No subject
Thu Jul 7 11:54:55 BRT 2011
On 07/07/2011, at 3:04, Carlos Costa <chncosta at gmail.com<mailto:chncosta at gm=
ail.com>> wrote:
Dear all,
Maria Cleudimar has cutaneous diffuse leishmaniasis due to Leishmania amazo=
nensis. She used to be a long time patient form Dr. Jackson Costa, in the c=
ountryside 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 Dorc=
as care, at the age of 30, living in the city of Teresina.
Her long time DCL does not respond to the treatment antimonium anymore. Alt=
hough we still prescribe liposomal amphotericin B at very low dose (3mg/kg/=
once a week), her situation is deteriorating progressively, her renal funct=
ion does not allow any additional dosing since creatinine is presently abov=
e 3mg/dL, and previous biopsy had shown tubular damage apparently secondary=
to the drug, without evidence of amyloidosis. We tried several combination=
s of different drugs, without success. Her situation worsened a lot during =
her recent pregnancy (the baby is eight months old now).
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).
With her permission I attached some of her pictures, hoping to sensitize cr=
itical people in order to help me to get miltefosine and the permission for=
prescription in Brazil (or any other oral drug with promising efficacy, an=
d without nephrotoxicity, if known). Moreover, we need to know about the do=
se adjustment for the renal impairment, and how long the drug could safely =
be used.
One picture shows her face before treatment, and another after the pregnanc=
y, with the baby. One shows the situation of her thighs, another the calf o=
f the leg and the last one the infiltration of the palate.
Hoping a little from friends, my kindest regards,
Carlos.
PS. Please understand that the pictures are allowed not for publication or =
public presentation. Cleudimar permission is restricted to this forum.
--
Carlos H. N. Costa, MD, DSc.
President
Sociedade Brasileira de Medicina Tropical
(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, prot=
egidas 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 trans=
mission. It is forbidden any unauthorized use, alteration, reproduction an=
d distribution. If you are not the correct recipient, please notify us imme=
diately by return e-mail and delete this message from your system.
<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<mailto:Leish-l at lineu.icb.usp.br>
http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l
--
Carlos H. N. Costa, MD, DSc.
President
Sociedade Brasileira de Medicina Tropical
(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, prot=
egidas 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 trans=
mission. It is forbidden any unauthorized use, alteration, reproduction an=
d distribution. If you are not the correct recipient, please notify us imme=
diately by return e-mail and delete this message from your system.
--_000_4CE52687AFBDBD4EB137E3BF027BAE214F2F423DSEEXMBX03sidase_
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<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">Dear Carlos,<o:p></o:p></=
span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">As with so many things th=
e answer is more like “both” Parasite and host. There are propo=
nents for the host being the most relevant and others for the parasite
also playing a role.<o:p></o:p></span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D"><o:p> </o:p></span><=
/p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">When it comes to
<i>L. aethiopica</i> induced DCL my colleagues and I have done a series of =
laboratory studies that suggest that the parasite that causes DCL and that =
which causes LCL, induce different responses (cytokines, proliferation etc)
<i>in vitro</i>. (example of publications </span><i><span style=3D"font-fam=
ily:"Calibri","sans-serif"">Akuffo HO, Fehniger TE, Bri=
tton S. Differential recognition of Leishmania aethiopica antigens by lymph=
ocytes from patients with local and diffuse cutaneous
leishmaniasis. Evidence for antigen-induced immune suppression. J Immunol.=
1988 Oct 1;141(7):2461-6</span></i><span style=3D"font-family:"Calibr=
i","sans-serif"">.
<span style=3D"color:#558ED5;mso-style-textfill-fill-color:#558ED5;mso-styl=
e-textfill-fill-alpha:100.0%">
AND </span><i>Akuffo H, Maasho K, Blostedt M, Hojeberg B, Britton S, Bakhie=
t M. Leishmania aethiopica derived from diffuse leishmaniasis patients pref=
erentially induce mRNA for interleukin-10 while those from localized leishm=
aniasis patients induce interferon-gamma.
J Infect Dis. 1997 Mar;175(3):737-41</i>)</span><span style=3D"font-size:1=
1.0pt;font-family:"Calibri","sans-serif";color:#1F497D"=
> Whether this is because the infecting organism is different or there are =
changes that occur in the parasite when they are in the
host for some time, has not been studied. However we have not been a=
ble to find genetic differences in the organisms derived from DCL versus th=
ose derived from LCL. (example of publication
</span><i><span style=3D"font-size:10.0pt;font-family:"Calibri",&=
quot;sans-serif";mso-fareast-language:SV">Sch=F6nian G, Akuffo H, Lewi=
n S, Maasho K, Nyl=E9n S, Pratlong F, Eisenberger CL, Schnur LF, Presber W.=
Genetic variability within the species Leishmania aethiopica
does not correlate with clinical variations of cutaneous leishmaniasis. Mo=
l Biochem Parasitol. 2000 Mar 5;106(2):239-48</span></i><span style=3D"font=
-size:11.0pt;font-family:"Calibri","sans-serif";color:#=
1F497D"> ).
<o:p></o:p></span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D"><o:p> </o:p></span><=
/p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">As we know, the low or no=
n-existent cellular immune response in DCL is antigen specific but in a ver=
y small study we did show that the use of intra-lesional
IL-2 did stimulate the local immune response and reduce the number of amst=
igotes (</span><i><span style=3D"font-family:"Calibri","sans=
-serif"">Akuffo H, Kaplan G, Kiessling R, Teklemariam S, Dietz M, McEl=
rath J, Cohn ZA. Administration of recombinant interleukin-2
reduces the local parasite load of patients with disseminated cutaneous le=
ishmaniasis. J Infect Dis. 1990 Apr;161(4):775-80</span></i><span style=3D"=
font-family:"Calibri","sans-serif"">)</span><span style=
=3D"font-size:11.0pt;font-family:"Calibri","sans-serif"=
;color:#1F497D">.
<o:p></o:p></span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D"><o:p> </o:p></span><=
/p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">I hope this information s=
heds some light on your question to Jennie. There is so much more to unders=
tand about DCL.<o:p></o:p></span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">Best regards<o:p></o:p></=
span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D">Hannah Akuffo<o:p></o:p><=
/span></p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D"><o:p> </o:p></span><=
/p>
<p class=3D"MsoNormal"><span style=3D"font-size:11.0pt;font-family:"Ca=
libri","sans-serif";color:#1F497D"><o:p> </o:p></span><=
/p>
<p class=3D"MsoNormal"><b><span lang=3D"EN-US" style=3D"font-size:10.0pt;fo=
nt-family:"Tahoma","sans-serif"">From:</span></b><span =
lang=3D"EN-US" style=3D"font-size:10.0pt;font-family:"Tahoma",&qu=
ot;sans-serif""> leish-l-bounces at lineu.icb.usp.br [mailto:leish-l-boun=
ces at lineu.icb.usp.br]
<b>On Behalf Of </b>Carlos Costa<br>
<b>Sent:</b> den 10 juli 2011 23:44<br>
<b>To:</b> Jennie Blackwell<br>
<b>Cc:</b> Leish-L<br>
<b>Subject:</b> Re: [Leish-l] miltefosine for diffuse leishmaniasis<o:p></o=
:p></span></p>
<p class=3D"MsoNormal"><o:p> </o:p></p>
<p class=3D"MsoNormal">Hi Jennie,<o:p></o:p></p>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">Thanks for the drug information. Now, I have to chec=
k the permission for its use in Brazil and how to justify its use to the pu=
blic system in order to be acquired by the government. Meanwhile, we are lo=
oking for miltefosine, paramomycin,
and alternative therapies.<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">But if the immunosuppression is species specific do =
you think that a general stimulation would reverse it? Does anyone knows wh=
ich is the mechanism behind the DCL induced immunosuppression? Parasite or =
host or both? <o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">Cheers,<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal" style=3D"margin-bottom:12.0pt">Carlos.<o:p></o:p></p=
>
<div>
<p class=3D"MsoNormal">2011/7/7 Jennie Blackwell <<a href=3D"mailto:jmb3=
7 at cam.ac.uk">jmb37 at cam.ac.uk</a>><o:p></o:p></p>
<div>
<div>
<p class=3D"MsoNormal">Hello Carlos<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">My memory from late 80s was that these patients resp=
onded 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=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">In psoriasis they use creams with Vitamin D. Has any=
one ever tried this for DCL?<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">I'm sure this is going to elicit a round of response=
s - 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=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal">Cheers, Jennie <br>
<br>
Jenefer M. Blackwell<o:p></o:p></p>
<div>
<p class=3D"MsoNormal">TICHR, CCHR, UWA<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal">Phone: +61 8 94897910<o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal">From my iPhone<o:p></o:p></p>
</div>
</div>
<div>
<div>
<div>
<p class=3D"MsoNormal" style=3D"margin-bottom:12.0pt"><br>
On 07/07/2011, at 3:04, Carlos Costa <<a href=3D"mailto:chncosta at gmail.c=
om" 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=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Dear all,</span><o:p></o:p>=
</p>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Maria Cleudimar has cutaneo=
us 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 wa=
s 10 years old, after a disease that started when she was just five. Now, s=
he 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=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Her long time DCL does not =
respond to the treatment antimonium anymore. Although we still prescribe li=
posomal 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 sit=
uation worsened a lot during her recent pregnancy (the baby is eight months=
old now).</span><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Our hope now stands only in=
miltefosine, for oral chronic use, but the drug is not licensed or availab=
le in Brazil yet (to my knowledge).</span><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">With her permission I attac=
hed some of her pictures, hoping to sensitize critical people in order to h=
elp me to get miltefosine and the permission for prescription
in Brazil (or any other oral drug with promising efficacy, and without nep=
hrotoxicity, if known). Moreover, we need to know about the dose adjustment=
for the renal impairment, and how long the drug could safely be used.</spa=
n><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","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=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Hoping a little from friend=
s, my kindest regards,</span><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">Carlos.</span><o:p></o:p></=
p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><span style=3D"font-size:13.5pt;font-family:"Ve=
rdana","sans-serif";color:black">PS. Please understand that =
the pictures are allowed not for publication or public presentation. Cleudi=
mar permission is restricted to this forum.</span><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><o:p> </o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><br>
-- <br>
<b><span style=3D"font-family:"Verdana","sans-serif"">C=
arlos H. N. Costa, MD, DSc.</span></b><o:p></o:p></p>
<div>
<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">President</span></b><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">Sociedade Brasileira de Medicina Tropical </span=
></b><o:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">(Brazilian Society of Tropical Medicine)</span></b><o=
:p></o:p></p>
</div>
<div>
<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;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=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">Rua Artur de Vasconcelos 151-Sul</span></b><o:p></o:p=
></p>
</div>
<div>
<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;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&=
quot;"><br>
</span><span style=3D"font-size:10.0pt;font-family:"Verdana",&quo=
t;sans-serif"">Aviso: As informa=E7=F5es contidas nesta mensagem s=E3o=
CONFIDENCIAIS, protegidas pelo sigilo legal, por direitos autorais e desti=
nadas 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 trans=
mission. It is forbidden any unauthorized use, alteration, reproducti=
on 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=3D"MsoNormal"><o:p> </o:p></p>
</div>
</div>
</blockquote>
</div>
</div>
<div>
<blockquote style=3D"margin-top:5.0pt;margin-bottom:5.0pt">
<div>
<p class=3D"MsoNormal"><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=3D"MsoNormal"><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=3D"MsoNormal"><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=3D"MsoNormal"><cleu panturrilhas.jpg><o:p></o:p></p>
</div>
</blockquote>
<blockquote style=3D"margin-top:5.0pt;margin-bottom:5.0pt">
<div>
<p class=3D"MsoNormal"><cleu palato.jpg><o:p></o:p></p>
</div>
</blockquote>
<blockquote style=3D"margin-top:5.0pt;margin-bottom:5.0pt">
<div>
<p class=3D"MsoNormal">_______________________________________________<br>
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-- <br>
<b><span style=3D"font-family:"Verdana","sans-serif"">C=
arlos H. N. Costa, MD, DSc.</span></b><o:p></o:p></p>
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">President</span></b><o:p></o:p></p>
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">Sociedade Brasileira de Medicina Tropical </span=
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">(Brazilian Society of Tropical Medicine)</span></b><o=
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">Instituto de Doen=E7as Tropicais Natan Portella<br>
Universidade Federal do Piau=ED</span></b><o:p></o:p></p>
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">Rua Artur de Vasconcelos 151-Sul</span></b><o:p></o:p=
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<p class=3D"MsoNormal"><b><span style=3D"font-family:"Verdana",&q=
uot;sans-serif"">64049-750 Teresina-PI<br>
Brazil<br>
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<br>
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