Philip Davis Marsden

Mucosal leishmaniasis (“espundia” Escomel, 1911)

One of the more serious clinical forms of leishmaniasis occurs in espundia when the mucosae of the upper respiratory passages are inflamed. This complication is a metastasis from a skin lesion caused by Leishmania braziliensis braziliensis (Lbb) although cases have been described associated with other leishmanial species. Epidemiological data suggest that a detectable mucosal metastasis occurs in fewer than 5% of patients infected with Lbb in our study area. The determinants of this complication are still largely obscure. The granuloma usually commences on the nasal septum. In about two-thirds of our patients the lesion remained restricted to the nose. In the rest the pharynx, palate, larynx and lips were involved, in this order. It is often difficult to isolate the parasite and for routine diagnosis the leishmanin skin reaction and serological tests are helpful. Although a serious condition, with possible mutilation and even death as subsequent complications, treatment is still mainly with pentavalent antimonials, introduced 40 years ago. These are most unsatisfactory for field use, being given parenterally and relatively toxic. In mucosal leishmaniasis, if sufficient antimony can be administered in a regular daily dose, the relapse rate is small (3 of 42 patients followed for a mean of 5 years). Also, antimony treatment of the initial skin ulcer due to Lbb followed for a mean of 4 years of 83 patients resulted in subsequent mucosal metastasis in only 2. Since espundia is relatively rare, specific treatment targeted to this specific problem is the efficient short term solution. At present there is no satisfactory alternative drug to those in current use.

Plants used in the treatment of leishmanial ulcers due to Leishmania (Viannia) braziliensis in an endemic area of Bahia, Brazil

This paper records the plants used in the treatment of cutaneous leishmaniasis due to Leishmania (Viannia) braziliensis (L(V)b) among the rural population of a cocoa-producing coastal area of Bahia state, Brazil. An enquiry conducted among a hundred patients identified 49 plants species used to treat skin ulceration caused by this Leishmania species. The principal plants used are caju-branco (Anacardium occidentale, Anacardiaceae), used by 65% of the population, folha-fogo (Clidemia hirta,Melastomataceae) 39%, alfavaca-grossa (Plectranthus amboinicus, Lamiaceae) 33%, mastruz (Chenopodium ambrosioides, Chenopodiaceae) 31%, erva-de-santa-maria (Solanum americanum, Solanaceae) (25%) and transagem (Plantago major, Plantaginaceae) 2%.

Clinical and immunopathological aspects of disseminated cutaneous leishmaniasis

The clinico-pathological and immunological findings in eight patients from Bahia, Brazil with disseminated cutaneous leishmaniasis are described. This condition differs from anergic diffuse cutaneous leishmaniasis (DCL) and from classical American cutaneous leishmaniasis (ACL). The number of lesions in these patients ranged from 75 to 800 and were characterized by papules and an acneiform type of lesion with a few ulcers rather than nodules that are the main characteristic of DCL. On the other hand the high incidence of mucosal disease (38%) in patients with disseminated cutaneous leishmaniasis make the prevalence of mucosal involvement in this condition higher than that observed in ACL. L. amazonensis (five cases) and L. braziliensis (two cases) were the causal agents in the patients where the infecting agent was characterized. Antibody titers in disseminated cutaneous leishmaniasis were higher than those observed in ACL and patients with the highest antibody titers had mucosal involvement. Abnormalities in cellular immunity that are not observed in ACL such as decrease in CD4+ cells and absence of T cell response to leishmania antigen were observed in several patients with disseminated cutaneous leishmaniasis but restoration of these abnormalities occurred after treatment. In spite of the great number of lesions, the therapeutic response was good in six patients with disappearance of the lesions in a period shorter than that observed in ACL. In the two patients that presented therapeutic failure the causal agent was L. amazonensis. In such patients there was a predominance of ulcerated lesions, and a high titer of antibody was detected.

Pentavalent antimonials: old drugs for new diseases

Clinicians like myself feel a sense of pressure because things change so slowly for the patient in spite of the volume of current research. This is currently the case in the chemotherapy of leishmaniasis where the drug formulations used in the first line treatment have not changed for four decades. Neither is a practical altemative on the horizon. There is no money to be made in treating the poor people of rural areas suffering from this disease. The small efforts that have been extended in this direction have not met with success. Therefore we must try to use antimonials more efficiently for the benefit o f the patient and this is the chief purpose of this review.

Human mucocutaneous leishmaniasis in Três Braços, Bahia - Brazil: an area of Leishmania braziliensis braziliensis transmission. II. Cutaneous disease. Presentation and evolution

Foram analisados os dados clinicos de 182 pacientes com leishmaniose cutânea, provavelmente causada por Leishmania braziliensis braziliensis. Sessenta e oito por cento apresentavam uma unica lesao, usualmente uma ulcera, na terca parte inferior anterior da tibia. Todos os grupos etarios estavam representados e muitos apresentaram historico de um a dois meses. Treze por cento apresentavam lesoes fechadas de natureza verrucosa ou em placa. Apos tratamento, a evolucao destas lesoes foi relacionada a regularidade da terapia por antimonio. Embora a cura usualmente ocorresse em tres meses, o tempo de cicatrizacao, apos o inicio de tratamento, foi variavel e relativo ao tamanho da lesao (p < 0.01). Em geral a lesao fechava quando era dado suficiente antimonio como tratamento. Sete entre dez pacientes que apresentavam teste cutâneo negativo para leishmania tomavam positivos apos o tratamento. Observou-se por fluorescencia indireta, um declinio significante nos titulos de anticorpos em pacientes acompanhados durante e apos a terapia.

Características epidemiológicas da leishmaniose tegumentar americana em uma região endêmica do Estado da Bahia: III. Fauna flebotomínica

The phlebotomine fauna is highly varied in tres Bracos, an endemic area american cutaneous leishmaniasis, situated in the cacao growing region in the southeast of Bahia State, brazil. Thirty species of the Lutzomyia genus were identified in 13,535 spcecimens collected between 1976 and 1984. Lutzomyia whitmani was the dominant species accounting for 99% or flies in the periodomicile and 97.5% of those caught in homes. In the forest the predominant species were Lu. ayrozai and Lu. yulli. Lu whitmani accounted for only 1.0% of the specimens examined. Lu. flaviscutellata, the proven vector of Leishmania mexicana amazonensis, was also collected in small numbers, I.u. wellcomei, a known vector of L. braziliensis braziliensis in the Serra dos Carajas, Para, Brazil was not encountered in the Tres Bracos region where the parasite causing human infections is usually L.b. braziliensis. Although we have not encountered a natural infection with leishmanial promastigotes in 1.832 females of the various species examined, we discuss the probability that Lu. whitmani is the vector of L.b braziliensis in the region mantaining transmission in dogs and man.

Histopatologia da leishmaniose tegumentar por Leishmania braziliensis braziliensis: 1. Padrões histopatológicos e estudo evolutivo das lesões

The Authors describe the histopathological findings observed in biopsies from 378 cases of Mucocutaneous Leishmaniasis, caused by Leishmania braziliensis braziliensis. All the patients lived in the locality of Tres Bracos, State of Bahia, an endemic area of Leishmaniasis in Brazil. Parasites were found in 63.7% of patients with cutaneous form and in 35.7% of cases with mucous lesions, although always in reduced number. Histopathologic findings allowed the caracterization of five different patterns: 1. Exsudative-cellular reaction, due to infiltraction of histiocytes, lymphocytes and plasm cells; 2. Exsudative-necrotic reaction, characterized by the association of necrosis with cellular infiltration; 3. Exsudative and necrotic-granulomatous reaction, corresponding to pattern described as chronic-granulomatous inflammation with necrosis; 4. Exsudativegranulomatous reaction, characterized a disorganized granulomatous reaction, without tissue necrosis; 5. Exsudative-tuberculoid reaction — in which a typical tuberculoid granuloma is formed. The follow-up study in 49 patients showed, in sucessive biopsies, changes in the histopathologic patterns in 63.2% of cutaneous forms and in 45.4% of the mucous forms. It was concluded that the exsudative-cellular reaction represents both the inicial and final pattern of Mucocutaneous Leishmaniasis lesion. The other four histopathologic patterns characterize intermediate forms found during the evolution of the disease.

Leishmaniose mucocutânea humana em Três Braços, Bahia - Brasil: uma área de transmissão de Leishmania braziliensis braziliensis. III. Comprometimento mucoso e evolução inicial

In an analysis of 57 patients mucosal disease was commonestin males(77%) in the third decade of life although the age range was wide and even two children were affected. All but nine patients (16%) had signs of cutaneous leishmaniasis but in only 8(14%) was this lesion active. The nose was affected in 100% of 19 patients with multiple lesions and 92% of 38 patients with single lesions. The pharynx, palate, larynx and upper lip were affected in this order. 42% of patients with multiple lesions had laryngeal disease and in two patients this site existed as a lone lesion. No age difference could be discemed as to whether lesions were single or multiple. Duration of mucosal disease was very variable from less than 4 months to 264 months. Only 7% developed mucosal disease more than ten years after the cutaneous lesion. Usually patients responded to adequate antimonial treatment but there were exceptions, when amphotericin B had to be used Three patients who refused to collaborate regarding treatment died Only 18% of patients in whom measurements were made had positive fluorescent antibodies two years after treatment.

Mucosal leishmaniasis due to Leishmania (Viannia) braziliensis L(V)b in Três Braços, Bahia-Brazil

Brazilian mucosal leishmaniasis is briefly reviewed, emphasis being given to recent advances clinical management. Patients continue to occupy much hospital bed space and in some cases are notoriously difficult to treat. Indefinite follow up is recommended. Many aspects of the aetiology remain mysterious although Leishmania (Viannia) braziliensis is the most common organism isolated. Perspectives for a more effective treatment, oral and cheap, are still remote.

Human mucocutaneous leishmaniasis in Tres Bracos. Bahia - Brazil. An area of Leishmania braziliensis braziliensis transmission. I. Laboratory diagnosis.

Leishmanial parasites were detected in 71.2% of patients with cutaneous disease and 48% of patients with mucosal disease, using principally scanning of imprints mears and histological sections and hamster inoculation. Parasites were more frequent in early cutaneous lesions (p < 0.005) o fless than two month duration. Also they were more common in multiple than single mucosal lesions (p < 0.02) in spite of considerable prior glucan time therapy in the former group. 93% of cutaneous lesions had a positive leishmanin skin test and most of the negatives occurred in patients with lesions of less than one month duration. 97% of patients with single mucosal lesion and 79% with multiple mucosal lesions had a positive skin test. 86% of cutaneous disease and 90% of mucosal disease was associated with a positive indirect immunofluorescent antibody test at a ≥ 1/20 dilution. In both groups multiple lesions were associated with higher titres and titres were significantly higher in patients with mucosal disease compared with cutaneous disease (p < 0.01).