(Upper panel) Parasite enumeration during pregnancy and postpartum.

<p>Amastigotes present in the lesions were enumerated by in situ immunohistochemistry in active cutaneous lesions of both pregnant patients (PP1, PP2) before treatment, in the eighth month of pregnancy (gray bars) and 2–6 months after birth (black bars). Amastigote numbers present in lesions of nonpregnant ATL patients (average of three patients) before treatment are shown as comparison. The results are expressed as number of parasites per mm², using a grid-scale consisting of 20×20 subdivisions in an area of 10 mm²×10 mm², adapted to slides as previously described <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002472#pntd.0002472-Morgado2" target="_blank">[24]</a>. The results shown are median ± SEM. n.d. = not detectable; (Lower panel) Serum arginase activity. Arginase activity (U/mL) was determined in sera obtained from peripheral blood of pregnant ATL patients collected at 3, 5, and 9 months of pregnancy (black bar PP1; grey bar PP2) as well as four age-matched nonpregnant ATL patients (hatched bars). The results shown are median ± SEM.</p

Determination of IFN-γ and IL-10–producing cells in the peripheral blood during pregnancy and postpartum.

<p>(A) The number of IFN-γ and (B) of IL-10–producing cells in peripheral blood was determined at 8 months of pregnancy and 2–6 months after birth in both pregnant ATL patients by ELISPOT assay and compared to those present in nonpregnant ATL patients before specific treatment and in healthy volunteers. Spontaneous release (black bars) as well as antigen-specific responses to restimulation with <i>Leishmania</i>-antigen in vitro (grey bars) are shown. The results from antigen-stimulated PBMC were expressed as the difference of the number of spots/10,000 PBMC in the antigen-stimulated wells minus the mean number of spots in control wells (with medium alone = spontaneous release) from the same donor. The results shown are median ± SEM.</p

Inflammatory reaction in active cutaneous lesions of untreated ATL patient (PP1) during pregnancy and postpartum.

<p>The inflammatory response in the lesions was assessed by in situ immunohistochemistry. (A,B) CD8⁺ cells, (C,D) CD68⁺ cells, (E,F) NOS2, (G,H) IFN-γ, and (I,J) IL-10 expression in active lesions of pregnant ATL patient (PP1). (A,C,E,G,I) at 8 months of pregnancy; (B,D,F,H,J) at 2–6 months post delivery; Magnification: 200× (bar = 50 µm); arrows indicate examples of positive areas.</p

Effect of secondary infection on epithelialisation and total healing of cutaneous leishmaniasis lesions

<div><p> BACKGROUND Cutaneous leishmaniasis (CL) generally presents with a single or several localised cutaneous ulcers without involvement of mucous membranes. Ulcerated lesions are susceptible to secondary contamination that may slow the healing process. OBJECTIVE This study verified the influence of non-parasitic wound infection on wound closure (epithelialisation) and total healing. METHODS Twenty-five patients with a confirmed diagnosis of CL and ulcerated lesions underwent biopsy of ulcer borders. One direct microbial parameter (germ identification in cultures) and four indirect clinical parameters (secretion, pain, burning sensation, pruritus) were analysed. FINDINGS Biopsies of ten lesions showed secondary infection by one or two microorganisms (Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus faecalis, Streptococcus pyogenes and Candida parapsilosis). “Secretion” and “burning sensation” influenced epithelialisation time but not total healing time. Positive detection of germs in the ulcer border and “pain” and “pruritus” revealed no influence on wound closure. CONCLUSIONS Our borderline proof of clinical CL ulcer infection inhibiting CL wound healing supports the need to follow antimicrobial stewardship in CL ulcer management, which was recently proposed for all chronic wounds.</p></div

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)

<div><p> BACKGROUND American 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. OBJECTIVES To evaluate lethality and the incidence of relapse and development of late ML in CL patients treated at NIID from 2001 until 2013. METHODS Data were recovered from records of all ATL patients diagnosed during that period. FINDINGS Out 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 CONCLUSIONS Alternative MA schedules resulted in low lethality without increase of relapse or late ML incidence.</p></div

Low versus high dose of antimony for American cutaneous leishmaniasis: A randomized controlled blind non-inferiority trial in Rio de Janeiro, Brazil

<div><p>Background</p><p>Although high dose of antimony is the mainstay for treatment of American cutaneous leishmaniasis (ACL), ongoing major concerns remain over its toxicity. Whether or not low dose antimony regimens provide non-inferior effectiveness and lower toxicity has long been a question of dispute.</p><p>Methods</p><p>A single-blind, non-inferiority, randomized controlled trial was conducted comparing high dose with low dose of antimony in subjects with ACL treated at a referral center in Rio de Janeiro, an endemic area of <i>Leishmania (Viannia) braziliensis</i> transmission. The primary outcome was clinical cure at 360 days of follow-up in the modified-intention-to-treat (mITT) and per-protocol (PP) populations. Non-inferiority margin was 15%. Secondary objectives included occurrence of epithelialization, adverse events and drug discontinuations. This study was registered in ClinicalTrials.gov: <a href="https://clinicaltrials.gov/ct2/show/NCT01301924" target="_blank">NCT01301924</a>.</p><p>Results</p><p>Overall, 72 patients were randomly assigned to one of the two treatment arms during October 2008 to July 2014. In mITT, clinical cure was observed in 77.8% of subjects in the low dose antimony group and 94.4% in the high dose antimony group after one series of treatment (risk difference 16.7%; 90% CI, 3.7–29.7). The results were confirmed in PP analysis, with 77.8% of subjects with clinical cure in the low dose antimony group and 97.1% in the high dose antimony group (risk difference 19.4%; 90% CI, 7.1–31.7). The upper limit of the confidence interval exceeded the 15% threshold and was also above zero supporting the hypothesis that low dose is inferior to high dose of antimony after one series of treatment. Nevertheless, more major adverse events, a greater number of adverse events and major adverse events per subject, and more drug discontinuations were observed in the high dose antimony group (all p<0.05). Interestingly, of all the subjects who were originally allocated to the low dose antimony group and were followed up after clinical failure, 85.7% achieved cure after a further treatment with local therapy or low dose of antimony.</p><p>Conclusions</p><p>Compared with high dose, low dose of antimony was inferior at the pre-specified margin after one series of treatment of ACL, but was associated with a significantly lower toxicity. While high dose of antimony should remain the standard treatment for ACL, low dose antimony treatment might be preferred when toxicity is a primary concern.</p></div

Baseline demographic and clinical characteristics of the modified intention-to-treat population.

<p>Baseline demographic and clinical characteristics of the modified intention-to-treat population.</p

Bubble plot of -log10(Raw p-value) by risk difference with a two-sided 95% confidence interval sized by number of subjects with adverse events in high dose versus low dose antimony groups.

<p>Note: Grey zone area corresponds to area of p-value<0.05; X stands for point estimates; point estimates within the grey zone area have p-values<0.05; circles are sized by the number of patients with adverse events; circles located to the right of the vertical solid line favor more adverse events in the high dose antimony group.</p

Different stages of the wound healing process in American cutaneous leishmaniasis.

<p>Different stages of the wound healing process in American cutaneous leishmaniasis.</p

Subgroup analysis: Forest plot of absolute risk difference (RD) and relative risk (RR) with two-sided 95% confidence interval (CI) for major adverse events according to low versus high dose antimony treatment.

<p>Squares located to the right of the vertical solid line favor more major adverse events in the high dose antimony group.</p