Leishmaniasis in Emergency Medicine Medication

  • Author: Jennifer J Lee, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 16, 2010
 

Medication Summary

Antiparasitic pentavalent antimonials, such as sodium stibogluconate (Pentostam) or meglumine antimonate, are the mainstays of therapy. Until recently, sodium stibogluconate was the only recommended treatment in the United States and was available only through the CDC, but amphotericin B in its liposomal form (as opposed to amphotericin B deoxycholate) has been approved and is now considered to be the drug of choice for visceral leishmaniasis because of its shorter course and lower toxicity.

Cost issues prevent the use of liposomal drugs in most countries, where the mainstay of treatment is still prolonged intravenous treatment with antimonials, despite ever-increasing patterns of resistance and an increasing incidence of treatment failures. Alternative treatments, such as amphotericin B, should be used when resistance is endemic or when other reasons for using an alternative parenteral exist (eg, lower toxicity profile).

In terms of oral medications, miltefosine is the sole agent that has been shown to be effective. Miltefosine is currently approved in India for visceral leishmaniasis, but it is not yet available in the United States.

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Antiparasitic

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

Sodium antimony gluconate

 

DOC for treatment of leishmaniasis in the United States. Children often tolerate therapy better than adults. First-line treatment in most forms. Not marketed in United States. Contact CDC Parasitic Drug Service at (404) 639-3670.

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Amphotericin B (AmBisome)

 

An evolving second-line drug to be used after failure of antimonials to treat mucocutaneous and visceral leishmaniasis.

New lipid-associated formulations are taken up well by the reticuloendothelial system and poorly by the kidney. These formulations target the cells that host the parasite and have decreased nephrotoxicity.

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Antiprotozoal

Class Summary

Protozoal infections occur throughout the world and are a major cause of morbidity and mortality in some regions. Immunocompromised patients are especially at risk. Primary immune deficiency is rare; whereas, secondary deficiency is more common. Immunosuppressive therapy, cancer and its treatment, HIV infection, and splenectomy all may increase vulnerability to infection. Infectious risk is proportional to neutropenia duration and severity. Protozoal infections are typically more severe in immunocompromised patients than in immunocompetent patients.

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Pentamidine (Pentam-300)

 

Inhibits growth of protozoa by interacting with trypanosomal kinetoplast DNA and interferes with polyamine synthesis by a decrease in the activity of ornithine decarboxylase. Pentamidine also works by inhibiting incorporation of nucleic acids into RNA and DNA, causing inhibition of protein and phospholipid synthesis. First-line medication in cutaneous leishmaniasis except L mexicana (ketoconazole 600 mg PO qd for 28 d). Pentamidine is a treatment alternative in visceral leishmaniasis.

Drug is well absorbed and highly tissue bound. Because patients receiving daily injections do not reach a steady-state plasma concentration and elimination half-life is 12 d, a great deal of accumulation of pentamidine can occur in tissues such as the liver, kidney, and spleen.

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Antineoplastic

Class Summary

These agents inhibit cell growth and proliferation.

Miltefosine

 

Currently unavailable in United States. Developed first as an antineoplastic agent and later found to have considerable antiproliferative activity against leishmaniasis as well as against other trypanosome parasites. Attractive agent in areas, such as India, that have drug resistance against traditional chemotherapy.

Mechanism is likely due to inhibition of phospholipid and sterol biosynthesis via interference with cell signal transduction pathways. Resistance against miltefosine has been found.

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Contributor Information and Disclosures
Author

Jennifer J Lee, MD  Attending Physician, Department of Dermatology, Beth Israel Deaconess Medical Center, Boston; Instructor, Department of Dermatology, Harvard Medical School

Jennifer J Lee, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Renee Y Hsia, MD, MSc  Clinical Instructor, Division of Emergency Medicine, University of California at San Francisco; Attending Physician, Department of Emergency Medicine, San Francisco General Hospital

Renee Y Hsia, MD, MSc is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons, American Heart Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John Halpern, DO, FACEP  Clinical Assistant Professor, Department of Family Medicine, Nova Southeastern University College of Osteopathic Medicine; Medical Director, Health Career Institute; Medical Director Emergency Department, Palms West Hospital

John Halpern, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Photo courtesy of Robert Norris, MD, Stanford University Medical Center.
Leishmaniasis. Image courtesy of the CDC Public Health Image Library.
Leishmaniasis. Ethiopian woman with 1-year history of asymptomatic pink-erythematous infiltrative plaque with overlying scale and central crust.
 
 
 
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