[Leish-l] spleen

Wed Sep 18 15:17:39 BRT 2013

I just received this interesting case form my student José Carlos, about
the role of splenectomy in kala-azar:

The reference is:

Bada JL, Arderiu A, Gimenez J, Gumez-Acha JA. Kala-azar of longstanding
evolution in an asplenic patient. Trans R Soc Trop Med Hyg. 1979;73(3):347-8.
PubMed PMID: 473333.

[image: extract-image]

2013/9/6 Carlos Costa <chncosta at gmail.com>

> Anthony Bryceson is probably right when he suggests that a good review
> (systematic?) should be undertaken on the effect of splenectomy for the
> cure of kala-azar patients resistant to drug therapy.
>
> The references bellow show that: (1) Many drug resistant patients are
> cured after splenectomy, including patients with HIV infection; (b) One
> previously splenectomized patient under immunosuppresive therapy acquired
> kala-azar, suggesting that immunosupression is necessary for bone marrow
> parasitism in the absence of spleen. (c) There is no evidence that
> splenectomy without additional drug therapy is efficient.
>
> Additionally, the comments by Sinha and Bryceson suggest that the response
> of L. donovani kala-azar may be different from those with L. infantum
> kala-azar.
>
> The subject is hot and enlightening.
>
> PS. I was unable to access and check  the paper cited by Dutra et al:
> Mukhopadhyay B, Sarkar AK, Dasgupta A, Mukhopadhyay M, Chowdhury MM, Sarkar
> S. Drug - resistant childhood visceral leishmaniasis. Is splenectomy a
> solution? Pediatr Surg Int 1993; 8:314-315
>  Results: 4
>  1.
> Int J STD AIDS. <http://www.ncbi.nlm.nih.gov/pubmed#> 2012
> Apr;23(4):289-90. doi: 10.1258/ijsa.2009.009234.
> Successful therapeutic splenectomy in an HIV patient with relapsing visceral
> leishmaniasis. <http://www.ncbi.nlm.nih.gov/pubmed/22581957>
> Alon D<http://www.ncbi.nlm.nih.gov/pubmed?term=Alon%20D%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Chowers M<http://www.ncbi.nlm.nih.gov/pubmed?term=Chowers%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>
> .
> Source
>
> Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel.
> dr.danny.alon at gmail.com
> Abstract
>
> A 43-year-old HIV-positive Ethiopian immigrant presented with persistent
> diarrhoea, hepatosplenomegaly and pancytopaenia. Visceral leishmaniasiswas diagnosed by multiple gastrointestinal tract biopsies. Blood polymerase
> chain reaction (PCR) was positive for Leishmania donovani. Despite highly
> active antiretroviral therapy (HAART) and multiple courses of
> antileishmanial treatments, including liposomal amphotericin and sodium
> stibogluconate, the patient had multiple relapses. CD4 counts remained at
> 40-60 cells/µL although viral loads were undetectable. Splenectomyresulted in resolution of the patient's pancytopaenia and in rising CD4
> levels, which enabled a long-lasting remission.
> PMID:22581957 [PubMed - indexed for MEDLINE]
> Related citations<http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=22581957>
> Publication Types, MeSH Terms, Substances<http://www.ncbi.nlm.nih.gov/pubmed#>
>
>    -
>
> 2.
> Rev Soc Bras Med Trop. <http://www.ncbi.nlm.nih.gov/pubmed#> 2012
> Feb;45(1):130-1.
> Splenectomy in a patient with treatment-resistant visceral leishmaniasis:
> a case report. <http://www.ncbi.nlm.nih.gov/pubmed/22370845>
> Dutra RA<http://www.ncbi.nlm.nih.gov/pubmed?term=Dutra%20RA%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Dutra LF<http://www.ncbi.nlm.nih.gov/pubmed?term=Dutra%20LF%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Reis Mde O<http://www.ncbi.nlm.nih.gov/pubmed?term=Reis%20Mde%20O%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Lambert RC<http://www.ncbi.nlm.nih.gov/pubmed?term=Lambert%20RC%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>
> .
> Source
>
> Departamento de Cirurgia Pediátrica, Santa Casa de Franca, Franca, SP.
> Abstract
>
> Visceral leishmaniasis (VL), also known as Kala-azar, is a systemic
> infection caused by a protozoan (Leishmania) and, in its classic form, is a
> serious illness associated with malnutrition, anemia, hepatosplenomegaly,
> infectious processes and coagulopathies. The effect of splenectomy in
> patients with visceral leishmaniasis is not well defined; however, it is
> known that the spleen is the largest reservoir of infected cells belonging
> to the reticulo endothelial system. Therefore, the surgical procedure is an
> option for the debulking of parasites, providing a cure for refractory VL
> and minimizing the complications of hypersplenism.
> PMID:22370845 [PubMed - indexed for MEDLINE]
> Free full text
> Related citations<http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=22370845>
> [image: Icon for Scientific Electronic Library Online]<http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0037-86822012000100027&lng=en&nrm=iso&tlng=en>
> Publication Types, MeSH Terms <http://www.ncbi.nlm.nih.gov/pubmed#>
>
>    -
>
> 3.
> New Microbiol. <http://www.ncbi.nlm.nih.gov/pubmed#> 2009 Apr;32(2):223-7.
> Visceral leishmaniasis in a patient with common variable immunodeficiency
> and evans syndrome: clinical remarks.<http://www.ncbi.nlm.nih.gov/pubmed/19579705>
> Maio P<http://www.ncbi.nlm.nih.gov/pubmed?term=Maio%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Leone S<http://www.ncbi.nlm.nih.gov/pubmed?term=Leone%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Volpe S<http://www.ncbi.nlm.nih.gov/pubmed?term=Volpe%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> dell'Aquila G<http://www.ncbi.nlm.nih.gov/pubmed?term=dell%27Aquila%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Giglio S<http://www.ncbi.nlm.nih.gov/pubmed?term=Giglio%20S%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Magliocca M<http://www.ncbi.nlm.nih.gov/pubmed?term=Magliocca%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Nigro FS<http://www.ncbi.nlm.nih.gov/pubmed?term=Nigro%20FS%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Pacifico P<http://www.ncbi.nlm.nih.gov/pubmed?term=Pacifico%20P%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Acone N<http://www.ncbi.nlm.nih.gov/pubmed?term=Acone%20N%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>
> .
> Source
>
> Infectious Diseases Department, A.O.R.N. S.G. Moscati, Avellino, Italy.
> patriziamaio at yahoo.it
> Abstract
>
> Visceral Leishmaniasis (VL) is a vector-borne zoonosis endemic in
> Southern Italy whose usual clinical features include fever, splenomegaly,
> pancytopenia and hypergammaglobulinemia. The clinical and biochemical
> picture may be misleading in patients with immunodeficiency diseases
> hampering the diagnosis. We describe a VL case in a patient whose spleen
> had been removed and who had Common Variable Immunodeficiency and Evans
> syndrome.
> PMID:19579705 [PubMed - indexed for MEDLINE]
> Free full text
> Related citations<http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=19579705>
> [image: Icon for Italian Society for Medical, Odontoiatric, and Clinical
> Microbiology]<http://www.newmicrobiologica.org/PUB/allegati_pdf/2009/2/223.pdf>
> Publication Types, MeSH Terms, Substances<http://www.ncbi.nlm.nih.gov/pubmed#>
>
>    -
>
> 4.
> Parasitology. <http://www.ncbi.nlm.nih.gov/pubmed#> 2007 May;134(Pt
> 5):621-4. Epub 2006 Dec 11.
> The role of splenectomy in HIV-infected patients with relapsing visceral
> leishmaniasis. <http://www.ncbi.nlm.nih.gov/pubmed/17156583>
> Troya J<http://www.ncbi.nlm.nih.gov/pubmed?term=Troya%20J%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Casquero A<http://www.ncbi.nlm.nih.gov/pubmed?term=Casquero%20A%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Muñiz G<http://www.ncbi.nlm.nih.gov/pubmed?term=Mu%C3%B1iz%20G%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Fernández-Guerrero ML<http://www.ncbi.nlm.nih.gov/pubmed?term=Fern%C3%A1ndez-Guerrero%20ML%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>,
> Górgolas M<http://www.ncbi.nlm.nih.gov/pubmed?term=G%C3%B3rgolas%20M%5BAuthor%5D&cauthor=true&cauthor_uid=22581957>
> .
> Source
>
> Division of Infectious Diseases, Fundación Jiménez Díaz-UTE, Universidad
> Autónoma de Madrid, Avda. de Reyes Católicos 2, 28040 Madrid, Spain.
> jestrogar at hotmail.com
> Abstract
>
> The treatment of visceral leishmaniasis (VL) in HIV-infected patients is
> characterized by having a protracted course and frequent relapses, despite
> the use of adequate anti-leishmanial drugs and effective anti-retroviral
> therapy. A small subset of patients with significant splenomegaly develops
> severe cytopaenias and chronic leishmania infection. The use of elective
> splenectomy is effective for restoring the haematological parameters and
> reduces the need for blood transfusions but it does not avoid relapsing visceral
> leishmaniasis.
> PMID:17156583 [PubMed - indexed for MEDLINE]
> Related citations<http://www.ncbi.nlm.nih.gov/pubmed?linkname=pubmed_pubmed&from_uid=17156583>
> [image: Icon for Cambridge University Press]<http://journals.cambridge.org/abstract_S0031182006002058>
>
> <http://www.ncbi.nlm.nih.gov/pubmed#>
>
>
> 2013/9/6 prabhat sinha <pksinha18 at yahoo.com>
>
>> Dear All,
>> In Bihar,India  I have seen patients of Kala azar (VL) with splencetomy
>> without clinical cure and hepatic aspirates are laden with parasites. How
>> can it be said that splenectomy cures VL?
>> Prabhat Kumar Sinha
>> Rajendra Memorial Research Instt. of Medical Sciences(ICMR).
>> Patna,India
>>
>>   *From:* Anthony Bryceson <a.bryceson at doctors.org.uk>
>> *To:* Carlos Costa <chncosta at gmail.com>
>> *Cc:* Leish-L <Leish-l at lineu.icb.usp.br>
>> *Sent:* Friday, August 30, 2013 10:11 PM
>> *Subject:* Re: [Leish-l] spleen
>>
>>  Who says that splenectomy cures VL?
>> I last reviewed the literature in 1984 ("*Therapy in Man" in Leishmaniasis
>> in Biology and Medicine. Eds W Peters, R Killick-Kendrick, Academic Press,
>> London, 1987, p 893)*, and there was not much to review (Napier 1949,
>> Wang and Wu 1959, Das and Sen Gupta 1950,  Sen Gupta and Chatterji 1961). I
>> concluded that "splenectomy may cure VL without further chemotherapy in
>> about 1 in 5 cases, and in a greater proportion with the aid of further
>> chemotherapy, despite apparent unresponsiveness previously. The operation
>> carries a mortality and may be followed by fatal septicaemia or further
>> relapse". In 1984. Rees et al reported 5 cases in children in Nairobi, 3
>> improved and 2 died.
>>
>> Is there a more recent review or collection of published cases?
>>
>> There is still something of a mystery about the spleen in VL. The
>> concentration of parasites is greatest there and parasites seem to remain
>> longer in the spleen than in other organs following chemotherapy. What is
>> the nature of the attraction? Is it immunological as "David et al" suggest,
>> or due to cells that cannot respond as Farrokh suggests? Splenectomy might
>> be of benefit in either instance, and it removes an  immunosuppressive
>> antigenic load.  Suppression of antigenic load permitting the emergence of
>> an immune response is the rationale for prolonged treatment of DCL.
>>
>> I have two suggestions:
>> 1. Someone collects all published and unpublished case reports  and
>> writes a review that includes indications, risks and precautions, bearing
>> in mind that failed cases may not be reported,
>> 2. An immunologist and a parasitologist be invited to join the physician
>> and surgeon, whenever splenectomy is being considered for a patient with
>> unresponsive VL.
>>
>> Best wishes
>> Anthony
>>
>>
>>
>> On 21 Aug 2013, at 13:52, Carlos Costa wrote:
>>
>>  Dear leishimmunologists,
>>
>> Do you have any guess on why splenectomy cures kala-azar? Would it be the
>> absence of spleen-derived IL-10?
>>
>> All my best,
>>
>> Carlos.
>>
>> --
>>  Carlos H. N. Costa, MD, DSc.
>> Coordenador
>> Laboratório de Leishmanioses - LabLeish
>> Universidade Federal do Piauí
>>  Instituto de Doenças Tropicais Natan Portella
>> Rua Artur de Vasconcelos 151-Sul
>>  64001-450 Teresina-PI
>> Brazil
>> Telephones: +55 86 3222-4377 (W),
>> +55 86 3221-3062 (W),
>> +55 86 3237-1075 (R).
>>
>>
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>
>
> --
> Carlos H. N. Costa, MD, DSc.
> Coordenador
> Laboratório de Leishmanioses - LabLeish
> Universidade Federal do Piauí
> Instituto de Doenças Tropicais Natan Portella
> Rua Artur de Vasconcelos 151-Sul
> 64001-450 Teresina-PI
>  Brazil
> Telephones: +55 86 3222-4377 (W),
> +55 86 3221-3062 (W),
> +55 86 3237-1075 (R).
>
>
> Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS,
> protegidas pelo sigilo legal, por direitos autorais e destinadas
> exclusivamente à pessoa ou organização 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.
>

-- 
Carlos H. N. Costa, MD, DSc.
Coordenador
Laboratório de Leishmanioses - LabLeish
Universidade Federal do Piauí
Instituto de Doenças Tropicais Natan Portella
Rua Artur de Vasconcelos 151-Sul
64001-450 Teresina-PI
Brazil
Telephones: +55 86 3222-4377 (W),
+55 86 3221-3062 (W),
+55 86 3237-1075 (R).

Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas
pelo sigilo legal, por direitos autorais e destinadas exclusivamente à
pessoa ou organização 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.
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