Monitoring the response of patients with cutaneous leishmaniasis to treatment with pentamidine isethionate by quantitative real-time PCR, and identification of Leishmania parasites not responding to therapy.

BACKGROUND: Leishmania (Viannia) guyanensis is believed to be the principal cause of cutaneous leishmaniasis (CL) in Suriname. This disease is treated with pentamidine isethionate (PI), but treatment failure has increasingly been reported. AIM: To evaluate PI for its clinical efficacy, to compare parasite load, and to assess the possibility of treatment failure due to other infecting Leishmania species. METHODS: Parasite load of patients with CL was determined in skin biopsies using real-time quantitative PCR before treatment and 6 and 12 weeks after treatment. Clinical responses were evaluated at week 12 and compared with parasite load. In parallel, molecular species differentiation was performed. RESULTS: L. (V.) guyanensis was the main infecting species in 129 of 143 patients (about 90%). PI treatment led to a significant decrease (P < 0.001) in parasite counts, and cured about 75% of these patients. Treatment failure was attributable to infections with Leishmania (Viannia) braziliensis, Leishmania (Leishmania) amazonensis and L. (V.) guyanensis (1/92, 1/92 and 22/92 evaluable cases, respectively). There was substantial agreement beyond chance between the parasite load at week 6 and the clinical outcome at week 12, as indicated by the κ value of 0.61. CONCLUSIONS: L. (V.) guyanensis is the main infecting species of CL in Suriname, followed by L. (V.) braziliensis and L. (L.) amazonensis. Furthermore, patient response to PI can be better anticipated based on the parasite load 6 weeks after the treatment rather than on parasite load before treatment.

[More of the Surinam and Antilles drug addicts involved in the GG&GD (Community Medical and Health Service) methadone program in Amsterdam should be referred to the family physician for their methadone maintenance]. / Van de Surinaamse en Antilliaanse drugsverslaafden betrokken bij het GG&GD-methadonprogramma in Amsterdam zouden er meer voor hun methadonverstrekking bij de huisarts terechtkunnen.

OBJECTIVE: To study the possibility of referring Surinam and Netherlands Antillean drug users from a 'low-threshold' municipal methadone programme to general practice for methadone maintenance treatment. (Methadone maintenance treatment for drug users leads to a more regulated life and makes it possible to implement measures to ameliorate their living conditions.) Fewer Surinam and Netherlands Antillean drug users are referred to general practice than native Dutch drug users. DESIGN: Descriptive. SETTING: Municipal Health Service, Department of Mental Health, Unit on Drugs, Amsterdam, the Netherlands. METHOD: 141 Surinam and Netherlands Antillean drug users participating in the 'low-threshold' methadone programme were examined on the following items: psychiatric status, drug and alcohol abuse, judicial problems, relationships, personal care, insurance and housing. With these items the level of regulated drug use was assessed and the possible reference to general practice evaluated. RESULTS: 21% of the drugs user group was found to be well regulated. They could have been referred to general practice immediately. Another 18% were also well regulated but they received methadone on a daily basis at the moment of investigation; when they would have proven to manage methadone prescription on a weekly basis, they could also be referred to general practice. 61% could not be referred because they were addicted to benzodiazepines (22%) or alcohol (33%), lived in unsuitable housing (45%), had judicial problems (53%), psychiatric problems (30%) or no insurance (15%), or were very problematic drug users receiving Palfium (dextromoramide) through the 'low-threshold' municipal methadone programme (15%). CONCLUSION: Of Surinam and Netherlands Antillean drug users from a municipal methadone programme, approximately 20% could have been directly referred to general practice for their methadone maintenance treatment and 20% at a later stage, and 60% could not.