No subject
Thu Jul 7 11:54:55 BRT 2011
On 07/07/2011, at 3:04, Carlos Costa <chncosta at gmail.com> wrote:
Dear all,
=20
Maria Cleudimar has cutaneous diffuse leishmaniasis due to Leishmania
amazonensis. She used to be a long time patient form Dr. Jackson Costa, =
in
the countryside of Maranh=E3o State, Brazil, since she was 10 years old, =
after
a disease that started when she was just five. Now, she is under my and
Dorcas care, at the age of 30, living in the city of Teresina.
=20
Her long time DCL does not respond to the treatment antimonium anymore.
Although we still prescribe liposomal amphotericin B at very low dose
(3mg/kg/once a week), her situation is deteriorating progressively, her
renal function does not allow any additional dosing since creatinine is
presently above 3mg/dL, and previous biopsy had shown tubular damage
apparently secondary to the drug, without evidence of amyloidosis. We =
tried
several combinations of different drugs, without success. Her situation
worsened a lot during her recent pregnancy (the baby is eight months old
now).
=20
Our hope now stands only in miltefosine, for oral chronic use, but the =
drug
is not licensed or available in Brazil yet (to my knowledge).
=20
With her permission I attached some of her pictures, hoping to sensitize
critical people in order to help me to get miltefosine and the =
permission
for prescription in Brazil (or any other oral drug with promising =
efficacy,
and without nephrotoxicity, if known). Moreover, we need to know about =
the
dose adjustment for the renal impairment, and how long the drug could =
safely
be used.
=20
One picture shows her face before treatment, and another after the
pregnancy, with the baby. One shows the situation of her thighs, another =
the
calf of the leg and the last one the infiltration of the palate.
=20
Hoping a little from friends, my kindest regards,
=20
Carlos.
=20
PS. Please understand that the pictures are allowed not for publication =
or
public presentation. Cleudimar permission is restricted to this forum.
=20
--=20
Carlos H. N. Costa, MD, DSc.
President
Sociedade Brasileira de Medicina Tropical=20
(Brazilian Society of Tropical Medicine)
Instituto de Doen=E7as Tropicais Natan Portella
Universidade Federal do Piau=ED
Rua Artur de Vasconcelos 151-Sul
64049-750 Teresina-PI
Brazil
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).
Aviso: As informa=E7=F5es contidas nesta mensagem s=E3o CONFIDENCIAIS, =
protegidas
pelo sigilo legal, por direitos autorais e destinadas exclusivamente =E0
pessoa ou organiza=E7=E3o para a qual a mensagem foi destinada.
Warning: This message is meant only for the intended recipient of the
transmission. It is forbidden any unauthorized use, alteration,
reproduction and distribution. If you are not the correct recipient, =
please
notify us immediately by return e-mail and delete this message from your
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=20
<cleu antes grav 13jan09.jpg>
<cleu e nene.jpg>
<cleu santada recorte.jpg>
<cleu panturrilhas.jpg>
<cleu palato.jpg>
_______________________________________________
Leish-l mailing list
Leish-l at lineu.icb.usp.br
http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l
--=20
Carlos H. N. Costa, MD, DSc.
President
Sociedade Brasileira de Medicina Tropical=20
(Brazilian Society of Tropical Medicine)
Instituto de Doen=E7as Tropicais Natan Portella
Universidade Federal do Piau=ED
Rua Artur de Vasconcelos 151-Sul
64049-750 Teresina-PI
Brazil
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).
Aviso: As informa=E7=F5es contidas nesta mensagem s=E3o CONFIDENCIAIS, =
protegidas
pelo sigilo legal, por direitos autorais e destinadas exclusivamente =E0
pessoa ou organiza=E7=E3o para a qual a mensagem foi destinada.
Warning: This message is meant only for the intended recipient of the
transmission. It is forbidden any unauthorized use, alteration,
reproduction and distribution. If you are not the correct recipient, =
please
notify us immediately by return e-mail and delete this message from your
system.=20
=20
=20
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{size:612.0pt 792.0pt;
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<o:idmap v:ext=3D"edit" data=3D"1" />
</o:shapelayout></xml><![endif]--></head><body lang=3DES-CO link=3Dblue =
vlink=3Dpurple><div class=3DWordSection1><p class=3DMsoNormal><span =
lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'>Dear all,<o:p></o:p></span></p><p class=3DMsoNormal><span =
lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'><o:p> </o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'>I received some days ago a specific question regarding miltefosine =
use in patients with renal impairment. I delay my answer asking to other =
people because this is not an easy answer; this is the =
conclusion:<o:p></o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'><o:p> </o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
>“Miltefosine is mildly nephrotoxic [Soto. CID 2004; =
38:1266–72] in leishmaniasis patients with normal renal function, =
Whether or not miltefosine would further diminish renal function in =
renally-impaired patients is not known. If renal function is already =
very low, however, a further effect on renal function might not be seen. =
<o:p></o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
><o:p> </o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
>My personal view would be to not lower dosing because of a possible =
adverse effect on the kidneys, specially because, in the specific case, =
full dose could mean the difference between improving and =
failure.<o:p></o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
><o:p> </o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
>Regards from Bolivia,<o:p></o:p></span></p><p class=3DMsoNormal><span =
lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
><o:p> </o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:10.0pt;font-family:"Arial","sans-serif";color:#1F497D'=
>Jaime soto </span><span lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'><o:p></o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'>=A0<o:p></o:p></span></p><p class=3DMsoNormal><span lang=3DEN-US =
style=3D'font-size:11.0pt;font-family:"Calibri","sans-serif";color:#1F497=
D'><o:p> </o:p></span></p><div =
style=3D'border:none;border-top:solid #B5C4DF 1.0pt;padding:3.0pt 0cm =
0cm 0cm'><p class=3DMsoNormal><b><span lang=3DES =
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>De:</span></=
b><span lang=3DES =
style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'> =
leish-l-bounces at lineu.icb.usp.br =
[mailto:leish-l-bounces at lineu.icb.usp.br] <b>En nombre de </b>Carlos =
Costa<br><b>Enviado el:</b> domingo, 10 de julio de 2011 05:44 =
p.m.<br><b>Para:</b> Jennie Blackwell<br><b>CC:</b> =
Leish-L<br><b>Asunto:</b> SPAM-LOW: Re: [Leish-l] miltefosine for =
diffuse leishmaniasis<o:p></o:p></span></p></div><p =
class=3DMsoNormal><o:p> </o:p></p><p class=3DMsoNormal>Hi =
Jennie,<o:p></o:p></p><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>Thanks for the drug information. Now, I have to check =
the permission for its use in Brazil and how to justify its use to the =
public system in order to be acquired by the government. Meanwhile, we =
are looking for miltefosine, paramomycin, and alternative =
therapies.<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>But if the immunosuppression is species specific do =
you think that a general stimulation would reverse it? Does anyone knows =
which is the mechanism behind the DCL induced immunosuppression? =
Parasite or host or both? <o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>Cheers,<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt'>Carlos.<o:p></o:p></p><div><p =
class=3DMsoNormal>2011/7/7 Jennie Blackwell <<a =
href=3D"mailto:jmb37 at cam.ac.uk">jmb37 at cam.ac.uk</a>><o:p></o:p></p><di=
v><div><p class=3DMsoNormal>Hello Carlos<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>My memory from late 80s was that these patients =
responded well to interferon-gamma treatment. With all the moves to make =
drugs more affordable for disease endemic countries, has it not been =
possible to consider this option?<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>In psoriasis they use creams with Vitamin D. Has =
anyone ever tried this for DCL?<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>I'm sure this is going to elicit a round of responses =
- but you know I'm not a clinician so I would just be interested to =
know!<o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal>Cheers, Jennie <br><br>Jenefer M. =
Blackwell<o:p></o:p></p><div><p class=3DMsoNormal>TICHR, CCHR, =
UWA<o:p></o:p></p></div><div><p class=3DMsoNormal>Phone: +61 8 =
94897910<o:p></o:p></p></div><div><p class=3DMsoNormal>From my =
iPhone<o:p></o:p></p></div></div><div><div><div><p class=3DMsoNormal =
style=3D'margin-bottom:12.0pt'><br>On 07/07/2011, at 3:04, Carlos Costa =
<<a href=3D"mailto:chncosta at gmail.com" =
target=3D"_blank">chncosta at gmail.com</a>> =
wrote:<o:p></o:p></p></div><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Dear all,</span><o:p></o:p></p><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Maria Cleudimar has cutaneous diffuse leishmaniasis due to =
<i>Leishmania amazonensis</i>. She used to be a long time patient form =
Dr. Jackson Costa, in the countryside of Maranh=E3o State, Brazil, since =
she was 10 years old, after a disease that started when she was just =
five. Now, she is under my and Dorcas care, at the age of 30, living in =
the city of Teresina.</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Her long time DCL does not respond to the treatment antimonium anymore. =
Although we still prescribe liposomal amphotericin B at very low dose =
(3mg/kg/once a week), her situation is deteriorating progressively, her =
renal function does not allow any additional dosing since creatinine is =
presently above 3mg/dL, and previous biopsy had shown tubular damage =
apparently secondary to the drug, without evidence of amyloidosis. We =
tried several combinations of different drugs, without success. Her =
situation worsened a lot during her recent pregnancy (the baby is eight =
months old now).</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Our hope now stands only in miltefosine, for oral chronic use, but the =
drug is not licensed or available in Brazil yet (to my =
knowledge).</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>With her permission I attached some of her pictures, hoping to =
sensitize critical people in order to help me to get miltefosine and the =
permission for prescription in Brazil (or any other oral drug with =
promising efficacy, and without nephrotoxicity, if known). Moreover, we =
need to know about the dose adjustment for the renal impairment, and how =
long the drug could safely be used.</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>One picture shows her face before treatment, and another after the =
pregnancy, with the baby. One shows the situation of her thighs, another =
the calf of the leg and the last one the infiltration of the =
palate.</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Hoping a little from friends, my kindest =
regards,</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>Carlos.</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><span =
style=3D'font-size:13.5pt;font-family:"Verdana","sans-serif";color:black'=
>PS. Please understand that the pictures are allowed not for publication =
or public presentation. Cleudimar permission is restricted to this =
forum.</span><o:p></o:p></p></div><div><p =
class=3DMsoNormal><o:p> </o:p></p></div><div><p =
class=3DMsoNormal><br>-- <br><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Carlos H. N. Costa, MD, =
DSc.</span></b><o:p></o:p></p><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>President</span></b><o:p></o=
:p></p></div><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Sociedade Brasileira de =
Medicina Tropical </span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>(Brazilian Society of =
Tropical Medicine)</span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Instituto de Doen=E7as =
Tropicais Natan Portella<br>Universidade Federal do =
Piau=ED</span></b><o:p></o:p></p><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Rua Artur de Vasconcelos =
151-Sul</span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>64049-750 =
Teresina-PI<br>Brazil<br>Telephones: +55 86 3221-3413 (work); +55 86 =
8838-3303 (mobile).<br></span></b><span =
style=3D'font-family:"Verdana","sans-serif"'><br></span><span =
style=3D'font-size:10.0pt;font-family:"Verdana","sans-serif"'>Aviso: As =
informa=E7=F5es contidas nesta mensagem s=E3o CONFIDENCIAIS, protegidas =
pelo sigilo legal, por direitos autorais e destinadas exclusivamente =E0 =
pessoa ou organiza=E7=E3o para a qual a mensagem foi =
destinada.<br>Warning: This message is meant only for the intended =
recipient of the transmission. It is forbidden any unauthorized =
use, alteration, reproduction and distribution. If you are not the =
correct recipient, please notify us immediately by return e-mail and =
delete this message from your system. =
</span><o:p></o:p></p></div></div><p =
class=3DMsoNormal><o:p> </o:p></p></div></div></blockquote></div></d=
iv><div><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><cleu antes grav =
13jan09.jpg><o:p></o:p></p></div></blockquote><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><cleu e =
nene.jpg><o:p></o:p></p></div></blockquote><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><cleu santada =
recorte.jpg><o:p></o:p></p></div></blockquote><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><cleu =
panturrilhas.jpg><o:p></o:p></p></div></blockquote><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal><cleu =
palato.jpg><o:p></o:p></p></div></blockquote><blockquote =
style=3D'margin-top:5.0pt;margin-bottom:5.0pt'><div><p =
class=3DMsoNormal>_______________________________________________<br>Leis=
h-l mailing list<br><a href=3D"mailto:Leish-l at lineu.icb.usp.br" =
target=3D"_blank">Leish-l at lineu.icb.usp.br</a><br><a =
href=3D"http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l" =
target=3D"_blank">http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-=
l</a><o:p></o:p></p></div></blockquote></div></div></div><p =
class=3DMsoNormal><br><br clear=3Dall><br>-- <br><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Carlos H. N. Costa, MD, =
DSc.</span></b><o:p></o:p></p><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>President</span></b><o:p></o=
:p></p></div><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Sociedade Brasileira de =
Medicina Tropical </span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>(Brazilian Society of =
Tropical Medicine)</span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Instituto de Doen=E7as =
Tropicais Natan Portella<br>Universidade Federal do =
Piau=ED</span></b><o:p></o:p></p><div><p class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>Rua Artur de Vasconcelos =
151-Sul</span></b><o:p></o:p></p></div><div><p =
class=3DMsoNormal><b><span =
style=3D'font-family:"Verdana","sans-serif"'>64049-750 =
Teresina-PI<br>Brazil<br>Telephones: +55 86 3221-3413 (work); +55 86 =
8838-3303 (mobile).<br></span></b><span =
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