Pediatric Leishmaniasis Treatment & Management

  • Author: Conjivaram Vidyashankar, MD, MRCP; Chief Editor: Russell W Steele, MD   more...
 
Updated: Aug 10, 2011
 

Medical Care

Sodium stibogluconate, a pentavalent antimonial compound (Sbv), is the drug of choice in the treatment of visceral leishmaniasis, except for in Europe and Sbv -unresponsive regions of India. However, resistance is on the rise. Resistance is as high as 43% in the Bihar province of India, where visceral leishmaniasis is endemic. Amphotericin B deoxycholate is the drug of choice in India, whereas the lipid formulation liposomal amphotericin is used in Europe. Miltefosine is used in combination with liposomal amphotericin in endemic areas of north India.[3] A short-course regimen consisting of a single dose of liposomal amphotericin followed by 7-14 days of miltefosine has resulted in cure rates of over 90%.

A phase IV trial from Bangladesh found monotherapy with oral miltefosine (2.5 mg/kg/d) for 28 days effective in treatment of visceral leishmaniasis in children and adults.[4]

The earliest sign of improvement is an improvement in symptoms. Regression of splenomegaly takes a few months.

Supportive treatment includes rest, high-calorie diet, blood transfusions, and treatment of secondary infections.

Resistant visceral leishmaniasis

Drug resistance can be primary or secondary. Resistance can be caused by delayed diagnosis (prolonged duration of illness), interrupted and low-dose treatment, immunological failure, emergence of resistant strains of parasites, and leishmaniasis associated with AIDS. Visceral leishmaniasis is an important opportunistic infection associated with AIDS. Leishmaniasis in AIDS, mainly reported in southern Europe, is now observed in other parts of the world, including South America, Asia, and North Africa. Patients co-infected with HIV can develop unusual manifestations of leishmaniasis. Parasitologic diagnosis using peripheral blood smear and buffy coat smear is easier in patients with HIV co-infection because parasites are more commonly found in the circulating monocytes of these patients. Guidelines for prevention and treatment of opportunistic diseases in patients with HIV have been established.[5]

Patients resistant to stibogluconate should be treated with alternative agents, such as liposomal amphotericin (0.5-3 mg/kg) on alternate days until a dose of 20 mg/kg or pentamidine (2-4 mg/kg) on alternate days for 15 doses. Pentamidine is available in 2 preparations: pentamidine isethionate (Pentam 300) and pentamidine dimethane sulphonate (Lomidine). However, the effectiveness of pentamidine has recently declined. Other alternatives include miltefosine, the first oral antileishmanial agent licensed for use in India.

Liposomal amphotericin is a lipid complex with amphotericin that is more active than amphotericin B. The 3 preparations formulated include amphotericin B lipid complex, liposomal amphotericin B, and amphotericin B colloidal dispersion. Cure rates of more than 90% have been observed in various studies. The high cost of this drug is a disadvantage to its use in areas where visceral leishmaniasis is prevalent.

Combination of stibogluconate with drugs, such as aminosidine and interferon gamma, has also produced good results in patients who with a poor response to stibogluconate therapy alone. Other alternatives include miltefosine, the first oral antileishmanial drug that has been licensed for use in India. Aminosidine, an aminoglycoside identical to paromomycin, has also been found to be effective in trials in India. A shift from monotherapy to multidrug combinations in short courses delivered at no or affordable cost, through directly observed therapy, appears to be the only way to effectively treat and prevent drug resistance.

Research is being carried out on newer drug delivery systems for amphotericin, including the use of nanoparticles and cochleates but these are yet to enter human trials.[6]

Cutaneous leishmaniasis

Treatment essentially remains the same; sodium antimony gluconate and pentamidine are the drugs of choice, although some authors have indicated that a shorter course of pentamidine for 4 days has been effective in Colombia.[7] Oral drugs such as ketoconazole, itraconazole, and allopurinol are also effective but only in combination with the first-line drugs. Other approaches include local application of paromomycin and intralesional stibogluconate, but these are of limited value only. A single report from Tunisia has found doxycycline effective in cutaneous lesihmaniasis.[8] . In a randomized controlled trial from Brazil, miltefosine used alone was significantly better than parenteral stibogluconate in older children and adults.[9]

Mucocutaneous leishmaniasis

This responds to a 20-day course of sodium antimony gluconate (ie, sodium stibogluconate); resistant cases are treated with amphotericin.

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Diet

A high-protein and high-calorie diet is required during the course of treatment.

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Contributor Information and Disclosures
Author

Conjivaram Vidyashankar, MD, MRCP  Specialty Doctor Paediatrics, Stafford District General Hospital, Stafford, UK

Conjivaram Vidyashankar, MD, MRCP is a member of the following medical societies: European Society for Paediatric Infectious Diseases, Indian Academy of Pediatrics, International AIDS Society, and Royal College of Paediatrics and Child Health

Disclosure: Nothing to disclose.

Coauthor(s)

Ruchir Agrawal, MD  Chief, Allergy and Immunology, Aurora Sheboygan Clinic

Ruchir Agrawal, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary J Noel, MD  Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician, New York-Presbyterian Hospital

Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Martin Weisse, MD  Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Sanofi Pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Distribution map of visceral leishmaniasis.
Distribution map of cutaneous leishmaniasis.
Distribution map of human immunodeficiency virus (HIV) and leishmaniasis co-infection.
The predominant mode of transmission is the sandfly's bite.
Leishmania donovani is one of the main Leishmania species that infects humans.
 
 
 
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