Your browser doesn't support javascript.
Show: 20 | 50 | 100
Results 1 - 20 de 57
Rev. Soc. Bras. Med. Trop ; 54: e04542020, 2021. tab
Article in English | LILACS | ID: biblio-1155531


Abstract INTRODUCTION: The objective of this study was to estimate the direct medical costs of the treatment for mucosal leishmaniasis (ML) using three therapeutic approaches in the Brazilian context. METHODS: We performed this economic assessment from the perspective of the Brazilian public healthcare system. The following therapeutic approaches were evaluated: meglumine antimoniate, liposomal amphotericin B, and miltefosine. Direct medical costs were estimated considering four treatment components: a) drug, b) combined medical products, c) procedures, and d) complementary tests. RESULTS: Treatment with meglumine antimoniate had the lowest average cost per patient (US$ 167.66), followed by miltefosine (US$ 259.92) in the outpatient treatment regimen. The average cost of treatment with liposomal amphotericin B was US$ 715.35 both in inpatient regimen. In all estimates, the drugs accounted for more than 60% of the total cost for each treatment approach. CONCLUSIONS: These results demonstrate the marked differences in costs between the therapeutic alternatives for ML. In addition to efficacy rates and costs related to adverse events, our data have the potential to support a complete cost-effectiveness study in the future. Complete analyses comparing costs and benefits for interventions will assist health managers in choosing drugs for ML treatment in Brazil as well as in establishing effective public health policies.

Humans , Leishmaniasis, Mucocutaneous/drug therapy , Antiprotozoal Agents/therapeutic use , Brazil , Cost-Benefit Analysis , Meglumine Antimoniate/therapeutic use
Rev. Soc. Bras. Med. Trop ; 53: e20200040, 2020. graf
Article in English | ColecionaSUS, LILACS, ColecionaSUS, SES-SP | ID: biblio-1136884


Abstract Mucocutaneous leishmaniasis (MCL) is a chronic infection that can affect the skin and mucous membranes. We report a case of oral, nasopharyngeal, and penile lesions in a 35-year-old cocaine user. The patient presented with ulcerated lesions in 2014. Histopathologic analysis revealed amastigotes, and serological test results were positive for leishmaniasis. Systemic therapy with meglumine antimoniate was administered; however, the patient failed to present for follow-up. In 2018, he returned with nasal collapse, and another histopathologic test confirmed MCL. This case illustrates the importance of careful differential diagnosis of skin and mucous ulcers to identify the particular pathology.

Humans , Male , Adult , Leishmaniasis, Mucocutaneous/diagnosis , Cocaine-Related Disorders/complications , Meglumine Antimoniate/administration & dosage , Antiprotozoal Agents/administration & dosage , Leishmaniasis, Mucocutaneous/complications , Leishmaniasis, Mucocutaneous/drug therapy
Rev. Soc. Bras. Med. Trop ; 52: e20180236, 2019. graf
Article in English | LILACS | ID: biblio-977116


Abstract In Brazil, meglumine antimoniate is the first drug of choice for mucosal leishmaniasis treatment followed by amphotericin B and pentamidine isethionate. We report the case of a patient with severe mucosal lesions caused by Leishmania (Viannia) braziliensis that were difficult to treat. Over a 14-year period, the patient showed low adherence and three treatment attempts with meglumine antimoniate failed. Additionally, there was an unsatisfactory response to liposomal amphotericin B and nephrotoxicity when using amphotericin B deoxycholate that persisted after new treatment attempt with liposomal amphotericin B. Finally, healing was achieved with pentamidine isethionate and maintained during nine months of monitoring.

Humans , Male , Pentamidine/therapeutic use , Leishmania braziliensis/drug effects , Leishmaniasis, Mucocutaneous/drug therapy , Antiprotozoal Agents/therapeutic use , Treatment Outcome , Middle Aged
Rev. Soc. Bras. Med. Trop ; 52: e20180292, 2019. tab, graf
Article in English | LILACS | ID: biblio-990435


Abstract INTRODUCTION: The treatment of mucosal leishmaniasis (ML) is difficult due to the toxicity and route of administration of standard drugs. Miltefosine is an oral agent used for leishmaniasis treatment; however, no data exist regarding its use for ML in Brazil. In this study, we aimed to evaluate the efficacy of miltefosine for ML treatment compared to that of pentavalent antimonial in a pilot study. METHODS: We performed a randomized clinical trial with two parallel groups. The tested intervention consisted of miltefosine 1.3-2 mg/kg/day (two capsules) for 28 days or intravenous 20 mg SbV/kg/day of meglumine antimoniate (N-MA) for 30 days. The final endpoint was defined as complete healing of the lesion four years after treatment. We also analyzed an early endpoint at 90 days after treatment. RESULTS: Forty patients were included in this study: each experimental group comprised 20 patients. Applying a multivariate model in an intention-to-treat analysis, we observed that patients treated with miltefosine had a cure probability 2.08 times greater (95% confidence interval [CI] = 1.03-4.18) than those treated with N-MA at 90 days after treatment. At the final endpoint, we observed no differences in cure probability between miltefosine and N-MA (relative risk = 0.66; 95% CI = 0.33-1.32). With respect to adverse reactions, significant differences between groups were related to gastrointestinal effects, which were more frequent in the miltefosine group. CONCLUSIONS: Miltefosine may be an interesting alternative for treating ML because of its oral administration and cure rate after long-term follow-up.

Humans , Male , Female , Phosphorylcholine/analogs & derivatives , Leishmaniasis, Mucocutaneous/drug therapy , Meglumine Antimoniate/administration & dosage , Antiprotozoal Agents/administration & dosage , Phosphorylcholine/administration & dosage , Time Factors , Pilot Projects , Treatment Outcome , Middle Aged
Rev. Soc. Bras. Med. Trop ; 51(3): 318-323, Apr.-June 2018. tab, graf
Article in English | LILACS | ID: biblio-957424


Abstract INTRODUCTION Pentavalent antimonials (Sbv) are the most commonly used drugs for the treatment of mucosal leishmaniasis (ML), despite their high toxicity and only moderate efficacy. The aim of this study was to report therapeutic responses with different available options for ML. METHODS This study was based on a review of clinical records of 35 patients (24 men and 11 women) treated between 2009 and 2015. RESULTS The median age of patients was 63 years, and the median duration of the disease was 24 months. Seventeen patients received Sbv, while nine patients were treated with liposomal amphotericin B (AmB), and another nine patients were treated with fluconazole. Patients treated with AmB received a total median accumulated dose of 2550mg. The mean duration of azole use was 120 days, and the daily dose ranged from 450 to 900mg. At the three-month follow-up visit, the cure rate was 35%, 67%, and 22% for Sbv, AmB, and azole groups, respectively. At the six-month follow-up visit, the cure rates for Sbv, AmB, and azole groups were 71%, 78%, and 33%, respectively. CONCLUSIONS There is a scarcity of effective ML treatment alternatives, and based on our observations, fluconazole is not a valid treatment option.

Humans , Male , Female , Adult , Aged , Aged, 80 and over , Leishmaniasis, Mucocutaneous/drug therapy , Fluconazole/therapeutic use , Amphotericin B/therapeutic use , Antimony/therapeutic use , Antiprotozoal Agents/therapeutic use , Severity of Illness Index , Treatment Outcome , Middle Aged
Rev. Fed. Argent. Soc. Otorrinolaringol ; 24(2): 58-62, 2017. ilus, tab
Article in Spanish | LILACS | ID: biblio-908139


La leishmaniasis es una zoonosis parasitaria causada por protozoos. Puede afectar la piel y las mucosas o presentarse como una enfermedad visceral. La variedad mucocutánea conduce a la destrucción parcial o completa de las membranas mucosas de la nariz, las fauces y la faringe. Aproximadamente un 90% de los casos con afectación mucocutánea se producen en Brasil, Bolivia y Perú. En nuestro país afecta en forma endémica a las provincias del norte desde principios del siglo XX. Se relata el caso de un paciente de 53 años con odinodisfagia de aproximadamente 6 meses de evolución, asociado a formaciones granulomatosas medio- faciales, en el que se diagnosticó leishmaniasis cutaneomucosa mediante el rescate de amastigotes en muestras tomadas de lesiones de paladar blando para estudio anatomopatológico con tinción de Giemsa. Se realizó tratamiento con meglumina antimoniato con buena evolución clínica a partir de los quince días de instaurado el mismo.

Leishmaniasis is a parasitic zoonosis caused by protozoa. It can affect skin, mucous membranes or presented as visceral disease. Mucocutaneous variety leads to partial or complete destruction of the mucous membranes of the nose, mouth and pharynx. Approximately, 90% of cases with mucocutaneous involvement occurs in Brazil, Bolivia and Peru. In our country it affects endemic to the northern provinces since the beginning of the century. The case of a 53-year-old patient with odinodisphagia of approximately 6 months of evolution, associated with mid-facial granulomatous formations in which cutaneomucous leishmaniasis was diagnosed by rescue of amastigotes in samples taken from lesions of soft palate for anatomopathological study with Staining of Giemsa. Treatment with meglumina antimonia was carried out with good clinical evolution from the fifteen days of the same establishment.

A leishmaniose é uma zoonose parasitária causada por protozoários. Ele pode afectar a pele e membranas mucosas ou presente como doença visceral. variedade mucocutânea conduz à destruição parcial ou completa das membranas mucosas do nariz, boca e faringe. Aproximadamente 90% dos casos com envolvimento mucocutânea ocorrem no Brasil, Bolívia e Peru. Em nosso país que afeta endêmica para as províncias do norte, desde o início do século XX. O caso de um odinodisfagia 53 anos, aproximadamente, 6 meses evolução associada com formações granulomatosas mediofaciais em que a leishmaniose mucocutânea foi diagnosticada por resgatar amastigotas em amostras tomadas a partir de lesões do palato mole para estudo histopatológico contou Giemsa. O tratamento foi realizado com antimoniato de meglumina com boa evolução clínica a partir de quinze dias introduzidas ele.

Male , Humans , Middle Aged , Leishmaniasis, Mucocutaneous/diagnosis , Leishmaniasis, Mucocutaneous/drug therapy , Antimony/therapeutic use , Granulomatosis, Orofacial/diagnosis , Granulomatosis, Orofacial/therapy , Meglumine/therapeutic use
Medicina (B.Aires) ; 74(5): 371-377, oct. 2014. ilus, tab
Article in Spanish | LILACS | ID: lil-734403


El tratamiento convencional para la leishmaniasis tegumentaria es el antimoniato de meglumina, el cual presenta falla terapéutica creciente, producción de efectos adversos graves, y necesidad de administración parenteral, justificando la búsqueda de alternativas terapéuticas. Presentamos aquí los resultados preliminares de un ensayo clínico de fase II en pacientes con leishmaniasis mucosa, en el que se comparó la eficacia de miltefosina por vía oral con respecto a la del compuesto antimonial. La evaluación de la respuesta a los tratamientos se realizó mediante un seguimiento con videofibroscopia nasofaríngea, utilizándose un score de gravedad de lesiones mucosas para aplicar en cada momento del seguimiento de los pacientes. No se encontraron hasta ahora diferencias significativas entre el número de pacientes curados con miltefosina o con la quimioterapia convencional. Los resultados favorables de este trabajo sugieren que miltefosina podría constituir una alternativa terapéutica efectiva y segura en la región.

The conventional treatment for tegumentary leishmaniasis is meglumine antimoniate, which needs parenteral administration, has increased therapeutic failure, and produces serious adverse effects, justifying the search for therapeutic alternatives. We report here the preliminary results of a phase II clinical trial in patients with mucosal leishmaniasis, in which the efficacy of oral miltefosine versus the antimonial compound was assessed. The evaluation of response to the treatment was performed by monitoring with nasopharyngeal video-fibroscopy, using a score of mucosal injury severity for patients at each follow-up point. We found no significant differences so far between the number of patients cured with miltefosine or conventional chemotherapy. The favorable results of this study suggest that miltefosine could be an effective and safe oral therapeutic alternative in the region.

Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Young Adult , Antiprotozoal Agents/therapeutic use , Leishmaniasis, Mucocutaneous/drug therapy , Meglumine/therapeutic use , Organometallic Compounds/therapeutic use , Phosphorylcholine/analogs & derivatives , Comparative Effectiveness Research , Injury Severity Score , Nasopharynx/parasitology , Phosphorylcholine/therapeutic use
Rev. méd. Minas Gerais ; 22(4)dez. 2012.
Article in Portuguese | LILACS | ID: lil-698419


Introdução: a leishmaniose tegumentar americana afeta 15 milhões de pessoas no mundo. Na forma tegumentar, o parasita Leishmania (Viannia) braziliensis é o seu principal agente, sendo que a forma mucosa ocorre em 3-5% dos pacientes com a forma cutânea da doença. Objetivo: analisar casos notificados de leishmaniose mucosa do município de BeloHorizonte, com enfoque no acompanhamento otorrinolaringológico para controle de cura após tratamento específico. Pacientes e método: estudo analítico do banco de dados da Secretaria Municipal de Saúde de Belo Horizonte referente aos casos notificados entre 2001 e 2008 de leishmaniose tegumentar americana nas formas cutânea e mucosa e avaliação clínica dos casos com a forma mucosa. Resultados: foram notificados 745 pacientes, sendo 539 (72%) com a forma cutânea, 137 (18%) mucosa e 69 (9%) não identificados. Contato foi tentado com os 137 pacientes com a forma mucosa. Contudo, dados incorretos da fichade notificação permitiram contato efetivo com nove (6,6%) pacientes previamente tratados com a forma mucosa. Todos haviam sido tratados com antimoniato de N-metilglucamina há mais de um ano e submetidos a exame otorrinolaringológico. Endoscopia nasal e biópsia confirmaram recidiva em três de nove casos avaliados. Nos três casos, o diagnóstico ocorreu exclusivamente pela busca ativa decorrente deste estudo. Conclusão: em Belo Horizonte, os casos de leishmaniose mucosa não estão sendo adequadamente notificados e é frequente a recidiva de casos previamente tratados com antimoniato de N-metilglucamina,ocorrendo após o primeiro ano de tratamento. Busca ativa para o acompanhamento pós-tratamento deveria ser medida adotada nos centros de referência e tratamento dessa zoonose.

Introduction: Introduction: The American Tegumentary Leishmaniasis affects 15 million people in the world. In tegumental form, the Leishmania (Viannia) braziliensis parasite is its main agent, and the mucosal form happens in 3 to 5% of the patients in the disease cutaneous condition. Objective: To analyze mucosal leishmaniasis reported cases in Belo Horizonte, Minas Gerais, Brazil, focusing on the otorhinolaryngological follow-up in order to control cure after specific treatment. Patients and Method: Analytical study from Belo Horizonte Municipal Secretariat of Health database regarding cases that were reported from 2001 to 2008 ofthe American Tegumentary Leishmaniasis in the cutaneous and mucosal forms, and clinical evaluation of the mucosal form cases. Results: 745 patients were reported, being 539 (72%) in the cutaneous form, 137 (185) as mucosal, and 69 (9%) as non-identified. It was tried to make contact with 137 mucosal form patients. However, incorrect data from their reporting form allowed an effective contact with only 9 (6.6%) patients that had been previously treated with the mucosal form. The N-methylglucamine antimoniate was given to all the patients for more than one year, and they were later submitted to otorhinolaryngologicalexam. Nasal endoscopy and biopsy confirmed recurrence in 3 from the 9 assessed cases. In 3 of them, diagnosis happened exclusively from the active search carried out in the present study. Conclusion: In Belo Horizonte, the mucosal leishmaniasis cases are not being properlyreported, and recurrence of the ones that were previously treated with N-methylglucamine antimoniate has being confirmed as frequent after the first year of treatment. An active search for post-treatment follow-up should be an adopted measure in reference centers and to treat such zoonosis.

Humans , Leishmaniasis, Mucocutaneous/drug therapy , Recurrence , Disease Notification , Leishmaniasis/epidemiology
Bol. malariol. salud ambient ; 52(1): 15-19, jun. 2012. ilus
Article in Spanish | LILACS | ID: lil-659196


Se registra, en un paciente masculino de 48 años, la detección de Leishmania (Viannia) braziliensis en muestra de lesión mucosa crónica con 16 años de evolución clínica. El caso presentado cursa con perforación del tabique nasal no evidenciándose lesión cutánea primaria sugestiva de leishmaniasis. Por su ocupación el paciente ha frecuentado, por largos períodos, bosques en áreas endémicas para leishmaniasis en el occidente de Venezuela. Continuas evaluaciones clínicas, inmunológicas e histopatológicas realizadas durante varios años fallaron en establecer un diagnóstico certero incrementando la severidad del caso. Exámenes recientes realizados en nuestro laboratorio revelan la presencia de amastigotes en muestras de la lesión nasal activa en extendidos coloreados con tinción de Giemsa. La identificación del parásito como L. braziliensis y la verificación de la infección por este parásito en el paciente, fue lograda por ensayos de PCR y Western Blot, respectivamente. Se concluye que el caso presentado sufre una leishmaniasis mucocutánea de vieja data con una baja respuesta inmunológica, a juzgar por la frecuente negatividad en pruebas de IDR y/o la detección de anticuerpos circulantes anti-Leishmania. Se discute sobre la imprecisión diagnóstica en el caso presentado y se advierte sobre el riesgo epidemiológico potencial de casos similares.

The detection of Leishmania (Viannia) braziliensis from a chronic mucosal lesion with 16 years of clinical evolution in a 48 years old male patient is reported. The patient showed destruction of the nasal septal cartilage with no evidence of primary leishmanial lesion. Due to his professional work he frequently visited areas of western Venezuela where leishmaniasis is endemic. Frequent clinical, immunologic and histopathologic evaluations carried out during several years failed to establish a right diagnosis, increasing the severity of the mucosal lesion. The finding of a sparse number of amastigotes in a sample from the mucosal lesion stained by Giemsa stain, suggested a mucosal infection by Leishmania. The identification of the parasite as L. braziliensis and the verification of the infection by this parasite in the reported case were carried out using a PCR assay and a Western Blot test, respectively. It is concluded that the patient was suffering a long-lasting, reluctant to heal and severe lesion with a low immunological response due to infection by L. braziliensis causing mucocutaneous leishmaniasis (MCL). The fail in the diagnosis of this particular case of MCL and the potential epidemiological risk in similar cases are discussed.

Humans , Male , Adult , Leishmania braziliensis/growth & development , Leishmaniasis, Mucocutaneous/diagnosis , Leishmaniasis, Mucocutaneous/ethnology , Leishmaniasis, Mucocutaneous/physiopathology , Leishmaniasis, Mucocutaneous/pathology , Leishmaniasis, Mucocutaneous/drug therapy , Parasitology/methods , Venezuela
Rev. Soc. Bras. Med. Trop ; 38(3): 258-260, maio-jun. 2005. ilus
Article in Portuguese | LILACS | ID: lil-399920


Os autores relatam um caso de leishmaniose cutâneomucosa em um paciente de 45 anos que foi tratado com antimonial pentavalente por 30 dias, sem haver remissão da lesão. Dez dias após essa fase do tratamento e antes de iniciar uma nova série terapêutica com a mesma droga, o paciente foi acometido por uma parada cardíaca súbita que o levou a óbito.

Humans , Male , Middle Aged , Antiprotozoal Agents/adverse effects , Death, Sudden, Cardiac/etiology , Leishmaniasis, Mucocutaneous/drug therapy , Meglumine/adverse effects , Antiprotozoal Agents/therapeutic use , Fatal Outcome , Meglumine/therapeutic use
Arq. bras. oftalmol ; 64(6): 580-582, nov.-dez. 2001. ilus
Article in Portuguese | LILACS | ID: lil-304149


Objetivo:Apresentar um portador de leishmaniose com lesäo palpebral e dilataçäo de via lacrimal excretora. Relato de caso: O paciente em questäo foi portador de leishmaniose do tipo cutâneo-mucosa, tendo apresentado múltiplas lesöes de pele, ectrópio da pálpebra inferior, lesöes na mucosa nasal e alteraçöes na drenagem lacrimal. Discussäo: O acometimento da pálpebra e da via lacrimal raramente ocorre em portadores de leishmaniose. Os autores chamam atençäo para o diagnóstico e para a necessidade de se adotar medidas preventivas contra os vetores e a rápida instituiçäo do tratamento.

Humans , Male , Middle Aged , Lacrimal Apparatus , Leishmaniasis, Mucocutaneous/diagnosis , Eyelids/pathology , Antiprotozoal Agents , Leishmaniasis, Mucocutaneous/drug therapy
Archives of Iranian Medicine. 2001; 4 (3): 138-140
in English | IMEMR | ID: emr-56252


The leishmaniases are parasitic infections with various clinical manifestations and great geographical distribution. Mucosal leishmaniasis [ML] is an important problem in Latin America but is rarely encountered in Iran. There has been a report of the involvement of mucosal tissues with L. major and/ or L. tropica in the Southwest of Iran. In this report, we describe 3 rare clinical presentations of mucosal leishmaniasis, which were treated with meglumine antimoniate [Glucantime]. No evidence of recurrence was noted after several years of follow-up

Humans , Male , Leishmaniasis, Mucocutaneous/drug therapy , Leishmaniasis/epidemiology , Leishmania/pathogenicity
São Paulo; s.n; 2001. 276 p. ilus, mapas, tab, graf.
Thesis in Portuguese | LILACS | ID: lil-313755


A leishmaniose é doença amplamente distribuída no mundo, afetando mais de 80 países. A quimioterapia desta doença caracteriza-se pela falta de fármacos de ação específica e eficiente, sendo o tratamento de escolha baseado em compostos antimoniais, cuja ação tóxica sobre o organismo do hospedeiro é intensa. Com base na ação das enzimas DHFR e PTR1, envolvidas na biossíntese dos folatos, e na existência de receptores de manose na superficíe dos macrófagos, células parasitadas pela Leishmania sp., foram sintetizados fármacos dirigidos de pirimetamina, fármaco inibidor da DHFR e da PTR1. Para liberação seletiva nos macrófagos, utilizaram-se, como transportadores, derivados de dextrano e manana...

Animals , Mice , Epidemiology , Leishmaniasis , Leishmaniasis, Visceral , Leishmaniasis, Cutaneous/parasitology , Leishmaniasis, Cutaneous/drug therapy , Leishmaniasis, Cutaneous/virology , Leishmaniasis, Mucocutaneous/parasitology , Leishmaniasis, Mucocutaneous/drug therapy , Leishmaniasis, Mucocutaneous/virology , Chemistry, Pharmaceutical/methods , Biological Assay , Chromatography , Chromatography, Thin Layer , Cell Count/methods , Pharmacology
Rev. Inst. Med. Trop. Säo Paulo ; 42(6): 321-5, Nov.-Dec. 2000. tab
Article in English | LILACS | ID: lil-274889


Response to treatment with antimonial drugs varies considerably depending on the parasite strain involved, immune status of the patient and clinical form of the disease. Therapeutic regimens with this first line drug have been frequently modified both, in dose and duration of therapy. A regimen of 20 mg/kg/day of pentavalent antimony (Sb5+) during four weeks without an upper limit on the daily dose is currently recommended for mucosal disease ("espundia"). Side-effects with this dose are more marked in elderly patients, more commonly affected by this form of leishmaniasis. According to our experience, leishmaniasis in Rio de Janeiro responds well to antimony and, in cutaneous disease, high cure rates are obtained with 5 mg/kg/day of Sb5+ during 30 to 45-days. In this study a high rate of cure (91.4 percent) employing this dose was achieved in 36 patients with mild disease in this same geographic region. Side-effects were reduced and no antimony refractoriness was noted with subsequent use of larger dose in patients that failed to respond to initial schedule

Humans , Female , Middle Aged , Antiprotozoal Agents/therapeutic use , Leishmaniasis, Mucocutaneous/drug therapy , Meglumine/therapeutic use , Antiprotozoal Agents/administration & dosage , Follow-Up Studies , Meglumine/administration & dosage , Polymerase Chain Reaction , Severity of Illness Index , Time Factors
Pediatr. mod ; 36(1/2): 47-: 50-: 54-48, 52, 54, jan.-fev. 2000.
Article in Portuguese | LILACS | ID: lil-311075


A autora estuda conceito, etiologia, epidemiologia e apresentação clínica das formas visceral e mucocutânea da leishmaniose, detendo-se nos diversos esquemas de tratamento modernamente disponíveis, considerando as drogas de primeira e segunda linhas, a terapêutica tópica e os critérios de cura.

Humans , Amphotericin B , Leishmaniasis, Visceral , Administration, Topical , Antimony Sodium Gluconate/therapeutic use , Leishmaniasis, Mucocutaneous/epidemiology , Leishmaniasis, Mucocutaneous/etiology , Leishmaniasis, Mucocutaneous/drug therapy , Leishmaniasis, Mucocutaneous/therapy , Leishmaniasis , Leishmania