Genomic analysis of Plasmodium vivax describes patterns of connectivity and putative drivers of adaptation in Ethiopia.

Ethiopia has the greatest burden of Plasmodium vivax in Africa, but little is known about the epidemiological landscape of parasites across the country. We analysed the genomic diversity of 137 P. vivax isolates collected nine Ethiopian districts from 2012 to 2016. Signatures of selection were detected by cross-country comparisons with isolates from Thailand (n = 104) and Indonesia (n = 111), representing regions with low and high chloroquine resistance respectively. 26% (35/137) of Ethiopian infections were polyclonal, and 48.5% (17/35) of these comprised highly related clones (within-host identity-by-descent > 25%), indicating frequent co-transmission and superinfection. Parasite gene flow between districts could not be explained entirely by geographic distance, with economic and cultural factors hypothesised to have an impact on connectivity. Amplification of the duffy binding protein gene (pvdbp1) was prevalent across all districts (16-75%). Cross-population haplotype homozygosity revealed positive selection in a region proximal to the putative chloroquine resistance transporter gene (pvcrt-o). An S25P variant in amino acid transporter 1 (pvaat1), whose homologue has recently been implicated in P. falciparum chloroquine resistance evolution, was prevalent in Ethiopia (96%) but not Thailand or Indonesia (35-53%). The genomic architecture in Ethiopia highlights circulating variants of potential public health concern in an endemic setting with evidence of stable transmission.

Population pharmacokinetics of a combination of miltefosine and paromomycin in Eastern African children and adults with visceral leishmaniasis.

OBJECTIVES: To improve visceral leishmaniasis (VL) treatment in Eastern Africa, 14- and 28-day combination regimens of paromomycin plus allometrically dosed miltefosine were evaluated. As the majority of patients affected by VL are children, adequate paediatric exposure to miltefosine and paromomycin is key to ensuring good treatment response. METHODS: Pharmacokinetic data were collected in a multicentre randomized controlled trial in VL patients from Kenya, Sudan, Ethiopia and Uganda. Patients received paromomycin (20 mg/kg/day for 14 days) plus miltefosine (allometric dose for 14 or 28 days). Population pharmacokinetic models were developed. Adequacy of exposure and target attainment of paromomycin and miltefosine were evaluated in children and adults. RESULTS: Data from 265 patients (59% ≤12 years) were available for this pharmacokinetic analysis. Paromomycin exposure was lower in paediatric patients compared with adults [median (IQR) end-of-treatment AUC0-24h 187 (162-203) and 242 (217-328) µg·h/mL, respectively], but were both within the IQR of end-of-treatment exposure in Kenyan and Sudanese adult patients from a previous study. Cumulative miltefosine end-of-treatment exposure in paediatric patients and adults [AUCD0-28 517 (464-552) and 524 (456-567) µg·day/mL, respectively] and target attainment [time above the in vitro susceptibility value EC90 27 (25-28) and 30 (28-32) days, respectively] were comparable to previously observed values in adults. CONCLUSIONS: Paromomycin and miltefosine exposure in this new combination regimen corresponded to the desirable levels of exposure, supporting the implementation of the shortened 14 day combination regimen. Moreover, the lack of a clear exposure-response and exposure-toxicity relationship indicated adequate exposure within the therapeutic range in the studied population, including paediatric patients.

Atypical Mucocutaneous Leishmaniasis Presentation Mimicking Rectal Cancer.

Cutaneous leishmaniasis is a neglected tropical disease affecting mostly the exposed skin, causing severe and disfiguring lesions in Ethiopia. In this report, we present two cases of atypical mucocutaneous leishmaniasis; one HIV positive and one HIV negative patient. Cases. A 32-year-old male HIV patient presented with 40 days of bleeding per-rectum and a perianal lesion of 5 years. An erythematous nontender plaque measuring 5 cm by 5 cm was observed over the right perianal area with circumferential constricting firm swelling of the rectum. The patient was cured with AmBisome and miltefosine after an incisional biopsy revealed leishmaniasis. A 40-year-old presented with bleeding per-rectum and stool incontinence of 3 months, generalized body swelling of 2 months, and mass around his anus for ten years. A 6 by 3 cm indurated ulcerating mass surrounding the anus and a fungating circumferential mass of 8 cm were seen above the proximal anal verge. An excisional biopsy revealed leishmaniasis, and the patient was treated with AmBisome but passed away due to complications with colostomy diarrhea. Conclusion. Clinicians should consider atypical mucocutaneous leishmaniasis as a possible diagnosis in patients with chronic skin lesions resembling hemorrhoids and colorectal masses, especially in endemic areas such as Ethiopia, regardless of their HIV status.

Detection of asymptomatic Leishmania infection in blood donors at two blood banks in Ethiopia.

Visceral leishmaniasis (VL) is a disease caused by Leishmania parasites. While predominantly transmitted by sandflies, cases of VL transmitted through blood transfusion have been reported, particularly in immunocompromised recipients. Although Leishmania parasites have been found in blood donors in some VL endemic areas, this has never been studied in East-Africa, where HIV prevalence is relatively high. We established the prevalence of asymptomatic Leishmania infection and associated socio-demographic factors among blood donors presenting at two blood bank sites (Metema and Gondar) in northwest Ethiopia between June and December 2020. Metema is located in a VL-endemic area; Gondar has historically been considered VL non-endemic but as an outbreak of VL has occurred around Gondar, it was defined as previously VL non-endemic. Blood samples were tested by the rK39 rapid diagnostic test (RDT), rK39 ELISA, direct agglutination test (DAT) and qPCR targeting kinetoplast DNA (kDNA). Asymptomatic infection was defined as positive by any of these tests in a healthy person. A total of 426 voluntary blood donors were included. The median age was 22 years (IQR, 19-28 years); 59% were male and 81% resided in urban areas. Only one participant had a history of VL and three had a family history of VL. Asymptomatic infection was detected in 15.0% (n = 32/213) in Metema and 4.2% (n = 9/213) in Gondar. The rK39 ELISA was positive in 5.4% (n = 23/426), the rK39 RDT in 2.6% (11/426), PCR in 2.6% (11/420) and DAT in 0.5% (2/426). There were six individuals with two positive tests: one positive on rK39 RDT and PCR and five positive on rK39 RDT and ELISA. The prevalence of asymptomatic infection was higher in Metema (VL-endemic) and males but was not associated with age, a history of VL amongst family members or living in a rural area. Antibodies against Leishmania and parasite DNA was detected in a substantial number of blood donors. Future research should be directed at better defining the risk to recipients, including parasite viability studies and longitudinal studies amongst recipients.

Outcomes and Predictors of Severe Community-acquired Pneumonia Among Adults Admitted to the University of Gondar Comprehensive Specialized Hospital: A Prospective Follow-up Study.

Background: Severe community-acquired pneumonia is a common life-threatening infection with a high rate of unfavorable outcome. This study aimed to assess the outcomes and predictors of hospitalized severe community-acquired pneumonia patients at University of Gondar comprehensive specialized hospital. Methods: A prospective follow-up study was conducted at University of Gondar comprehensive specialized hospital from May 1 to September 31, 2021. The data was collected by reviewing patients' charts and interviewing the patients themselves. Descriptive statistics, binary and multivariable logistic regression analysis were performed accordingly. Variables with p-value <0.2 on binary logistic regression were analyzed using multivariable logistic regression and variables with p<0.05 were considered to have significant association. Results: A total of 239 admitted patients with severe community-acquired pneumonia were enrolled in the study. An unfavorable outcome was observed in 105 (44%) patients; 24.27% was in-hospital all-cause mortality, 12.5% was nonresolution, 5.8% was complicated cases, and 1.26% were gone against medical care for poor prognosis. After analyzing multivariable logistic regression, confusion (OR= 4.84; 95%CI: 1.47-15.88), anemia (OR= 2.36; 95%CI: 1.01-5.52), leukopenia (OR=4.38; 95%CI: 1.26-15.25), leukocytosis (OR=3.15; 95%CI: 1.23-7.96), elevated creatinine (OR=5.67; 95%CI: 1.72-18.65), intubation (OR=7.27; 95%CI: 1.58-33.37) and antibiotic revision during treatment for a different reason (OR=0.02; 95%CI: 0.01-0.07) were variables significantly associated with unfavorable outcome. Conclusion: Unfavorable outcome was high among hospitalized severe community acquired pneumonia patients, and confusion, elevated creatinine, anemia, leukopenia, leukocytosis, intubation during admission, and antibiotic revision during the course were independent predictors associated significantly with the unfavorable outcome. It is important to consider the development of a treatment protocol for the hospital and to further research incorporating the microbiologic profile of the patients.

PCR for detection of Leishmania donovani from microscopically negative tissue smears of suspected patients in Gondar, Ethiopia.

BACKGROUND: As untreated visceral leishmaniasis (VL) is fatal, reliable diagnostics are pivotal for accurate treatment allocation. The current diagnostic algorithm for VL in Ethiopia, which is based on the rK39 rapid diagnostic test and microscopy of tissue smears, lacks sensitivity. This probably leads to missed cases and patients not receiving treatment. METHODOLOGY: We conducted a retrospective study on stored microscopically negative spleen and bone marrow smears from suspected VL patients collected at the Leishmaniasis Research and Treatment Center (LRTC) in Gondar, northern Ethiopia between June 2019 and November 2020. Sociodemographic, clinical and treatment data were collected and samples were tested by real-time PCR targeting kinetoplast DNA. PRINCIPLE FINDINGS: Among the 191 eligible samples (135 spleen and 56 bone marrow) with a microscopically negative and valid PCR result, 119 (62.3%) were positive by PCR, although Ct values for some were high (median 33.0). Approximately three quarters of these undiagnosed primary VL (77.3%) and relapse (69.6%) patients did not receive antileishmanial treatment. Of the 56 microscopically negative bone marrow samples, 46 (82.1%) were PCR positive, which is considerably higher compared to the microscopically negative spleen samples, for which 73 out of 135 (54.1%) were PCR positive. The odds of being PCR positive were significantly higher for bone marrow aspirates and higher when white blood cell values were lower and splenomegaly (in cm) was more pronounced. CONCLUSIONS: This study demonstrates that a lot of suspected VL patients remain undiagnosed and untreated. This indicates the urgent need for better diagnostics for VL in the East-African region. The outcomes of PCR positive should be closely monitored and treatment should be provided if the patient deteriorates. In resource limited settings, implementation of PCR on bone marrow aspirate smears of patients with low WBC values and splenomegaly could lead to considerable improvements in patient management.

Paromomycin and Miltefosine Combination as an Alternative to Treat Patients With Visceral Leishmaniasis in Eastern Africa: A Randomized, Controlled, Multicountry Trial.

BACKGROUND: This study aimed to determine whether paromomycin plus miltefosine (PM/MF) is noninferior to sodium stibogluconate plus paromomycin (SSG/PM) for treatment of primary visceral leishmaniasis in eastern Africa. METHODS: An open-label, phase 3, randomized, controlled trial was conducted in adult and pediatric patients at 7 sites in eastern Africa. Patients were randomly assigned to either 20 mg/kg paromomycin plus allometric dose of miltefosine (14 days), or 20 mg/kg sodium stibogluconate plus 15 mg/kg paromomycin (17 days). The primary endpoint was definitive cure after 6 months. RESULTS: Of 439 randomized patients, 424 completed the trial. Definitive cure at 6 months was 91.2% (155 of 170) and 91.8% (156 of 170) in the PM/MF and SSG/PM arms in primary efficacy modified intention-to-treat analysis (difference, 0.6%; 97.5% confidence interval [CI], -6.2 to 7.4), narrowly missing the noninferiority margin of 7%. In the per-protocol analysis, efficacy was 92% (149 of 162) and 91.7% (155 of 169) in the PM/MF and SSG/PM arms (difference, -0.3%; 97.5% CI, -7.0 to 6.5), demonstrating noninferiority. Treatments were well tolerated. Four of 18 serious adverse events were study drug-related, and 1 death was SSG-related. Allometric dosing ensured similar MF exposure in children (<12 years) and adults. CONCLUSIONS: PM/MF and SSG/PM efficacies were similar, and adverse drug reactions were as expected given the drugs safety profiles. With 1 less injection each day, reduced treatment duration, and no risk of SSG-associated life-threatening cardiotoxicity, PM/MF is a more patient-friendly alternative for children and adults with primary visceral leishmaniasis in eastern Africa. CLINICAL TRIALS REGISTRATION: NCT03129646.

Efficacy, Safety, Tolerability, and Pharmacokinetics of MMV390048 in Acute Uncomplicated Malaria.

An open label, phase IIa study conducted in Ethiopia evaluated the efficacy, safety, tolerability, and pharmacokinetics of a single 120-mg dose of the phosphatidylinositol 4-kinase inhibitor MMV390048 in Plasmodium vivax malaria. The study was not completed for operational reasons and emerging teratotoxicity data. For the eight adult male patients enrolled, adequate clinical and parasitological response at day 14 (primary endpoint) was 100% (8/8). Asexual parasites and gametocytes were cleared in all patients by 66 and 78 hours postdose, respectively. There were two recurrent P. vivax infections (days 20 and 28) and a new Plasmodium falciparum infection (day 22). MMV390048 exposure in P. vivax patients was lower than previously observed for healthy volunteers. Mild adverse events, mainly headache and gastrointestinal symptoms, were reported by eight patients. Single-dose MMV390048 (120 mg) rapidly cleared asexual parasites and gametocytes in patients with P. vivax malaria and was well tolerated.

A molecular barcode and web-based data analysis tool to identify imported Plasmodium vivax malaria.

Traditionally, patient travel history has been used to distinguish imported from autochthonous malaria cases, but the dormant liver stages of Plasmodium vivax confound this approach. Molecular tools offer an alternative method to identify, and map imported cases. Using machine learning approaches incorporating hierarchical fixation index and decision tree analyses applied to 799 P. vivax genomes from 21 countries, we identified 33-SNP, 50-SNP and 55-SNP barcodes (GEO33, GEO50 and GEO55), with high capacity to predict the infection's country of origin. The Matthews correlation coefficient (MCC) for an existing, commonly applied 38-SNP barcode (BR38) exceeded 0.80 in 62% countries. The GEO panels outperformed BR38, with median MCCs > 0.80 in 90% countries at GEO33, and 95% at GEO50 and GEO55. An online, open-access, likelihood-based classifier framework was established to support data analysis (vivaxGEN-geo). The SNP selection and classifier methods can be readily amended for other use cases to support malaria control programs.

Snakebite case management: a cohort study in Northwest Ethiopia, 2012-2020.

INTRODUCTION: Timely and appropriate management of snakebites in the tropics is a lifesaver. Many snakebite patients are being bitten in remote rural areas and do not manage to get in due time to healthcare facilities. This study assessed the clinical features and the risk factors associated with treatment outcomes of snakebite patients admitted at two hospitals in the Northwest of Ethiopia. METHODOLOGY: In a retrospective cohort study, routinely collected data from 250 patients' medical charts at University of Gondar Hospital and Metema Hospital, between September 2012 and August 2020, were reviewed. RESULTS: The median age of the snakebite cases was 24 years (95% CI = 22-26), with 80.8% male patients. At admission 148/250 patients presented in Clinical stage 1 or 2 (local symptoms only) and 73.7% presented more than 12 hours after the bite, 80.2% received antibiotics and 79.0% antivenom. The median duration of hospitalization was 3 days (95% CI = 3-4); 72% of the patients recovered and were discharged, 10.8% died and 0.5% underwent an amputation. On logistic regression analysis, residence in rural areas (AOR = 2.52, 95 % CI = 1.2-5.3), sign of bacterial superinfection on the bite site (AOR = 4.69. 95% CI = 1.4-15.4), clinical stage 3 or 4 with systemic symptoms or toxic signs at admission (AOR = 4.84, 95% CI = 1.3-18.0) and no treatment with antivenoms (AOR = 6.65, 95% CI = 1.6-27.7) were associated with bad outcome (death, amputation and/or referred/ went against medical advice). CONCLUSIONS: Timely presentation at early clinical stage, appropriate clinical management and availability of antivenoms are cornerstones to reduce snakebite morbidity and mortality.

An open dataset of Plasmodium vivax genome variation in 1,895 worldwide samples.

This report describes the MalariaGEN Pv4 dataset, a new release of curated genome variation data on 1,895 samples of Plasmodium vivax collected at 88 worldwide locations between 2001 and 2017. It includes 1,370 new samples contributed by MalariaGEN and VivaxGEN partner studies in addition to previously published samples from these and other sources. We provide genotype calls at over 4.5 million variable positions including over 3 million single nucleotide polymorphisms (SNPs), as well as short indels and tandem duplications. This enlarged dataset highlights major compartments of parasite population structure, with clear differentiation between Africa, Latin America, Oceania, Western Asia and different parts of Southeast Asia. Each sample has been classified for drug resistance to sulfadoxine, pyrimethamine and mefloquine based on known markers at the dhfr, dhps and mdr1 loci. The prevalence of all of these resistance markers was much higher in Southeast Asia and Oceania than elsewhere. This open resource of analysis-ready genome variation data from the MalariaGEN and VivaxGEN networks is driven by our collective goal to advance research into the complex biology of P. vivax and to accelerate genomic surveillance for malaria control and elimination.

COVID-19 vaccine acceptability among healthcare workers in Ethiopia: Do we practice what we preach?

OBJECTIVE: We assessed healthcare workers (HCWs) COVID-19 vaccine acceptability in Ethiopia. METHODS: We carried out a cross-sectional survey from February to April 2021 in HCWs from five teaching hospitals. HCWs were selected using convenient sampling, and data were collected through a survey link. Descriptive analysis and mixed-effect logistic regression were performed. A total of 1,314 HCWs participated in the study. RESULTS: We found that 25.5% (n = 332) of the HCWs would not accept a COVID-19 vaccine and 20.2% (n = 264) were not willing to recommend COVID-19 vaccination to others. Factors associated with vaccine non-acceptance were female sex (AOR = 1.8; 95% CI: 1.3-2.5), the perception that vaccines are unsafe (AOR = 15.0; 95% CI: 8.7-25.9), not considering COVID-19 as health risk (AOR = 4.4; 95% CI: 2.0-9.5) and being unconcerned about contracting COVID-19 at work (AOR = 3.5; 95% CI: 1.5-8.4). Physicians were more willing to accept vaccination than other HCWs. Higher vaccine acceptability was also noted with increasing age. Participants most often indicated safety concerns as the determining factor on their decision to get vaccinated or not. CONCLUSION: Overall, a quarter of HCWs would not accept a COVID-19 vaccine. Communications and training should address vaccine safety concerns. Additionally, emphasis should be given to showing current and future impact of COVID-19 on the personal, public and country level unless control efforts are improved. Interventions aimed to increase vaccine uptake should focus their efforts on younger and non-physician HCWs.

Evaluation of the CL Detect Rapid Test in Ethiopian patients suspected for Cutaneous Leishmaniasis.

BACKGROUND: Cutaneous leishmaniasis (CL) is common in Ethiopia, mainly affecting impoverished populations in rural areas with poor access to health care. CL is routinely diagnosed using skin slit smear microscopy, which requires skilled staff and appropriately equipped laboratories. We evaluated the CL Detect Rapid Test (InBios, Washington, USA), which is supplied with a dental broach sampling device, as a diagnostic alternative which could be used in field settings. METHODOLOGY/PRINCIPAL FINDINGS: We evaluated the diagnostic accuracy of the CL Detect Rapid Test on skin slit and dental broach samples from suspected CL patients at the Leishmaniasis Research and Treatment Center in Gondar, Ethiopia. A combined reference test of microscopy and PCR on the skin slit sample was used, which was considered positive if one of the two tests was positive. We recruited 165 patients consecutively, of which 128 (77.6%) were confirmed as CL. All microscopy-positive results (n = 71) were also PCR-positive, and 57 patients were only positive for PCR. Sensitivity of the CL Detect Rapid Test on the skin slit was 31.3% (95% confidence interval (CI) 23.9-39.7), which was significantly higher (p = 0.010) than for the dental broach (22.7%, 95% CI 16.3-30.6). Sensitivity for both methods was significantly lower than for the routinely used microscopy, which had a sensitivity of 55.5% (IQR 46.8-63.8) compared to PCR as a reference. CONCLUSIONS/SIGNIFICANCE: The diagnostic accuracy of the CL Detect Rapid Test was low for skin slit and dental broach samples. Therefore, we do not recommend its use neither in hospital nor field settings. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov as NCT03837431.

Aetiologies of acute undifferentiated febrile illness at the emergency ward of the University of Gondar Hospital, Ethiopia.

OBJECTIVE: Causes of acute febrile illness (AFI) often remain undetermined in developing countries, due to overlap of symptoms and limited available diagnostics. We aimed to assess the aetiology of AFI in adults in a referral hospital in northwest Ethiopia. METHODS: While all participants were tested for malaria by rapid diagnostic test (RDT), microscopy was only done on physician's request. Dengue virus (DENV) infections were detected using an RDT and ELISAs and dengue, yellow fever and chikungunya cases were identified by PCR. Bacterial aetiologies were investigated using blood culture and PCR. RESULTS: The aetiology of acute infection was identified for 20.5% of 200 patients enrolled. Eleven percent tested positive for Plasmodium, while microscopy was only requested for half of the identified malaria cases. For 4.0% of the Plasmodium-infected patients, an acute or past DENV (co-)infection was detected. We found 7.5% acute and 13.0% past DENV - all serotype 3 - infections. Bacterial infections were observed in 4.5% of the patients. CONCLUSION: Malaria is still a considerable aetiology of AFI and dengue is underrecognised. There are areas where both diseases occur concomitantly, and the DENV-3 serotype presumably spreads from Sudan to northern Ethiopia. As only 20.5% of the aetiologies were identified, a broader testing platform is required.

Assessment of liver function test and associated factors among visceral leishmaniasis patients attending university of gondar leishmaniasis research and treatment center, Northwest Ethiopia.

BACKGROUND: Visceral leishmaniasis (VL) is one of the major public health burden, mainly distributed throughout tropical and subtropical regions of the world. Among the Sub-Saharan African countries, Ethiopia is the second most affected country with VL. An Alteration of liver function is a typical manifestation of the disease. OBJECTIVE: The purpose of conducting this study was to assess liver function tests and associated risk factors among VL patients at Leishmaniasis Research and Treatment Center of University of Gondar Comprehensive Specialized Hospital, North West Ethiopia. METHOD: Hospital based comparative cross-sectional study design was conducted. A total of 102 study participants were involved in this study. Newly diagnosed VL patients who were attended at Leishmaniasis Research and Treatment Center of University of Gondar Comprehensive Specialized Hospital from 21st February 2020 to 30th September 2020 were included under case group category. On the other hand, age-sex matched apparently healthy study subjects were categorized as control group. Written consent was obtained willingness of patients to participate after ethical clearance was obtained from the Institutional Review Board of School of Medicine, University of Gondar. After overnight fasting, 5ml venous blood was drawn from both VL patients and controls to evaluate liver function tests, including AST, ALT, total bilirubin, albumin, and total protein. Thus, senior health professionals (laboratory technologist) investigate the results using Cobas Integra 400 Plus clinical chemistry analyzer. Data was entered into Epi-data version 4.6 and exported to STATA 14 for analysis of liver function tests and associated risk factors. RESULT: The result of this study showed that significant mean difference was exhibited in aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, serum albumin, and total protein level among VL patients and controls. It showed that there was a statistically significant elevation in the level of AST, ALT, and total bilirubin among cases as compared to control. The serum AST level was significantly (p<0.001) elevated among cases as compared to controls. Serum ALT was significantly (p<0.001) elevated among cases compared to controls. Additionally, the total serum bilirubin level was significantly increased (P<0.001) among cases as compared to controls. There was a statistically significant (P<0.001) reduction of serum albumin level among VL patients as compared to controls. Similarly, serum total protein was significantly (P<0.001) reduced in VL patients than control groups. CONCLUSION: There were significantly higher mean levels of serum AST, ALT, and total bilirubin among VL patients as compared to controls. On the other hand, VL patients showed significantly lowered level of albumin and total protein as compared to controls.

Assessment of serum amylase, lipase and associated factors among patients with visceral leishmaniasis treated with sodium stibogluconate/paromomycin at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

BACKGROUND: Visceral leishmaniasis (VL) is a life-threatening parasitic disease next to malaria, which is responsible for the death of 50,000 patients annually. It has three major clinical stages, including visceral, cutaneous, and mucocutaneous leishmaniasis. Ethiopia is one of the east African countries commonly affected with leishmanisis disease. There are many drugs for leishmaniasis, including sodium stibogluconate and paromomycin combined therapy. However, the adverse effect of those combined drugs is not well-defined. Therefore, the purpose of this study was to assess serum amylase, lipase, and associated factors among patients with VL treatment with those combined drugs. METHODS: Hospital-based cross-sectional study was conducted at the University of Gondar Comprehensive Specialized Hospital Leishmaniasis Research and Treatment Center from February to September 2020 G.C. Simple random sampling technique was utilized to select study participants. The study participants who fulfill the inclusion criteria were included in the study with written informed consent. 5 ml of blood was withdrawn by an experienced health professional to analyze serum amylase and lipase level. Descriptive data was presented by tables, charts and graphs. Data was cleared, entered by Epi-data version 3.1 then transfer to STATA 14.1 SE version and for analysis paired t-test was used, for factors correlation and regression was used. Those factor variable who have p-value <0.25 was filtered and goes to multivariate regression and p-value <0.05 was considered as significant variables. RESULTS: The result of this study showed that there was a significant mean difference between serum pancreatic amylase and lipase before and after treatment. The mean ± SD level of serum amylase after treatment showed a statistically significant elevation (P<0.001) as compared to its level before treatment. Similarly, the mean ± SD level of serum lipase after treatment showed a statistically significant elevation (P<0.001) as compared to its level before treatment. There was also significant association between age and baseline serum amylase as compared to serum amylase after treatment. Similarly, there was also significant relation of age and serum lipase with serum lipase after treatment. CONCLUSION: In this study, the level of serum amylase and lipase at treatment of cure was higher and there was an increase in mean serum amylase and lipase after a patient taking sodium stibogluconate and paromomycin combined drugs. Consequently, the elevated result of these biochemical profiles mainly associated with drug induced adverse effect and associated risk factors in VL patients.

Hematological profiles of visceral leishmaniasis patients before and after treatment of anti-leishmanial drugs at University of Gondar Hospital; Leishmania Research and Treatment Center Northwest, Ethiopia.

BACKGROUND: Visceral leshimaniasis is a parasitic disease characterized by systemic infection of phagocytic cells and an intense inflammatory response. The progression of the disease or treatment may have an effect on hematological parameters of these patients'. Thus, the current study sought to compare the hematological profiles of visceral leishmaniasis patients before and after treatment with anti-leishmaniasis drugs. METHOD: An institutional-based retrospective cohort study was conducted among visceral leishmaniasis patients admitted to the University of Gondar comprehensive specialized referral hospital leishmaniasis research and treatment centre between September 2013 and August 2018. Hematological profiles were extracted from the laboratory registration book before and after treatment. Data were entered to Epi-info and exported to SPSS for analysis. Descriptive statistics were summarized using frequency and percentage to present with the table. The mean, standard deviation, median, and interquartile range were used to present the data. Furthermore, using the paired t-test and the Wilcoxon Signed rank test, the mean difference for normally and non-normally distributed data was compared. Spearman and Pearson correlation analysis were used to describe the relationship between hematological parameters and various variables. A P value of 0.05 was considered statistically significant. RESULT: With the exception of the absolute neutrophil count, all post-treatment hematological parameters show a significant increase when compared to pre-treatment levels. Prior to treatment, the prevalence of anemia, leukopenia, and thrombocytopenia was 85.5, 83.4, and 75.8%, respectively, whereas it was 58.3, 38.2, and 19.2% following treatment. Furthermore, parasite load was found to have a statistically significant negative correlation with hematological profiles, specifically with white blood cell and red blood cell parameters. CONCLUSION: According to our findings, patients with visceral leishmaniasis had improved hematological profiles after treatment. The effect of treatment on parasite proliferation and concentration within visceral organs, in which the parasite load could directly affect the patient's hematological profiles, may be associated with the change in hematological profiles.

Efficacy and safety of a combined treatment of sodium stibogluconate at 20mg/kg/day with upper maximum daily dose limit of 850mg and Paromomycin 15mg/kg/day in HIV negative visceral leishmaniasis patients. A retrospective study, northwest Ethiopia.

BACKGROUND: Visceral leishmaniasis (VL) is one of the most neglected tropical infectious diseases. It is fatal if left untreated. The objective of this study was to assess the efficacy and safety of 17-day injections of combined regimen of sodium stibogluconate and paromomycin (SSG/PM) in HIV-negative VL patients. METHODS: A retrospective analysis of medical records of VL patients treated in the University of Gondar Hospital during period 2012-2019 was carried out. RESULTS: A total of 2836 patients were treated for VL from 2012 to 2019. Of these 1233 were treated with SSG-PM, and 1000 of them were included in the study. Initial cure was achieved in 922 (92.2%) patients. The frequency of treatment failure, treatment interruptions, default and deaths respectively were 30 (3%), 20 (2%), 13 (1.3%) and 15 (1.5%). Among 280 patients who completed 6-month follow up, the final cure was 93.9% (263/280), 4 (1.4%) relapsed and 13 (4.6%) developed post-kala-azar dermal leishmaniasis (PKDL). The most common adverse events (AEs) were raised liver transaminases (35.1%; 351 patients), injection site pain (29.1%, 291 patients) and raised serum alpha-amylase (29.1%, 291 patients). Factors associated with poor treatment outcomes were sepsis, pneumonia, and adverse events. CONCLUSION: A combination of SSG at 20mg/kg with upper daily maximum dose of 850mg and PM was effective for achieving initial cure at end of treatment and safe for treatment of HIV negative VL patients in northwestern Ethiopia. Our data are consistent with previous reports and confirms effectiveness of SSG/PM treatment regimen in the Eastern African countries. Efficacy at 6-months (93.9%) was estimated on data derived from patients who completed follow up and needs to be interrogated by future studies.

Miltefosine for the treatment of cutaneous leishmaniasis-A pilot study from Ethiopia.

BACKGROUND: Cutaneous leishmaniasis (CL) in Ethiopia, caused by Leishmania aethiopica, is often severe and hard to treat compared to CL caused by other species elsewhere. Miltefosine is the only oral anti-leishmanial drug, with a favorable side-effect profile compared to routinely available sodium stibogluconate (SSG), but evidence about its use for L. aethiopica is lacking. METHODOLOGY AND PRINCIPAL FINDINGS: In an observational cohort study, treatment outcomes, safety and adherence among CL patients who required systemic treatment and received miltefosine for 28 days in Boru Meda Hospital and University of Gondar Hospital were studied. Patient cure was defined as 100% flattening for non-ulcerated lesions and 100% flattening and 100% re-epithelization for ulcerated lesions. Outcomes were documented for day 28, 90 and 180, both per site, and pooled, adjusting for site as a fixed effect with effect coding. Among 94 included patients (32 in Gondar, 62 in Boru Meda), median lesion duration was 12 months, median size six cm, and mucosal involvement (46.8%) and diffuse (30.9%) lesions were common. Adherence to miltefosine was good, and side-effects were tolerable. Initial outcomes at day 28 were promising, with 68.8% and 94.0% of patients having good improvement or cure in Gondar and Boru Meda respectively. In Boru Meda, outcomes were good with 72.7% and 72.9% cure at day 90 and day 180 respectively. In Gondar, results were less promising, with only 12.5% and 26.7% cure at day 90 and day 180, although confidence intervals were wide. In pooled estimates, 48.7% of patients reached cure at day 180, and 32.3% relapsed. Outcomes were better in Boru Meda Hospital, for smaller lesions and for mucosal lesions. CONCLUSIONS/SIGNIFICANCE: Based on miltefosine's good initial response, tolerable side-effects, tablet-form, we propose to include miltefosine for future clinical trials using extended treatment schedules, combination therapy, or targeting specific subgroups. TRIAL REGISTRATION: ClinicalTrials.gov NCT04004754.

Case Report: Atypical Presentation of Visceral Leishmaniasis: Two Cases from Northwest Ethiopia.

Human visceral leishmaniasis (VL) is a life-threatening disease caused by protozoan parasites belonging to the Leishmania donovani complex. Atypical cases of leishmaniasis and HIV coinfection have been documented in case reports, mostly associated with gastrointestinal tract, kidney, and skin involvement. We report two VL cases with atypical localizations not reported from east Africa before, both diagnosed and treated at the Leishmaniasis Research and Treatment Center, Gondar, Ethiopia. The first case was an HIV-infected patient with scrotal and penile involvement. Leishmania parasites were detected in the spleen and the scrotum. The second case was an immunocompetent individual with esophageal, laryngeal, and pharyngeal involvement and facial lesions. Leishmania parasites were detected in the spleen, skin, and esophageal biopsies. Current evidence suggests atypical presentation can occur in patients irrespective of their HIV status. Therefore, we suggest a high index of suspicion for VL among clinicians working in endemic areas of Ethiopia.