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MUCOSAL LEISHMANIASIS (“ESPUNDIA”) RESPONSIVE TO LOW DOSE OF N-METHYL GLUCAMINE
(GLUCANTIME ®) IN RIO DE JANEIRO, BRAZIL
Manoel Paes de OLIVEIRA-NETO(1), Marise MATTOS(1), Claude PIRMEZ(2), Octavio FERNANDES(3), Sylvio Celso GONÇALVES-COSTA(4),
Celeste de Freitas Silva de SOUZA(4) & Gabriel GRIMALDI JUNIOR(5)
SUMMARY
Response to treatment with antimonial drugs varies considerably depending on the parasite strain involved, immune status of the
patient and clinical form of the disease. Therapeutic regimens with this first line drug have been frequently modified both, in dose and
duration of therapy. A regimen of 20 mg/kg/day of pentavalent antimony (Sb5+) during four weeks without an upper limit on the daily
dose is currently recommended for mucosal disease (“espundia”). Side-effects with this dose are more marked in elderly patients,
more commonly affected by this form of leishmaniasis. According to our experience, leishmaniasis in Rio de Janeiro responds well
to antimony and, in cutaneous disease, high cure rates are obtained with 5 mg/kg/day of Sb5+ during 30 to 45-days. In this study a high
rate of cure (91.4%) employing this dose was achieved in 36 patients with mild disease in this same geographic region. Side-effects
were reduced and no antimony refractoriness was noted with subsequent use of larger dose in patients that failed to respond to initial
schedule.
KEYWORDS: Mucosal leishmaniasis; Leishmania (Viannia) braziliensis; Antimony; Therapy.
INTRODUCTION
METHODS
Rio de Janeiro state located in southeast Brazil, is an endemic area
of Leishmania (Viannia) braziliensis infection. Mucosal leishmaniasis
(ML) is a dreaded late consequence of cutaneous leishmaniasis due to
the serious esthetic and functional sequel that may occur in severe cases.
Although incidence of mucosal disease is low (perhaps less than 5% 16),
treatment is generally more difficult than for cutaneous cases and only
two cases of self-healing mucosal disease have been reported21. The drug
of choice for treatment of ML is Sb5+ with the dose of 20mg/kg/day
during four weeks17,23,34,36. Some authors believe that severity of the
disease may impair the efficacy of Sb5+ compounds19. It has been
demonstrated that some Leishmania isolates are innately more susceptible
to antimony than others13. This seems to be the case of Leishmania
parasites present in Rio de Janeiro, where high cure rates for cutaneous
disease were obtained with low doses and even intralesional therapy28-31.
ML in the state of Rio de Janeiro is present as a mild to moderate disease,
with a great number of cases restricted to the nose. The disfiguring,
destructive lesions commonly associated with this form of leishmaniasis
are, nowadays, rarely seen. Mucosal cases are more frequent in the fifth
and sixth decades of life as are side effects of antimonial therapy1,2,7,8,14,15,18.
For this reason and the fact that the majority of patients studied here
presented mild disease it was decided to observe their therapeutical
responsiveness to low Sb5+ dose.
Patients: Patients with mild to moderate ML (see definition below)
with no age limit were eligible for the study when at least four of the
following five criteria were present: (a) compatible clinical lesions and
disease history; (b) a positive leishmanin skin test. Leishmanin was
provided by Instituto de Ciências Biológicas da Universidade Federal
de Minas Gerais 26 and considered positive when the diameter of
induration was equal to or greater then 5 mm; (c) suggestive
histopathology; (d) negative tests for other diseases that may affect the
oronasal mucous membranes notably leprosy, paracoccidioidomycosis
and syphilis; (e) demonstration of leishmania in cultures, histopathology
and/or PCR analysis. Exclusion criteria were pregnancy, known or
suspected allergy to Sb5+ and use of Sb5+, amphotericin B or ketoconazole
in the last six months before the study. Patients were recruited from the
spontaneous demand at the leishmaniasis out-patient unit, Evandro
Chagas’ Hospital, Oswaldo Cruz Foundation. Dermatologic examination
included the upper respiratory/digestive mucosae evaluation using an
optical fibroscope (Storz, Mainz, Germany). Anterior rhinoscopy was
performed for all patients. Patients presenting lesions of the oral mucosa
were submitted to endoscopic examination searching for extension of
the lesions to the pharynx or larynx. The level of severity of ML was
defined according the criteria suggested by LLANOS-CUENTAS et al.20:
mild disease when only the nasal mucosa is affected with symptoms
(1) Hospital Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
(2) Depto. de Bioquímica e Biologia Molecular, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
(3) Depto. de Medicina Tropical, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
(4) Departamento de Protozoologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
(5) Depto. de Imunologia, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.
Correspondence to: Manoel Paes de Oliveira Neto, Hospital Evandro Chagas, Fundação Oswaldo Cruz, Av. Brasil 4365, 21 045-900 Rio de Janeiro, Brasil. Tel.: (21) 598-4266 (Extension106),
Fax: (21) 590-9988. e-mail: onetohec@fiocruz.br
OLIVEIRA-NETO, M.P.; MATTOS, M.; PIRMEZ, C.; FERNANDES, O.; GONÇALVES-COSTA, S.C.; SOUZA, C.F.S. & GRIMALDI JUNIOR, G. - Mucosal leishmaniasis (“espundia”)
responsive to low dose of N-methyl glucamine (Glucantime ®) in Rio de Janeiro, Brazil. Rev. Inst. Med. trop. S. Paulo, 42(6):321-325, 2000.
confined to the nose (obstruction, bleeding) and moderate disease when
two or more mucosal sites are affected, with nasal symptoms plus
odinophagia and/or dysphonia and no or mild respiratory distress.
Study design: The study was non-comparative, open, randomized
and was designed to assess the value of Sb5+ low doses in the clinical
management of ML patients.
Treatment regimen, evaluation and follow-up of patients: Patients
were treated with N-methyl glucamine (Glucantime ®, Rhodia
Laboratories, Rhône-Poulenc, France) at the dose of 5 mg/kg/day of
Sb5+ intramuscularly applied during thirty-days. If the lesions did not
improve or heal after that period, the same therapy was continued for
another 15 days. In an attempt to reduce treatment period, a small group
of patients (N = 4) received the same total amount of Sb5+ but with the
dose of 15 mg/kg/day during ten-days. In this case, since the volume to
be injected was greater, the intravenous route was used diluting the drug
solution in 100 ml of 5% glucose. Affected mucous membranes were
re-examined at the end of therapy, three months, six months and one
year after. Yearly examinations were performed during follow-up. Side
effects were detected by clinical examination and laboratory tests. The
following laboratory tests were performed before therapy, within two
weeks and at the end of therapy: electrocardiogram, complete blood
count, aminotransferases, amilase, lipase, alkaline phosphatase, bilirrubin
(total and fractions), blood urea nitrogen, creatinin and urinalysis.
Biopsies, histopathology and cultures: Biopsies were performed
utilizing proper forceps preferably on palate and nasal mucosa. No
biopsies were performed on cavum and pharynx. In two patients a biopsy
of epiglottis was possible and a fragment of a maxillary sinus lesion was
obtained by surgery. Topical anesthesia with 1% Neo-tutocaine was
employed for nasal mucosa and local anesthesia for palate lesions. Biopsy
specimens were processed for paraffin embedding, H&E stain and culture
in special modified Schneider’s medium10.
PCR analysis: Genomic DNA was extracted from biopsy fragments
using an anion-exchange chromatography spin-column following the
manufacture’s instructions (Pharmacia, Upsalla, Sweden). Final DNA
pellet was resuspended in 20 ml of 10mM Tris-HCl pH 8.0/1mM EDTA
pH 8.0, and stored frozen at –20 °C until use. A hot-start PCR was
performed using oligonucleotides that anneal to the origin of replication
of both strands of the minicircle molecules as previously described32.
Definition of cure: Cure was defined considering the following
clinical criteria: healing of the lesions with disappearance of edema,
infiltration, induration or other inflammatory signs and scarring or
epithelization of ulcerative lesions. We considered as treatment failure
only those cases showing inflammatory alterations after 45 days of
therapy.
RESULTS
Clinical characteristics of patients: A total of 36 patients were
enrolled for the study. Clinically, nasal mucosa lesions were characterized
by diffuse infiltration, with a granular surface and ulceration mainly of
the nasal septum and inferior cornet. Mucosa of both soft and hard
palate presented diffuse infiltration with an irregular and bulged surface,
classically compared to a cobbled street. The uvula was frequently
4
compromised and the posterior wall of pharynx showed similar lesions.
In the larynx, lesions frequently affected the epiglottis, which was
oedematous and hyperemic due to diffuse infiltration, a process that
results in a hoarse and weak voice. The majority of patients were in the
5th and 6th decades of life and presented long lasting disease. Leishmanin
skin test was positive in all patients usually showing strong reactions.
(Table 1).
Table 1
General clinical characteristics
Total number of patients
Males
Females
36
22
14
Mean age (years) ± SD
Median
57.6 ± 15.2
60
Mean duration of disease (months) ± SD
Median
127.6 ± 118.6
96
LST (mm), ± SD
Median
55.5 ± 22.6
55
Half of the patients had only one mucosal site affected and, in this
case, always located at the nose. The other half presented 2, 3 or 4 sites
affected (Table 2). Nasal mucosa lesion was detected in all cases, the
other lesion sites being the palate, pharynx, larynx and cavum. One patient
presented lesions in maxillary sinus (Table 3).
Table 2
Characteristics of mucosal disease
No. of mucosal sites affected
No. of patients
%
1
2
3
4
18
9
6
3
50.0
25.0
16.6
8.3
Table 3
Location of the mucosal lesions
Mucosal location
No. of patients
%
Nasal
Palate
Pharynx
Larynx
Cavum
Maxillary sinus
36
14
10
7
4
1
100
38.8
27.7
19.4
11.1
2.7
Biopsies, histopathological findings, cultures and PCR analysis:
Thirty-one patients were submitted to mucosal biopsies.
Histopathological findings included a mixed inflammatory infiltrate with
granuloma formation in all cases, but amastigotes were present in only
five cases. Culture was positive in 16 cases, negative in seven and there
was a high rate of culture contamination (8 cases - 22.2%), a frequent
OLIVEIRA-NETO, M.P.; MATTOS, M.; PIRMEZ, C.; FERNANDES, O.; GONÇALVES-COSTA, S.C.; SOUZA, C.F.S. & GRIMALDI JUNIOR, G. - Mucosal leishmaniasis (“espundia”)
responsive to low dose of N-methyl glucamine (Glucantime ®) in Rio de Janeiro, Brazil. Rev. Inst. Med. trop. S. Paulo, 42(6):321-325, 2000.
event when mucosal samples are cultivated in vitro. On the other hand,
demonstration of Leishmania DNA at the site of lesion using PCR
analysis was possible in 29 patients showing 79.3% of positive results
(Table 4).
Table 4
Results of histopathology, culture and PCR analysis
Test
# Positive/
total examined
%
5/31
16/31
23/29
16.1
51.6
79.3
Histopathology*
Culture
PCR
DISCUSSION
*Histopathology was considered positive when amastigotes were detected on
pathological examination of sections.
Response to therapy: One patient did not return for follow-up and
was withdrawn from the study. Thirty-one patients were treated with 5
mg/kg/day. Twenty-one patients (67.7%) had a good response after 30
days of therapy (Fig.1). Ten patients were not healed after a 30-days
period and were therefore treated for 15 more days totalizing a 45-days
therapy. Seven of these patients achieved total cure after that period;
three were considered treatment failure because of the presence of active
lesions at the end of 45 days. These latter patients were further treated
with higher doses, finally achieving cure. The patients treated with 15
mg/kg/day during 10 days showed a good result (Table 5).
Table 5
Response to therapy
Dose
Period
5mg/kg/day 30-days
5mg/kg/day 45-days
15mg/kg/day 10-days
Total
Follow-up and sequels: Twenty-eight patients who responded to
5mg/kg/day and treated for 30 or 45-days were followed for periods up
to seven years. Eleven were followed-up from one to three years; ten
from three to five years; seven from five to seven years. The four patients
treated with 15mg/kg/day during 10 days were followed for three years.
No relapse was observed during the follow-up period. The most common
sequel was perforation of nasal septum, present in 25 patients. Other
sequel more rarely found was uvula destruction in five patients. One
patient showed perforation of the nose skin and the patient with extension
of the lesions to maxillary sinus presented destruction of orbit’s floor.
Number of
patients
Cure
%
Failure
%
21
10
4
35
21
7
4
32
100.0
70.0
100.0
91.4
0
3
0
3
0
30
0
8.5
Side-effects: Side effects were noted in 25 of the 35 patients (71.4%).
These side effects were mild in the majority of patients, being more
intense in the four patients who received the schedule of 15 mg/kg/day
during 10-days. The most common side-effects noted were: arthralgias
(16 patients – 45.7%), astenia (13 patients – 37.1%), mialgias (10 patients
– 27.7%), nausea and vomiting (7 patients – 20%), alterations in
electrocardiogram – increased QT interval, arrhythmia, extrasystoles,
diffuse alterations in repolarization (7 patients – 20%), hematological
abnormalities – eosinophilia, leukopenia, decreased hematocrit – (6
patients – 17.1%), local pain at the site of the injection (6 patients –
17.1%). In five patients (14.2%) worsening of lesions was noted at the
first injections. Four patients (11.4%) presented fever at the beginning
of therapy. Two cases developed herpes zoster and three presented herpes
simplex by the end of therapy.
Elevation of aminotransferase levels was noted in two patients and
raised amilase and lipase in one patient. These three patients received
the dose of 15 mg/kg/day during 10-days.
Leishmaniasis is really a complex disease with a great number of
possible combinations of different leishmanial syndromes, parasite
species involved and diverse epidemiological patterns in many geographic
areas of prevalence of infection. Such combinations result in different
clinical presentations, easiness of diagnosis and response to therapy16.
This study focus on the therapeutical significance of a low antimonial
dose in a non comparative fashion, since the efficacy of a 20 mg/kg/day
dosage is well-established3,7,21,25,36.
ML, an hyperergic, invasive, ulcerative form of leishmaniasis that
progresses in the absence of any apparent cellular defect, is most
frequently associated with Leishmania (Viannia) braziliensis. In our study
area cutaneous and mucosal disease is caused, so far, exclusively by
this species10,11. The clinical picture of ML today is quite different from
the mutilating cases so frequently seen in the beginning of the century.
Such difference may be explained by the difficulty in diagnosis and lack
of specific treatment in those early days. The presence of such destructive
and menacing disease justified an aggressive therapy employing high
doses of antimony. Even nowadays with the increased knowledge about
the disease, diagnostic facilities and routine examination of mucous
membranes, ML is generally considered very resistant to antimonial
therapy and unresponsive cases have been described6,24,27,33. The group
of patients studied in this paper presented a mild to moderate mucosal
disease, with scanty leishmanial organisms and a tuberculoid response
at the lesion. In addition, all patients presented a strong cell-mediated
immunity (as demonstrated by the high response to leishmanin skin test)
and were responsive to a low dosage of Sb5+. This level of response to
therapy was different from that described for patients presenting ML in
other endemic areas6,11,17,22,36. The good result observed in our patients
might be related with a non refractoriness of the parasite strain causing
the disease and/or distinct host response to this particular parasite. There
were significant differences in susceptibility to Sb5+ among clones of a
single isolate obtained from an untreated patient13. Resistance to Sb5+
exists among Leishmania strains in nature and some isolates are innately
less or more susceptible to this drug than others13.
Because of differences in virulence and in the response to
chemotherapeutic agents among the various Leishmania species or strain
variants, correct parasite identification is essential. Studies using several
DNA based methods have shown the wide diversity of parasites within
L.(V.) braziliensis5. Genetic variation is extensive with some clones widely
distributed and others seemingly unique and localized to a particular
endemic focus. These studies should provide the basis to monitor
transmission and for disease control4,5. Future research using molecular
biology should aim to identify and follow Leishmania types in nature
44
OLIVEIRA-NETO, M.P.; MATTOS, M.; PIRMEZ, C.; FERNANDES, O.; GONÇALVES-COSTA, S.C.; SOUZA, C.F.S. & GRIMALDI JUNIOR, G. - Mucosal leishmaniasis (“espundia”)
responsive to low dose of N-methyl glucamine (Glucantime ®) in Rio de Janeiro, Brazil. Rev. Inst. Med. trop. S. Paulo, 42(6):321-325, 2000.
and correlate genetic typing with important clinical characteristics such
as virulence, pathogenicity, drug resistance and antigenic variation4.
Genetic or racial differences also may play a role in determining some
of the variations observed among patients in the course of the infection35.
The median age of patients studied was 60-years. ML in elderly
patients is usually associated with internal diseases frequent in aged
people, such as hypertension, diabetes, arthrosis among others that may
increase the severity of the disease and/or side-effects during
chemotherapy. In such patients the use of lower doses is desirable since
the toxic effects of antimony are less pronounced and, consequently, the
adhesion to therapy is greater. No antimony refractoriness has increased
in the three patients that did not responded to the low dose. These patients
responded well to the dose of 20 mg/kg/day during four weeks. Also,
the use of a dose of 5 mg/kg/day reduced significantly the price of
treatment. The use of a dose of 15 mg/kg/day during ten days, resulting
in the same amount of antimony applied at the dose of 5 mg/kg/day
during 30-days, was also effective but with more severe side-effects and
with the inconvenient of intravenous injection since the volume to be
injected was too great for intramuscular therapy. Elevation of
aminotransferase, amilase and lipase plasma levels was noted only with
the dose of 15 mg/kg/day. It is important to emphasize that no relapses
were noted during the follow-up which extended from one to seven years.
In conclusion we may say that the dose of 5 mg/kg/day of Sb5+ during
30 or 45 days seems to be effective for mucosal leishmaniasis. Sideeffects, although frequently observed, were always of slight intensity
and very well tolerated by the patients. In case of failure, this initial low
dose therapy apparently do not impair the responsiveness of the patients
to the use of subsequent larger dose. We think that a low dose could be
the first line of treatment, at least for patients of the same geographic
area here reported or even in cases of mild ML occurring in other endemic
area.
RESUMO
Leishmaniose mucosa (“espundia”) respondendo a baixa dose de
N-metil-glucamina (Glucantime Ò) no Rio de Janeiro, Brasil
A resposta de pacientes com leishmaniose ao tratamento antimonial
pode variar em função de fatores como a cepa do parasito envolvido,
estado imunológico do paciente e a forma clínica da doença. Os esquemas
terapêuticos com antimônio pentavalente (Sb5+) têm sido frequentemente
modificados quanto à dose e duração da terapia. Os efeitos colaterais
observados com o uso de 20 mg/kg/dia de Sb5+ durante quatro semanas
(dose recomendada para o tratamento da forma mucosa) são mais
acentuados em pacientes idosos, os mais afetados pela forma mucosa
(espundia) da doença. Nossa experiência demonstra que a forma cutânea
ocorrendo no Rio de Janeiro responde muito bem ao tratamento com a
dose de 5 mg/kg/dia de Sb5+ durante 30 ou 45 dias. Neste estudo foi
obtida elevada eficácia (91,4%) com o mesmo regime terapêutico em 36
pacientes com espundia (que evoluem, contudo, com lesão crônica menos
destrutiva do que o observado em outras áreas endêmicas) procedentes
desta região. Os efeitos colaterais foram reduzidos, não havendo também
qualquer resistência ao emprego de doses maiores nos casos que não
responderam ao tratamento inicial.
4
ACKNOWLEDGEMENTS
This study was supported by FAPERJ (Fundação de Amparo à
Pesquisa no Rio de Janeiro), process nº E-26/170-825/95.
The authors thank João Moreira, M.D., for evaluation of mucosal
lesions.
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Received: 15 May 2000
Accepted: 17 July 2000
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