Low dose systemic or intralesional meglumine antimoniate treatment for American tegumentary leishmaniasis results in low lethality, low incidence of relapse, and low late mucosal involvement in a referral centre in Rio de Janeiro, Brazil (2001-2013)

Abstract

BACKGROUNDAmerican tegumentary leishmaniasis (ATL) is a non-lethal parasitic disease that presents with cutaneous (CL) and mucosal (ML) clinical forms. ATL treatment aims at healing the lesions and preventing the development of the late mucosal form. Systemic meglumine antimoniate (MA) therapy with 10-20 mg Sb5+/kg/day is the first choice of treatment. However, alternative therapies using 5 mg Sb5+/kg/day or intralesional (IL) MA are the usual regimens at the National Institute of Infectious Diseases (NIID), Rio de Janeiro, Brazil.OBJECTIVESTo evaluate lethality and the incidence of relapse and development of late ML in CL patients treated at NIID from 2001 until 2013.METHODSData were recovered from records of all ATL patients diagnosed during that period.FINDINGSOut of 777 patients, 753 were treated with MA (96.9%). Of those, 89.1% received alternative therapy of 9.9% IL and 79.2% systemic 5 mg Sb5+/kg/day. Some patients required 1-3 additional courses of treatment, thus making a total of 997 courses; 85.2% of them were subjected to alternative therapies. Lethality was 0.1%, relapse incidence 5.8%, and late ML incidence 0.25%. As a final outcome for the 777 patients, 95.9% were cured, 0.1% died and 4.0% were not able to follow-up.MAIN CONCLUSIONSAlternative MA schedules resulted in low lethality without increase of relapse or late ML incidence.

Good response to pentamidine isethionate in a case of Mucosal Leishmaniasis caused by Leishmania (Viannia) braziliensis that was difficult to treat: Case Report

“…As an outcome of all 777 patients, 95.9% were cured, 0.1% died (one patient treated with MA 20 mg Sb 5+ /kg/day) and 4% abandoned follow-up. Such results are promising when compared with other Brazilian regions that do not use alternative therapeutic schemes for ATL treatment 5 . The use of alternative schemes should be attempted in other regions outside Rio de Janeiro when the use of the standard scheme is risky for patients 1,11 .…”

“…At INI, between 2001 and 2013, amphotericin B (desoxycholate or liposomal forms) was the drug of choice for the initial treatment of 17 (2.2%) patients with contraindication to MA. However, in patients with therapeutic failure or relapse after MA, 42.1% (8/19) presented healing with amphotericin B (deoxycholate and liposomal forms) 5 .…”

“…Until 2016, in Brazil, the Ministry of Health recommended treating ML patients with 20 mg Sb 5+ /kg/day of meglumine antimoniate (MA) over 30 days 1 . In Rio de Janeiro, MA is used in doses of 5 mg Sb 5+ /kg/day intramuscularly administered, without interruption, until epithelialization of the mucosa, which generally occurs between 30 and 90 days 3,4,5 . In case of unsatisfactory responses, the treatment can be repeated 1 .…”

“…In case of unsatisfactory responses, the treatment can be repeated 1 . If the second treatment fails, amphotericin B or pentamidine isethionate are indicated 1,5 . Treatment must be monitored, due to the risk of adverse effects that may demand its interruption 1 .…”

Miltefosine Combined with Intralesional Pentamidine for Leishmania braziliensis Cutaneous Leishmaniasis in Bolivia

“…Cure rates for one species in one country treated with one drug can even differ between locations within that country. For L. braziliensis treated with parenteral antimony, the cure rate in Rio de Janeiro was 81%, 9 whereas the cure rate in Bahia was 45%. 10 Given the remarkable variability of CL cure rate with Leishmania species and geographic location, we think the best historic controls for our present experience are data from the same species at our own site.…”