Treatment of Mucosal Leishmaniasis in Latin America: Systematic Review

Abstract

Mucosal leishmaniasis (ML) is an important endemic disease and public-health problem in underdeveloped countries because of its significant morbidity and mortality. Increases in ecological tourism have extended this problem to developed countries. This form of leishmaniasis, caused by reactivation after primary cutaneous lesion, has a natural history of progressive destruction of the nasal septa and soft and hard palates, causing facial disfiguration and leading to respiratory disturbances. Treatment of ML, based on several therapies, depends on use of toxic compounds, and few drugs have emerged over the past 40 years. Drug resistance has increased, and the cure rate is no better than 70% in the largest studies. Despite these data, there has been no systematic review of therapies used to treat this important tropical disease. The aim of this study is to determine the best drug management for treatment of ML in Latin America based on the best studies offered by the medical literature. The MEDLINE, LILACS, EMBASE, Web of Science, and Cochrane Library databases were searched to identify articles related to ML and therapy. The studies were independently selected by 2 authors. Articles with sufficient data for cure and treatment failures, internal and external validity information, and > 4 patients in each treatment were included. Validation of this systematic review was based on guidelines to guarantee quality; 22 articles met our inclusion criteria. Stibogluconate achieved a 51% cure rate (76/150 patients), and 88% of patients treated with meglumine were cured (121 patients). Pentamidine and amphotericin were as effective as meglumine. Use of itraconazole and other therapies (pentoxifylline, allopurinol, or interferon-gamma) was controversial, and numbers of patients in some studies were insufficient for statistical analysis. Meglumine may be the drug of choice in the treatment of ML, as it offers similar cure rates when compared with amphotericin B and pentamidine. Cost, adverse effects, local experience, and availability of drugs to treat ML are strong points to be considered before determining the best management of this disease, especially in developing countries.

Can We Use a Lower Dose of Liposomal Amphotericin B for the Treatment of Mucosal American Leishmaniasis?

“…However, the cost of antimonial is US$176.55 for the total treatment. 3 Therefore, we believe that further studies are needed to confirm these findings in additional relevant populations. Abstract.…”

“…2 Pentavalent antimonials are the current drugs of choice for the treatment of mucosal leishmaniasis (ML), although they are far from ideal because of serious adverse side effects. 3 Similarly, pentamidine and amphotericin B deoxycholate are parenteral agents that can be poorly tolerated by patients and require close medical supervision to avoid well-known serious adverse events with both drugs. Liposomal amphotericin B has been used as an alternative treatment of cutaneous leishmaniasis and, in comparison to conventional amphotericin B deoxycholate, has demonstrated a similar efficacy and lower toxic effects, although the optimum dosing regimen is undefined.…”

Efficacy and Safety of Liposomal Amphotericin B for the Treatment of Mucosal Leishmaniasis from the New World: A Retrospective Study

“…In Andean countries, ML reaches an average of 7.1%, and Bolivia has a high frequency of 20%. 9,10 In Brazil, the incidence can range from 0.4% to 2.7%. 1 The treatment currently available for ML is systemic, and most cases are based on use of pentavalent antimonials.…”

“…3,9 A systematic review of ML treatment reported a mean cure rate of 88% with the use of pentavalent antimonial. 10 In different clinical situations, other alternative agents can be used, such as pentavalent antimonials plus oral pentoxifylline, amphotericin B deoxycholate, or liposomal amphotericin B. 11 Amphotericin B deoxycholate is an effective antileishmanial drug, with low rates of recurrence, but kidney failure and electrolyte abnormalities limit its use in the clinical practice.…”

Reactivation of Mucosal and Cutaneous Leishmaniasis in a Renal Transplanted Patient

“…2 The pathogenicity of mucosal leishmaniasis is dependent of an increase in the inflammatory cytokines, mainly TNF-α, 6 which is not compatible with reactivation, despite six reports in the medical literature. 4 However, this is the first case of simultaneous mucosal and cutaneous leishmaniasis reactivation caused by The treatment of mucosal and cutaneous forms of NWL is well established, 7,8 however patients with renal transplantation must use drugs with lower nephrotoxicity to avoid the renal failure. 9 Considering the current arsenal of treatment, the drug used for this case was a lipid formulation of amphotericin B.…”