Intralesional Sodium Stibogluconate Research Articles

Long-term efficacy of single-dose radiofrequency-induced heat therapy vs. intralesional antimonials for cutaneous leishmaniasis in India

Radiofrequency-induced heat therapy (RFHT) has been found to be safe and effective against cutaneous leishmaniasis (CL) in the short term, but its long-term efficacy is unclear. To compare the long-term efficacy of RFHT vs. intralesional sodium stibogluconate (SSG) injections in the treatment of CL in India. One hundred patients with a confirmed diagnosis of CL were randomly assigned in a 1 : 1 ratio to receive topical RFHT for 30-60 s or seven intralesional injections of SSG (50 mg cm(-2) of lesion). Improvement and recurrence were monitored every 15 days after the initiation of treatment for 4 months and then at 5, 6, 9, 12 and 18 months post-treatment; the rates of complete cure were compared. Lesions were healed in 47 out of 50 patients (94%) in the RFHT group and in 46 out of 50 patients (92%) in the SSG group at week 12. Time to complete healing was comparable in the two groups. At 6 months post-treatment, cure rates in the RFHT and SSG groups were 98% [95% confidence interval (CI) 94-100%] and 94% (95% CI 86-100%), respectively. Age, sex and lesion size or number had no effect on cure rates. No relapse of infection was recorded in cured patients in either group up to 12-18 months after initiation of treatment. Skin biopsies of cured lesions in eight out of eight (100%) patients from the RFHT group and three of three from the SSG group at 12 months showed minimal fibrosis and were negative for Leishmania tropica by polymerase chain reaction test. A single application of RFHT is safe, cosmetically acceptable and effective in inducing a long-term cure of CL.

A rare case of diffuse cutaneous leishmaniasis in an immunocompetent patient from sub-Himalayan India

Diffuse cutaneous leishmaniasis (DCL) is a rare variant of cutaneous leishmaniasis (CL) characterised by multiple (≥10), widespread, slowly progressive, cosmetically disfiguring, non-ulcerating nodules without visceral involvement. The disease is resistant to chemotherapy and characterized by relapses. We present a rare case of a patient with DCL who had extensive lesions (282) and who was HIV negative from a new focus of leishmaniasis in sub-Himalayan India. A favourable response with a regression of the lesions was observed after a month of treatment with intravenous and intralesional sodium stibogluconate with oral pentoxiphyline. Familiarity with such exceptional cases in immunocompetent individuals may facilitate diagnosis and a promising treatment outcome.

Leishmaniasis of the lip diagnosed by lymph node aspiration and treated with a combination of oral ketaconazole and intralesional sodium stibogluconate

A 26-year-old male who presented to the dermatology OPD with complaints of a swelling on his lip of 6 months′ duration was on examination found to have a solitary ulcerated nodule over the lip and an enlarged submental lymph node. Skin smear and biopsy from the lesion did not yield the diagnosis. Needle aspiration from the draining lymph node revealed the diagnostic Leishman-Donovan bodies. The patient responded to treatment with a combination of oral ketoconazole and intralesional sodium stibogluconate. We report this case because of both the unusual location of the lesion and the unusual method of diagnosis and treatment.

Liposomal amphotericin B treatment of cutaneous leishmaniasis due to Leishmania tropica

Cutaneous leishmaniasis (CL) is endemic in Israel, and in the past, has been attributed almost exclusively to Leishmania major. Over the last decade or so, an increase in Leishmania tropica (L. tropica) infections has occurred in several regions of Israel. Topical treatment of Old World CL is usually the rule, however, in some cases systemic treatment is indicated. Liposomal amphotericin B (L-AmB) is efficacious and safe for treating visceral leishmaniasis but its role in treating various forms of CL is yet to be defined. In this study, we summarize the efficacy and safety of L-AmB treatment in a series of Israeli patients with L. tropica infection. Cases of PCR-proven CL caused by L. tropica were treated in an outpatient setting. Treatment schedule consisted of five consecutive days of 3 mg/kg L-AmB, followed by a sixth dose on day 10. Thirteen consecutive patients (11 men, two women), received L-AmB. Mean age was 15.3 years; of the 13 patients, 85% had facial lesions. Six had previously failed intralesional sodium stibogluconate treatment and four had failed topical paromomycin treatment. Eleven of 13 patients (84%) achieved complete clinical cure within 2 months. Mean follow-up of 11 months revealed no relapses. Side effects were mild and none terminated treatment prematurely. A non-randomized study, with a small number of patients. Liposomal amphotericin B treatment for L. tropica is effective, well tolerated and cost beneficial in countries where cost of hospital-care is significant.

Liquid nitrogen cryotherapy on Leishmania donovani cutaneous leishmaniasis

Objective: To evaluate the efficacy and the safety of liquid nitrogen cryotherapy (LN) on Leishmania donovani cutaneous leishmaniasis and on type V skin. Methods: LN was applied to 65 patients (121 lesions) using cotton swabs attached to ekels. Cryosessions were performed for 15–20 seconds, two per site, weekly for 1–3 weeks, fortnightly for 4–5 weeks and then monthly until cure. Patients were followed-up for 6 months after cure. Results: A total of 91.7% of patients were cured within one to seven cryosessions; mean 3.57. With one to four cryosessions, papules ≤ 1 cm in diameter showed rapid healing (90.5%) in comparison with those of > 1 cm diameter (64.28%). The cure rates for lesions on the head (84.61%) and upper limb (82.6%) were greater than those for the lower limbs (71.42%) and trunk (66.66%). With LN, local pain lasted for 15–30 minutes; ulceration (33%), depigmentation (46.9%) and scarring (43%) were noticed. During 6 months of follow-up there was one (1.6%) recurrence. Conclusions: LN (77.15% cure within one to four cryosessions) is an alternative to intralesional sodium stibogluconate in the treatment of papules measuring ≤ 1 cm. In type V skin, LN should be avoided on the face, and on patients who have a tendency to form keloids. We recommend giving cryotherapy using cryoguns (instead of cotton swabs attached to ekels) fortnightly (not weekly), which may minimize ulceration, and therefore scarring.

Efficacy of short-duration (twice weekly) intralesional sodium stibogluconate in treatment of cutaneous leishmaniasis in India

Cutaneous leishmaniasis (CL) is caused by Leishmania major and L. tropica in the old world. Bikaner, the 'Thar Desert', situated in the north-western corner of India, is an endemic pocket for CL caused by L. tropica. Skin lesions of CL heal slowly, causing disfiguring scars if remaining untreated. Current recommended treatment for CL comprises systemic administration of sodium stibogluconate (SSG) for 2-3 weeks. Five to seven injections of SSG intralesionally have also been found to be effective. To determine the efficacy of a short-duration, twice-weekly intralesional SSG treatment for CL. Two hundred and twenty patients with CL having 298 lesions were included in the present study. They were divided into groups A and B (110 patients each). Patients were treated with five to seven intralesional injections of SSG in doses of 50 mg cm(-2) of lesion either once (group A) or twice (group B) weekly. Improvement was recorded at 6, 8, 10, 12, 16, 20 and 24 weeks and the rate of complete cure was compared. Complete cure rate at 6, 8 and 10 weeks was higher (20%, 57% and 73%, respectively) in group B as compared with group A (12%, 36% and 62%, respectively). The differences in cure rates at these time points were statistically significant (P < 0.05). The complete cure rate at 24 weeks was similar in both groups (96% in group B and 92% in group A). The remaining 4% and 8% of patients in groups B and A were 'nonresponders', respectively. No major side-effects were observed in either group. In all cured cases, there were no relapses reported up to 2 years after treatment. A short-duration, twice-weekly intralesional SSG treatment for CL accelerates cure and is highly effective and well tolerated.

Randomized, double-blind, comparative clinical trial on the efficacy and safety of intralesional sodium stibogluconate and intralesional 7% hypertonic sodium chloride against cutaneous leishmaniasis caused by L. donovani

Introduction: Since cutaneous leishmaniasis (CL) is a self healing disease, an ideal therapy should be rapidly effective, easily administered, cheap, available at all times at all centers and should have no side effects. Objectives: To determine the efficacy and safety of intralesional 7% hypertonic saline in comparison to intralesional sodium stibogluconate against L. donovani CL. Methods: Intralesional hypertonic saline (HS) and sodium stibogluconate (SSG) were randomly allocated to 154 patients (229 lesions); these were followed-up for 18 months. Results: The M:F ratio was 1.8:1 (99:55). The average age of our population was 32 years. SSG was given to 87 patients (136 lesions); HS was given to 67 patients (93 lesions). SSG showed a 100% cure rate within one to six injections (average 3.24); HS showed a 92.2% cure rate within one to 10 injections (average 5.27). The average duration of treatment with SSG and HS was 5.11 and 8.78 weeks respectively. There was no difference in efficacy for both therapies with regard to ulcers or papules, and small or large, exposed or unexposed lesions. There was no association between the rapidity of clinical response and the duration and location of lesions. There were no local or systemic side effects except pain during injection. The lesions in the two groups showed post-inflammatory hyperpigmentation after treatment. During 18 months of follow-up there were no recurrences and no visceralization. Conclusions: The most effective therapy for Leishmania donovani cutaneous leishmaniasis was intralesional SSG (average 3.24 injections). HS was effective, but needed an average of 5.27 injections in total per lesion. HS was cheap, with no risk of systemic side effects and was easily available at all centers.

Intralesional sodium stibogluconate alone or its combination with either intramuscular sodium stibogluconate or oral ketoconazole in the treatment of localized cutaneous leishmaniasis: a comparative study

Cutaneous leishmaniasis (CL) is a disease caused by leishmania species. Intralesional sodium stibogluconate (SSG) has been considered the first line therapy for localized cutaneous leishmaniasis. There is still a need for more effective and less time-consuming therapeutic methods for this condition. The aim of the present study was to investigate if the combination of intramuscular (IM) SSG or oral ketoconazole with intralesional (IL) SSG would be more effective than the intralesional SSG given alone in the treatment of localized cutaneous leishmaniasis. Thirty patients with confirmed diagnosis of cutaneous leishmaniasis were included in the study. They were randomly assigned to three groups. The first group (10 patients with 12 lesions) was treated with intralesional SSG alone. The second group (10 patients with 15 lesions) was treated with the combination of intralesional SSG + intramuscular SSG. The third group (10 patients with 13 lesions) was treated with the combination of intralesional SSG and oral ketoconazole. A follow-up was performed every 4 weeks for a treatment period of 12 weeks, then monthly for a period of 6 months after the end of the treatment. Complete cure occurred in 58.3% of lesions in group 1, while 93.3% and 92.3% of lesions were cured in group 2 and 3 respectively. The difference between group 1 and the other groups was statistically significant (P < 0.05). Combined intramuscular SSG or oral ketoconazole with intralesional SSG is more effective than intralesional SSG alone for the treatment of CL. Oral ketoconazole is much easier and safer therapy than intramuscular SSG in combination with intralesional SSG in the treatment of localized cutaneous leishmaniasis.

Treatment of cutaneous leishmaniasis with intralesional sodium stibogluconate

Cutaneous leishmaniasis is endemic in Israel. Leishmania major is the most prevalent species that cause cutaneous leishmaniasis. Current treatment options are limited and there are few investigations in search of alternative ones. This study aims to assess our experience with intralesional sodium stibogluconate (SSG) in the treatment of cutaneous leishmaniasis. A retrospective evaluation for all adult cases of cutaneous leishmaniasis treated by intralesional and intravenous SSG (Pentostam, GlaxoSmithKline) between 2004 and 2006 was performed, for cases referred to a tertiary care university-affiliated medical centre in Israel. Intralesional SSG was injected at 0.5 mL per lesion (50 mg). Treatment was repeated every 2-3 weeks for a total of 12 weeks. Intravenous SSG was administered at a dose of 20 mg/kg for 10-20 days. Thirty-three cases of cutaneous leishmaniasis were treated with intralesional SSG during the study period. The patients consist of 26 males and 7 females, mostly Israeli military personnel, and there were a total of 93 lesions. Within 3 months from treatment onset, 91% (30/33) had completed healing of the cutaneous lesions after an average of 3 treatments (range 1-6). Side-effects were mild and were mostly pain during injection, with two patients developing mild local site reaction after the injection. Intralesional SSG treatment is safe, effective and well tolerated with minimal side-effects.

Interventions for Old World cutaneous leishmaniasis

Cutaneous leishmaniasis is caused by a parasitic infection and is considered one of the most serious skin diseases in many developing countries. Antimonials are the most commonly prescribed treatment but other drugs have been used with varying success. To assess the effects of treatments for Old World cutaneous leishmaniasis (OWCL). We searched the Cochrane Skin Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (2003-April 2008), EMBASE (2005-April 2008), CINAHL (1982-August 2007), LILACS (from inception to April 2008) and ongoing trials databases (August 2007). Randomised controlled trials assessing treatments in immuno-competent people with OWCL confirmed by smear, histology, culture or polymerase chain reaction. Two authors independently assessed trial quality and extracted data. We included 49 trials involving 5559 participants. Reporting quality was generally poor and only two studies contained sufficiently similar data to pool.In Leishmania major infections, there was good RCT evidence of benefit of cure around 3 months after treatment when compared to placebo for 200 mg oral fluconazole (1 RCT n = 200, RR 2.78; 95% CI 1.86, 4.16), topical 15% paromomycin + 12% methylbenzethonium chloride (PR-MBCL) (1 RCT n = 60, RR 3.09; 95% CI 1.14, 8.37) and photodynamic therapy (1 RCT n = 60, RR 7.02; 95% CI 3.80, 17.55). Topical PR-MBCL was less efficacious than photodynamic therapy (1 RCT n = 65, RR 0.44; 95% CI 0.29, 0.66). Oral pentoxifylline was a good adjuvant therapy to intramuscular meglumine antimoniate (IMMA) when compared to IMMA plus placebo (1 RCT n = 64, RR 1.63; 95% CI 1.11, 2.39)In Leishmania tropica infections, there was good evidence of benefit for the use of 200 mg oral itraconazole for 6 weeks compared with placebo (1 RCT n = 20, RR 7.00; 95% CI 1.04, 46.95), for intralesional sodium stibogluconate (1 RCT n = 292, RR 2.62; 95% CI 1.78, 3.86), and for thermotherapy compared with intramuscular sodium stibogluconate (1 RCT n = 283, RR 2.99; 95% CI 2.04, 4.37). Most trials have been designed and reported poorly, resulting in a lack of evidence for potentially beneficial treatments. There is a desperate need for large well conducted studies that evaluate long-term effects of current therapies. We suggest the creation of an international platform to improve quality and standardization of future trials in order to inform clinical practice.

Leishmaniasis Recidivans in a Palestinian Bedouin Child

In February 2005, a 12-year-old Palestinian Bedouin child with a small lesion on his upper cheek just below the right eye was referred to Leishmania Research Unit medical laboratory in Jericho for diagnosis of suspected cutaneous leishmaniasis. He lived in a rocky desert area by Wadi-Qelt, approximately 4 km from Jericho City center and attended the school in the adjacent Aqabat Jabr refugee camp, which borders Jericho City. He remained confined to this area for the few months before the lesion's appearance. The lesion was less than 1 cm in diameter, was bacterially clean, and had a small encrusted crater in its center. The lesion was 2 months old when first examined. There were no indications of previous cutaneous leishmaniasis, but other family members described having been exposed to cutaneous leishmaniasis. The family's residential area was rocky and cavernous with a continuously flowing stream that provided Jericho with drinking and irrigation water. There were irrigated banana plantations nearby. Extracellular amastigotes were seen in tissue smears stained with Giemsa stain (Figure 1). These parasites were identified as Leishmania tropica by DNA analysis. This was done by amplifying the internal transcribed spacer-1 of the ribosomal RNA genes, using a Gene Amp PCR-system 9700 (Applied Biosystems, Foster City, CA) followed by restriction fragment length polymorphism.1,2 The DNAs of leishmanial species reference strains were included for comparison (Figure 2). The patient was treated with sodium stibogluconate injected intralesionally at 10 mg/kg/d every other day for 3 weeks, then twice a week for 2 months, and once a week thereafter for 3 months. The lesion seemed to re-epithelialize during the 3 months from February to early May. The patient was lost to follow-up until November 2005, when he returned with a small, red, smooth macule. This enlarged, and papules typical of Leishmaniasis recidivans appeared at its margins. Microscopic examination and DNA analysis were repeated and again showed the presence of L tropica. The patient was treated with intralesional sodium stibogluconate for another 5 months. The patient returned a third time in April 2006, 14 months after initial presentation, with a more severe and destructive nodular condition (Figure 3). Microscopic examination and DNA analysis were repeated, during which 2 tubes of rabbit blood-agar semisolid medium were inoculated with tissue aspirate to isolate the parasite. This time, no amastigotes were seen in the stained smears, and the internal transcribed spacer-1-PCR results were negative, but culture medium in 1 tube grew promastigotes. The lesion remained active throughout further treatment. The Bedouin family said they would apply a traditional therapy. Figure 1. Giemsa-stained smear showing extracellular amastigotes (original magnification ×1000). Download figure to PowerPoint Figure 2. Restriction fragment length polymorphism analysis of the amplified internal transcribed spacer-1-Gene Amp PCR products (Applied Biosystems, Foster City, CA) following digestion with HaeIII: left to right, the World Health Organization reference strains of Leishmania infantum (MHOM/TN/1980/IPT1), Leishmania tropica (MHOM/AZ/1974/SAF-K27), and Leishmania major (MHOM/TM/1973/5ASKH); leishmanial DNA from the patient's samples taken in February 2005; and leishmanial DNA following the relapse in November 2005. Download figure to PowerPoint Figure 3. The 12-year-old Palestinian boy with Leishmaniasis recidivans, showing small papules at the edge of the central lesion after several months of almost complete cure. After 5 months of antimony treatment following relapse, promastigotes were isolated, while the microscopic examination and internal transcribed spacer-1-Gene Amp PCR (Applied Biosystems, Foster City, CA) results were negative. Download figure to PowerPoint

Comparative efficacy of intralesional sodium stibogluconate (SSG) alone and its combination with intramuscular SSG to treat localized cutaneous leishmaniasis: Results of a pilot study

Intralesional sodium stibogluconate (SSG) has become first line therapy for localized cutaneous leishmaniasis (LCL). This study compares the efficacy of intralesional SSG given alone with that of intralesional SSG combined with intramuscular SSG. Thirty-two patients aged between 5-56 years were included in the study. The first group received three injections of intralesional SSG on alternate days while the other group received three injections of intralesional SSG similar to the first group and the rest of the calculated dose as a simultaneous, intramuscular injection. Patients were followed up every four weeks to assess for cure/ the need for repeating the treatment. Five patients from group 1 having small nodular lesions of < six months duration were cured after 1-2 treatment cycles. However, six patients with mucosal lesions, large lesions and lesions of > six months duration needed 3-5 treatment schedules. Most plaques and mucosal lesions in seven patients in group 2 cleared with two treatment cycles. Intralesional combined with intramuscular SSG appears more effective in LCL and gave qualitatively superior healing than intralesional SSG given alone.

Cutaneous leishmanisis in South Australia – A case series

Cutaneous leishmaniasis is a disease caused by protozoan parasites that are transmitted by the female sandfly. Australia is receiving increasing numbers of immigrants from regions endemic for leishmaniasis, most frequently Afghanistan. As a result a skin disease which was once a rare presentation to Australian Dermatology clinics is being increasingly diagnosed. A case series of nine patients with leishmaniasis diagnosed in South Australia in the last 5 years is presented followed by an overview of the epidemiology, clinical and histopathological features and treatment options of leishmaniasis. The classical clinical appearance of leishmaniasis, is one to two necrotic nodules, 0.5–3 centimetres in diameter on an exposed site. Biopsy is required for definitive diagnosis. A Giemsa stain most effectively demonstrates amastigotes within the cytoplasm of macrophages. Occasionally non‐caseating granulomatous inflammation is evident, without being able to identify organisms. Intralesional sodium stibogluconate was effective in our case series of patients.

Cutaneous Leishmaniasis: Three Children with Leishmania major Successfully Treated with Itraconazole

We report the rare instance of four family members with numerous cutaneous lesions of Leishmania major contracted while on holiday in Algeria. Treatment was successful with oral itraconazole for the children and intralesional sodium stibogluconate for the mother. Cutaneous leishmaniasis should be considered in those with apparently sterile plaques returning from endemic areas. These results suggest that itraconazole, which is ideally suited for use in children, is an effective monotherapy for L. major.

Leishmania tropica in northern Israel: A clinical overview of an emerging focus

In Israel, most cutaneous leishmaniasis (CL) is caused by Leishmania major. Recently a new focus of CL caused by Leishmania tropica has been described in Tiberias and the surrounding area of northern Israel. The aim of this study was to evaluate clinical (size, number, location, and type of lesion) and laboratory (culture and polymerase chain reaction [PCR] analysis) parameters at diagnosis, response to treatment, and outcome of patients with CL due to L tropica. Between September 2002 and March 2004, patients with direct smear-confirmed CL were evaluated; clinical records were reviewed and a telephone survey was performed. Forty nine patients, 34 (69%) male and 15 (31%) female, were studied. Mean age was 31.1 years (median 26 years, range 1-70); 76% of patients live in Tiberias and the surrounding area. The mean number of lesions was 2.6 (median 2, range 1-10). Lesions were commonly located on the face (61%) and upper limbs (57%). PCR analysis was performed in 27 patients and was positive for L tropica in 26. Fifty percent of patients studied received multiple therapeutic regimens because of incomplete response or treatment failure. Topical paromomycin was used in 44 patients (90%), with a complete response reported in only 17 (39%); of the 9 patients treated with intralesional sodium stibogluconate, a complete response was reported in 6 (67%); of the 5 patients treated with intravenous sodium stibogluconate, 4 (80%) were cured. The relatively small number of patients studied combined with the fact that some were assessed retrospectively limit our conclusions. In addition, 50% of the patients studied received multiple therapeutic regimens because of failure of, or incomplete responses to, their initial therapy, thereby making comparisons difficult. The cure rate in those completing a course of antimony therapy, either 10 or more days of intravenous therapy or therapy administered intralesionally, was 75% (95% confidence interval [CI], 50.5-99.5%) as compared with 45% (95% CI, 28.9-60.5%) among those completing at least 10 days of topical paromomycin. To date, no standardized, simple, safe, and highly effective regimen for treating L tropica exists. Large, controlled clinical trials to evaluate current treatment regimens as well as new medications for CL, and especially CL attributed to L tropica, are urgently needed.

LOCALIZED CUTANEOUS LEISHMANIASIS DUE TO LEISHMANIA DONOVANI AND LEISHMANIA TROPICA: PRELIMINARY FINDINGS OF THE STUDY OF 161 NEW CASES FROM A NEW ENDEMIC FOCUS IN HIMACHAL PRADESH, INDIA

Localized cutaneous leishmaniasis (LCL) in India is due mostly to Leishmania tropica. It is mainly endemic in the deserts of Rajasthan. Recently, Himachal Pradesh has been identified as a new endemic focus for the disease. In the last few years, the number of new cases has been increasing almost to epidemic proportions. This report presents the preliminary findings of clinico-epidemiologic and investigative results of 161 new localized cases of LCL seen between May 2001 and December 2003. The study populaton was composed of 80 males and 81 females between 10 months and 75 years of age. All were indigenous to the sub-alpine valley along the Satluj River in the mountainous region of the Kinnaur District (altitude = 700-2,900 meters). Most patients were seen from April to September and had 1-8 lesions (duration = 1-6 months) that involved mainly the face. Tissue smears were positive for amastigotes in 37% and histopathology showed non-caseating epitheloid cell granuloma in 77% of the cases. Analysis by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) of the ribosomal gene region of 10 biopsy specimens showed amplicons indistinguishable from L. donovani in eight cases and L. tropica in two cases. Leishmania was cultured on modified Nicole-Novy-McNeal (NNN) medium containing RPMI 1640 medium and heat-inactivated fetal bovine serum from 13 of 38 biopsy samples. Three of these isolated strains were identified as L. donovani while a fourth was L. tropica by PCR-RFLP of the ribosomal internal transcribed spacer region. One strain had a gp63 sequence identical to that of east African strains. Another strain had a unique gp63 sequence that has not been found in L. donovani complex strains. Sand flies trapped in the cattle sheds of a few patients were identified as Phlebotomus longiductus (Parrot 1928). Treatment with intralesional sodium stibogluconate was effective in all patients without any major side effects. One patient developed lupoid leishmaniasis that responded to higher dose of sodium stibogluconate. Though rarely reported as a cause of LCL, L. donovani seems to be the predominant pathogen in this new focus of cutaneous leishmaniasis. Phlebotomus longiductus is a possible vector, albeit based on circumstantial evidence.

Cutaneous leishmaniasis in Afghani refugees

Four Afghani refugees with cutaneous leishmaniasis presented to the dermatology clinic at the Women's and Children's Hospital in Adelaide. Three of the patients had biopsy-proven cutaneous leishmaniasis that was treated initially with topical and then oral ketoconazole, without success. Intralesional sodium stibogluconate was then used for these patients with good results. The fourth patient had several plaques of biopsy-proven cutaneous leishmaniasis, for which cryotherapy was used. This was quite efficacious; however, a small area of recurrence required re-treatment. Leishmaniasis is rarely seen in Australia, but an index of suspicion is warranted when treating persons with typical clinical features who are from endemic regions.

Efficacy of Thermotherapy to Treat Cutaneous Leishmaniasis Caused byLeishmania tropicain Kabul, Afghanistan: A Randomized, Controlled Trial

Pentavalent antimony is the agent recommended for treatment of cutaneous leishmaniasis (CL). Its use is problematic, because it is expensive and because of the potential for drug-associated adverse effects during a lengthy and painful treatment course. We tested the efficacy of thermotherapy for the treatment of CL due to Leishmania tropica in a randomized, controlled trial in Kabul, Afghanistan. We enrolled 401 patients with a single CL lesion and administered thermotherapy using radio-frequency waves (1 treatment of >or=1 consecutive application at 50 degrees C for 30 s) or sodium stibogluconate (SSG), administered either intralesionally (a total of 5 injections of 2-5 mL every 5-7 days, depending on lesion size) or intramuscularly (20 mg/kg daily for 21 days). Cure, defined as complete reepithelialization at 100 days after treatment initiation, was observed in 75 (69.4%) of 108 patients who received thermotherapy, 70 (75.3%) of 93 patients who received intralesional SSG, and 26 (44.8%) of 58 patients who received intramuscular SSG. The OR for cure with thermotherapy was 2.80 (95% confidence interval [CI], 1.45-5.41), compared with intramuscular SSG treatment (P=.002). No statistically significant difference was observed in the odds of cure in comparison of intralesional SSG and thermotherapy treatments. The OR for cure with intralesional SSG treatment was 3.75 (95% CI, 1.86-7.54), compared with intramuscular SSG treatment (P<.001). The time to cure was significantly shorter in the thermotherapy group (median, 53 days) than in the intralesional SSG or intramuscularly SSG group (median, 75 days and >100 days, respectively; P=.003). Thermotherapy is an effective, comparatively well-tolerated, and rapid treatment for CL, and it should be considered as an alternative to antimony treatment.

The efficacy of treatment with intralesional meglumine antimoniate alone, compared with that of cryotherapy combined with the meglumine antimoniate or intralesional sodium stibogluconate, in the treatment of cutaneous leishmaniasis.

It would be very useful to have a more effective and more rapid method available for the treatment of cutaneous leishmaniasis (CL). The main aim of the present, Iranian study, was to see if the combination of cryotherapy and intralesional injections with meglumine antimoniate (C + MA) would be more effective than the injections given alone (MA) or the combination of cryotherapy plus intralesional sodium stibogluconate (C + SS). Forty patients (with 67 lesions) were treated with C + MA, another 40 (with 65 lesions) were treated with C + SS and 100 patients (with 180 lesions) were treated with MA. Follow-up for 6 months after the final treatment indicated that 89.5% of the lesions treated with C + MA, 92.3% of those treated with C + SS but only 50% of the lesions treated with MA only were completely cured. The frequencies of cure in the two cryotherapy groups were similar, both being significantly higher than that in the MA group (P < 0.05). The combination of cryotherapy with intralesional injections of meglumine antimoniate or sodium stibogluconate, which is much more effective than the use of intralesional meglumine antimoniate alone, should be promoted.

Treatment of Cutaneous Leishmaniasis by Direct Current Electrotherapy: The Baghdadin Device

Electrical stimulation has been used as a mode of therapy for a number of clinical conditions. However, it has not been used for the treatment of cutaneous leishmaniasis (CL). For this purpose, we designed the "Baghdadin device". A total of 146 lesions of acute CL in 54 patients were treated by this device. Twenty-one lesions in the same patients were left untreated as controls. In addition, 36 lesions in 15 patients were treated with intralesional sodium stibogluconate. Treatment by the Baghdadin device consisted of weekly sessions of 10 minutes of direct current electrical stimulation. The intensity of the direct current ranged between 5 and 15 milliamperes, and the voltage was kept below 40 volts. Of the 146 lesions, 135 (92.5%) showed total clearance or marked improvement in 4-6 weeks time. Approximately 67% of the lesions needed only one or two sessions. Scarring was not observed after resolution. None of the untreated lesions showed any signs of improvement in 6 weeks. Of the lesions treated with sodium stibogluconate, 32 lesions (88.9%) showed total clearance or marked improvement, which was not significantly different from the results with the Baghdadin device.