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<body lang=EN-US link=blue vlink=blue>Dear KP,<br/>Everytime I have these patients I wonder if I can have something better. Indeed, now miltefosine shows to be better and safer.<br/>Also, you could try the heat machine, that sounds pretty good, as suggested by John and Abhay.<br/>So, if you could get, use them. If not, go to the standard treatment with SbV, as prescribed. Young people are more resistant to side effects.<br/>Best regards,<br/>Carlos.<p>Sent from my BlackBerry® smartphone from Oi</p><hr/><div><b>From: </b> "Chang, Kwang-Poo" <KwangPoo.Chang@rosalindfranklin.edu>
</div><div><b>Date: </b>Mon, 25 Jul 2011 13:58:33 -0500</div><div><b>To: </b>Carlos Costa<chncosta@gmail.com></div><div><b>Cc: </b><gzischke@thermosurgery.com>; Abhay Satoskar<Abhay.Satoskar@osumc.edu>; John David<jdavid@hsph.harvard.edu>; <generhedin@thermosurgery.com>; JoshBerman<Jbe9320457@aol.com>; <dagobertosilveira@superig.com.br>; RaimundaSampaio<rsampaio@unb.br>; Dorcas Lamounier Costa<dorcas.lc@gmail.com>; MarkNawacki<mnawacki@paladinlabs.com>; <jurbina@mac.com>; Pierre BUFFET<pierre.buffet@upmc.fr>; <joseanegodinho@yahoo.com.br>; Robert Vinson<rvinson@paladinlabs.com>; Shyam Sundarmail<Drshyamsundar@hotmail.com>; <robertobadaro768@gmail.com>; Leish-L<Leish-l@lineu.icb.usp.br>; FernandoKoremblum<fkorembl@paladinlabs.com>; Fabiana Alves<falves@dndi.org>; Fabiana Alves<fabipalves@gmail.com></div><div><b>Subject: </b>RE: [Leish-l] miltefosine for diffuse leishmaniasis</div><div><br/></div>
<div class=Section1>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'>I am writing to ask for your help with
information and suggestion about treating cutaneous leishmaniasis in <st1:country-region
w:st="on"><st1:place w:st="on">Panama</st1:place></st1:country-region>.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'>I have only very sketchy information about
the case as follows:<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<ol style='margin-top:0pt' start=1 type=1>
<li class=MsoNormal style='color:navy;mso-list:l0 level1 lfo1'><font size=2
color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial'>An
American young man has 2 skin lesions, one of which is on the abdomen. <o:p></o:p></span></font></li>
<li class=MsoNormal style='color:navy;mso-list:l0 level1 lfo1'><font size=2
color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial'>He
was diagnosed to have cutaneous leishmaniasis<o:p></o:p></span></font></li>
<li class=MsoNormal style='color:navy;mso-list:l0 level1 lfo1'><font size=2
color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial'>A
course of 30-day intra-muscular injection of pentavalent antimony is
prescribed.<o:p></o:p></span></font></li>
</ol>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'>I wonder about the intramuscular instead
of intra-lesion antimony treatment and also the duration of the treatment for
30 days ?<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'>Looking forward to hearing from you at
your earliest convenience.<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'>KP<o:p></o:p></span></font></p>
<p class=MsoNormal><font size=2 color=navy face=Arial><span style='font-size:
10.0pt;font-family:Arial;color:navy'><o:p> </o:p></span></font></p>
<div>
<div class=MsoNormal align=center style='text-align:center'><font size=3
face="Times New Roman"><span style='font-size:12.0pt'>
<hr size=2 width="100%" align=center tabindex=-1>
</span></font></div>
<p class=MsoNormal><b><font size=2 face=Tahoma><span style='font-size:10.0pt;
font-family:Tahoma;font-weight:bold'>From:</span></font></b><font size=2
face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma'> <st1:PersonName
w:st="on">Carlos Costa</st1:PersonName> [mailto:chncosta@gmail.com] <br>
<b><span style='font-weight:bold'>Sent:</span></b> Tuesday, July 12, 2011 2:46
PM<br>
<b><span style='font-weight:bold'>To:</span></b> Chang, Kwang-Poo<br>
<b><span style='font-weight:bold'>Cc:</span></b> gzischke@thermosurgery.com;
Abhay Satoskar; John David; generhedin@thermosurgery.com; Josh Berman;
dagobertosilveira@superig.com.br; Raimunda Sampaio; Dorcas Lamounier Costa;
Mark Nawacki; jurbina@mac.com; Pierre BUFFET; joseanegodinho@yahoo.com.br;
Robert Vinson; Shyam Sundarmail; robertobadaro768@gmail.com; Leish-L; Fernando
Koremblum; Fabiana Alves; Fabiana Alves<br>
<b><span style='font-weight:bold'>Subject:</span></b> Re: [Leish-l] miltefosine
for diffuse leishmaniasis</span></font><o:p></o:p></p>
</div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>Hi Gena,</span></font><o:p></o:p></p>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
</div>
<div>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>Thanks a lot for your
offer. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
</div>
<div>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>Our purpose is to work
together with John and Abhay, who I know personally for a long time. May be the
experience here will lead to broader application.</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
</div>
<div>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>I am forwarding your
email to DNDi to see if they could help us in getting the machine into the
country, since they have expertise in this kind of humanitarian treatment.</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
</div>
<div>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>My best regards,</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
</div>
<div>
<p class=MsoNormal><font size=4 color=black face=Verdana><span
style='font-size:13.5pt;font-family:Verdana;color:black'>Carlos. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
<div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'>2011/7/12 Chang, Kwang-Poo <<a
href="mailto:KwangPoo.Chang@rosalindfranklin.edu">KwangPoo.Chang@rosalindfranklin.edu</a>><o:p></o:p></span></font></p>
<div link=blue vlink=blue>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'>This is good to try.</span></font><o:p></o:p></p>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'> </span></font><o:p></o:p></p>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'>KP</span></font><o:p></o:p></p>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'> </span></font><o:p></o:p></p>
<div>
<div class=MsoNormal align=center style='text-align:center'><font size=3
face="Times New Roman"><span style='font-size:12.0pt'>
<hr size=2 width="100%" align=center>
</span></font></div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;font-weight:
bold'>From:</span></font></b><font size=2 face=Tahoma><span style='font-size:
10.0pt;font-family:Tahoma'> <a href="mailto:gzischke@thermosurgery.com"
target="_blank">gzischke@thermosurgery.com</a> [mailto:<a
href="mailto:gzischke@thermosurgery.com" target="_blank">gzischke@thermosurgery.com</a>]
<br>
<b><span style='font-weight:bold'>Sent:</span></b> Tuesday, July 12, 2011 12:47
PM<br>
<b><span style='font-weight:bold'>To:</span></b> <st1:PersonName w:st="on">Carlos
Costa</st1:PersonName>; Abhay Satoskar; John David; <a
href="mailto:generhedin@thermosurgery.com" target="_blank">generhedin@thermosurgery.com</a><br>
<b><span style='font-weight:bold'>Cc:</span></b> Josh Berman; <a
href="mailto:dagobertosilveira@superig.com.br" target="_blank">dagobertosilveira@superig.com.br</a>;
Raimunda Sampaio; Dorcas Lamounier Costa; Mark Nawacki; <a
href="mailto:jurbina@mac.com" target="_blank">jurbina@mac.com</a>; Pierre
BUFFET; <a href="mailto:joseanegodinho@yahoo.com.br" target="_blank">joseanegodinho@yahoo.com.br</a>;
Robert Vinson; Shyam Sundarmail; <a href="mailto:robertobadaro768@gmail.com"
target="_blank">robertobadaro768@gmail.com</a>; Leish-L; Fernando Koremblum;
Chang, Kwang-Poo<br>
<b><span style='font-weight:bold'>Subject:</span></b> RE: [Leish-l] miltefosine
for diffuse leishmaniasis</span></font><o:p></o:p></p>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 face="Times New Roman"><span style='font-size:12.0pt'> <o:p></o:p></span></font></p>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>Dear Dr. Costas,</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>Thermosurgery is committed to the research and treatment of
leishmaniasis. We are pleased to work with you and assist your
patients. We can lend you an instrument to use in your program. Our
biggest hurdle is getting the equipment into the country. If you work
with an NGO or government agency that can assist us in the importation that
would be helpful. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>Lets discuss the logistics to see if it is feasible to get you the
equipment. I would suggest that you work with Dr David and Dr Satoskar on
the recommended treatment protocol. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>We would want to receive documentation regarding the use of the
equipment and a paper so that we can educate others on the value of this
treatment. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>Warm regards,</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>gena</span></font><o:p></o:p></p>
</div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;margin-bottom:12.0pt'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>Gena Zischke<br>
Business Development<br>
Thermosurgery Technologies, Inc.<br>
2901 <st1:Street w:st="on"><st1:address w:st="on">W. Indian School Rd.</st1:address></st1:Street><br>
<st1:place w:st="on"><st1:City w:st="on">Phoenix</st1:City>, <st1:State w:st="on">AZ</st1:State>
<st1:PostalCode w:st="on">85017</st1:PostalCode></st1:place><br>
Phone: (602) 264-7300<br>
<br>
<br>
The information in this communication is confidential. It is intended solely
for the addressee. Access to this communication by anyone else is unauthorized.
If you are not the intended recipient, any disclosure, copying, distribution or
any action taken or omitted to be taken in reliance on it, is prohibited and
may be unlawful. If you have received this communication in error, please
notify us immediately by return email, and destroy this communication and all copies
thereof, including all attachments. Thank you. Thermosurgery Technologies, Inc.<br>
<br>
<br>
Fax: (602) 248-3809</span></font><o:p></o:p></p>
</div>
<blockquote style='border:none;border-left:solid blue 1.0pt;padding:0pt 0pt 0pt 4.0pt;
margin-left:3.95pt;margin-top:5.0pt;margin-bottom:5.0pt'>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;margin-bottom:12.0pt'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>-------- Original Message --------<br>
Subject: Re: [Leish-l] miltefosine for diffuse leishmaniasis<br>
From: <st1:PersonName w:st="on">Carlos Costa</st1:PersonName> <<a
href="mailto:chncosta@gmail.com" target="_blank">chncosta@gmail.com</a>><br>
Date: Sun, July 10, 2011 4:23 pm<br>
To: "Chang, Kwang-Poo" <<a
href="http://KwangPoo.Chang@rosalindfranklin.edu" target="_blank">KwangPoo.Chang@rosalindfranklin.edu</a>><br>
Cc: Josh Berman <<a href="mailto:Jbe9320457@aol.com" target="_blank">Jbe9320457@aol.com</a>>,
<a href="mailto:dagobertosilveira@superig.com.br" target="_blank">dagobertosilveira@superig.com.br</a>,<br>
Raimunda Sampaio <<a href="mailto:rsampaio@unb.br" target="_blank">rsampaio@unb.br</a>>,
Dorcas Lamounier Costa<br>
<<a href="http://dorcas.lc@gmail.com" target="_blank">dorcas.lc@gmail.com</a>>,
Mark Nawacki <<a href="mailto:mnawacki@paladinlabs.com" target="_blank">mnawacki@paladinlabs.com</a>>,<br>
<a href="mailto:jurbina@mac.com" target="_blank">jurbina@mac.com</a>, Pierre
BUFFET <<a href="mailto:pierre.buffet@upmc.fr" target="_blank">pierre.buffet@upmc.fr</a>>,<br>
<a href="mailto:joseanegodinho@yahoo.com.br" target="_blank">joseanegodinho@yahoo.com.br</a>,
Robert Vinson <<a href="mailto:rvinson@paladinlabs.com" target="_blank">rvinson@paladinlabs.com</a>>,<br>
Shyam Sundarmail <<a href="mailto:Drshyamsundar@hotmail.com" target="_blank">Drshyamsundar@hotmail.com</a>>,<br>
<a href="mailto:robertobadaro768@gmail.com" target="_blank">robertobadaro768@gmail.com</a>,
Leish-L <<a href="mailto:Leish-l@lineu.icb.usp.br" target="_blank">Leish-l@lineu.icb.usp.br</a>>,
Fernando<br>
Koremblum <<a href="mailto:fkorembl@paladinlabs.com" target="_blank">fkorembl@paladinlabs.com</a>><br>
<br>
KP, do you have any idea about prices? Please send me the brand name to see if
I can easily import them. Best wishes to Jean, Carlos</span></font><o:p></o:p></p>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>2011/7/10 Chang, Kwang-Poo <<a
href="mailto:KwangPoo.Chang@rosalindfranklin.edu" target="_blank">KwangPoo.Chang@rosalindfranklin.edu</a>></span></font><o:p></o:p></p>
<div link=blue vlink=blue>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'>Carlos will undoubtedly go with those, which are clinically acceptable
and feasible for the sake of expediency. </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'>In a separate message, the causative agent was said to have been
identified as L amazonensis. Thermosensitivity of this species has been
well-documented, suggestive of thermotherapy. There is already the suggestion
of hot bath. One-use heat pad/heat wrap available over-the-counter in the <st1:country-region
w:st="on"><st1:place w:st="on">USA</st1:place></st1:country-region> drug stores
is just as innocuous to consider as some topical ointments suggested.</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=navy face=Arial><span style='font-size:10.0pt;font-family:Arial;
color:navy'>KP</span></font><o:p></o:p></p>
</div>
<div>
<div class=MsoNormal align=center style='text-align:center'><font size=3
color=black face="Times New Roman"><span style='font-size:12.0pt;color:black'>
<hr size=2 width="100%" align=center>
</span></font></div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;
color:black;font-weight:bold'>From:</span></font></b><font size=2 color=black
face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;color:black'> <a
href="mailto:leish-l-bounces@lineu.icb.usp.br" target="_blank">leish-l-bounces@lineu.icb.usp.br</a>
[mailto:<a href="mailto:leish-l-bounces@lineu.icb.usp.br" target="_blank">leish-l-bounces@lineu.icb.usp.br</a>]
<b><span style='font-weight:bold'>On Behalf Of </span></b><st1:PersonName
w:st="on">Carlos Costa</st1:PersonName><br>
<b><span style='font-weight:bold'>Sent:</span></b> Saturday, July 09, 2011
10:07 AM</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;
color:black'><br>
<b><span style='font-weight:bold'>To:</span></b> Leish-L<br>
<b><span style='font-weight:bold'>Cc:</span></b> Josh Berman; <a
href="mailto:dagobertosilveira@superig.com.br" target="_blank">dagobertosilveira@superig.com.br</a>;
Dorcas Lamounier Costa; <a href="mailto:jurbina@mac.com" target="_blank">jurbina@mac.com</a>;
Pierre BUFFET; Robert Vinson; Raimunda Sampaio; Shyam Sundarmail; <a
href="mailto:robertobadaro768@gmail.com" target="_blank">robertobadaro768@gmail.com</a>;
Mark Nawacki; Fernando Koremblum; <a href="mailto:joseanegodinho@yahoo.com.br"
target="_blank">joseanegodinho@yahoo.com.br</a></span></font><o:p></o:p></p>
</div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;
color:black;font-weight:bold'>Subject:</span></font></b><font size=2
color=black face=Tahoma><span style='font-size:10.0pt;font-family:Tahoma;
color:black'> Re: [Leish-l] miltefosine for diffuse leishmaniasis</span></font><o:p></o:p></p>
</div>
<div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=4 color=black face=Verdana><span style='font-size:13.5pt;font-family:Verdana;
color:black'>Dear friends,</span></font><o:p></o:p></p>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=4 color=black face=Verdana><span style='font-size:13.5pt;font-family:Verdana;
color:black'>This is really a such touching and motivated community, and
leish-l is proving to be an excellent tool for solving the leishmaniasis
toughest problems throughout the world. The word "together" sounds
really powerful in such a cases.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=4 color=black face=Verdana><span style='font-size:13.5pt;font-family:Verdana;
color:black'>What os showing up from these kind emails is a face of science
coming not only from the bench, the hospitals, the field, but a science coming
straight from the heart.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>Let me summarize some of the lessons and suggestions. Please
correct me if I skip some.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>1) Hot bath - <st1:City w:st="on"><st1:place w:st="on">Teresina</st1:place></st1:City>
is very hot, and hot showers are rare here. However, we can easily provide her
an electric shower. Should it be a tube? How long the bath would last?</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>2) BCG - one or two shots. We will do it. Any hint about the
intervals between the shots?</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>3) Previous drug therapy: ImunoglucanTM (cell wall of <i><span
style='font-style:italic'>Saccharomyces cerevisiae</span></i>), and saquinavir,
after her delivery (</span></font><font color=black face=Verdana><span
style='font-family:Verdana;color:black'><a
href="http://www.ncbi.nlm.nih.gov/pubmed/18816190" target="_blank">Intracellular
survival of Leishmania species that cause visceral leishmaniasis is
significantly reduced by HIV-1 protease inhibitors.</a>).</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>4) Besides miltefosine we got a good hint where to find it (<st1:place
w:st="on"><st1:City w:st="on">Paladino</st1:City>, <st1:country-region w:st="on">Canada</st1:country-region></st1:place>),
which has excellent temporary effect (Zerpa et al, 2006), we should
consider: </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>a) lower/corrected doses of paramomycin (Bryceson) - we have also
to find the drug outside <st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region>,
since it is not distributed/approved here; </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>b) gamma-interferon (who produces/sells it?).</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>c) fluconazol/itraconazol/(voriconazol?).</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>d) amiodarone - <i><span style='font-style:italic'>in vitro</span></i>
testing does not sounds so good.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>e) topic imiquimod (IxiumTM cream) - apparently easy to
find. concentration of 5%?</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>f) photodynamic therapy - with Dr. Dagoberto Silveira, we are
investigating where to do it around.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>g) immunotherapy with suicide photo-inactivated <i><span
style='font-style:italic'>Leishmania</span></i> (KP Chang).</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>Please check what really seems reasonable. My feeling is that most
of the suggestions can be tried.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>My warmest regards,</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=5 color=black face=Verdana><span style='font-size:18.0pt;font-family:Verdana;
color:black'>Carlos.</span></font><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
<div>
<div style='margin-bottom:12.0pt'>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'>2011/7/8 Pierre BUFFET <<a href="mailto:pierre.buffet@upmc.fr"
target="_blank">pierre.buffet@upmc.fr</a>></span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'>Anthony,<br>
<br>
<br>
because there are only a few options left, would you consider at one point low
dose pentamidine (3 mg/kg every week or so, as you did in DCL patinets in <st1:country-region
w:st="on"><st1:place w:st="on">Ethiopia</st1:place></st1:country-region> in the
70s if I remember)? Could be used either to stabilize the situation before
starting on a coadministration, or as a maintenance after the
co-administration, in both cases with careful monitoring of kidney function ?<br>
<br>
<st1:City w:st="on"><st1:place w:st="on">Pierre</st1:place></st1:City><br>
<br>
<br>
Anthony Bryceson <<a href="mailto:a.bryceson@doctors.org.uk"
target="_blank">a.bryceson@doctors.org.uk</a>> a écrit :</span></font><o:p></o:p></p>
</div>
<div>
<div>
<blockquote style='border:none;border-left:solid windowtext 1.0pt;padding:0pt 0pt 0pt 6.0pt;
margin-left:4.8pt;margin-top:5.0pt;margin-right:0pt;margin-bottom:5.0pt;
border-color:-moz-use-text-color -moz-use-text-color -moz-use-text-color rgb(204, 204, 204)'>
<div style='margin-bottom:12.0pt'>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
<div style='margin-bottom:12.0pt'>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'>Dear Carlos<br>
As you are well aware DCL is very difficult to treat. The big problem is that
the defect in specific CMI is more profound than that in VL and may never recover,
in contrast with the defect in VL which bounces back quickly.<br>
<br>
To have any chance of curing the patient, treatment should be monitored
by quantitative slit skin smears (as for splenic aspirates in VL) from multiple
pre-selected sites, every week or two weeks, and treatment continued until
negativity and for some weeks or months longer. When slit skin smears
become negative, hunt for any nodular or infiltrated lesions and take deep
biopsies and look for amastigotes there. Keep on hunting and smearing.
Sometimes, at the end of all this, evidence of CMI may appear, and cure becomes
a possibility. I am sure that the method of treating is more important than the
choice of drug - so long of course that the parasite is susceptible to the
drug.<br>
<br>
Hannah Akuffo has sent you the abstract relating to 3 patients treated by
Sabawork Teklemariam in Addis Abeba. That article details this approach.<br>
<br>
Do you know the species of Leishmania causing Maria's DCL, and its
sensitivities? In Addis Abeba parasites were cultured from two of the patients
and sensitivities determined and isobolograms drawn to look for synergy. The
isolates were sensitive to paromomycin and sodium stibogluconate was
synergistic. It would be worth while to make cultures before you start any new treatment
and have the isolate tested in this way. I expect that you have a lab that
could do this; if not, Simon Croft might be able to advise.<br>
<br>
Miltefosine has been very successful in a number of situations in South
American CL and showed promise for DCL, but patients relapsed despite
prolonged treatment.<br>
1. Zerpa O, Ulrich M, Blanco B, et al. Diffuse cutaneous leishmaniasis responds
to miltefosine but then relapses. Br J Dermatol. 2007;156:1328-1335.<br>
<br>
In a few patients with VL-HIV confection whom I treated in <st1:City w:st="on"><st1:place
w:st="on">London</st1:place></st1:City>, miltefosine worked well at first, but
the patients relpased while still on treatment and drug resistance was supected
but not tested. Miltefosine has a pharmacokinetic profile with a long tail that
might make it susceptible to the devlopment of resistance, especially if the
therapeutic window for a given isolate was narrow. So you might want to think
about adding a second drug to go with miltefosine from the beginning. I am not
sure what might be the best drug for combination; perhaps Josh Berman might
have an opinion. It is of course essential to ensure contraception.<br>
<br>
You could also consider the combination of paromomycin and low dose SSG. In
view of Maria's poor renal function you might need to modify the dose of
paromomycin and to monitor function.<br>
<br>
Robert Vinson is CEO of Paladin Labs, and would I am sure help you locate
miltefosine. <<a href="mailto:rvinson@paladin-labs.com" target="_blank">rvinson@paladin-labs.com</a>><br>
<br>
Richard Chin is CEO of One World Health, and would, I am equally sure, help
you locate paromomycin, should you consider that path. <a
href="http://www.oneworldhealth.org/contact-us" target="_blank">http://www.oneworldhealth.org/contact-us</a>
Phone: +1 415-421-4700 Fax: +1 415-421-4747<br>
<br>
I wish you and Maria all the best in this venture.<br>
Anthony<br>
<br>
<br>
Dear Jennie<br>
Immunotherapy proved rather disappointing in VL. It seems that the patient
needs a decent immune response in the first place to benefit from
immuno-boosting.<br>
Sadly<br>
Anthony<br>
<br>
<br>
On 6 Jul 2011, at 20:04, <st1:PersonName w:st="on">Carlos Costa</st1:PersonName>
wrote:</span></font><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'>Dear all,<br>
<br>
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 <st1:place w:st="on"><st1:City w:st="on">Maranhão State</st1:City>,
<st1:country-region w:st="on">Brazil</st1:country-region></st1:place>, 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 <st1:City
w:st="on"><st1:place w:st="on">Teresina</st1:place></st1:City>.<br>
<br>
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).<br>
<br>
Our hope now stands only in miltefosine, for oral chronic use, but the drug is
not licensed or available in <st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region>
yet (to my knowledge).<br>
<br>
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 <st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region>
(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.<br>
<br>
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.<br>
<br>
Hoping a little from friends, my kindest regards,<br>
<br>
Carlos.<br>
<br>
PS. Please understand that the pictures are allowed not for publication or
public presentation. Cleudimar permission is restricted to this forum.<br>
<br>
<br>
--<br>
Carlos H. N. Costa, MD, DSc.<br>
President<br>
Sociedade Brasileira de Medicina Tropical<br>
(Brazilian Society of Tropical Medicine)<br>
Instituto de Doenças Tropicais Natan Portella<br>
Universidade Federal do Piauí<br>
Rua Artur de Vasconcelos 151-Sul<br>
64049-750 Teresina-PI<br>
<st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region><br>
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<br>
<br>
Aviso: As informações contidas nesta mensagem são CONFIDENCIAIS, protegidas
pelo sigilo legal, por direitos autorais e destinadas exclusivamente à pessoa
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<br>
<cleu antes grav 13jan09.jpg><cleu e nene.jpg><cleu santada
recorte.jpg><cleu panturrilhas.jpg><cleu
palato.jpg>_______________________________________________<br>
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<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</blockquote>
<div style='margin-bottom:12.0pt'>
<p class=MsoNormal style='mso-margin-top-alt:auto;margin-bottom:12.0pt'><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
</div>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'><br>
<br clear=all>
<br>
-- <br>
</span></font><b><font color=black face=Verdana><span style='font-family:Verdana;
color:black;font-weight:bold'>Carlos H. N. Costa, MD, DSc.</span></font></b><o:p></o:p></p>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>President</span></font></b><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>Sociedade Brasileira de Medicina Tropical </span></font></b><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>(Brazilian Society of Tropical Medicine)</span></font></b><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>Instituto de Doenças Tropicais Natan Portella<br>
Universidade Federal do Piauí</span></font></b><o:p></o:p></p>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>Rua Artur de Vasconcelos 151-Sul</span></font></b><o:p></o:p></p>
</div>
</div>
<div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=3 color=black face=Verdana><span style='font-size:12.0pt;font-family:Verdana;
color:black;font-weight:bold'>64049-750 Teresina-PI<br>
<st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region><br>
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<br>
</span></font></b><font color=black face=Verdana><span style='font-family:Verdana;
color:black'><br>
</span></font><font size=2 color=black face=Verdana><span style='font-size:
10.0pt;font-family:Verdana;color:black'>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.<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></font><o:p></o:p></p>
</div>
</div>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=3 color=black face="Times New Roman"><span style='font-size:12.0pt;
color:black'> </span></font><o:p></o:p></p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'><br>
<br clear=all>
<br>
-- <br>
<b><span style='font-weight:bold'>Carlos H. N. Costa, MD, DSc.</span></b></span></font><o:p></o:p></p>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>President</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>Sociedade Brasileira de Medicina Tropical </span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>(Brazilian Society of Tropical Medicine)</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>Instituto de Doenças Tropicais Natan Portella<br>
Universidade Federal do Piauí</span></font></b><o:p></o:p></p>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>Rua Artur de Vasconcelos 151-Sul</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><b><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black;font-weight:bold'>64049-750 Teresina-PI<br>
<st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region><br>
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<br>
</span></font></b><font size=2 color=black face=Verdana><span style='font-size:
10.0pt;font-family:Verdana;color:black'><br>
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.<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></font><o:p></o:p></p>
</div>
</div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'> </span></font><o:p></o:p></p>
<div class=MsoNormal align=center style='text-align:center'><font size=2
color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>
<hr size=2 width="100%" align=center>
</span></font></div>
<p class=MsoNormal style='mso-margin-top-alt:auto;mso-margin-bottom-alt:auto'><font
size=2 color=black face=Verdana><span style='font-size:10.0pt;font-family:Verdana;
color:black'>_______________________________________________<br>
Leish-l mailing list<br>
<a href="mailto:Leish-l@lineu.icb.usp.br" target="_blank">Leish-l@lineu.icb.usp.br</a><br>
<a href="http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l"
target="_blank">http://lineu.icb.usp.br/cgi-bin/mailman/listinfo/leish-l</a></span></font><o:p></o:p></p>
</div>
</blockquote>
</div>
</div>
</div>
</div>
</div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><br>
<br clear=all>
<br>
-- <br>
</span></font><b><font face=Verdana><span style='font-family:Verdana;
font-weight:bold'>Carlos H. N. Costa, MD, DSc.</span></font></b><o:p></o:p></p>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>President</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>Sociedade Brasileira de Medicina
Tropical </span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>(Brazilian Society of Tropical Medicine)</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>Instituto de Doenças Tropicais Natan
Portella<br>
Universidade Federal do Piauí</span></font></b><o:p></o:p></p>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>Rua Artur de Vasconcelos 151-Sul</span></font></b><o:p></o:p></p>
</div>
<div>
<p class=MsoNormal><b><font size=3 face=Verdana><span style='font-size:12.0pt;
font-family:Verdana;font-weight:bold'>64049-750 Teresina-PI<br>
<st1:country-region w:st="on"><st1:place w:st="on">Brazil</st1:place></st1:country-region><br>
Telephones: +55 86 3221-3413 (work); +55 86 8838-3303 (mobile).<br>
</span></font></b><font face=Verdana><span style='font-family:Verdana'><br>
</span></font><font size=2 face=Verdana><span style='font-size:10.0pt;
font-family:Verdana'>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.<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></font><o:p></o:p></p>
</div>
</div>
<p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:
12.0pt'><o:p> </o:p></span></font></p>
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