Mucosal leishmaniasis: urgent need for more research
Leishmaniasis is generally seen as one of the most neglected tropical diseases and strongly associated with poverty. Mucosal leishmaniasis (ML) or mucocutaneous leishmaniasis is an important and devastating form of the disease, which usually develops after the primary cutaneous lesion or as primary manifestation. ML pathogenesis is related to parasite and host factors, in particular, host’s immunological response. ML may present many distinct manifestations, from lesions limited to the nasal and oral cavity (mild stage), involvement of epiglottis (moderate stage), to the involvement of laringe, trachea and even bronchi (severe stage). ML may lead to the destruction of face structures and respiratory failure associated with death. The disfigurement related to ML often leads to economical loss, severe stigmatization and it may cause psychological disorders, as well as restrict social participation of the individual. Over 90% of ML cases occur in Bolivia, Brazil, Ethiopia and Peru. In the American Region, ML represents around 4% of tegumentary leishmaniasis cases.
Current treatment recommendations for ML are: 1) pentavalent antimonials (Sbv); or 2) Sbv in combination with oral pentoxifylline 3) liposomal amphotericin B; or 4) amphotericin B deoxycholate (AB); or 5) pentamidine isethionate (PT). All of these drugs have limitations in terms of toxicity, variable efficacy and inconvenient treatment schedules (e.g. long administration times, parenteral administration). Moreover, the treatment outcome also depends on the stage of the diseases.
Current efforts towards new treatments for leishmaniasis focus largely on visceral leishmaniasis and less on cutaneous leishmaniasis. Despite the difficulties and limitations of using current treatment options and the severe complications of the disease (including stigma, mutilation, and even death), there are no efforts made towards new treatment options for patients with mucosal leishmaniasis. Even though progress has been made in the identification and preclinical development of compounds against Leishmania species, in a short period of time (5-7 years) what is currently available will probably represent almost the entire therapeutic arsenal for the coming years. Hence the need to explore ways to optimize the use of existing tools and generate solid evidence in order to improve the treatment of ML.
Acknowledging these constraints, the 4th redeLEISH meeting proposed a special session on “Mucosal Leishmaniasis” which took place during the World Leish 6 in Toledo on May 16th 2017.
The investigators present at the meeting agreed that there is an urgent need to:
1. Increase incentive and funding for the conduction of well-structured clinical trials with L- AmB, or other drugs and combinations of treatments, in order to develop more effective and safer treatments for ML using existing options and generate robust evidence for the adoption of new treatment recommendations.
2. Encourage investment to develop new, rapid and non-invasive diagnostic tests.
3. Raise awareness on the social problem of ML and engaging governments to support scientific research related to public health and ML.
4. Promote a better access to early diagnostic and treatment for patients with ML.
In view of the current situation and the limited options available, the participants in the redeLEISH meeting expressed their support to make all efforts to improve treatment of ML in line with the above statement.
To continue this support movement, the participants of 53rd Brazilian Society of Tropical Medicine Congress (MedTrop) are also committed with the ML issue and joined the redeLEISH investigators.
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