These articles have been accepted for publication in the British Journal of Dermatology and are currently being edited and typeset. Readers should note that articles published below have been fully refereed, but have not been through the copy-editing and proof correction process. Wiley-Blackwell and the British Association of Dermatologists cannot be held responsible for errors or consequences arising from the use of information contained in these articles; nor do the views and opinions expressed necessarily reflect those of Wiley-Blackwell or the British Association of Dermatologists This article is protected by copyright. All rights reserved.
Accepted Date : 05-Jan-2015 Article type
: Correspondence
Title: Clinical and immunologic evidence that low doses of pentavalent antimonial are effective in maintaining a long-term cure of Leishmania (Vianna) braziliensis cutaneous lesions. Running title: Long-term cure of cutaneous leishmaniasis using low-dose antimony therapy Authors: R. Vieira-Gonçalves1, R.S. Nogueira1, J.F. Heringer1, C.O. Mendes-Aguiar 1, A. Gomes-Silva1, J.R. Santos-Oliveira 1, 3, M.P. Oliveira-Neto2*, A.M. Da-Cruz1* Affiliations:
1
Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo
Cruz/FIOCRUZ, Rio de Janeiro, Brazil. Chagas/FIOCRUZ, Rio de Janeiro, Brazil.
2
Instituto Nacional de Infectologia Evandro 3
Instituto Federal de Educação, Ciência e
Tecnologia do Rio de Janeiro - IFRJ, Brazil.
*Address correspondence to Alda Maria Da-Cruz or Manoel Paes Oliveira-Neto Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz-FIOCRUZ, Av. Brasil 4365, Pav. Cardoso Fontes 1º. Andar. Manguinhos, Rio de Janeiro-RJ, Brazil. CEP 21040-900. Telephone number: 00.55.21.2562-1039. Electronic mail: [email protected], [email protected] Financial support: This work was funded by IOC/FIOCRUZ internal funds, by PAPESV/VPPDT/FIOCRUZ and by FAPERJ APQ-1, CNPq Edital Universal. RV-G was a PhD student, and JRS-O is postdoctoral fellow sponsored by CNPq. AG-S is a researcher
This article is protected by copyright. All rights reserved. sponsored by CNPq/VPPLR-FIOCRUZ (Research Visitor Program). AMD-C is a CNPq and FAPERJ (CNE) research fellow. Conflict of interest: The authors declare they have no conflicts of interest in this study.
Pentavalent
antimonial
(Sb5+)
remains
an
effective
therapy
for
cutaneous
1
leishmaniasis (CL) but causes serious adverse effects . Low-dose therapies have been proven safe for CL due to Leishmania (Viannia) braziliensis in the state of Rio de JaneiroBrazil with cure rates varying from 80% to 100%2,3,4. However, the long-term effectiveness of low-dose antimonial therapy is not well known. Our goal was to determine whether lowdoses therapies are as effective as regular doses for the long-term curative maintenance of CL. A transverse and retrospective study was conducted comparing two groups of by chance selected patients with long-term cure of CL who had been successfully treated with unsupervised intramuscular Sb5+ injections: 1) Low-dose group (LowD): 37 patients who had been treated with Sb5+ at 5mg/kg/day for 30 days; these patients had participated in a former FIOCRUZ research study; 2) Regular-dose group (RegD): 33 patients treated with a dose of Sb5+ at 15mg/kg/day (3 series of treatments lasting 10-days, with 10-day intervals between treatments, i.e., in accordance with standard treatment protocols at that time). CL diagnosis was confirmed by parasitological methods5 in 22/25 LowD and in 10/13 RegD patients. The Montenegro Skin Test was positive in all patients: LowD (median 22mm, range 17 to 30mm); RegD (median 15mm, range 10 to 15.3mm). The average accumulated Sb5+ dose per patient was 8,574mg in the LowD and 22,041mg in the RegD. The average follow-up durations were 14 years (range 11-26 years) in the LowD and 18 years (range 6-27 years) in the RegD (Figure-1). Examinations for scars or skin lesions compatible with CL and for signs or symptoms of mucosal leishmaniasis (ML) were performed. Blood samples were collected for Leishmania spp. DNA detection by polymerase chain reaction assay6, for the quantification of immunoglobulin isotypes7 and for measuring the levels of type-1 (IFN-γ, TNF) and type-2 (IL-4, IL-10) cytokines by flow cytometry (Table).
This article is protected by copyright. All rights reserved. During active CL, both groups presented similar clinical features. The duration of illness prior to diagnosis varied from 2 to 3 months. The male/female ratio was 12/25 in the LowD and 11/22 in the RegD. The mean ages (±SD) were 31.5±18.5 years in the LowD and 26.5±16.5 years in the RegD. The median numbers of lesions was 1.7 (LowD) and 1.4 (RegD) lesions per patient. All patients had ulcerated lesions, and the average lesion area was higher in LowD (6.7±6.0cm2) than in RegD (2.7±2.9cm2; p=0.036). The limbs (legs and arms) were affected in 65% and 70% of cases whereas the face was affected in 21% and 24% of cases in LowD and RegD, respectively. Mucosal involvement was absent in all patients. Among LowD, 86.5% (32/37) of the patients cured. Two patients required two further low dose rounds until successful healing was achieved, and three patients required a regular dose therapy to be cured. One of these patients relapsed one year after the second regimen and was successfully treated with amphotericin B (575 mg). One patient developed ML one year after treatment and was successfully treated with Sb5+ 20mg/kg/day for 21 days and with amphotericin B (1,462mg). Among RegD, 97% (32/33) of the patients cured. Only one patient required a second round of the same therapeutic regimen to cure. Four patients relapsed between one to four years after treatment and were successfully treated with another regular Sb5+ regimen. One patient developed ML three years after treatment and was cured after a 30-day course of Sb5+15mg/kg/day. At the endpoint of the clinical examination, neither evolution to ML nor active CL lesions were detected. Positive PCR tests (for Leishmania DNA) were observed in 5/23 evaluated RegD patients (21.8%). The reaction was negative in all LowD patient samples (n=31). Anti-Leishmania IgG antibody levels were negative in the majority of patients (Table). However, although not significant, the percentage of cases presenting IgG1- or IgG3positive titres was higher in the LowD than in the RegD. No difference was observed in the levels of type-1 and type-2 cytokines (Table). Our patients treated with low Sb5+ dose reached an excellent cure rate of 86.5% after treatment and a cure rate of 100% at the long-term follow-up. Although these patients presented higher average lesion areas than the RegD, the effectiveness of both therapeutic regimens was not affected. Relapses or ML episodes were infrequent in both patients groups. These episodes were already expected to occur up to 5 years after therapy, even in
This article is protected by copyright. All rights reserved. patients who had been treated successfully8. Patients followed-up subsequently remained clinically cured; even LowD remained cured after 11 years. Another positive aspect was a 2.57 times lower reduced Sb5+ dose accumulation in LowD patients. This implies a lower risk of adverse side-effects and a great impact on the cost of treatment, with an estimated mean savings of 48 per patient. Both therapeutic regimens were able to control the infection. No leishmanial DNA was detected in LowD, although leishmanial DNA was detected in 21.8% of RegD. However, no clinical evidence for relapsed disease was observed, in agreement with previous descriptions of patients who had been cured of L. braziliensis6. Less than 30% of the patients in both groups remained positive for L. braziliensis IgG1 or IgG3 even many years after therapy. The maintenance of antibody titers in some patients7 and decreasing levels of anti-L. braziliensis IgG after cure have been described previously9. The reasons for this immunoglobulin positivity remain unclear. Parasite persistence6 can result in continuous immunological stimuli, likely assuring memory response to leishmanial antigens. Otherwise, cytokine profiled were quite similar. Regional differences in genotypes among L. braziliensis clones could also influence the failure rate of antimony therapy10,11. Further randomised studies of low-dose regimens should be considered for this same region and to other endemic areas of Brazil12 where CL has a good response to antimonial therapy. Although this is a retrospective study, which is a limitation of long-term CL evaluations, the observational results indicate that low-dose therapy was as efficient as regular dose in the long-term curative maintenance of CL. This regimen may be recommended in the future to treat patients with CL in Rio de Janeiro state. Acknowledgements: we are grateful to Dr. AH Pons and CM Cascabulho from “Plataforma de Citometria de Fluxo” from IOC/FIOCRUZ and to Ms. R Batista for the PCR reactions. We also thank all of the patient volunteers. References
1) Ministério da Saúde (2010) Manual de Vigilância da Leishmaniose Tegumentar Americana [WWW document]. URL http://bvsms.saude.gov.br/bvs/publicacoes/manual_vigilancia_leishmaniose_teg umentar americana.pdf [accessed on December 2013]
This article is protected by copyright. All rights reserved. 2) Oliveira-Neto MP, Schubach A, Araújo ML et al. High and low doses of antimony (Sbv) in American cutaneous leishmaniasis. A five years follow-up study of 15 patients. Mem Inst Oswaldo Cruz 1996; 91:207-209. 3) Schubach AO, Marzochi KB, Moreira JS et al. Retrospective study of 151 patients with cutaneous leishmaniasis treated with meglumine antimoniate. Rev Soc Bras Trop 2005; 38:213-217. 4) Vasconcellos ECF, Schubach AO, Valete-Rosalindo CM et al. American tegumentary leishmaniasis in older adults: 44 cases treated with an intermittent low-dose antimonial schedule in Rio de Janeiro. Brazil. J Am Geriatr Soc 2010; 58:614-616. 5) Vieira-Goncalves R, Pirmez C, Jorge ME et al. Clinical features of cutaneous and disseminated cutaneous leishmaniasis cauded by Leishmania (Viannia) braziliensis in Paraty, Rio de Janeiro. Int J Dematol 2008; 47: 926-932. 6) Oliveira-Camera P, Junger J, do Espirito Santo SPF et al. Haematogenous dissemination of Leishmania (Viannia) braziliensis in human American tegumentary leishmaniasis. Trans R Soc Trop Med Hyg 2006; 100: 1112-1117.
7) Fagundes-Silva GA, Vieira-Goncalves R, Nepomuceno MP et al. Decrease in antiLeishmania IgG3 and IgG1 after cutaneous leishmaniasis lesion healing is correlated with the time of clinical cure. Parasite Immunol 2012; 34:486-491. 8) Zajtchuk JT, Casler JD, Netto EM et al. Mucosal leishmaniasis in Brazil. Laryngoscope 1989; 99: 925-939. 9) Mendonça SC, Souza WJ, Nunes MP et al. Indirect immunofluorescence test in New World leishmaniasis: serological and clinical relationship. Mem Inst Oswaldo Cruz. 1988; 83: 347-355. 10) Cupolillo E, Brahim LR, Toaldo CB et al. Genetic polymorphism and molecular epidemiology of Leishmania (Viannia) braziliensis from different hosts and geographic areas in Brazil. J Clin Microb 2003; 41:3126-3132. 11) Jirmanus L, Glesby MJ, Guimarães LH et al. Epidemiological and clinical changes in American tegumetary leishmaniasis is an area of Leishmania (Viannia) braziliensis transmission over a 20-year period. Am J Trop Med Hyg 2012; 86:426-433.
12) Falqueto A, Sessa PA, Ferreira AL et al. Epidemiological and clinical features of Leishmania (Viannia) braziliensis in American cutaneous and mucocutaneous leishmaniasis in the State of Espírito Santo, Brazil. Mem Inst Oswaldo Cruz 2003; 98:1003-1010.
This article is protected by copyright. All rights reserved. Figure Legends Figure 1: Clinical aspects of lesions in patients with active cutaneous leishmaniasis before treatment (1a, 2a, 3a and 4a), and the maintenance of a long-term cure after low-dose antimony therapy in these same patients. 1b and 3b: 24 years after therapy; 2b: 13 years after therapy; 4b: 14 years after therapy.
Table:
Anti-Leishmania (Viannia) braziliensis
induced
immunoglobulin
and
cytokine
production by individuals clinically cured of cutaneous leishmaniasis (CL) who were evaluated years after treatment with low or regular doses of pentavalent antimony
Cured CL cases presenting negative
Lb in vitro induced cytokines production
anti-Leishmania braziliensis
by peripheral blood mononuclear cells
immunoglobulin n§
(pg/mL) n§§
Therape utic regimen IgG
LowD
RegD
54.8%
66.7%
IgG 1
74.2%
85.8%
IgG 2
83.8%
90.5%
IgG 3
83.8%
71.5%
IgG 4
IFN-γ
TNF
IL-4
IL-10
2,266
169.2
0.0
103.3
[622.73,755]
[82.6874]
[0.0-1.7]
[26.8159]
96.8%
95.2%
789.8
217.5
0.0
80.9
[268.6-
(35.4-
[0.0-0.3]
(13.2-
2,340]
499]
179]
Pentavalent antimonial regimen: low dose (LowD) = Sb5+ 5 mg/kg/day/30 days; regular dose (RegD) = Sb5+ 15 mg/kg/day/30 days (in 3 series of treatments lasting 10 days, with an interval of 10 days between each series; n, number of patients; §LowD = 31 / RegD = 21, §§
LowD = 14 / RegD = 21. For cytokine evaluation, peripheral blood mononuclear cells were
cultured with a crude extract of L. braziliensis antigens (Lb) or with medium only, and the
This article is protected by copyright. All rights reserved. supernatants were collected after 72 h for cytokine quantification. Interferon gamma (IFN-γ), tumour necrosis factor (TNF) interleukin-4 (IL-4) and interleukin-10 (IL-10). Cytokine levels were measured using a Cytometric Beads Array kit (CBA, BD Biosciences, San Diego, CA, USA) and analysed using a FACSCalibur system (FCAP Array, BD Biosciences). Statistical analysis was performed using the Kruskal-Wallis test. Note: interquartile range values are listed in square brackets. For all parameters no significant differences were observed between LowD group and RegD group.
Accepted Date : 05-Jan-2015 Article type
: Correspondence
Title: Clinical and immunologic evidence that low doses of pentavalent antimonial are effective in maintaining a long-term cure of Leishmania (Vianna) braziliensis cutaneous lesions. Running title: Long-term cure of cutaneous leishmaniasis using low-dose antimony therapy Authors: R. Vieira-Gonçalves1, R.S. Nogueira1, J.F. Heringer1, C.O. Mendes-Aguiar 1, A. Gomes-Silva1, J.R. Santos-Oliveira 1, 3, M.P. Oliveira-Neto2*, A.M. Da-Cruz1* Affiliations:
1
Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo
Cruz/FIOCRUZ, Rio de Janeiro, Brazil. Chagas/FIOCRUZ, Rio de Janeiro, Brazil.
2
Instituto Nacional de Infectologia Evandro 3
Instituto Federal de Educação, Ciência e
Tecnologia do Rio de Janeiro - IFRJ, Brazil.
*Address correspondence to Alda Maria Da-Cruz or Manoel Paes Oliveira-Neto Laboratório Interdisciplinar de Pesquisas Médicas, Instituto Oswaldo Cruz-FIOCRUZ, Av. Brasil 4365, Pav. Cardoso Fontes 1º. Andar. Manguinhos, Rio de Janeiro-RJ, Brazil. CEP 21040-900. Telephone number: 00.55.21.2562-1039. Electronic mail: [email protected], [email protected] Financial support: This work was funded by IOC/FIOCRUZ internal funds, by PAPESV/VPPDT/FIOCRUZ and by FAPERJ APQ-1, CNPq Edital Universal. RV-G was a PhD student, and JRS-O is postdoctoral fellow sponsored by CNPq. AG-S is a researcher
This article is protected by copyright. All rights reserved. sponsored by CNPq/VPPLR-FIOCRUZ (Research Visitor Program). AMD-C is a CNPq and FAPERJ (CNE) research fellow. Conflict of interest: The authors declare they have no conflicts of interest in this study.
Pentavalent
antimonial
(Sb5+)
remains
an
effective
therapy
for
cutaneous
1
leishmaniasis (CL) but causes serious adverse effects . Low-dose therapies have been proven safe for CL due to Leishmania (Viannia) braziliensis in the state of Rio de JaneiroBrazil with cure rates varying from 80% to 100%2,3,4. However, the long-term effectiveness of low-dose antimonial therapy is not well known. Our goal was to determine whether lowdoses therapies are as effective as regular doses for the long-term curative maintenance of CL. A transverse and retrospective study was conducted comparing two groups of by chance selected patients with long-term cure of CL who had been successfully treated with unsupervised intramuscular Sb5+ injections: 1) Low-dose group (LowD): 37 patients who had been treated with Sb5+ at 5mg/kg/day for 30 days; these patients had participated in a former FIOCRUZ research study; 2) Regular-dose group (RegD): 33 patients treated with a dose of Sb5+ at 15mg/kg/day (3 series of treatments lasting 10-days, with 10-day intervals between treatments, i.e., in accordance with standard treatment protocols at that time). CL diagnosis was confirmed by parasitological methods5 in 22/25 LowD and in 10/13 RegD patients. The Montenegro Skin Test was positive in all patients: LowD (median 22mm, range 17 to 30mm); RegD (median 15mm, range 10 to 15.3mm). The average accumulated Sb5+ dose per patient was 8,574mg in the LowD and 22,041mg in the RegD. The average follow-up durations were 14 years (range 11-26 years) in the LowD and 18 years (range 6-27 years) in the RegD (Figure-1). Examinations for scars or skin lesions compatible with CL and for signs or symptoms of mucosal leishmaniasis (ML) were performed. Blood samples were collected for Leishmania spp. DNA detection by polymerase chain reaction assay6, for the quantification of immunoglobulin isotypes7 and for measuring the levels of type-1 (IFN-γ, TNF) and type-2 (IL-4, IL-10) cytokines by flow cytometry (Table).
This article is protected by copyright. All rights reserved. During active CL, both groups presented similar clinical features. The duration of illness prior to diagnosis varied from 2 to 3 months. The male/female ratio was 12/25 in the LowD and 11/22 in the RegD. The mean ages (±SD) were 31.5±18.5 years in the LowD and 26.5±16.5 years in the RegD. The median numbers of lesions was 1.7 (LowD) and 1.4 (RegD) lesions per patient. All patients had ulcerated lesions, and the average lesion area was higher in LowD (6.7±6.0cm2) than in RegD (2.7±2.9cm2; p=0.036). The limbs (legs and arms) were affected in 65% and 70% of cases whereas the face was affected in 21% and 24% of cases in LowD and RegD, respectively. Mucosal involvement was absent in all patients. Among LowD, 86.5% (32/37) of the patients cured. Two patients required two further low dose rounds until successful healing was achieved, and three patients required a regular dose therapy to be cured. One of these patients relapsed one year after the second regimen and was successfully treated with amphotericin B (575 mg). One patient developed ML one year after treatment and was successfully treated with Sb5+ 20mg/kg/day for 21 days and with amphotericin B (1,462mg). Among RegD, 97% (32/33) of the patients cured. Only one patient required a second round of the same therapeutic regimen to cure. Four patients relapsed between one to four years after treatment and were successfully treated with another regular Sb5+ regimen. One patient developed ML three years after treatment and was cured after a 30-day course of Sb5+15mg/kg/day. At the endpoint of the clinical examination, neither evolution to ML nor active CL lesions were detected. Positive PCR tests (for Leishmania DNA) were observed in 5/23 evaluated RegD patients (21.8%). The reaction was negative in all LowD patient samples (n=31). Anti-Leishmania IgG antibody levels were negative in the majority of patients (Table). However, although not significant, the percentage of cases presenting IgG1- or IgG3positive titres was higher in the LowD than in the RegD. No difference was observed in the levels of type-1 and type-2 cytokines (Table). Our patients treated with low Sb5+ dose reached an excellent cure rate of 86.5% after treatment and a cure rate of 100% at the long-term follow-up. Although these patients presented higher average lesion areas than the RegD, the effectiveness of both therapeutic regimens was not affected. Relapses or ML episodes were infrequent in both patients groups. These episodes were already expected to occur up to 5 years after therapy, even in
This article is protected by copyright. All rights reserved. patients who had been treated successfully8. Patients followed-up subsequently remained clinically cured; even LowD remained cured after 11 years. Another positive aspect was a 2.57 times lower reduced Sb5+ dose accumulation in LowD patients. This implies a lower risk of adverse side-effects and a great impact on the cost of treatment, with an estimated mean savings of 48 per patient. Both therapeutic regimens were able to control the infection. No leishmanial DNA was detected in LowD, although leishmanial DNA was detected in 21.8% of RegD. However, no clinical evidence for relapsed disease was observed, in agreement with previous descriptions of patients who had been cured of L. braziliensis6. Less than 30% of the patients in both groups remained positive for L. braziliensis IgG1 or IgG3 even many years after therapy. The maintenance of antibody titers in some patients7 and decreasing levels of anti-L. braziliensis IgG after cure have been described previously9. The reasons for this immunoglobulin positivity remain unclear. Parasite persistence6 can result in continuous immunological stimuli, likely assuring memory response to leishmanial antigens. Otherwise, cytokine profiled were quite similar. Regional differences in genotypes among L. braziliensis clones could also influence the failure rate of antimony therapy10,11. Further randomised studies of low-dose regimens should be considered for this same region and to other endemic areas of Brazil12 where CL has a good response to antimonial therapy. Although this is a retrospective study, which is a limitation of long-term CL evaluations, the observational results indicate that low-dose therapy was as efficient as regular dose in the long-term curative maintenance of CL. This regimen may be recommended in the future to treat patients with CL in Rio de Janeiro state. Acknowledgements: we are grateful to Dr. AH Pons and CM Cascabulho from “Plataforma de Citometria de Fluxo” from IOC/FIOCRUZ and to Ms. R Batista for the PCR reactions. We also thank all of the patient volunteers. References
1) Ministério da Saúde (2010) Manual de Vigilância da Leishmaniose Tegumentar Americana [WWW document]. URL http://bvsms.saude.gov.br/bvs/publicacoes/manual_vigilancia_leishmaniose_teg umentar americana.pdf [accessed on December 2013]
This article is protected by copyright. All rights reserved. 2) Oliveira-Neto MP, Schubach A, Araújo ML et al. High and low doses of antimony (Sbv) in American cutaneous leishmaniasis. A five years follow-up study of 15 patients. Mem Inst Oswaldo Cruz 1996; 91:207-209. 3) Schubach AO, Marzochi KB, Moreira JS et al. Retrospective study of 151 patients with cutaneous leishmaniasis treated with meglumine antimoniate. Rev Soc Bras Trop 2005; 38:213-217. 4) Vasconcellos ECF, Schubach AO, Valete-Rosalindo CM et al. American tegumentary leishmaniasis in older adults: 44 cases treated with an intermittent low-dose antimonial schedule in Rio de Janeiro. Brazil. J Am Geriatr Soc 2010; 58:614-616. 5) Vieira-Goncalves R, Pirmez C, Jorge ME et al. Clinical features of cutaneous and disseminated cutaneous leishmaniasis cauded by Leishmania (Viannia) braziliensis in Paraty, Rio de Janeiro. Int J Dematol 2008; 47: 926-932. 6) Oliveira-Camera P, Junger J, do Espirito Santo SPF et al. Haematogenous dissemination of Leishmania (Viannia) braziliensis in human American tegumentary leishmaniasis. Trans R Soc Trop Med Hyg 2006; 100: 1112-1117.
7) Fagundes-Silva GA, Vieira-Goncalves R, Nepomuceno MP et al. Decrease in antiLeishmania IgG3 and IgG1 after cutaneous leishmaniasis lesion healing is correlated with the time of clinical cure. Parasite Immunol 2012; 34:486-491. 8) Zajtchuk JT, Casler JD, Netto EM et al. Mucosal leishmaniasis in Brazil. Laryngoscope 1989; 99: 925-939. 9) Mendonça SC, Souza WJ, Nunes MP et al. Indirect immunofluorescence test in New World leishmaniasis: serological and clinical relationship. Mem Inst Oswaldo Cruz. 1988; 83: 347-355. 10) Cupolillo E, Brahim LR, Toaldo CB et al. Genetic polymorphism and molecular epidemiology of Leishmania (Viannia) braziliensis from different hosts and geographic areas in Brazil. J Clin Microb 2003; 41:3126-3132. 11) Jirmanus L, Glesby MJ, Guimarães LH et al. Epidemiological and clinical changes in American tegumetary leishmaniasis is an area of Leishmania (Viannia) braziliensis transmission over a 20-year period. Am J Trop Med Hyg 2012; 86:426-433.
12) Falqueto A, Sessa PA, Ferreira AL et al. Epidemiological and clinical features of Leishmania (Viannia) braziliensis in American cutaneous and mucocutaneous leishmaniasis in the State of Espírito Santo, Brazil. Mem Inst Oswaldo Cruz 2003; 98:1003-1010.
This article is protected by copyright. All rights reserved. Figure Legends Figure 1: Clinical aspects of lesions in patients with active cutaneous leishmaniasis before treatment (1a, 2a, 3a and 4a), and the maintenance of a long-term cure after low-dose antimony therapy in these same patients. 1b and 3b: 24 years after therapy; 2b: 13 years after therapy; 4b: 14 years after therapy.
Table:
Anti-Leishmania (Viannia) braziliensis
induced
immunoglobulin
and
cytokine
production by individuals clinically cured of cutaneous leishmaniasis (CL) who were evaluated years after treatment with low or regular doses of pentavalent antimony
Cured CL cases presenting negative
Lb in vitro induced cytokines production
anti-Leishmania braziliensis
by peripheral blood mononuclear cells
immunoglobulin n§
(pg/mL) n§§
Therape utic regimen IgG
LowD
RegD
54.8%
66.7%
IgG 1
74.2%
85.8%
IgG 2
83.8%
90.5%
IgG 3
83.8%
71.5%
IgG 4
IFN-γ
TNF
IL-4
IL-10
2,266
169.2
0.0
103.3
[622.73,755]
[82.6874]
[0.0-1.7]
[26.8159]
96.8%
95.2%
789.8
217.5
0.0
80.9
[268.6-
(35.4-
[0.0-0.3]
(13.2-
2,340]
499]
179]
Pentavalent antimonial regimen: low dose (LowD) = Sb5+ 5 mg/kg/day/30 days; regular dose (RegD) = Sb5+ 15 mg/kg/day/30 days (in 3 series of treatments lasting 10 days, with an interval of 10 days between each series; n, number of patients; §LowD = 31 / RegD = 21, §§
LowD = 14 / RegD = 21. For cytokine evaluation, peripheral blood mononuclear cells were
cultured with a crude extract of L. braziliensis antigens (Lb) or with medium only, and the
This article is protected by copyright. All rights reserved. supernatants were collected after 72 h for cytokine quantification. Interferon gamma (IFN-γ), tumour necrosis factor (TNF) interleukin-4 (IL-4) and interleukin-10 (IL-10). Cytokine levels were measured using a Cytometric Beads Array kit (CBA, BD Biosciences, San Diego, CA, USA) and analysed using a FACSCalibur system (FCAP Array, BD Biosciences). Statistical analysis was performed using the Kruskal-Wallis test. Note: interquartile range values are listed in square brackets. For all parameters no significant differences were observed between LowD group and RegD group.
