A recurring disease outbreak following litchi fruit consumption among children in Muzaffarpur, Bihar-A comprehensive investigation on factors of toxicity.

Litchi fruits are a nutritious and commercial crop in the Indian state of Bihar. Litchi fruit contains a toxin, methylene cyclopropyl-glycine (MCPG), which is known to be fatal by causing encephalitis-related deaths. This is especially harmful when consumed by malnourished children. The first case of litchi toxicity was reported in Bihar in 2011. A similar event was recorded in 2014 among children admitted to the Muzaffarpur government hospital, Bihar. Litchi samples sent to ICMR-NIN were analyzed and MCPG was found to be present in both the pulp and seed of the fruit. Diethyl phosphate (DEP) metabolites were found in the urine samples of children who had consumed litchi fruit from this area indicating exposure to pesticide. The presence of both MCPG in litchi and DEP metabolites in urine samples highlights the need to conduct a comprehensive investigation that examines all factors of toxicity.

Observation on Treatment of Drug Resistant Kala-azar Patients with Fungizone in Patna, Bihar.

54 cases of drug resistant kala-azar patients, some cases were resistant to sodium stibogluconate, some to even single dose of ambisome and some to miltefosine came to us for treatment. All necessary investigations were done and splenic aspirations were positive for LD bodies. All these patients were treated with Fungizone at a dose of 1mg/kg body wt diluted with 5% glucose and given slowly in 4 hours. On the day 21st splenic aspiration was done and other necessary investigations were repeated. LD body was not found in any splenic aspirate except one case with HIV. Initially all the patients were divided into two groups, one group was fed adequate milk during their course of treatment and other group adequate amount of fish in their diet. The patients in both the groups were compared in the end. There was no difference between two groups regarding parasitological clearance. All the patients had parasitological cure except one patient with HIV. The weight of the patients improved in both groups. The patient with HIV needed 3 courses of anti kala-azar drug to become negative for parasites of kala-azar i.e LD body. That cases was given treatment for HIV also. The moment he became negative of kala-azar, he fled away.

T cell suppression in the bone marrow of visceral leishmaniasis patients: impact of parasite load.

Visceral leishmaniasis (VL) is a disseminated and lethal disease of reticulo-endothelial system caused by protozoan parasites Leishmania donovani and L. infantum, which are known to induce host T cell suppression. To understand the impact of parasite load on T cell function, the present was focused on parasite load with T cell function in bone marrow of 26 VL patients. We observed significant enrichment of forkhead box protein 3 (FoxP3)+ (P = 0·0003) and interleukin (IL)-10+ FoxP3+ regulatory T cells (Treg ) (P = 0·004) in the bone marrow (BM) of patients with high parasite load (HPL) compared with low parasite load (LPL). Concordantly, T effector cells producing interferon (IFN)-γ (P = 0·005) and IL-17A (P = 0·002) were reduced in the BM of HPL. Blocking of Treg -cell derived suppressive cytokines [(IL-10 and transforming growth factor (TGF)-ß] rescued the effector T cells and their functions. However, it was observed that TGF-ß levels were dominant, favouring Treg cell differentiation. Furthermore, the low ratio of IL-6/TGF-ß favours the suppressive milieu in HPL patients. Here we show the change in levels of various cytokines with the parasitic load during active VL, which could be helpful in devising newer immunotherapeutic strategies against this disease.

Enrichment of invariant natural killer T cells in the bone marrow of visceral leishmaniasis patients.

Lipid antigens of Leishmania donovani like lipophosphoglycans are shown as a potent ligand for the activation of invariant natural killer T (iNKT) cells. It is reported that activation of iNKT cells augments the disease pathology in experimental visceral leishmaniasis (VL). In this study, we demonstrate the enrichment of iNKT cells in the bone marrow, one of the disease sites among patients with VL.

High concentration of adenosine in human visceral leishmaniasis despite increased ADA and decreased CD73.

Absence of an effective Th-1 response has been demonstrated as a major cause for the disease pathology among patients with visceral leishmaniasis (VL). Defining strategies to prevent the development of Th-2 response and/or initiate/activate effective Th-1 response may be of help to reduce the growing incidence of drug unresponsiveness. Adenosine, which is considered as an endogenous anti-inflammatory agent is generated in injured/inflamed tissues by the enzymatic catabolism of adenosine triphosphate (ATP), and it suppresses inflammatory responses of essentially all immune cells. The extracellular adenosine-producing pathway comprises two major enzymes CD39 (ATP → ADP → AMP) and CD73 (AMP → Adenosine). In contrast, the adenosine-degrading pathway contains only one major enzyme adenosine deaminase (ADA). Our study shows high concentration of adenosine in diseased condition, varying expression of enzyme involved in adenosine-producing (CD73↓) and adenosine-degrading (ADA↑) pathways. These are less studied in infections like VL but are very important in terms of endogenous regulation of immune response among patients.

Options for active case detection of visceral leishmaniasis in endemic districts of India, Nepal and Bangladesh, comparing yield, feasibility and costs.

BACKGROUND: The VL elimination strategy requires cost-effective tools for case detection and management. This intervention study tests the yield, feasibility and cost of 4 different active case detection (ACD) strategies (camp, index case, incentive and blanket approach) in VL endemic districts of India, Nepal and Bangladesh. METHODOLOGY/PRINCIPAL FINDINGS: First, VL screening (fever more than 14 days, splenomegaly, rK39 test) was performed in camps. This was followed by house to house screening (blanket approach). An analysis of secondary VL cases in the neighborhood of index cases was simulated (index case approach). A second screening round was repeated 4-6 months later. In another sub-district in India and Nepal, health workers received incentives for detecting new VL cases over a 4 month period (incentive approach). This was followed by house screening for undetected cases. A total of 28 new VL cases were identified by blanket approach in the 1(st) screening round, and used as ACD gold standard. Of these, the camp approach identified 22 (sensitivity 78.6%), index case approach identified 12 (sensitivity--42.9%), and incentive approach identified 23 new VL cases out of 29 cases detected by the house screening (sensitivity--79.3%). The effort required to detect a new VL case varied (blanket approach--1092 households, incentive approach--978 households; index case approach--788 households had to be screened). The cost per new case detected varied (camp approach $21 - $661; index case approach $149 - $200; incentive based approach $50 - $543; blanket screening $112 - $629). The 2(nd) screening round yielded 20 new VL cases. Sixty and nine new PKDL cases were detected in the first and second round respectively. CONCLUSIONS/SIGNIFICANCE: ACD in the VL elimination campaign has a high yield of new cases at programme costs which vary according to the screening method chosen. Countries need the right mix of approaches according to the epidemiological profile, affordability and organizational feasibility.

Amphotericin B therapy in children with visceral leishmaniasis: daily vs. alternate day, a randomized trial.

A randomized study was carried out to compare the efficacy and adverse reactions of daily vs. alternate day regimens of amphotericin B in children with visceral leishmaniasis (VL). Six hundred and five children of VL below 14 years of age were randomized into two groups; Group A (302), who received amphotericin B at a dose of 1 mg kg(-1) day(-1) for 15 days and Group B (303); same doses but on alternate days. All patients in both groups were cured, who had completed course of amphotericin B therapy. None had relapsed at 1 and 6 months of follow-up. Adverse reactions in both groups were non-significant. The duration of stay and cost of therapy was significantly lower in Group A children who left the hospital against medical advice, which was also significantly more in Group B. Thus, daily regimen of amphotericin B is equally effective, well tolerated, not more toxic and cost-effective than alternate day regimen, which is currently practiced.

Comparison of treatment regimens of kala-azar based on culture & sensitivity of amastigotes to sodium antimony gluconate.

BACKGROUND & OBJECTIVE: Present treatment strategies for kala-azar (visceral leishmaniasis, VL) include use of first line drug sodium antimony gluconate (SAG) to all patients but a large number of patients do not get relief with this drug. If a patient does not respond to a full course of SAG, a second or third line drug is given. We undertook this study to test whether an improved outcome can be achieved by employing a strategy of treatment based on culture and sensitivity of amastigotes to SAG compared with conventional empirical treatment. METHODS: In a double-blind, randomized, controlled trial done in Balaji Utthan Sansthan, Patna, of the 181 patients screened,140 were finally randomly allocated to two groups A and B; group A patients were treated with SAG if their amastigotes were sensitive to SAG, and all patients in group B were treated with SAG to start with. Primary outcome measured was as no relapse within 6 months of follow up after cure and other outcomes measured were period of stay of patients in hospital, expenditure involved in the treatment, and infectivity periods of two groups, two-third of treatment period and whole of untreated period were taken as infectivity period. SAG was used at a dosage of 20 mg/kg given deep intramuscular injections in buttock for 28 days, amphotericin B (AMB) given at a dose of 1 mg/kg body wt daily for 20 days as a slow intravenous infusion in 5 per cent dextrose. RESULTS: Of the 70 patients in group A, 29 patients whose amastigotes were sensitive to SAG were treated with SAG, 2 patients were withdrawn due to drug toxicity; and 2 relapsed within 6 months of follow up and ultimate cure occurred in 25 (86.2%) patients only. Of the 70 patients in group B treated with SAG, 5 (7.1%) patients withdrew due to drug toxicity, 35 patients (50%) did not respond to treatment, 5 (7.1%) relapsed during 6 months of follow up and thus only 25 patients (35.7%) were ultimately cured. The difference between the two groups was significant (P<0.001). No patient died during treatment due to any toxicity because of early withdrawal of patients from treatment apprehending toxicity. Patients whose amastigotes were resistant to SAG, withdrawn from the study due to SAG toxicity, relapsed after cure with SAG, and who did not respond to SAG in both the groups were treated with AMB and all were cured. Groups B and A patients spent 3065 and 2340 days respectively in hospital, group B 1.3 times more than group A. The likely period of spread of parasites in society was 1965 days in group B and 1644 days in group A, group B 1.4 times more than group A. The total expenditure on treatment in groups B and A was dollars 65,575 and dollars 50,590 respectively; group B patient had to spend 1.3 times more than group A. INTERPRETATION & CONCLUSION: A new strategy for treatment of kala-azar based on culture and sensitivity of amastigotes improved the cure rate, saved expenditure on the patient's treatment, patients had to stay for shorter periods in hospital and reduced the chance of spread of SAG resistant disease in society. Till the government opts for better drugs, the treatment based on culture and sensitivity of the parasites to SAG may be a better method.

Impact of amphotericin-B in the treatment of kala-azar on the incidence of PKDL in Bihar, India.

BACKGROUND & OBJECTIVE: Of the two reservoirs of infection of kala-azar i.e., patients of kala-azar and post kala-azar dermal leishmaniasis (PKDL), PKDL provides easy access for the sandfly to pick up the parasites. In the last epidemic of 1977 in India, the importance of PKDL as a potential cause of increase in number of kala-azar cases was ignored. During recent years, we found an increase in the cases of kalaazar whereas cases of PKDL were decreasing in Bihar. We undertook this study to find out reasons for this phenomenon. METHODS: These three different settings were selected to study the trends of the disease. (i) Cases of PKDL registered in the Dermatology Department of Patna Medical College Hospital (PMCH), one of the largest and oldest teaching hospital in Bihar, between 1970 and 2005; (ii) Rajendra Memorial Research Institute of Medical Sciences, Patna (RMRIMS), a research institute exclusively devoted to kala-azar (2000 and 2005); and (iii) interviews with two leading dermatologists of Patna selected by lottery on the incidence of PKDL and possible causes of its decrease, if any. The number of cases of kala-azar (visceral leishmaniasis, VL) from Bihar was studied from Malaria Departments of the Government of Bihar and Government of India, the two nodal departments dealing with the kala-azar. RESULTS: Analysis of data from Dermatology Department of PMCH showed increase in number of cases of PKDL from two in 1970 to 12 in 1976, a year before the first epidemic of kala-azar in 1977 with 100,000 cases. Kala-azar cases decreased to 11,120 in 1982 due to control measures taken between 1977- 1979 but cases of PKDL reached 28 and kept on increasing. During 1950 to 1977, low dose and short duration regimen of sodium antimony gluconate (SAG) was mainly used in the treatment of kala-azar. Between 1977-1991 increasing incidence of unresponsiveness to SAG, led to the usage of longer duration and higher dose regimen of SAG, more use of amphotericin B (AMB) for SAG resistant cases and also as a first line drug for kala-azar and PKDL. The number of kala-azar cases started decreasing after control measures taken during 1992-1994 but cases of PKDL continued decreasing. The effect of control measures on the incidence of kala-azar was visible upto 2002, but decrease in number of PKDL cases continued. In 2005 the number of PKDL cases was 14 but number of kala-azar cases reached 21,177 in Bihar. In the interview, the two dermatologists also opined that PKDL was decreasing due to increased use of amphotericin B in the treatment of kala-azar. Trend analysis done on the data of PMCH and RMRIMS showed that PKDL will decrease in coming years and kala-azar will increase. INTERPRETATION & CONCLUSION: Incidence of PKDL decreased in PMCH and RMRIMS and also suggested by two dermatologists that extensive use of amphotericin B in the treatment of kala-azar might be responsible for decrease in number of cases of PKDL.

Tetany in kala azar patients treated with paromomycin.

Paromomycin, an aminoglycoside, is known to cause several side effects like nephrotoxicity and ototoxicity like other aminoglycosides but tetany has not been reported. Three cases of tetany were detected in the patients of kala-azar treated with paromomycin. They were promptly treated with intravenous 10 per cent calcium gluconate and tetany was relieved immediately and treatment with paromomycin continued with oral calcium supplement. After completion of 21 days treatment with paromomycin patients' splenic aspirates were free of parasites. Paromomycin may cause temporary tubular damage leading to calcium wasting in urine and hypocalcaemia resulting in tetany. Prompt detection of symptoms and intravenous calcium gluconate treatment promptly reverse the situation.

Clinical and laboratory comparison of different brands of amphotericin B used for the treatment of Kala-azar: an observational study.

The communication presents clinical response of cases of visceral leishmaniasis to treatment by two different brands of Amphotericin B. Fungizone was found to be slightly better than Amphotericin B, however, the difference is not statistically significant.

A new strategy for elimination of kala-azar from rural Bihar.

BACKGROUND & OBJECTIVE: Bihar State of India has been an endemic State for kala-azar. There has been many phases of DDT sprays for vector control. An outbreak of kala-azar occurred in Goanpura, 6 km from Patna, Bihar, in 2003. We undertook this study with a new approach of kala-azar elimination in this village with priority to treatment of cases followed by supplementation with supervised DDT spray for vector control. METHODS: This study included a camp approach to collect patients at in the camp, screening of patients with rK-39, transporting the patients to the hospital of Balaji Utthan Sansthan, Patna, Bihar, confirming the diagnosis by demonstration of Leishman-Donovan (LD) bodies in splenic aspirates after proper clinical and pathological investigations, and treatment with amphotericin B (Fungizone) at a dose of 1mg/kg body wt for 20 days. If parasites persisted after 20 days, five more infusions were given. The State Government was persuaded to do supervised DDT spray as per the guidelines. All patients were followed up for 6 months for any relapse, and the village of Goanpura for 3 years for occurrence of any new case. RESULTS: A camp was held in that village on September 11, 2003 after due publicity. A total of 368 patients having different ailments, attended the camp; 25 patients were screened with rk-39 for kala-azar and 21 patients gave positive results. All 21 patients were shifted to Balaji Utthan Sansthan for treatment. After thorough clinical examination and pathological tests splenic aspiration was done. All 21 patients were positive for LD bodies. One patient died and the remaining 20 completed full course of treatment and were cured. No patients relapsed within six months of follow up. Two rounds of supervised DDT spray were done. No new case occurred in the village during three years of follow up. No sandfly was detected in the village during the years of follow up. INTERPRETATION & CONCLUSION: Camp strategy to collect patients at one place, screening of patients with rk-39, transporting rk-39 positive patients to the hospital, treatment with an effective drug amphotericin B with no incidence of unresponsiveness and relapsed minimized transmission of the disease; only two rounds of supervised intensive spray of DDT eliminated sandflies from the village. This new cost effective approach in which treatment of patients was done with an effective drug followed by supervised DDT spray may be adopted for elimination of kala-azar from Bihar.

Pharmacovigilance in kala-azar patients with severe thrombocytopenia caused by sodium antimony gluconate & miltefosine.

Sodium antimony gluconate (SAG) and miltefosine used in the treatment of kala-azar are known to cause several side effects but severe thrombocytopenia has not been reported. Four cases of severe thrombocytopenia, two caused by SAG and two by miltefosine were promptly detected and treated by immediate withdrawal of the offending drugs, platelet and blood transfusions and dexamethasone. After improvement Leishman-Donovan (LD) bodies were demonstrated in splenic aspirates of both patients of SAG group and one of miltefosine and they were treated with 1 mg/kg body wt of amphotericin B for 20 days and cured. One patient of miltefosine group treated outside only on the basis of rK-39 positivity did not show LD bodies in splenic aspirates and improved without any antikala- azar drug. None of the patients relapsed within 6 months of follow up. Prompt detection of side effects under the concept of pharmacovigilance can save life of such patients.

Oral miltefosine for the treatment of Indian visceral leishmaniasis.

Large-scale antimony resistance in the treatment of visceral leishmaniasis (VL) in north Bihar, India, has led to the development of miltefosine as an alternative therapy. In a pilot study and later in three Phase II studies involving 249 patients, oral miltefosine, 100-150 mg/day for 28 days, was shown to cure approximately 90% patients with reasonable safety. In the pivotal Phase III trial, 299 patients were treated at three centres with amphotericin B as the comparator drug (99 patients). In this trial 38% and 20% patients had mild to moderate vomiting and diarrhoea respectively, similar to previous studies. Asymptomatic transient elevation of hepatic transaminases and mild renal dysfunction were observed in 15% and 10% patients respectively. The final cure rate was 94% with miltefosine and 97% with amphotericin B; based on these results, the drug was approved in India. Subsequently in two paediatric studies involving 119 patients in the age group of 2-11 years, the safety and efficacy of miltefosine (2.5 mg/kg daily for 28 days) was established with a cure rate (94%) similar to that seen in adults. Miltefosine is the first oral antileishmanial drug with a high degree of safety and efficacy for the treatment of VL.

Epidemiological, clinical & pharmacological study of antimony-resistant visceral leishmaniasis in Bihar, India.

BACKGROUND & OBJECTIVES: Sodium antimony gluconate (SAG) is reported to be losing its efficacy in Bihar as a first line drug for treatment of visceral leishmaniasis (VL). Concerned with the increasing incidence of antimony-resistant VL patients in Bihar, we undertook an epidemiological, clinical and pharmacological study to formulate a scientific basis for choosing a suitable first line drug for VL. METHODS: Consecutive, fresh and parasitologically confirmed patients of VL from different geographical areas of Bihar were considered for inclusion in the study. Parasites isolated from patients were tested in vitro to assess their response to sodium antimony gluconate (SAG) to 20 microg/ml, response to 20 mg/kg of SAG for 5 days in experimentally induced VL in BALB/c mice from those isolates, and response to SAG in patients treated with SAG for 28 days. Similarly response in culture (1 microg/ml) to amphotericin B (AMB) of all 282 isolates, (1 mg/kg body wt for 20 days) in patients and infected BALB/c mice (1 mg/kg body wt for 5 days) was determined. Antimony levels of plasma were determined at 2, 8 and 24 h after intramuscular injection of SAG. Patients unwilling for SAG treatment or relapsed after SAG treatment and withdrawn from SAG group because of toxicity were treated with AMB. Plasma antimony levels were estimated by atomic absorption spectrometer. RESULTS: Though antimony sensitive and resistant patient were distributed in all 14 districts of Bihar studied, there was a significant variation from district to district. Of the 123 patients included in the SAG treatment group, 19 were withdrawn due to development of toxicity and 2 died; 178 patients were treated with AMB. No patient in AMB group developed any toxicity or died. Only 47 (46%) of 102 patients, 106 (37.6%) of 282 infected macrophages, 90 (52.9%) of 170 experimental infections were cured with SAG. Mc Nemar's test on paired comparisons showed statistical significance difference (P<0.01) between infected macrophage and experimental infection. AMB cured all patients, infected mice and cleared parasites from all isolates. INTERPRETATION & CONCLUSION: Antimony resistant strains of L. donovani were wide spread over different geographical areas in Bihar. SAG cured lesser percentage of VL cases clinically compared to AMB and should be replaced by AMB as a first line drug.

A comparative evaluation of amphotericin B and sodium antimony gluconate, as first-line drugs in the treatment of Indian visceral leishmaniasis.

In a study to evaluate the relative efficacies of sodium antimony gluconate (SAG) and amphotericin B (AMB), each drug was used to treat 60 Indian cases of visceral leishmaniasis (VL). At the time of treatment, each case had recently been parasitologically confirmed. The patients received either 20 mg SAG/kg daily, by intramuscular injection, for 4 weeks, or 1 mg AMB/kg daily, infused slowly over 2 h, with no incremental dosage, for 20 days. The response of the patients was followed clinically and by the microscopical examination of bone-marrow aspirates (BMA). The infected macrophages in subsamples of the BMA collected pre-treatment were cultured so that the drug sensitivities of the parasites, to 20 microg SAG or 1 microg AMB/ml medium, could be determined in vitro. Other subsamples of the BMA were used to set up promastigote cultures that were then used to infect BALB/c mice. The responses of the mice to 5 days of treatment with SAG or AMB (at the same daily dosages as used in the clinical trials) were subsequently explored. SAG only cured 46.6% of the patients given the drug, only cleared amastigotes from 38.3% of the macrophage cultures, and only cured 53.3% of the infected mice. The corresponding values for AMB - 100%, 100% and 100% - were markedly higher (P <0.001 for each comparison). Although nine patients had to be withdrawn from the SAG group (all because of cardiac toxicity), all of the patients given AMB completed their treatment without any serious adverse effects (P <0.01). Two of the patients withdrawn from the SAG arm died shortly after their withdrawal; earlier withdrawal may have saved them. At least in the setting of the present study, AMB appears far superior to SAG as a first-line drug against VL and should replace it.