Immune response measured in human volunteers vaccinated with autoclaved Leishmania major vaccine mixed with low dose of BCG.

The immune responses induced against Leishmania antigens in volunteers who were vaccinated in a double-blind, randomized field efficacy trial of a preparation of autoclaved Leishmania major (ALM) mixed with a low dose of Bacille Calmette-Guerin vaccine (BCG) who developed either a cutaneous leishmaniasis (CL) lesion due to exposure to infected sandfly bite(s) or did not develop a lesion during the course of the trial were studied and compared with those of non-vaccinated controls. Blood samples were also assayed from different groups including volunteers with history of CL and volunteers with previous positive or negative leishmanin skin test (LST) without a history of CL. The vaccinated volunteers had received a single dose of either ALM mixed with a low dose of BCG or the same dose of BCG alone. The LST and in vitro proliferative response (stimulation index, SI), interferon gamma (IFN-gamma) production and, in a few cases, interleukin (IL)-4 production of peripheral blood mononuclear cells to soluble Leishmania antigens were measured. The results indicated that volunteers who developed CL in the vaccine arm showed a slightly higher SI than cases who received BCG alone. Volunteers with history of CL and volunteers with positive LST demonstrated the strongest proliferation indices and IFN-gamma production. The data suggest that a single dose of ALM + BCG induces a weak Th1 response in vaccinated volunteers that is far lower than that in volunteers with prior subclinical infection or volunteers with history of CL, who are presumed to be immune.

Treatment of cutaneous leishmaniasis with ketoconazole cream.

BACKGROUND: Cutaneous leishmaniasis (CL) is endemic in many countries. It has been recognized as a major public health problem in Iran. Many drugs have been suggested for the treatment of CL but most of them used intramuscularly or intravenously. Recently, a ketoconazole tablet has been used for the treatment of CL. OBJECTIVE: To compare the efficacy of ketoconazole cream with placebo in the treatment of CL. METHODS: The study was a double-blind, placebo-controlled trial. Patients with proven CL were treated with ketoconazole cream or placebo cream. The duration of treatment was 21 days and the patients were visited on days 7, 14 and 21. Follow-up was for 1 month after the end of treatment. RESULTS: The study was completed in 73 patients (45 male, 28 female). The mean age of the patients was 19.9 years. A total of 38 patients received ketoconazole and 35 patients were treated with the placebo cream. At the end of treatment (day 21), complete healing had occurred in 15.7% of the ketoconazole group in comparison with 14.3% of the patients who were treated with the placebo cream (p=0.86). One month after the end of treatment the lesions in 28.9% of the ketoconazole group and 22.8% of the placebo group were healed (p=0.55). CONCLUSION: Although the ketoconazole tablet has been reported to be effective in the treatment of some cases of CL, the low response rate in patients receiving ketoconazole cream indicates that it cannot be used as the single agent in the treatment of CL patients.

A randomised, double-blind, controlled trial of a killed L. major vaccine plus BCG against zoonotic cutaneous leishmaniasis in Iran.

Safety and efficacy of killed (autoclaved) L. major promastigotes, ALM, mixed with BCG against zoonotic cutaneous leishmaniasis was tested in healthy volunteers (n = 2453) in a randomized double blind trial vs. BCG as control. Side-effects were similar in both groups but tended to be slightly more frequent and prolonged in the ALM + BCG group. Leishmanin skin test conversion (induration > or =5 mm) was significantly greater in the ALM + BCG than in the BCG group (36.2% vs. 7.9% on day-80 and 33% vs. 19%, after 1 year, respectively). Cumulative incidence rates for 2 years, were similar in both groups (18.0% vs. 18.5%). However, LST responders on day 80 (> or =5 mm) had a significantly lower incidence (35%) of CL during the first year than non-responders. A single dose of ALM + BCG is not sufficiently immunogenic to provide a measurable response when compared to BCG alone. A single dose of this vaccine has been shown to be safe with no evidence of an exacerbating response following natural infection; hence, multiple doses or other adjuvants should be considered to increase its immunogenicity.

Randomised vaccine trial of single dose of killed Leishmania major plus BCG against anthroponotic cutaneous leishmaniasis in Bam, Iran.

BACKGROUND: A vaccine consisting of a single dose of whole-cell autoclave-killed Leishmania major (ALM) mixed with BCG was assessed in comparison with BCG alone against anthroponotic (human to human transmission) cutaneous leishmaniasis in a randomised double-blind trial in Bam, Iran. METHODS: 3637 schoolchildren, aged 6-15 years, with no history of cutaneous leishmaniasis and no response to a leishmanin skin test, were randomly assigned to receive 1 mg ALM mixed with BCG (n = 1839), or BCG alone (n = 1798). Safety of the vaccine and the incidence of confirmed cases of cutaneous leishmaniasis were followed up for 2 years. FINDINGS: Side-effects were those usually associated with BCG vaccination, but tended to persist longer in the ALM + BCG group. After exclusion of four cases occurring within 80 days of vaccination (one in the ALM + BCG group and three in the BCG group), the 2-year incidence of cutaneous leishmaniasis did not differ significantly between vaccine and BCG groups: 2.8% vs 3.3%, respectively (total cases 112). A sex-stratified analysis showed that in boys the vaccine conferred a protective efficacy of 18% and 78% for the first and second years, respectively--a crude 2-year overall protection of 55% (95% CI 19-75%, p < 0.01). In the first 9 months after vaccination, there was a non-significant excess of cases in the ALM + BCG group (25 vs 16), whereas the incidence of cutaneous leishmaniasis thereafter was significantly reduced in the ALM + BCG group (27 vs 44, p < 0.05). INTERPRETATION: A single dose of ALM + BCG was safe and more immunogenic than BCG alone, as measured by leishmanin skin test. The exact reason for the apparent protective effect of the vaccine in boys is unknown, and may be a chance finding. However, since boys are more exposed to the infection, which is indicated by higher disease prevalence in boys in this study population, the preferential protective effect in boys may have resulted from a greater booster effect produced by repeated exposure to infected sandflies. Booster injections or alternative adjuvants should be tried to improve the potential efficacy of this vaccine.

Treatment of cutaneous leishmaniasis with itraconazole. Randomized double-blind study.

OBJECTIVE: To compare the efficacy of itraconazole with placebo in the treatment of cutaneous leishmaniasis caused by Leishmania major. DESIGN: Double-blind placebo-controlled study. SETTING: Patients were selected from volunteers wit cutaneous leishmaniasis who lived in a hyperendemic area. PATIENTS: One hundred forty patients were randomly selected for this double-blind study. Exclusion criteria were pregnancy, gestation, age younger than 12 years, and duration of disease of more than 4 months. INTERVENTION: Each patient received itraconazole (7 mg/kg per day) or placebo for a 3-week period. The patients were kept under observation for an additional 30-day period. OUTCOME. The study was completed as planned in 131 patients. RESULTS: Complete healing occurred in 59% of the itraconazole group in comparison with 44.3% of the patients who were treated with placebo capsules. No difference was found between the 2 groups with respect to adverse effects. CONCLUSIONS: Although itraconazole has the advantage of being an oral agent that is used in the treatment of cutaneous leishmaniasis, the low response rate in patients receiving itraconazole indicates that itraconazole cannot be used as the single agent in the treatment of patients with cutaneous leishmaniasis caused by L. major.

Chronic lupoid leishmaniasis. Evaluation by polymerase chain reaction.

BACKGROUND: The cutaneous lesions in chronic lupoid leishmaniasis resemble those of lupus vulgaris, both clinically and histologically. The differential diagnosis is difficult and may depend on the detection of a few Leishmania amastigotes in the histologic sections, the growth of the promastigotes in cultures, or the identification of amastigotes by other techniques. Polymerase chain reaction was used to detect Leishmania amastigote DNA in tissue samples obtained from 65 patients with chronic lupoid leismaniasis, and the results were confirmed by Southern blot analysis. OBSERVATIONS: The histologic findings of a predominantly epithelioid cell granuloma surrounded by lymphocytic infiltrate in chronic lupoid leishmaniasis are very similar to those observed in lupus vulgaris. Extensive histologic examination of the sections in this series revealed occasional macrophages containing a few amastigotes in only 12 cases. Cultures in NNN medium yielded Leishmania promastigotes in 20 cases. Polymerase chain reaction studies using a Leishmania-specific primer identified Leishmania DNA in 30 of 63 cases, and those using a Mycobacterium tuberculosis primer were found to be negative for mycobacteria in 47 cases tested, including 11 cases with a positive tuberculin skin reaction. CONCLUSIONS: The histologic findings in chronic lupoid leishmaniasis resemble those of lupus vulgaris. Polymerase chain reaction studies were useful in identifying amastigotes in 30 (47.6%) of 63 cases. This study confirms the presence of DNA molecules of Leishmania amastigotes in samples of formalin-fixed, paraffin-embedded granulomatous tissue obtained from patients with chronic lupoid leishmaniasis.

Multiple giant disseminated pyogenic granuloma in three patients burned by boiling milk.

BACKGROUND: Pyogenic granuloma is a common benign skin tumor. The multiple disseminated form of the disease is relatively rare. METHODS: We examined three patients who developed giant pyogenic granuloma after burns from boiling milk. The patients were a 1.5-year-old boy, a 5-year-old girl, and a 35-year-old woman, All three patients had second-degree burns over their face and trunk. RESULTS: In these patients, pyogenic granuloma had developed over the previously burned areas 2-3 weeks after exposure. The general condition of the patients remained good and all lesions involuted spontaneously. In a 6-month follow-up period no relapse of the lesions was seen. CONCLUSIONS: The cause for development of multiple giant pyogenic granulomas after burns from milk remains unknown, but milk proteins or other components of milk, microorganisms, or the burn itself may be causative factors.

Treatment of recurrent cutaneous Leishmaniasis.

BACKGROUND: Cutaneous leishmaniasis is endemic in Iran. One of the clinical pictures of this disease is leishmaniasis recidivans (LR). Most of the drugs used for cutaneous leishmaniasis are ineffective in LR. METHODS AND PATIENTS: Twenty-five patients (13 women and 12 men), who had LR and whose disease had been proved by previous direct smears, were accepted for the study. The duration of disease in all patients was more than 2 years and they had previously been treated for their cutaneous leishmaniasis by different methods. All patients were treated with a combination of allopurinol (AL) (20 mg/kg/day for 30 days) and meglumine antimoniate (MA) (70 mg/kg/day for 15 days). Laboratory tests including hemograms, liver function, and kidney function tests, were done both at baseline and at the end of therapy. RESULTS: Twenty-four out of 25 patients (96%) responded well to treatment and after 1 year follow-up no relapse had occurred. The drugs were well tolerated by the patients producing no side effects nor any significant changes in laboratory values. CONCLUSIONS: A combination of AL and antimoniate is an effective method for the treatment of LR and for patients with cutaneous leishmaniasis who are resistant to the usual treatments.

Clinical picture of cutaneous leishmaniasis in Isfahan, Iran.

BACKGROUND: Cutaneous leishmaniasis caused by Leishmania tropica is endemic in Iran, being the second most prevalent vector-borne disease in the country (after malaria). From the five most infected provinces, Isfahan is third after Boushehr and Khouzestan. METHODS: To study the clinical picture of this disease, 1250 patients referred to the Leishmaniasis Training and Treatment Center (affiliated with Isfahan University of Medical Sciences) were studied during a 2-year period. RESULTS: The disease was more prevalent in the age group of 10-15 years. Nonindigenes had more lesions and their lesions were more acute and more severe than those of indigenes. The face was the most frequent site of involvement (39.7%), followed by the upper (32.4%) and lower extremities (19.4%), whereas only 8.1% of the lesions were found on the trunk. No direct relation was seen with age, sex, and clinical features of the lesions except for the erysipeloid cases that were rare and seen only in middle-aged and elderly women. Noduloulcerative and papular lesions dominated the clinical picture, followed by plaque, impetiginized, and nodular lesions. CONCLUSIONS: The reason why nonindigenous patients have more severe lesions and in greater number is not clear. It can be postulated that nonindigenous people were more exposed to the vector biting since they were living in more infected areas and that during a long period of time, a mild immunity might have developed in indigenous people.

Skin manifestations of mustard gas in a group of 14 children and teenagers: a clinical study.

BACKGROUND: During the Iraq-Iran war (1980-1988), a group of patients exposed to mustard gas (one of the chemical warfare agents used by Iraq) were referred to our dermatology department. This group included a subgroup of 14 children and teenagers. In this article, we attempted to review the skin manifestations of these patients. METHODS: A group of patients, including 14 children and teenagers, exposed to mustard gas were studied. Laboratory tests including blood cell counts, hemoglobin, hematocrit, urine analysis, etc., were determined. RESULTS: Among the most frequent disorders were facial involvement (78%), which dominated the clinical picture, followed by genital (42%), truncal, and axillary lesions (both 14%). Eosinophilia was the most prominent laboratory disorder seen in 12% of the patients. Skin lesions started 4-18 hours after exposure. Erythema developed within 20-30 hours after exposure, followed by blisters. CONCLUSIONS: The time of onset of manifestations had been shorter and severity of the lesions higher in children and teenagers compared with adults. Both phenomena could be attributed to the more delicate skin of the young patients. Genital manifestations were less frequent in this subgroup while ophthalmic, pulmonary, and gastrointestinal lesions were more frequently encountered in children than in adults. The unfortunate consequences of exposure to such chemicals reminds once again the urgency of international treaties to effectively ban the use of chemical weapons.

Skin manifestations of mustard gas. A clinical study of 535 patients exposed to mustard gas.

BACKGROUND: During the Iraq-Iran war (1980-1988), 535 patients who were exposed to mustard gas (one of the chemical warfare agents used by Iraq) were referred to our dermatology department. In this article, we have tried to review the skin manifestations of these patients. OBSERVATIONS: The skin lesions were of early or late onset. The early onset lesions consisted of erythema (76%), bulla (55%), and purpura (1.1%). These lesions were mostly found on the face and skin folds. The late-onset manifestations were pigmentation (20.4%) and desquamation (11.2%). Other complications were ophthalmic (85%), pulmonary (15%), and gastrointestinal (10%). Lymphopenia (7%) was the most serious laboratory disorder reported. Biopsy specimens of the lesions showed subepidermal bullae with mild dermal and epidermal necrosis. CONCLUSIONS: All patients were treated as for burns using sulfadiazine and furacine. All patients were cured in a period of 15 to 45 days. During a 6-month follow-up, no mortality was observed.