P.D. Marsden

A histological classification of mucocutaneous leishmaniasis in Brazil and its clinical evaluation.

Biopsies of skin and mucosal lesions were made on 60 well documented Brazilian patients with untreated cutaneous or mucocutaneous leishmaniasis, whose response to treatment was subsequently evaluated in 38 cases. The biopsies were examined with a view to classification after correlation with clinical and immunological findings. Although there was no simple or unified spectrum, five histological groups were defined and found to have some clinico-prognostic significance. In two groups the cases were all cutaneous with a relatively good prognosis. In another two groups they were evolving as mucocutaneous with a poor prognosis. The fifth group showed mixed characteristics with a tendency to relapse. There was no strong correlation with serum antibodies or Montenegro skin test, which were usually positive, or with parasite load, which was always low. The tissue response was distinguished from that in oriental sore by the degree of connective tissue involvement in all groups. It was the primary response in two groups, and subsidiary to a mono-nuclear response in the others. It suggested damage due to extra-cellular parasites or immune complexes. It did not correlate with the distinction between cutaneous and mucocutaneous disease. The single, most favourable, prognostic feature in either the cellular or connective tissue component was necrosis with a reactive response.

Long-term follow-up of patients with Leishmania (Viannia) braziliensis infection and treated with Glucantime®

Seventy-nine patients with cutaneous (62) or mucosal (17) infection with Leishmania (Viannia) braziliensis in Três Braços, Bahia, Brazil, were followed for at least 4 years after initiating treatment with antimony. Cutaneous relapses occurred in 6/62 (10%), mucosal relapse after cutaneous infection in 2/62 (3%), and mucosal relapse after mucosal disease in 2/17 (17%). It is concluded that relapse (cutaneous and mucosal) is rare after adequate antimony therapy and that no definite prediction of relapse (clinical, serological or by skin reaction) is possible.

Mucocutaneous leishmaniasis: a review of clinical aspects

In 1910 Gaspar Vianna suggested at a conference in Belo Horizonte that antimonial therapy was effective in the treatment of mucocutaneous leishmaniasis and this proved to be the case98. In 1926, Montenegro evaluated a skin test antigen which is o f diagnostic value. It is some measure o f the slow development of clinicai reasearch in this important human infection that today both these discoveries are still being applied as standard practice and still the laboratory diagnosis and treatment is far from satisfactory. We have written this review because in our clinicai work we have been in doubtsometimes about what is the best line o f management fo r our patients. Turning to the literature we did not always find the answer to our questions. This is, as the title suggests, a review concemed with the patients side o f the problem and fo r this reason begins w ith the clinically important aspects. Later on we disciiss the relevance of some recent biomedical research to our understanding o f how this infection behaves in man.

Tratamento da forma mucosa de leishmaniose sem resposta a glucantime, com anfotericina B liposomal

We treated six patients with mucosal leishmaniasis who failed to respond to glucantime (20 mg/kg/day) with ambisome (2-5 grams total dose). The daily dose was 2-3 mg/kg/day given for a minimum of 20 days. After 26-38 months of follow up, five patients were clinically cured. One relapsed after six months. No side effects of therapy were observed apart from headache after infection. Ambisome is a therapeutic option for patients with mucosal leishmaniasis unresponsive to antimonials.

A focus of mucocutaneous leishmaniasis in Três Braços, Bahia, Brazil: characterization and identification of Leishmania stocks isolated from man and dogs

The characterization and identification to species and subspecies of 20 stocks of Leishmania isolated from the region of Três Braços, Bahia, Brazil, are described: 17 stocks were from patients and three from dogs. The following techniques were used (i) biological (growth in culture, hamster tissues and phlebotomine gut), (ii) biochemical (isoenzyme and kinetoplast DNA analysis) and (iii) immunological (using monoclonal antibodies). All except two stocks belong to the L. braziliensis complex. One of these two corresponded to L. mexicana amazonensis but the other, while clearly in the mexicana complex, showed slight differences from the L. mexicana amazonensis reference strain on isoenzyme analysis. Two stocks from different lesions in the same patient and with different growth characteristics in hamster tissues were both identified as L. braziliensis braziliensis. All the fully characterized stocks of the L. braziliensis complex were identified as L. braziliensis braziliensis. L. braziliensis guyanensis was not identified. Dog and human stocks of L. braziliensis braziliensis were indistinguishable. From these findings and other evidence, L. braziliensis braziliensis seems to be the predominant species transmitted in Três Braços.

Mucosal leishmaniasis in Brazil.

The clinical diagnosis and laboratory identification of Leish‐mania brazilicnsis braziliensis, a parasitic disease affecting the upper aerodigestive tract, is difficult. A retrospective computer‐assisted analysis of patient records was done after examination of 58 patients with mucosal leishmaniasis in an endemic area of L. braziliensis braziliensis in Bahia, Brazil during January 1987. Biopsies of clinically active and clinically inactive mucosal patients were examined for parasites using routine hematoxylin and eosin histopathology and a new technique for rapid detection of Leishmania amastigotes using a genus‐specific indirect immunofluorescent assay.

Nifurtimox in the treatment of South American leishmaniasis

A trial of Nifurtimox (Lampit) in 26 patients with mucocutaneous leishmaniasis is reported. 13 patients with cutaneous lesions and 13 patients with mucosal disease were treated with a daily oral divided dose of 10 mg/kg body-weight for 30 days. 46% of the cutaneous cases and only 15% of the mucosal cases apparently responded to this regimen during at least one year of follow up. The difficulties of assessing cure in this disease are briefly discussed. We consider that Nifurtimox remains an investigational drug. While possibly exhibiting some anti-leishmanial activity it cannot be recommended for routine use in either form of the disease.

An outbreak of human Leishmania (Viannia) braziliensis infection

The occurrence of acute cutaneous leishmaniasis among inhabitants of 10 farms within 10 Km of the hamlet of Corte de Pedra, Bahia, Brazil was studied prospectively from 1984-1989. A mean population of 1,056 inhabitants living in 146 houses were visited every 6 months and the number of skin ulcers recorded. A leishmanin skin test survey was done people with suggestive skin scars or active disease in 1984. The incidence of skin ulcers due to Leishmania (Viannia) braziliensis (Lvb) reached 83/1,000 inhabitants but declined sharply in the subsequent 2 years. Retrospective data shows that leishmaniasis is a sporadic endemic disease. Although the reasons for this epidemic are unclear some possible aetiological factors are discussed.

Further trials of nifurtimox in mucocutaneous leishmaniasis

At a dosage level of 8 to 10 mg/kg body-weight daily for 120 days nifurtimox was associated with clinical healing of cutaneous leishmaniasis in five of eight patients. At a dosage level of 20 mg/kg body-weight daily for 10 days in six of 10 patients the skin ulcer healed. Results and the reasons why both schemes are impracticable are briefly discussed.

Pentavalent antimonial nephrotoxicity in the rat

Aspects of the renal function were assessed in rats treated with the pentavalent antimonials Glucantime (Meglumine Antimoniate, Rhodia) or Pentostam (Sodium Stibogluconate, Wellcome). In dose of 30 mg of Sbv (Glucantime or Pentostam) by 100 mg of weight by day for 30 days, renal functional changes were observed consisting of disturbances in urine concentrating capacity. Such disturbances were expressed by significantly low values of urine osmolality as compared to the basal values previous to the drugs. The decrease in urine osmolality was associated to a significant increase in urinary flow and in negative free-water clearance. There was no alteration in osmolar clearance and in fractional excretion of sodium. These observations suggest an interference of the drugs in the action of the antidiuretic hormone. The disturbance in urine concentration was reversible after a seven days period without the drugs administration. No significant histopathological alterations were observed in the kidneys of the rats treated with the drugs. On the other hand, the rats treated with a high dose of Pentostam (200 mg/100 grams of weight/day) showed the functional and the histopathological alterations of the acute tubular necrosis.