Современные вопросы медицинской паразитологии и инфекционных заболеваний
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Проблемы биологии и медицины, 2014, №3 (79)
require infrastructure beyond the means of endemic
areas. The standard treatment is toxic, costly and
needs a prolonged series of daily injections, the
efficacy is variable and resistance is rapidly
developing in many countries. Individuals upon cure
of CL lesion induced by natural infection or
leishmanization (LZ) are protected against further
lesion development, induction of protection in
experimental model of leishmaniasis is achieved,
most of the
Leishmania
parasites are easily cultured.
For all these reasons, in 1980s, global mobilization
to
develop
an
effective
vaccine
against
leishmaniasis under GMP/GCP guidelines with
support of WHO/TDR was initiated in new world
and old world. Several candidate antigens were
introduced and a few of the first generation (killed
parasite) vaccines were reached to phase 3 trials.
The results of efficacy trials in Brazil, Colombia,
Ecuador, Iran and Sudan using single and multiple
doses of first generation vaccines with or without
BCG are safe but not enough immunogenic to
protect against
Leishmania
infection. So far no
vaccine is available against any form of the disease.
Leishmanization is an inoculation of live
virulent
Leishmania major
to a predetermined part
of the div to induce a lesion similar to natural
infection. Leishmanized individuals are protected
against further natural infection which might be
multiple lesions in exposed parts of the div such as
on the face. LZ was practiced in Asian countries for
centuries and originally exudates of an active lesion
was used to scratch on buttocks of susceptible
individuals. When culture media was developed,
Leishmania
promastigotes from culture media were
used for inoculation in the early 1930s. LZ was
practiced in Uzbekistan, Israel and Iran. In the
1980s, as a preventive measure, massive LZ was
performed in Iran in which more than 2 million
soldiers and children were leishmanized. The
results of LZ in different endemic regions showed
the LZ is the most effective control measure against
CL, but accompanies limitations. Endemic countries
need to resume LZ and research on LZ issues should
be prioritized to standardize
Leishmania
stabilates,
develop well defined serum free media and possibly
lyophilize
Leishmania
. To facilitate vaccine
development, LZ should be used as live challenge to
evaluate candidate vaccines. The objective of the
current presentation is to overview history of
Leishmania
vaccines and LZ.
CUTANEOUS LEISHMANIASIS TREATMENT: A BRIEF OVERVIEW
A. Khamesipour
Center for Research and Training in Skin Diseases and Leprosy (Iran).
Human infection with
Leishmania
parasites
presents several different clinical forms of diseases;
Cutaneous Leishmaniasis (CL), the most common
form of the disease and Visceral Leishmaniasis
(VL) which is the fetal form of the disease. Due to
the diversity of epidemiological characteristics,
specific to each species and its environment, vector
and reservoir control are impractical, costly and
usually
requires
political
commitment
and
infrastructures beyond the means of the countries
suffering most from this disease and as such the
disease is expanding to new foci and the incidence
rate is increasing in some of the endemic areas. CL
is usually a self healing lesion but leaves a
disfiguring scar which leads to stigma, isolation and
barrier to marriage, especially for girls. In case of
severe forms of CL such as recidivans and non
healing forms no efficacious treatment is available.
Pentavalent antimonials (Sb
+5
) have been introduced
since 1930s and still is the first-line WHO
recommended treatment for all types of CL.
Antimonials require multiple injections which is
uncomfortable and painful, so full recommended
course is not tolerated by most of the patients and
resulted in low compliance. The efficacy of
antimonials depends upon the
Leishmania
species
and usually is low and resistant is reported.
Moreover, Antimonials are contraindicated in
pregnancy, heart/renal failure, hepatic disease and
diabetes and accompanies serious side effects which
in the worst scenario, it might cause death if not
carefully monitored. CL patients do not need
hospitalization so the cost of treatment is not high,
but still is not affordable for most the endemic areas.
Development of safe and efficacious drugs is
urgently needed. There is no global interest in drug
development against CL, so endemic countries,
NGOs and international agencies need to invest.
Clinical trials to assess the efficacy of various
modalities on leishmaniasis have been carried out in
different parts of the world, but mostly suffer from
inadequacies related different issues such as design,
sample size, endpoints and etc. Currently, in
addition to antimonials several lines of drugs like
Ambisome (liposomal form of Amphotericin B),
Miltefosine and Paromomycine are available for the
treatment of VL but not CL. Clinical trials on CL
using chemotherapy, physical therapy, traditional
medicine and immunotherapy have been published.
In this presentation, various clinical trials of
Медицинская паразитология
Биология ва тиббиёт муаммолари, 2014, №3 (79)
83
leishmaniasis will be discussed with emphasis on
clinical trials on CL and especially the ones which
have been completed in Iran including the efficacy
of oral Itraconazole on CL induced by
L. major
,
topical Paromomycine on the treatment of lesions
caused by
L. major
, Miltefosine in the treatment of
CL caused by
L. major
and
L. tropica
, combination
of Glucantime and imiquimod on the treatment of
CL induced by
L. tropica.
Current efforts to
develop
advanced
formulations
using
nano
technology with different drugs such as nano
liposomal forms of Amphotericin B, Paromomycine
etc and the related clinical trials will be discussed.
MINIIMAL INVASIVE SURGICAL METHOD OF TREATMENT
OF LIVER ECHINOCOCCOSIS
S.E. Mamarajabov
Tashkent medical academy
Objective: The aim of our investigation is to
improve surgical outcome of the patients with EL,
using minimal invasive surgery and postoperative
chemotherapy.
Material and Methods: Since (from 1998 till
current days) in the surgical department of the
hospital of Samarkand State medical institute has
been introduced a video assisted operation. This
introduction will be cause change to certain surgical
procedures in hydatid disease of liver and lungs.
During 1996-1998 years, before introduction video
assisted operation 69 patients (32 male and 37–
female) with plural EL were operated traditionally
by using laparotomic accesses. Echinococcectomy
(EE) using minimal invasive surgery has been
performed from 2010 to 2012 for 76 patients (36
male and 40-female) with plural EL. In total
(n=145) men were 68 (46.9%), women – 77
(53.1%).
Results: Diagnosis by ultrasonography has
important place in the detection of the disease. CT
examination has been used in 5 (2.7%) cases. After
using traditional laparotomic accesses in the surgical
treatment 69 patients founded by us the followings:
traumatism of approach (more then 22 cm), late
activity of patients (24-48 hours after operation),
prolonged and frequent anesthetization (3-4 time,
during 3-5 days), long hospitalization period (more
than 11 days) and cosmetics defects. Postoperative
complications such as suppuration of cyst (n=4),
cystobiliar fistula (n=3), rupture of cysts to biliary
tracts (n=2), rupture in abdominal cavity (n=1) were
found out in 9 (13.4%) patients. Recurrence of
disease exposed in 8 (11.6%) patients.
After introduction video assisted operation
different variants of echinococcectomy (EE) were
applied to 76 patients depending on size,
localization and condition of cysts. Only in 9
(11,8%) patients laparoscopic EE from the liver has
been performed. But, in these cases conversion has
been performed in 3 (33.3%) patients with transfer
to minilaparotomy. 67 (36.2%) patients received of
EE from the liver through minilaparotomic approach
using
“Mini-assist”
instruments.
Technical
simplicity of the operation in comparison with pure
laparoscopic EE made it possible to use this
operation more often. Shortcoming of this method is
difficulties performing the operation, with the cysts
located on inaccessible segments of the liver. There
were no complications in the postoperative period.
The patients stay in the hospital after such
operations was 5.8±1.4 days. So, single cysts, till 15
cm in diameter, with localization in the II,III,IV,V
segments and partially in the VI segment, can be
removed through minilaparotomic approach. It
should be noted that after minimal invasive surgery
activity of patient was in 6-12 hours after operation
and they don’t need long (only 1-2 time) and
frequent (only 1-2 days) anesthetization.
All patients of this group have undergone
the course of chemotherapy (Albendazol 12
mg/kg/day) in the postoperative period (2 or more
course) depending on the number, condition and
size of cysts. No recurrences have been noticed in
the followed-up patients.
Conclusion:
Comparative
analysis
of
patients who treated with traditional method and
video assisted operation showed that using of
minimal invasive surgery in the treatment of EL
made it possible to avoid extensive traumatic
approaches, to decrease painful syndrome and
expenditure of medicines in the postoperative
period, to diminish the terms of rehabilitation of
patients, to receive a good cosmetic effect.
Application
of
these
interferences
excludes
opportunity of development of postoperative
hernias, ligature fistulas, rough deforming cicatrexes
and commissure disease of the abdominal cavity.
