryceson mentioned that cryotherapy was not useful in L. braziliensis infections (44). More recent information is not available. Heat Therapy: In the above named placebo-controlled study in Guatemala of local heat and systemic Sb treatment with 22 patients in each group, 16 patients (73%) were cured in both treatment groups and 27% in the placebo group. Results of cure for proved L. braziliensis infections were 11 of 14 (79%) for Sb, 9 of 14 (64%) for heat and 0 of 11 for placebo (201). In a comparative study of heat therapy and meglumine antimonate of L. braziliensis infected patients heat therapy led to the same systemic cytokine response as iv antimony treatment and untouched lesions would also be cured (158). All heat treated patients were also treated with antimony at day 28 (at that time 75% of lesions had healed or were healing versus 90% in the antimony group, p=0.13) so conclusions on efficacy can not be made. Additionally it was mentioned that 7 patients who had not responded to long courses of antimony, 2 pregnant women and a patient allergic to Glucantime®, excluded for the comparative trial, all responded well to heat therapy (158). Topical treatment. In Belize (mainly L. braziliensis infections) a 68% cure rate was seen after paromomycin 10% in 12% methylbenzethonium treatment, 1 month after treatment (331). In Guatemala in a double blind, randomized, placebo controlled study (parasites not identified but normally 75% L. braziliensis and 25% L. mexicana species in the area) paromomycin/methylbenzethonium chloride ointment for 20 days proved effective at 12 months: 31 of 35 (88 %) cured versus 13 of 33 (39.4%) in the placebo group (14). but in another study addition of PMBCL to 7 or 3 days Sb gave cure rates of 58 and 20% respectively versus a cure rate of 53% for addition of placebo to 7 days Sb and of 84% for 20 days Sb alone (271). The place of topical paromomycin/methylbenzethonium chloride ointment remains to be established (107). Intralesional Therapy: Intralesional antimony treatment was used in small numbers of L. braziliensis infections (29,44,68). Eighty-two lesions in 74 patients living around Rio de Janeiro were treated with intralesional Sb, repeated after 15 days if there was no improvement. Fifteen of the 35 positive cultures were characterized and found to be L. braziliensis. At 12 weeks, 59 patients (79.2%) had healed after 1 dose in 47 and 2 doses in 12, and 12 (16.2%) had failed. Three (4.05%) were lost. Fifty-six were followed for at least 2, up to 10 years, 43 for 5 years or more. No relapses and no mucosal development occurred (209). The authors concluded that this treatment was effective, had no toxicity and could be applied in the field at low cost. Oral Treatment: Imidazoles: The importance of speciation of the parasite and of a control group was shown in a study in Guatemala: Sb cured 24 of 25 patients (96%) infected with L. braziliensis and 4 of 7 (57%) L. mexicana infections; ketoconazole cured 7 of 23 L. braziliensis infections (30%) and 8 of 9 (89%) L. mexicana infections. Placebo cured 1 of 15 L. braziliensis infections (7%) and 5 of 16 (38%) L. mexicana infections. The conclusion that Sb was effective in L. braziliensis infections but not better than placebo in L. mexicana infections and that ketoconazole deserved further study is reasonable but numbers are small (202). In a study in Colombia comparing Sb, pentamidine, itraconazole and no treatment (total 92 patients) itraconazole was not better than no treatment. The parasites in this study were not characterized, the majority would be L. panamensis, the rest L. braziliensis and L. mexicana (276). Treatment of L. mexicana lesions with ketoconazole or itraconazole seems justified but L. braziliensis infections need other treatment. Miltefosine: In an open phase I/II trial in 72 soldiers in Colombia miltefosine at 50-100 mg/d for 3 weeks cured 21 of 32 patients (66%) and at 133-150 mg/d for 3-4 weeks 30 of 32 patients (94%). The historic cure rate for Sb for the area is 93% (L. braziliensis parasites mainly). Dose related motion sickness was experienced by 40% (272). Subsequently a study was performed in Colombia and Guatemala with miltefosine 2.5 mg/kg/d for 28 days. In Colombia 73 patients were treated; 7 successful cultures showed L. panamensis which is the most prevalent parasite in the area. The per-protocol cure rate for miltefosine was 91%, for placebo 38%, comparable to historic values for Sb and placebo. In Guatemala, in an area where both L. braziliensis and L. mexicana were found, the per-protocol cure rate for miltefosine was 53% and for placebo 21% while the historic cure rate for Sb was > 90%. Forty-six of 60 parasite isolates were characterized: 29 were L. braziliensis (cure rate 33%), 17 L. mexicana (cure rate 60%) (273). Miltefosine did not seem to be useful in this study against L. braziliensis. Rubiano LC, et al. Noninferiority of Miltefosine versus Meglumine Antimoniate for cutaneous Leishmaniasis in Children. J. Infect Dis. 2012 Feb;205(4):684-92. Other Treatment: In an uncontrolled study of 24 patients in an area of L. braziliensis, azithromycin used in various dosages and different durations, showed promising results: 17 of 20 patients who completed the study were cured in 60 days (6), 90 days (7) and 120 days (4) without recurrences in 14 months follow-up (223). Allopurinol and allopurinol riboside. Marsden et al. mentioned that 5 patients with L. braziliensis infection did not respond to allopurinol treatment without giving further details (169). After a comparative study in Ecuador in 75 patients of no treatment, Sb and allopurinol riboside plus probenecid (23 isolates, 12 L. panamensis, 5 L. guyanensis, 3 L. braziliensis and 3 L. mexicana) no conclusion about the usefulness of allopurinol riboside could be made (116). Another comparative study of allopurinol and Sb in L. braziliensis patients concluded that allopurinol is not effective in this infection because of the difference in cure rates in the two groups, the difference in development of mucosal lesions and worsening of the lesions in 4 patients on allopurinol. (82). Parenteral Treatment: For L. braziliensis infections, in particular L.b. braziliensis, systemic treatment with a pentavalent antimonial at 20 mg/kg/d is generally recommended for cutaneous disease 20 days, for mucosal disease 28 days (44,145). Treatment failure is more frequent in children (218) and it is important to know the causative parasite because of the differences in susceptibility (240). In Central and South America treatment normally is with Glucantime that comes in ampoules of 5 ml, containing 425 mg Sb. In practice there will be a tendency to administer full ampoules in order not to waste drug so a person of 50 kg will likely receive 2 ampoules, 850 mg, 17 mg/kg/d. Studies reporting the actual dose per kg given (mean and range) are extremely rare. Results of Sb treatment are variable: 79-96% for adults in Guatemala and in Peru with L. braziliensis infections (12,201,202), 51% for L. braziliensis infections in Brazil (240) and only 25 % in children in Colombia, 5-15 year old (218). On the other hand, Arana et al (13) in a comparative study of 10 and 20 days Sb and Sb plus interferon-gamma for 10 days, concluded that 10 days Sb was sufficient treatment for L. braziliensis infection. A low dose of Sb, 5 mg/kg/d but with a longer course of 30 days also cured 84% (of 159 patients) (208). Of the 120 healed patients, 98 could be followed for at least one year, 75 for 5 years or more and 15 up to 10 years. In these 98 there was no mucosal development. Side effects were few in this study and treatment costs were relatively low (compared with high dose Sb for 30 days) (208). However, this 30 day treatment duration is long and cumbersome and costly for the patient especially in comparison to a 10 day treatment as this may be sufficient (13). In a campaign on diagnosis and treatment of cutaneous and mucocutaneous leishmaniasis in rural areas of Bolivia results were as follows: of 1667 patients with cutaneous infection (L. braziliensis) treated with Sb (20mg/kg/d for 20 days), 1553 (93.2%) were cured, 68 (4.1%) had to interrupt treatment because of side effects and 21 (1.3%) failed. They were further treated. Only 11 patients, 0.7%, had further re-activation and 24 patients could not be followed. Patients with mucocutaneous leishmaniasis were treated with amphotericin B, see below (71). In a recent study in Bolivia comparing several brands of Sb in 45 patients, cure rates were 86-94% in a per protocol analysis and 75-85% in an intention to treat analysis; parasites were not characterized but supposedly were L. braziliensis (274). In Peru, in a comparative study of 80 patients with L. braziliensis infection, of 40 treated with Sb (20 mg/kg/d, 20d), 31 (78%) were cured, 6 (15%) failed and 3 were lost while in 40 treated with pentamidine (2mg/kg/d, 7 injections) 14 (35%) were cured, 23 (58%) failed and 3 were lost (12). Most studies lack long observations. Netto et al. (205) reported on 4 year follow up in 79 patients with L. braziliensis infections, 62 with cutaneous and 17 with mucosal disease. Relapse was seen in 6 of the 62 cutaneous patients (10%) and in 2 mucosal manifestations developed (3%). Two of the 17 with mucosal disease had later mucosal relapse (17%). A review of 151 patients with L braziliensis infection, treated between 1967 and 1982 revealed that 45 received continuous Sb treatment from 25 up to 116 days and that 94 had intermittent treatments with various rest intervals. For 47.5% of patients the antimony dose could be calculated which appeared to vary from 3.9mg/kg/d to 28.7 mg/kg/d. There were no significant differences in time to healing between adults and children, between intermittent and continuous therapy or high and low antimony dose. Fifty-one patients could be reassessed 5 to 14 years after treatment and no one showed evidence of disease (74). Although an interesting and relatively reassuring report that invites for non-dogmatic thinking and properly conducted clinical trials, extrapolation to the present time with changed epidemiologies and sensitivity patterns remains difficult. Amphotericin B is considered the drug of second choice (36) but formal comparative studies are lacking. Lipid associated amphotericin B cured 2 immunocompromised patients: one HIV-infected patient with lesions due to L.(V.) guyanensis or L.(V.) shawi (not possible to distinguish between the 2) was cured after a total dose of 1500 mg amphotericin B colloidal dispersion. The other patient had developed cutaneous leishmaniasis (parasites not isolated) while on hemodialysis and was cured after a total of 600 mg liposomal amphotericin B (10).These authors refer to 3 other case reports, 2 successful, 1 failure. Aminosidine gave unsatisfactory results in L. panamensis infection in Colombia (268). In Belize 10 of 17 patients were cured with aminosidine compared to 15 of 17 treated with Sb. Amosidine seemed less good in L. braziliensis infection: 3 of 9 patients with proved L. braziliensis infection were cured (7 of 7 with Sb) while 3 of 3 with L. mexicana infection were cured, both by aminosidine and Sb. The numbers are small though (126). Immunotherapy: Immunotherapy is standard treatment in Venezuela for patients with localized cutaneous leishmaniasis due to L. (V.) braziliensis. Data for the period 1990-1999 were reviewed (59). Immunotherapy is by intradermal injection of a combined vaccine containing heat-killed L. (L.) amazonensis promastigotes and BCG. One or 2 additional injections were given with 6 to 8 weeks interval if clinical activity persisted. Of 11 532 patients treated, 5341 could be evaluated. Healing varied from 91.2%-98.7% (average 95.7%); adverse reactions were associated with BCG vaccination. Of the 143 failures, 54.5% were with localized ulcers and 45.5% with non-mucosal intermediate cutaneous leishmaniasis, meaning extensive chronic lesions. Less than 2% of all patients were intermediate cutaneous leishmaniasis patients, so immunotherapy should not be used as monotherapy in this group (59). In Brazil another L. amazonensis vaccine was studied in a controlled, double blind trial in comparison with antimony. The vaccine was administered subcutaneously together with Sb 8.5 mg/kg/d intramuscularly, both daily for 10 days. The comparison group received a daily s.c. injection of placebo and the same Sb injection, both for 10 days. After 10 days patients were evaluated and if not cured the same cycle was repeated up to a maximum of 4 cycles. Of 102 patients entered, 3 were wrong inclusions, 3 were lost. Forty seven of the 47 on immunotherapy were cured and 4 of 49 in the placebo group. Time to cure was 43 days in the treatment group and 102 days in the control group. The vaccine seems to be effective but the whole procedure is still far too cumbersome (166).
L. Guyanensis Infections L. guyanensis and L panamensis belong to this complex. Studies on L. panamensis mostly come from Colombia, those on L guyanensis from French Guyana. Mucosal leishmaniasis may be caused by both parasites but is very rare. L. guyanensis regularly comes with lymphatic involvement. Treatment of L. panamensis Infection: No Treatment: A spontaneous cure rate of 75% was reported in L. panamensis infection in Ecuador (113). Local Therapy: Topical treatment with paromomycin/methylbenzethonium chloride ointment (PMBCL) gave good results in an uncontrolled study of L. panamensis infection in Ecuador: 72% cure at day 50 (146) where a spontaneous cure rate of 75% had been reported (113). In Colombia (mainly L. panamensis infections) PMBCL in combination with Sb gave a 90% cure rate) (269). Oral Treatment: Ketoconazole (400 - 600 mg/d, 4 - 8 weeks) cured 16 of 22 (73%) patients with L. panamensis infection while 13 of 19 (68%) treated with Sb (dose 13 mg/kg/d) were cured. In a subsequent placebo study of 11 patients no one was cured after 1 month (246). As self cure may become apparent much later, this observation period is too short. In a study in Colombia comparing Sb, pentamidine, itraconazole and no treatment (total 92 patients) itraconazole was not better than no treatment, respectively 25 and 36% effect. Parasites were not characterized, the majority would be L. panamensis, the rest L. braziliensis and L. mexicana (276). Dapsone (215) and mefloquine (124) were not effective in L. panamensis infections. In a small, uncontrolled study of 18 patients with L. panamensis infection, 5 of 9 (56%) patients treated with allopurinol riboside together with probenecid and 3 of 9 treated with allopurinol alone were cured without relapse in 1 year; in a separate study Sb cured 59% but 22% relapsed within 1 year (245). Allopurinol plus Sb and Sb alone cured 74% (26 of 35) respectively 36% (12 of 35) of patients with L. panamensis infection in Colombia. There was no cure in 17 who refused to be treated and were followed, and 80% cure in 25 patients who refused antimonial treatment and who received allopurinol alone (172). A comment focused on the low Sb cure rate (126) but cure rates around 30 to 50% are no exception (245, 269). Another study in Colombia (mainly L. panamensis) comparing Sb alone and Sb plus allopurinol, gave similar cure rates: 39% for Sb and 71% for the combination (173). In a randomized controlled trial in Colombia with allopurinol and placebo given double blind, 33% of 55 patients on allopurinol were cured, 37% of 46 on placebo and 93% of 56 treated with Sb (325). Of the 187 patients 84% were infected with L. panamensis, 16 % with L. braziliensis. The authors concluded that allopurinol monotherapy was unlikely to be beneficial in American cutaneous leishmaniasis. Well designed studies should establish if combination therapy might be useful. These have not been published since. Parenteral Treatment: Sb 20 mg/kg/d for 20 d and pentamidine 2mg/kg/d for 7 injections cured ≥ 90% of patients (276, 325). More recently several brands of Sb showed cure rates from 75 to 90% (per protocol analysis) and from 70-87% (intention to treat analysis) (274). Four injections of pentamidine 3mg/kg per dose on alternate days cured 96% of 51 patients (267). Aminosidine alone gave unsatisfactory results in a study of different dosages and duration in Colombia (L. panamensis) (268). Treatment of L. guyanensis Infection: In a review, Dedet et al. reported that pentamidine at a dose of 3.5 mg/kg/d for 3 successive days cured 99% of patients. Ketoconazole and metronidazole had been found ineffective (69). Comparison of pentamidine treatment (4 mg base/kg on day 1 and 3) of 205 French soldiers treated in French Guiana and 32 treated in Marseille revealed cure rates of 95% and 75% respectively. The failure rate in Marseille was related to delay in treatment (155). Two injections of pentamidine 4 mg/kg , 48 hours apart cured 87% of 198 consecutive patients and 80% of the failures responded to a second course. Satellite papules (p=0.01;OR 3.5 (95%CI 1.3-11.1) and presence of more than 3 lesions (p=0.01) were associated with failure (198). Another retrospective study of 281 patients treated between 1996 and 2000 with pentamidine 7 mg/kg per dose (4 mg base), 2 injections 48 hours apart and 137 patients treated from 2000 – 2003 with a single injection at the same dose showed comparable results: 78.8% and 83.6% cure respectively for 1 and 2 injections (patients lost to follow up assumed to be cured) and 67.4% and 69.7% respectively, excluding those lost to follow up (152 respectively 89 evaluable) (244). In British Guyana of 110 patients treated with pentamidine 120 mg per injection (up to 2 mg/kg) for 7 injections once daily or on alternate days, 19 relapsed. The relapsed cases were given another course, 10 needed a third course. All were cured; duration of follow up is not mentioned. Parasites were not cultured but supposed to be L. guyanensis (164). A recent study in Brazil on Sb treatment (20 mg/kg/d, 20 days) for L. braziliensis (61 patients) and L. guyanensis (57 patients) infections, with follow up at 6 months, gave poor results: 50.8% of 52 in the braziliensis group and 26.3% in 49 in the guyanensis group (intention to treat analysis: 31 of 61, 50.8% and 15 of 57, 26.3% respectively). Parasite species was the most important factor predicting outcome (240). Pentamidine at 2 - 3 mg/kg/dose for 4 injections, given on alternate days, seems appropriate therapy for infection with L. guyanensis, possibly also with L. panamensis. Two injections of 7 mg/kg (4 mg base),48 hours apart, is likely to be as effective. Diffuse Cutaneous Leishmaniasis Due to L.m. mexicana: Diffuse cutaneous leishmaniasis due to L.m. mexicana is a very difficult condition. Two patients who had received multiple cycles of Sb treatment, thermotherapy, ketoconazole, metronidazole and nifurtimox were treated with pentamidine plus allopurinol and γ IFN and seemingly were cured but relapsed after 3 months. In vitro the parasites were sensitive to pentamidine and paromomycin and resistant in different degrees to the other drugs (31). According to these authors no patient with the advanced stage of this disease has ever been cured. Mucocutaneous (Mucosal) Leishmaniasis: Spontaneous cure is rare in this condition but has been reported (170). In a review published in 1986, Marsden reported that if sufficient Sb could be given in regular daily doses (20 mg/kg/d for 30 days) the relapse rate should be low; 3 of 42 patients with a follow up of 5 years Amphotericin B to a total dose of 2.5 g was the alternative (168). Antimony: Differences in reported cure and relapse rates depend on extensiveness of disease, duration of treatment given and follow up. A 28 day treatment course of Sb at 20 mg/kg/d cured 6 of 8 patients with mild (i.e. limited to the nose) to moderate (i.e. involvement of nose with septal perforation) disease but only 2 of 21 with severe disease, meaning involvement of nose and oral cavity in Peru (103). Extending this treatment to 40 days was of no benefit (104) but in the latter study the cure rate with Sb for 28 days for severe disease was 63%. In a study of 16 patients with mild mucosal L. panamensis infection (nose involvement only, 1 with septal perforation) 28 days Sb treatment resulted in cure without relapse during 12 months in 10 of 13 who completed treatment, 3 relapsed. The other 3 who discontinued treatment because of toxicity did not heal. The overall cure rate was thus 63%, but in those who completed treatment 77% (247). Llanos-Cuentas et al., using different definitions of moderate disease (more than 2 mucous membranes involved with "mild or no respiratory distress") and severe disease (moderate disease plus severe respiratory distress) compared Sb alone versus Sb plus allopurinol in 22 patients with severe and 59 patients with moderate disease. Results are shown in Table 3. Cure rates depended on severity of disease, with up to 10% cures in severe and 75% in moderate disease. Addition of allopurinol was of no clinical benefit (157). Amphotericin B: Amphotericin B is considered second line treatment and is effective (168) but good information from comparative trials is lacking. Of 211 patients with mucosal disease treated with a total of 2.25 g amphotericin B, 186 patients were cured (88%), 22 had to interrupt treatment (10.4%), but failures and further reactivations were very few. One patient could not be followed (71). Use of lipid formulations of amphotericin B has been reported in a few patients: 5 of 6 patients who failed to treatment with Sb were cured after total doses of 2.10 to 5.1 g; 1 patient relapsed at 6 months (250). A patient with dysphagia for 1 year, a penile ulcer, Leishmania positive, and extensive lesions of palatum, larynx and epiglottis, HIV positive, was treated with pentamidine. He had been diagnosed with mucosal leishmaniasis 12 years earlier and had received cycles of Sb with improvement but no cure. Under pentamidine the penile lesion cured, the mucosal lesions persisted and he developed diabetes mellitus. After a total dose of 12,800 mg lipid amphotericine B, all lesions were cured (10). Pentamidine: Marsden reported on a few patients treated with pentamidine showing initial favorable results and refers to a few more reported cases (168). Sb plus γ-IFN: Combined treatment of Sb 10mg/kg/d for 30 d with γ-IFN in 13 patients (4 cutaneous, 9 mucosal disease) who had failed previous Sb treatment and who were first treated by the authors with Sb 20mg/kg/d for 29 days, resulted in complete healing in 11 (amongst these the patients with cutaneous disease), 10 of whom were followed for 6 months. One patient stopped prematurely because of side effects but seemed cured at 4 months follow up. In one patient with severe disease of the upper respiratory tract and genital mucosa, treatment failed. Overall efficacy thus was 91% (97). Miltefosine: Soto reported favorable results of miltefosine treatment in several patients with mucosal leishmaniasis, some of them with extensive disease (Congress report, Congress American Society of Tropical Medicine and Hygiene, Washington, 2005). Published results are not yet available. Other Treatment: A patient with extensive mucosal leishmaniasis (parasite proved) and pulmonary tuberculosis was treated with streptomycine, rifampicine, isoniazide and pyrazinamide for 2 monthts, followed by rifampicine and INH for 7 months, without antileishmanial treatment and was cured of both diseases (94).
Special Situations Post-Kala Azar Dermal Leishmaniasis: Patients with post-kala azar dermal leishmaniasis are sources of infection of sand flies and play a role in transmission. In India, treatment is considered necessary but long course treatment, formerly with Sb more recently with amphotericin B is needed (226,312). Recently a patient who did not respond to Sb treatment was cured after miltefosine for 12 weeks (294). Pentamidine was not effective, amphotericin B and ketoconazole (800 mg/d for 9 months) were both effective but toxic; rifampicin and allopurinol have been used in an uncontrolled way (226). In East Africa, post-kala azar dermal leishmaniasis often clears by itself or is more amenable to treatment (192,337) although long Sb treatment courses may be needed (87). Combination of terbinafine and itraconazole was not satisfactory in a small study in Sudan (140). Immunocompromised Patients Including Leishmania/HIV Co-infection: Initial treatment is as for immunocompetent patients in the region; efficacy generally is less than in immunocompetent patients; about 40-65% for Sb, amphotericin B or amphotericin B lipid complex (70,150,162,196,242,315). High frequency of serious toxicity is reported in several studies (48,72,152,236). Lipid associated amphotericin B may be the preferred treatment (37,185). Reports on miltefosine are still limited, dose and duration in this condition need to be established (236,265). "Initial cure" is often, if not always, followed by relapse if no "secondary prophylaxis" is given. Despite secondary prophylaxis relapse occurs (64). Many drugs in many combinations and schemes have been tried to prevent relapse, often in a few patients and in an uncontrolled way. An “evidence based” advice can not be given. Six of 7 AIDS patients on secondary prophylaxis with different combinations of amphotericin B, itraconazole and allopurinol, had no relapse with a mean follow up of 10 months (range 2-12); 1 relapsed at 3 months, after stopping secondary prophylaxis (220). In another, retrospective, open, sequential study of 46 patients, the probability of remaining relapse free at 12 months was 9% (95% CI, 0 - 22) for those who did not receive secondary prophylaxis, 21% (95% CI, 0 - 51) when allopurinol was taken and 93% (95% CI, 82 - 100)for those who received a monthly injection of Sb (231). Pentamidine each fortnight or each month was effective in a few patients (162). Case reports of secondary prophylaxis with liposomal amphotericin B (160), with pentamidine (162,165,220), with metronidazole (153), with fluconazole or itraconazole with or without allopurinol (225,316) indicate the need for formal comparative studies. Lipid associated amphotericin B was useful in 2 small series of patients (163,189) Administration of Sb, pentamidine or (lipid) amphotericin B (monthly, bi-weekly, or weekly), of flu- or itraconazole with or without allopurinol is to be considered and needs formal comparison and assessment. Highly active antiretroviral therapy (HAART) has reduced the incidence of Leishmania/HIV co-infection (100,181,317) but “ secondary prophylaxis” remains necessary (100,181,327) until CD4 numbers are above 200/mm3 (181) or preferably above 350/ mm3 (34,109,181). Patients on HAART had a longer relapse free interval (317). Three studies from different areas of Spain report that HAART reduced incidence of Leishmania/HIV coinfection but did not influence clinical picture and did not prevent relapses (100,181,327). Secondary prophylaxis with monthly Sb (327) or lipid associated amphotericin B once per 2, 3 or 4 weeks (163,174,189) is advised. Several Leishmania/HIV co-infected patients with diffuse cutaneous manifestations resembling post-kala azar dermal leishmaniasis after treatment of visceral leishmaniasis, have been described. They responded to Sb after lipid amphotericin B failure (8). Pregnancy and Breastfeeding: Amphotericin B and the lipid formulations can safely be used during pregnancy (143). Detailed descriptions were published on treatment of 5 pregnant women with Amphotericin B (313) and 5 with liposomal amphotericin B (217). Treatment was effective without harm to the fetus and mother. Antimony can probably be given during pregnancy and breastfeeding in the normal dose and for the normal duration but data are limited as are data on pentamidine. Miltefosine is teratogenic and should not be used in pregnancy. Aminosidine, an aminoglycoside, should not be given during pregnancy and lactation. Data on allopurinol in the dose used for gout are limited but those available do not indicate increased incidence of fetal harm. For lactation there are no data. For the dose used in leishmaniasis, data are lacking. The azole drugs are not to be used during pregnancy and lactation (143). Prevention of Drug Resistance The genetic background of resistance to antileishmanial drugs is not known. Monotherapy or Combination Therapy Monotherapy is still the normal practice in antileishmanial therapy. Resistance to antimony can be created in the laboratory under drug pressure (114) and is created in dogs after several courses of treatment (113). The Sb resistance now prevailing in Bihar (156, 286) is likely to be due to the widespread misuse of Sb drugs with low dosing, interrupted treatment courses, short duration of treatment and possibly also the quality of drugs (289). Fears about development of resistance to miltefosine have been expressed (292). In order to prevent further deterioration of the situation, and to protect newly introduced drugs from development of resistance, combination therapies like in tuberculosis, leprosy AIDS and malaria is advocated. The armamentarium against Leishmania parasites is limited but when oral miltefosine and sitamaquine and parenteral aminosidine become available, these drugs should be studied for combination with each other and with the other available drugs, appropriate for the region (Sb, amphotericin B) (258). For the spreading epidemic of Leishmania/HIV co-infection in Ethiopia and the impending epidemic in India, plans, funds and action are urgently needed. Properly planned studies are required to be able to give advice for the long run and at large scale. Investments in drugs and studies will first have to be made, in order to gain later. But where will the money come from? Potera C. Heart Drug Helps to Beat Chagas, Leishmania Parasites. Microbe 2009;4:490-491.
ADJUNCTIVE THERAPY Guided Medline Search Visceral Leishmaniasis Old remedies of cauterization, still practiced in traditional medicine, blister provoking herbal medicines, injections of turpentine (199) may find a scientific justification in provoking an "acute phase response", a cytokine response and or a leukocytosis which sometimes might have been beneficial. Strategies for immune intervention in visceral leishmaniasis based on animal models were reviewed (139,195,196). Interferon gamma (IFN-γ) a potent activator of macrophages has been used alone and in addition to antimonials in previously not treated patients and in patients with relapsing or drug-unresponsive visceral disease (25,26,278). Its role in Leishmania/HIV co-infection is not clear. IFN-γ has side effects (flu-like illness), and is expensive; it may have a limited role in combination with other antileishmanials in difficult to treat cases. Human granulocyte-macrophage colony stimulating factor (GMCSF) was beneficial in experimental leishmaniasis (193). Recombinant human GMCSF was well tolerated, reversed neutropenia, eosinopenia and monocytopenia and reduced the number of secondary infections. Costs of treatment combined with antimony were slightly more than with antimony alone ($850 versus 744), assuming reduction in hospital costs (10 versus 20 days of hospitalization), and reduction of complications and treatment thereof (27). IL-12 restored IFN-γ production and lymphocyte proliferation in in vitro cultures of peripheral blood mononuclear cells of patients with visceral leishmaniasis (23). Study of its use as an immunotherapeutic adjuvant seems justified. Splenectomy may cure visceral leishmaniasis in exceptional cases that fail to respond to any treatment. Further drug treatment is required but may then be effective (40,212,213,228). The operation carries morbidity and mortality, and splenectomized patients run risks of septicaemias (and in endemic areas of malaria) (44,228). Cutaneous Leishmaniasis of the Old World In a review, Koff and Rosen (145) report that intralesional IFN-γ was of no benefit but that IL-12 was useful in the treatment of some patients with disseminated disease. Perilesional injections of Sb were effective and by far superior to IFN-γ injections in L. tropica lesions (122). In a preliminary study in Iran Leishmania-antigen preparations showed promise (187), but apparently this was not followed further. Cutaneous Leishmaniasis of the New World As mentioned, immunotherapy with killed L. amazonensis promastigotes with BCG became standard therapy for infection with L. braziliensis parasites in Venezuela, based on studies by Convit et al. (57,58). Eleven patients with intermediate disease (10 with L. braziliensis, 1 with L. panamensis) were cured or improved after treatment with immunotherapy alone (6 patients) or immunotherapy combined with antimony (5 patients). Of 10 patients with diffuse cutaneous leishmaniasis (all L. mexicana) 9 were markedly improved after combined immuno- and chemotherapy (58). Intralesional injection of IFN-γ gave reduction of lesion size in 12 of 13 L. guyanensis lesions (only 4 were free of parasites) (121) and in one case of diffuse cutaneous leishmaniasis due to L. amazonensis infection, prolonged combined treatment with Sb and IFN-γ, interspersed with amphotericin B, was successful; 5 more patients were treated but results of follow up were not yet known by the time of reporting (26). IFN-γ contributed to the side effects but not to the results of treatment in a group of patients mainly with L. braziliensis lesions, treated with Sb alone and Sb with IFN-γ (13). Sb plus GMCSF (10 patients) was compared with Sb alone (10 patients) in a randomized double blind study in Brazil (parasites not identified but reported to be L. b. braziliensis in the area). All lesions were healed at 270 days but after combination treatment 70% were cleared at day 40 and all at day 110 while in the Sb group 10% were cleared at day 40 and 50% at day110 (6). A cream of S-nitroso-N-acetylpenicillamine, a compound that generates NO, was applied every 4 hours (not during sleeping) for 10 days in 11 patients with L. b. braziliensis lesions in Ecuador. After 30 days all lesions were healed; in 5 control patients they were not. There was no recurrence up to 8 months (161). This is an interesting observation that deserves further study. Imiquimod cream, an FDA approved immune response-activating compound, proved useful in combination with Sb (90% cure at 6 months) in 12 patients with cutaneous leishmaniasis (L. peruviana) who had not responded to Sb. Nine of 10 showed no relapse at 6 months (15).
ENDPOINTS FOR MONITORING THERAPY Guided Medline Search Visceral Leishmaniasis Generally immunocompetent patients respond quickly to treatment; they feel better within 5 to 7 days and the temperature is normal by this time. Haematological parameters improve gradually and the spleen regresses in size. With a satisfactory clinical, haematological and biochemical response to treatment and likelihood of follow up, there is no need to assess "parasitological cure" at the end of treatment: "parasitological cure" meaning not finding parasites in aspirates of lymph node, bone marrow or spleen. A patient who has had a favorable clinical, hematological and biochemical response at the end of treatment and who is parasitologically cured, will be labeled "initial cure". In the absence of satisfactory response or when follow up seems unlikely, parasitological assessment is advisable and this may lead to further or alternative treatment. Not finding parasites at the end of treatment does not guarantee "cure" (definite cure). Follow up at 6 weeks, 3 and 6 months is recommended; longer follow up is probably not necessary (207). At 6 months the patient should have no symptoms, no fever, and should have gained weight. The spleen should be smaller, not necessarily non palpable and hematological parameters should be normal. Gammaglobulin levels may still be high and serological tests may remain positive for a long period of time (119). If all these criteria are fulfilled, the patient will be discharged as "definite cure". In the presence of symptoms or signs, and a still palpable spleen, a search for parasites must be undertaken. This is the more pressing if further follow up is not guaranteed. In immunocompromised patients the same criteria apply but without "maintenance therapy" or "secondary prophylaxis" relapse seems inevitable. HAART does not seem to change this until CD4 counts have risen to levels of 350 per mm3 (34,109,181,327). Cutaneous Leishmaniasis In cutaneous leishmaniasis endpoints are complete re-epithelialization of the lesion (all lesions) and no residual wound inflammation and no reactivation or recurrence in 6 months. Maucocutaneous Leishmaniasis Assessment of treatment in mucocutaneous leishmaniasis is difficult; clinical and histological criteria apply. After medical treatment for leishmaniasis and secondary bacterial infections, plastic surgery is often required.
VACCINES Guided Medline Search There is no effective vaccine available for any of the leishmaniases. The fact that many people in the endemic areas become naturally resistant to disease and that others may have immunity to disease indicates that immunization should be possible. A review on old and new Leishmania vaccines appeared in 1997 (120). In the Middle East, leishmanization (inoculation of material from ulcers on a covered part of the body, provoking leishmaniasis with, after cure, immunity) was practiced traditionally, and leishmanization with cultured parasites was practiced in the former Soviet Union, in Israel and Iran. Because of the adverse effect of chronic ulcers this practice was abandoned. An autoclave-killed L. major vaccine (ALM) was developed and tested in large scale, well designed studies in Iran (186,260) in the prevention of cutaneous leishmaniasis. A single dose of this vaccine, given plus BCG to enhance immunogenicity, was not effective in protecting against cutaneous leishmaniasis. There was an unexpected apparent protective effect in boys which remained unexplained but might be due to a booster effect produced by repeated exposure to sandflies (260). This same ALM vaccine proved inefficient for protection of visceral leishmaniasis in Sudan (141). Armijos et al. refer to trials of vaccination against American cutaneous leishmaniasis dating from more than 60 years ago and to other vaccine studies (16). A vaccine of whole, killed promastigotes of L. amazonensis, guyanensis and braziliensis, together with BCG as adjuvant, proved effective in a randomized controlled double-blinded study in Ecuadorian children (protective efficacy 72.9%, 95% CI 36.1 to 88.5). The control group given BCG alone experienced less cutaneous leishmaniasis than normally seen in the region and those who received only one dose of vaccine plus BCG or only one dose of BCG instead of 2 doses, developed cutaneous leishmaniasis in the same proportion as non-vaccinated children. This raised the question if BCG by its immunomodulatory activity may provide some protection against cutaneous leishmaniasis (16). Monjour et al. reported on a small, promising trial with a L. b. braziliensis fraction (lbbF2) in Brazil (188). Machado-Pinto et al. report that their promastigote vaccine could prevent 50% of acute cutaneous leishmaniasis infections (166).
PREVENTION OF LEISHMANIASIS Guided Medline Search Smart search Antiparasitic Drugs Antiparasitic drugs are not used for the prevention of leishmaniasis. Prevention of Insect Bites Sand flies become active in the evening and night; they may bite in daytime, when disturbed. Repellents based on N,N-diethyl-m-toluamide (DEET) and soap based on DEET do have repellent activity but this lasts only for some hours (3). Sand flies can pass wide-meshed bed nets but bed nets as used for malaria protection, impregnated with insecticides are effective protection against sand fly bites (88). A controlled trial of wearing uniforms impregnated with permethrin by Colombian soldiers showed protection against leishmaniasis and malaria (270). In Kabul, Afghanistan, a 65% protective efficacy for insecticide treated bednets (ITNs) and also for chaddars (sleeping dress), impregnated with insecticide was shown, as well as a 40 % protective efficacy for house spraying. ITNs were most popular (230). In Brazil, diagnosing leishmaniasis in the dog reservoir and killing all serologically positive dogs, is considered an essential element in the control of visceral leishmaniasis (219). Dogs can be protected by collars impregnated with insecticide (142). Bougainvillea glabra is noxious for sand flies and affords local protection against sand fly bites, at least in Israel (252). This seems an attractive way of protection.
COMMENTS AND CONTROVERSIES Urgent questions are those on the number of available treatments and on the thread of development of resistance to the few available drugs, in particular miltefosine. The number of available treatments for visceral leishmaniasis is extremely limited: miltefosine, amphotericin B in various forms, antimony, pentamidine, aminosidine, still in development/evaluation and sitamaquine, in early development and evaluation. There is only one oral drug available and one is in development. All other drugs are parenteral; most have considerable toxicity and are expensive. Miltefosine, a very promising drug, is now freely available in India without supervision and without regulated prescription. Miltefosine has a long elimination half life and with the free availability there is a serious risk that low dose and short course treatments are taken and resistance will develop. Another problem with the free availability is the possible use of the drug by women in early pregnancy of which the woman may not yet be aware or pregnancy within 1 or 2 months after a course of treatment. In animal studies miltefosine is embryotoxic and teratogenic and its use is contraindicated in pregnancy and during 2 months after treatment. Women of fertile age should use/practice effective contraception during treatment and during 2 months thereafter. Miltefosine distribution and prescription should be restricted to licensed doctors and the drug should be used under supervision. It should ideally be available free of charge to all victims of visceral leishmaniasis but in a well regulated system. Miltefosine should be combined with a second drug; as soon as aminosidine becomes available it should be combined with this drug. Otherwise, combination with amphotericin B should be studied. In Bihar combination with Sb is no longer beneficial because of the widespread resistance to this drug but elsewhere this combination may still be useful. Lipid associated amphotericin B is extremely expensive. Should we use antimony, amphotericin B (classical) or lipid associated amphotericin B? In endemic countries in Africa, Asia and Latin America there is not much discussion about this; the costs of lipid associated amphotericin B are prohibitive. There these drugs are only used in studies and with support from outside. In many hospitals in industrialized countries, the use of lipid associated amphotericin B is also restricted. In the case of visceral leishmaniasis one could make an analysis of costs, including hospitalization costs, and those of complications and treatment of complications. Hospitalization is shorter with lipid associated amphotericin B, in Mediterraneam visceral leishmaniasis of children it may only be for a few days. On the other hand, a patient who quickly responds to antimony treatment may be discharged after about a week and continue treatment on an out-patient basis. So, making the balance will not always be easy. The increasing and spreading Sb resistance will probably shift the balance. Experience with miltefosine will soon become available for all endemic areas and this will further increase the possibility of treatment of visceral leishmaniasis on an outpatient basis. Combination treatment should be advocated but at present we do not have much to choose. Combination of miltefosine and aminosidine is, of proved benefit in in vitro and in vivo studies. Aminosidine is not yet available and a disadvantage is that it has to be given by intramuscular injection.. Two oral drugs are forthcoming, miltefosine and sitamaquine. Dose and duration of miltefosine for the different endemic areas and for Leishmania/HIV co-infected patients have still to be worked out and there is concern about its teratogenic potential. Sitamaquine is slow in its development and its safety profile is not yet clear (136,330). We do not know if allopurinol would help in retarding development of resistance. In recent years more information has become available on treatment of intralesional Sb administration, on cryo- and heat therapy for cutaneous leishmaniasis both of the Old World and of the New World. In view of the impending increase of patients with Leishmania/HIV co-infection in East-Africa and in India, there is an urgent need to know more about "secondary prophylaxis", or "maintenance treatment". What drugs to use, at what dose and frequency?
TABLES AND FIGURES Table 1: Drugs for the Treatment of Visceral Leishmaniasis [Download PDF] Table 2: Adverse Events During Antimony Treatment as Reported in Different Studies. Table 3: Results of Treatment of mucosal leishmaniasis with Pentavalent Antimony Alone or Pentavalent Antimony Plus Allopurinol in One Study.
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