Diagnosis of O. volvulus infection via skin exposure to diethylcarbamazine: clinical evaluation of a transdermal delivery technology-based patch.

BACKGROUND: Elimination of onchocerciasis in Africa is now regarded as an achievable goal in many areas. This makes monitoring changes in infection prevalence a key component of control programmes. Monitoring is currently based on determining the presence of O. volvulus microfilariae in skin snips, an invasive, labour-intensive method. The Onchocerciasis Control Programme (OCP) had established procedures to detect O. volvulus infections via the localized skin reaction induced by killing of microfilariae upon skin exposure to diethylcarbamazine via a patch (OCP-patch). Large scale OCP - patch use is difficult due to labour-intensive patch preparation. At the request of TDR, a manufacturer specialized in transdermal-delivery systems developed a ready-to-use diethylcarbamazine (DEC) containing patch (LTS-2 patch). To qualify this patch for large scale studies of its sensitivity and specificity, this study evaluated its ease of application, ability to detect infection and DEC exposure related adverse reactions compared to the OCP-patch in 30 infected individuals. METHODS: Each participant with 0.2-36.8 O. volvulus microfilariae/mg skin received the OCP-patch and 4 days later the LTS-2 patch at the left and right iliac crest, respectively, for 24 h. Presence and characteristics of local skin reactions were assessed at patch removal and 6 h later. Skin reaction and Mazzotti reaction rates were compared with Fisher's exact and a paired t-test, respectively. RESULTS: The LTS-2 patch could be applied within 10 s. Mild itching occurred at 63.3 % of OCP-patch (duration 8.9 ± 11.8 h) and 26.7 % of LTS-2 patch sites (duration 1.0 ± 2.5 h) and was the most frequent Mazzotti reaction. At patch removal after 24 h, a diagnostic local skin reaction was present under 90 % of OCP-patches and 83 % of LTS-2 patches; 6 h later, it was present at 93 % of OCP-patch and 100 % of LTS-2 patch sites. CONCLUSIONS: The data suggest that safety, tolerability and ability to detect infections of the LTS-2 patch are comparable to those of the OCP-patch. They qualify the LTS-2 patch for field studies to determine LTS-2 patch sensitivity, specificity and utility during large scale use and thus to inform use of the LTS-2 patch by onchocerciasis control programmes to determine prevalence of infection. TRIAL REGISTRATION: Current controlled Trials ISRCTN76875372 .

Useful field of view as a reliable screening measure of driving performance in people with Parkinson's disease: results of a pilot study.

PURPOSE: To determine the correlations of the Useful Field of View (UFOV), compared to other clinical tests of Parkinson's disease (PD); vision; and cognition with measures of on-road driving assessments and to quantify the UFOV's ability to indicate passing/failing an on-road test in people with PD. METHODS: Nineteen randomly selected people with idiopathic PD, mean age = 74.8 (6.1), 14 (73.7%) men, 18 (94.7%) Caucasians, were age-matched to 104 controls without PD. The controls had a mean age of 75.4 (6.4), 59 (56.7%) men, 96 (92.3%) Caucasians. Both groups were referred for a driving evaluation after institutional review board approval. RESULTS: Compared to neuropsychological and clinical tests of vision and cognition, the UFOV showed the strongest correlations (r > .75, p < 0.05) with measures of failing a standardized road test and number of driving errors. Among PD patients, the UFOV Risk Index score of 3 (range 1-5) was established as the optimal cutoff value for passing the on-road test, with sensitivity 87 percent and specificity 82 percent, AUC = 92 percent (SE 0.61, p = .002). Similarly, the UFOV 2 (divided attention) optimum cutoff value is 223 ms (range 16-500 ms), sensitivity 87.5 percent, specificity 81.8 percent, AUC = 91 percent (SE 0.73, p = .003). The UFOV 3 (selected attention) optimal cutoff value is 273 ms (range 16-500 ms), sensitivity 75 percent, specificity 72.7 percent, AUC = 87 percent (SE 0.81, p = .007). CONCLUSION: In this pilot study among PD patients, the UFOV may be a superior screening measure (compared to other measures of disease, cognition, and vision) for predicting on-road driving performance but its rigor must be verified in a larger sample of people with PD.

Ivermectin selection on beta-tubulin: evidence in Onchocerca volvulus and Haemonchus contortus.

Ivermectin resistance is common in trichostrongylid nematodes of livestock, such as Haemonchus contortus. This anthelmintic is the only drug approved for mass administration to control onchocerciasis caused by the nematode parasite, Onchocerca volvulus. In parts of West Africa up to 18 rounds of ivermectin treatment have been administered to communities and there are reports of poor parasitological responses to treatment. Understanding ivermectin resistance and ivermectin selection is an important step to reduce selection pressure for resistance, and to develop molecular markers which can be used to monitor the development of resistance and its spread. Here we report evidence that ivermectin selection changes the frequency of beta-tubulin alleles in both the sheep parasite, H. contortus, and the human parasite, O. volvulus. In O. volvulus we have been able to look at the frequency of beta-tubulin alleles in O. volvulus obtained before any ivermectin was used in humans in Africa, and following its widespread use. In H. contortus, we have been able to look at the frequency of beta-tubulin alleles in a strain which has not seen any anthelmintic selection and in an ivermectin selected strain derived from the unselected strain. We have found ivermectin selects on beta-tubulin in both of these nematode species. In the case of O. volvulus, we had previously reported that ivermectin selects for specific single nucleotide polymorphisms in the O. volvulus beta-tubulin gene. This polymorphism results in three amino acid changes in the H3 helix of beta-tubulin, as well as deletions in an associated intron. We report a simple PCR assay to detect the amplicon length polymorphism, resulting from these intronic deletions, which can be used to monitor the frequency of the beta-tubulin allele selected for by ivermectin in O. volvulus.

The safety, tolerability and pharmacokinetics of levamisole alone, levamisole plus ivermectin, and levamisole plus albendazole, and their efficacy against Onchocerca volvulus.

Two randomized, double-blind, placebo-controlled trials, in which levamisole (2.5 mg/kg) was given alone or co-administered with ivermectin (200 microg/kg) or albendazole (400 mg), were conducted. In Trial 1, safety and drug-drug interaction were explored in 42 healthy male volunteers. During Trial 2, the safety of the same treatment regimens and their efficacy against the adult worms and microfilariae of Onchocerca volvulus were investigated in 66 infected subjects of both sexes. Safety was determined from the results of detailed clinical and laboratory examinations before treatment, during hospitalization and on day 30. The pharmacokinetic parameters for levamisole alone and the combinations were determined in Trial 1 and then compared with historical data for ivermectin and albendazole, given as single agents, to determine if drug-drug interaction had occurred. The level of efficacy against the adult worms was determined by the examination of histology sections of nodules excised 6 months posttreatment and from the changes seen in the levels of microfilaridermia within a year of treatment. Microfilaricidal efficacy was estimated from the reductions in the levels of microfilaridermia between day 0 (1 day pre-treatment) and day 30. Although the regimens were generally well tolerated, there were unexpected adverse effects in both healthy volunteers and infected subjects. Clinically significant drug-drug interactions resulted in an increase in the bio-availability of ivermectin but a reduction in that of albendazole when these drugs were co-administered with levamisole. Levamisole given alone or with albendazole had little effect on O. volvulus. The combination of levamisole with ivermectin was neither macrofilaricidal nor more effective against the microfilariae and the adult worms than ivermectin alone. The pathogenesis of the adverse events and the drug-drug interactions are discussed.

Thirty-month follow-up of sub-optimal responders to multiple treatments with ivermectin, in two onchocerciasis-endemic foci in Ghana.

The pathogenesis of the sub-optimal response of Onchocerca volvulus to ivermectin was investigated in a 30-month follow-up of 28 individuals who, in a previous study, had been found to show a sub-optimal (N = 15) or adequate response (N = 13) to multiple treatments with the drug. Verbal informed consent was obtained before each subject was given a general clinical and ocular examination. Skin snips were taken from both iliac crests and both calves. Seventeen nodule carriers were hospitalized for nodulectomy. Adult worms were harvested, embryogrammes were constructed and all developmental stages were counted; degenerate, stretched microfilariae were noted separately. All the subjects were in good general health and all except one had received at least one additional treatment with ivermectin since the earlier study. A large proportion of the adult female worms in 10 out of the 11 sub-optimal responders who were nodule carriers were in full embryonic production but most of the stretched microfilariae they carried were degenerate. This picture is similar to that found in adult worms exposed to the first dose of ivermectin. In one subject who had no viable worms in his nodules, the existence of occult but actively reproductive worms was inferred from the high level of microfilaridermia observed less than 12 months after treatment. These observations confirm the existence of populations of adult female O. volvulus that respond poorly to repeated doses of ivermectin. The use of suramin in the treatment of the sub-optimal responders is discussed.

An investigation of persistent microfilaridermias despite multiple treatments with ivermectin, in two onchocerciasis-endemic foci in Ghana.

If ivermectin-based programmes for the control of human onchocerciasis are to be successful, the drug must remain effective for as long as necessary. In an open, case-control study, an attempt was made to determine if the persistent, significant, Onchocerca volvulus microfilaridermias seen in some individuals who had received at least nine treatments with ivermectin were the result of the development of drug resistance in the parasite. Twenty-one of these 'sub-optimal' responders (cases) were matched, by age, weight, number of treatments, locality and skin microfilarial counts, with seven amicrofilaridermic responders and 14 ivermectin-naive subjects. The number of treatments taken, any potential drug interactions and significant underlying disease were determined from detailed clinical and laboratory studies. Each subject was treated with ivermectin during the study, so that plasma concentrations of the drug could be determined for 72 h from the time of dosage. The microfilarial and adult-worm responses to this treatment were assessed from skin microfilarial counts (obtained before the treatment and at days 8, 90 and 365 post-treatment), day-90 embryogrammes, and the results of fly-feeding experiments. Parasite-sensitivity criteria for various time-points were derived from earlier data on skin microfilaridermias and the effects of ivermectin on the adult worms. The results indicate that the significant microfilaridermias that persist despite multiple treatments with ivermectin are mainly attributable to the non-response of the adult female worms and not to inadequate drug exposure or other factors. The possibility that some adult female worms have developed resistance to ivermectin cannot be excluded. These results justify the routine monitoring of treatment efficacy in any ivermectin-based programme of disease control.

The co-administration of ivermectin and albendazole--safety, pharmacokinetics and efficacy against Onchocerca volvulus.

A randomized, double-blind, placebo-controlled trial was conducted, to determine whether the co-administration of ivermectin with albendazole is safe and more effective against Onchocerca volvulus than ivermectin alone, and whether a significant pharmacokinetic interaction occurs. Forty-two male onchocerciasis patients received ivermectin (200 mug/kg) alone, albendazole (400 mg) alone or the combination. Safety was determined from the results of detailed clinical and laboratory examinations before treatment, during hospitalization and on day 30. Microfilaricidal efficacy was estimated from the reductions in skin counts between day 0 (pretreatment) and day 30. To determine efficacy against the adult worms, two independent observers examined histology slides prepared from nodules excised on day 180; changes in the skin counts of skin microfilariae between days 30 and 365 provided additional indicators of the level of adulticidal activity. Pharmacokinetic parameters for ivermectin and albendazole sulphoxide were defined over 72 h post-treatment. The co-administration of ivermectin with albendazole did not produce more severe adverse effects than ivermectin alone. Both nodule examiners found that the combination was not macrofilaricidal and that it was not clearly superior to ivermectin alone in the effects on reproductive activity; this was supported by the similar efficacy of the two regimens in the suppression of skin microfilariae. There was no significant pharmacokinetic interaction. Although the co-administration of ivermectin with albendazole appears safe, it offers no advantage over ivermectin alone in the control of onchocerciasis. The combination does not require an alteration in the dosage of either component.

Comparison between the skin snip test and simple dot blot assay as potential rapid assessment tools for Onchocerciasis in the postcontrol era in Ghana.

Successful control of onchocerciasis through mass distribution of ivermectin needs to be coupled with reliable, sensitive, specific, yet affordable diagnostic methods to monitor and ensure the efficacy of such measures. The effort put into the development of diagnostic methods for onchocerciasis that can substitute for or work in combination with the present "gold standard," the skin snip test, has resulted in the discovery of a number of immunogenic proteins with potential use as diagnostic tools in the postcontrol era. Most of these proteins have now been produced through recombinant DNA techniques. However, when costs are not a trivial issue, none of them have yet found their way into the areas where the disease still exists. In the present study, we have evaluated the performance of a simple dot blot assay which uses a mixture of native proteins designated PakF as a serious contender in the quest for a less invasive and more sensitive method to detect Onchocerca volvulus infection in areas with diverse endemicities. Our results indicate that the assay we propose is more sensitive than the skin snip test and shows high specificity, both characteristics required for a suitable tool for the monitoring of onchocerciasis in the postcontrol era.

An analysis of the safety of the single dose, two drug regimens used in programmes to eliminate lymphatic filariasis.

This review of the safety of the co-administration regimens to be used in programmes to eliminate lymphatic filariasis (albendazole + ivermectin or albendazole + diethylcarbamazine [DEC]) is based on 17 studies conducted in Sri Lanka, India, Haiti, Ghana, Tanzania, Kenya, Ecuador, the Philippines, Gabon, Papua New Guinea, and Bangladesh. The total data set comprises 90,635 subject exposures and includes individuals of all ages and both genders. Results are presented for hospital-based studies, laboratory studies, active surveillance of microfilaria-positive and microfilaria-negative individuals, and passive monitoring in both community-based studies and mass treatment programmes of individuals treated with albendazole (n = 1538), ivermectin (9822), DEC (576), albendazole + ivermectin (7470), albendazole + DEC (69,020), or placebo (1144). The most rigorous monitoring, which includes haematological and biochemical laboratory parameters pre- and post-treatment, provides no evidence that consistent changes are induced by any treatment; the majority of abnormalities appear to be sporadic, and the addition of albendazole to either ivermectin or DEC does not increase the frequency of abnormalities. Both DEC and ivermectin show, as expected, an adverse event profile compatible with the destruction of microfilariae. The addition of albendazole to either single-drug treatment regimen does not appear to increase the frequency or intensity of events seen with these microfilaricidal drugs when used alone. Direct observations indicated that the level of adverse events, both frequency and intensity, was correlated with the level of microfilaraemia. In non microfilaraemic individuals, who form 80-90% of the 'at risk' populations to be treated in most national public health programmes to eliminate lymphatic filariasis (LF), the event profile with the compounds alone or in combination does not differ significantly from that of placebo. Data on the use of ivermectin + albendazole in areas either of double infection (onchocerciasis and LF), or of loiais (with or without concurrent LF) are still inadequate and further studies are needed. Additional data are also recommended for populations infected with Brugia malayi, since most data thus far derive from populations infected with Wuchereria bancrofti.

The effects of high-dose ivermectin regimens on Onchocerca volvulus in onchocerciasis patients.

Ivermectin, at the standard dose of 150 micrograms/kg bodyweight, does not kill the adult worms of Onchocerca volvulus and does not disrupt embryogenesis or spermatogenesis. Repeated standard doses, if maintained, arrest microfilarial production but result in only a mild-to-modest macrofilaricidal effect. We investigated whether high doses would effectively kill the adult worms, and whether cessation of microfilarial production could be reproduced by an equivalent, single, high dose. One hundred men participated in a double-blind placebo-controlled trial and received increasing doses of ivermectin from 150 micrograms/kg to 1600 micrograms/kg bodyweight. Nodules were excised at day 180 and examined by histopathology. Total doses of ivermectin up to 1600 micrograms/kg were not significantly more effective than 150 micrograms/kg. Moreover, they did not reproduce the marked inhibitory effects of the repeat standard-dose regimens on embryogenesis, nor the modest effect on adult worm viability, at comparable total doses. These effects may be functions of multiplicities of dosages rather than of the total dose. Our findings also suggest that repeated high-dose regimens are unlikely to be more effective than a similar number of 150 micrograms/kg doses. This deficiency of ivermectin requires that the search for macrofilaricides remains a top priority.

Eosinophil sequestration and activation are associated with the onset and severity of systemic adverse reactions following the treatment of onchocerciasis with ivermectin.

To investigate the role of eosinophil activation and sequestration in the development and severity of adverse reactions after the treatment of Onchocerca volvulus infection, 40 O. volvulus-infected Ghanaians were randomized to receive placebo or standard- or high-dose ivermectin. Subjects were examined for typical physiologic and clinical events before and up to 48 h after treatment. Plasma samples were tested for interleukin (IL)-5 and eosinophil degranulation products (e.g., eosinophil-derived neurotoxin, EDN). After treatment, peripheral eosinophil counts declined in ivermectin-treated groups (P<.001), whereas circulating levels of IL-5 (P<.01) and EDN (P<.05) increased. Cumulative levels of IL-5 and EDN correlated with reaction scores (P<.01). High-dose ivermectin was associated with more-severe reactions, more-profound eosinopenia, and higher circulating levels of IL-5 and EDN, compared with the standard dose. These results suggest that eosinophil sequestration and activation/degranulation are associated with the initiation and severity of ivermectin-associated adverse reactions.

The safety and efficacy of amocarzine in African onchocerciasis and the influence of ivermectin on the clinical and parasitological response to treatment.

The hundred men from a forest area of Ghana, without vector control or ivermectin distribution, were randomized to receive a single dose of ivermectin (150 micrograms/kg body weight) on day 1 followed by amocarzine (3 mg/kg twice daily after meals) on days 8, 9 and 10 (34 patients), the ivermectin alone (33 patients) or the amocarzine alone (33 patients). Detailed clinical and laboratory examinations were made before, during and after drug administration. On day 120, all palpable nodules were excised, fixed, sectioned, stained and examined by two blinded observers and the results compared with those for nodules from untreated controls. Mazzotti-type reactions, such as itching, rash, peripheral sensory phenomena and swellings, were more severe or frequent with amocarzine than ivermectin. Pretreatment with ivermectin markedly suppressed these reactions to amocarzine but did not affect other manifestations such as dizziness and gaze-evoked nystagmus. Ocular effects were minor in all groups. Ivermectin produced minor macrofilaricidal effects on the adult male worms, marked degeneration of intra-uterine embryos, and potent microfilaricidal effects and suppressed skin microfilariae. Amocarzine did not affect the male worms or the intra-uterine embryos, was a less potent microfilaricide and did not suppress skin microfilariae. The efficacy of ivermectin plus amocarzine was similar to that of ivermectin alone. The present results do not support the findings from the Americas and show that amocarzine has no role in the treatment of onchocerciasis in Africa.

Research notes from the Onchocerciasis Chemotherapy Research Centre, Ghana.

Brief notes are given on drugs which have been tested at the Onchocerciasis Chemotherapy Research Centre at Tamale and Hohoe and found to have activity against Onchocerca volvulus. Ivermectin in single doses as high as 800 micrograms/kg was found to be no more effective than the standard dose of 150 micrograms/kg. The benzimidazole carbamates, mebendazole and albendazole, differ in their effects on O. volvulus. The former has microfilaricidal effects and is toxic to developing embryos surrounded by an egg shell but not the stretched microfilariae. Albendazole has no microfilaricidal activity but is toxic to all intra-uterine stages. The reasons for these differences are unclear. Early studies with amocarzine are described; the maximum tolerable dose is 20 mg/kg and the predominant activity, against the microfilariae, is marked only at doses greater than 12 mg/kg. None of the drugs tested has macrofilaricidal activity.

Immunoregulation in onchocerciasis: persons with ocular inflammatory disease produce a Th2-like response to Onchocerca volvulus antigen.

To examine the role of specific cytokines in mediating the clinical manifestations of human onchocercal disease, microfilariae-positive Ghanaian subjects with inflammatory ocular disease were compared with microfilariae-positive subjects without ocular disease. Onchocerca volvulus antigen (OvAg)-stimulated peripheral blood mononuclear cells (PBMC) from subjects with disease produced significantly more interleukin (IL)-10 (with disease = 447.34 vs. without disease = 292.22 pg/mL; P < .01) and IL-5 (with disease = 33.36 vs. without disease = 27.26 pg/mL; P = .02). OvAg-stimulated IL-4 and interferon (IFN)-gamma levels were essentially undetectable in either group. When cytokine mRNA levels were measured by reverse transcriptase-polymerase chain reaction ELISA, persons with disease produced significantly more OvAg-stimulated IL-4, IL-5, and IL-10 mRNA (P = .03, < .01, .05, respectively). No difference in IFN-gamma mRNA production by either group was seen. Addition of neutralizing alpha IL-10 antibody to OvAg-stimulated PBMC increased TFN-gamma production to detectable levels in 20 of 24 persons.

Elevations in granulocyte-macrophage colony-stimulating factor and interleukin-5 levels precede posttreatment eosinophilia in onchocerciasis.

The eosinophil survival assay was used to quantitate cytokines in 17 serial serum samples from 10 patients treated for onchocerciasis with diethylcarbamazine. Eosinophils isolated from normal donors were cultured for 4 days in the presence of patients' sera, and cell viability was determined. Serum specimens from 9 of 10 patients enhanced eosinophil survival from 4.8% +/- 2.2% (mean +/- SE) before treatment to 50.0% +/- 6.4% after treatment. Survival enhancement activity peaked before posttreatment eosinophilia. Antibodies to interleukin (IL)-5, granulocyte-macrophage colony-stimulating factor (GM-CSF), and IL-3 were used to block cytokine activity in 22 serum samples. Antibodies to IL-5 blocked survival in 5 samples, antibodies to GM-CSF blocked survival in 6 samples, and a combination of antibodies to IL-5 and GM-CSF blocked survival in 8 additional samples. Overall, posttreatment sera from patients treated for onchocerciasis enhanced eosinophil survival; both GM-CSF and IL-5 may promote the posttreatment eosinophilia in filarial infection.

Field diagnosis of onchocerciasis in an area of high versus low endemicity: evaluation of the Dot Blot Assay.

Parasitological examination of skin snips is the most widely used diagnostic method for onchocerciasis, but it is associated with inconvenience and low sensitivity. We describe an inexpensive antibody-based dot blot assay (DBA) for the detection of Onchocerca volvulus infection. A field evaluation of this method was performed in the onchocerciasis endemic country Ghana by testing 370 individuals living in a highly onchocerciasis endemic area and 122 in an area of low endemicity. Sera from individuals with other filarial infections were also tested. The DBA was able to detect 95% of the parasitologically confirmed infected individuals in the highly endemic area. Cross-reactivity occurred with a minority of the sera from individuals infected with other filarial worms. The DBA was as good as or superior to presently available diagnostic tests, and it also fulfilled the criteria for a good screening method.

The chemotherapy of onchocerciasis XX: ivermectin in combination with albendazole.

Ivermectin is a potent microfilaricide that also blocks microfilarial release while albendazole is toxic to all intrauterine stages. We investigated whether their combination would permanently sterilize the adult worms. In the first open phase, all 69 patients received 150 micrograms/kg of ivermectin. In the second double-blind phase one week later, 35 patients were randomized to receive 800 mg of albendazole with a fatty breakfast for three consecutive days while 34 patients received matching placebo tablets. Detailed clinical and laboratory examinations were done before treatment and were repeated at intervals over one year. Nodules were excised at three and six months. There was a rapid reduction in skin microfilariae, maximal at four weeks (99.9%). Counts increased subsequently and were between 11 and 18% of initial values at one year. Nodule histology showed no macrofilaricidal activity of the combination. A high proportion of the stretched intrauterine microfilariae were degenerate in both groups. Anterior chamber microfilarial counts were unchanged until day 18 and then fell successively. Low levels persisted in several patients at one year. Dead corneal microfilariae and corneal punctate opacities increased initially, fell with time and then disappeared in most patients. Systemic and ocular reactions were mild to moderate and biochemical abnormalities were minor. A pronounced posttreatment eosinophilia subsided by day 30. There was no significant difference between the two groups in clinical and laboratory tolerance or in alterations in skin and ocular parasites and no important differences in the effect on the adult worms. The combination of ivermectin with albendazole given one week apart is well tolerated but produces no additional effect against Onchocerca volvulus when compared to ivermectin given alone.

The chemotherapy of onchocerciasis. XIX: The clinical and laboratory tolerance of high dose ivermectin.

Ivermectin is the drug of choice for the treatment of onchocerciasis. However at the recommended dose of 150 micrograms/kg, it neither kills nor permanently sterilises the adult worms. We investigated whether high doses given with and without a preceding 150 micrograms/kg 'clearing' dose would be tolerable as well as effective against the adult worms. Seventy-five healthy males with moderate to heavy infections with Onchocerca volvulus were enrolled in a double-blind trial to receive one of the following treatment regimens: 150 micrograms/kg followed by placebo (9 patients); 400 micrograms/kg with (9 patients) or without (16 patients) a clearing dose; 600 micrograms/kg with (8 patients) or without (16 patients) a clearing dose and 800 micrograms/kg with (8 patients) or without (9 patients) a clearing dose. Detailed examinations were conducted before and at various times after treatment. A preliminary report on the clinical and laboratory safety as at 30 days is presented. All the regimens were well tolerated. No clinical or laboratory drug related effects were observed. The overall severity of the Mazzotti reaction was similar in all groups. Ocular reactions were minimal and there were no changes in ocular function or in fluorescein angiograms. The groups were similar in the extent of microfilaricidal activity; there was however a suggestion that microfilariae were killed more rapidly at 400 micrograms/kg and 600 micrograms/kg but not at 800 micrograms/kg. This needs further study. Single doses of ivermectin up to 800 micrograms/kg are well tolerated; no special precautions for treatment monitoring are required and a 'clearing' dose is not necessary.

The chemotherapy of onchocerciasis XVIII. Aspects of treatment with suramin.

We report the clinical and parasitological effects of a modified treatment regimen for suramin. Twenty adult males received up to 5 g (72.5 to 84.7 mg/kg) of suramin over 36 days. Detailed clinical and laboratory examinations were done before treatment and then at intervals over 2 years. Nodules were removed at 6, 13, 26 and 52 weeks for histology. Systemic tolerance was good. Anterior segment inflammation was however common and 2 patients required intervention to prevent posterior synechiae. No new posterior segment lesions developed; a rare improvement occurred in one patient with papillitis. Proteinuria, mostly mild, occurred in nearly all patients. Previously unreported renal glycosuria was documented in one patient. Microfilariae in the skin and anterior chamber did not change significantly for 5 or more weeks after which rapid reductions occurred. Ocular parasites were absent at 2 years and skin microfilariae were near zero. Peripheral blood eosinophil counts fell in parallel with those of microfilariae in the skin and anterior chamber and were normal at one and two years. These findings at 2 years may provide indirect evidence of a macrofilaricidal or a permanent chemosterilant effect on the adult worms. Nodule examination revealed an embryotoxic effect from week 6, a lethal effect on the male worms from month 3 and on the female worms from month 6 after treatment started. At one year 34% of the female worms examined were alive. Thus total doses of suramin in the range 72.5 to 84.7 mg/kg have only a modest lethal effect on the female worms. Suramin remains a restricted drug and a suitable replacement is urgently needed.

Evaluation of ultrasonography for the detection of drug-induced changes in onchocercal nodules.

Clinical trials of macrofilaricidal drugs against Onchocerca volvulus are impeded due to the lack of means for assessing in vivo drug-induced changes in the onchocercomas. The application of ultrasonography in the sequential monitoring of morphologic alterations of onchocercal nodules after six weeks of suramin therapy was evaluated in 20 male patients from Ghana with a total of 64 nodule sites. After each follow-up session, a number of onchocercal nodules were extirpated so that by the end of one year, all nodules had been removed for histologic examination. The sonomorphologic changes observed and their time of appearance correlated well with the histologic findings of the onchocercomas. Eighty-three percent of the onchocercal nodules became hyperechogenic and 22% developed echo-free areas at the end of the follow-up period. Absence of the lateral acoustic shadow increased by more than 30% and the lack of differentiation of the worm center from the capsule and the nodule from its surrounding tissue increased by the end of one-year posttreatment to 100% and 91%, respectively. A mean reduction of nodule size of 27% was also documented. The histologic studies revealed that the proportion of the dead female worms increased from 17% at the end of the suramin therapy to 48% six months later and reached 61% at one year. It is concluded that ultrasonographic monitoring of onchocercomas can provide essential information on drug effects and facilitate clinical trials of macrofilaricidal drugs, limiting histologic evaluation to a few objectively selected onchocercomas.