Eur J Clin Microbiol Infect Dis (2012) 31:109–118
DOI 10.1007/s10096-011-1276-0
REVIEW
Leishmaniasis: new insights from an old
and neglected disease
S. Antinori & L. Schifanella & M. Corbellino
Received: 11 February 2011 / Accepted: 12 April 2011 / Published online: 1 May 2011
# Springer-Verlag 2011
Abstract Leishmaniases are a clinically heterogeneous
group of diseases caused by protozoa of the genus
Leishmania. There is growing evidence that the true
incidence of the disease is underestimated, especially in
hyperendemic regions. Moreover, climate changes together
with the increasing movement of humans and animals raise
concerns about the possible introduction of Leishmania
infection in previously spared areas. The disease is
emerging in immunocompromised patients undergoing
bone marrow or solid organ transplantation or treatment
with biologic drugs. Furthermore, the deployment of
military troops and travel to endemic areas are associated
with the observation of a growing number of patients with
cutaneous disease. Improvement in diagnostic methods,
both in the field and in specialized laboratories, has been
obtained through the implementation of molecular amplifi-
cation methods and using the rK39 antigen as the substrate.
Finally, new therapeutic approaches are gaining attention,
such as the use of miltefosine for cutaneous leishmaniasis
and paromomycin for visceral leishmaniasis, as well as the
use of various antileishmanial drugs in combination.
Introduction
Leishmaniases are protozoan parasitic infections transmit-
ted to mammals (including human beings) by phlebotomine
sandflies and they are associated with three main types of
S. Antinori (*) : L. Schifanella : M. Corbellino
Department of Clinical Sciences L. Sacco,
Section of Infectious Diseases and Immunopathology,
Università degli Studi di Milano,
Via GB Grassi, 74,
20157 Milano, Italy
e-mail: spinello.antinori@unimi.it
disease manifestations: visceral, cutaneous, and mucocuta-
neous. Despite the fact that leishmaniasis is considered to
be a neglected disease, a large body of novel findings have
been generated in the last few years on the taxonomy,
epidemiology, clinical manifestations, diagnosis, and ther-
apy of these infections. An analysis of the published
research on leishmaniasis over a period of 50 years
(1957–2007) showed an increasing number of publications
over time, which peaked in 2006 with 1,226 published
items [1]. The articles originated from 140 countries, with
the United States of America (USA) and Brazil being the
two most productive, followed by six European countries
(i.e., United Kingdom, France, Germany, Spain, Switzer-
land, and Italy). These same countries, with the inclusion of
Canada and India, appear in the top ten list of the most
cited papers on the leishmaniases, with the USA and UK
ranking, respectively, first and second. Less than 20% of
the articles are the result of an international cooperation,
with USA and Brazil showing the highest degree of
cooperation.
In the present review, we will present an update of the
most recent advances on Leishmania infections.
Taxonomy
Unlike the Plasmodia, the different species of Leishmania
present identical morphology when classical diagnostic
methods such as microscopic examination or parasite
culture are used. Thus, the classification of Leishmania
was historically based on criteria such as geographical
distribution, vector, tropism, and clinical manifestation [2,
3]. The two known subgenera (L) Leishmania and (L)
Viannia were separated according to their ability to develop
in the foregut (Suprapylaria) and hind-midgut (Peripylaria)
110 Eur J Clin Microbiol Infect Dis (2012) 31:109–118

of the sandfly, respectively. Recognition of the species
within the subgenera was accomplished by using as the
gold standard multilocus enzyme electrophoresis (MLEE)
[4]. However, the validity of the current classification
system that recognizes 30 species, of which 20 are
responsible for human disease, has been repeatedly ques-
tioned [5]. Although several molecular methods have been
used for defining Leishmania taxonomy, this is still a matter
of increasing debate [6]. Very recently, Fraga et al. used
sequences of the highly conserved 70-kDa heat shock
protein (hsp70 gene) to analyze isolates and strains of
different geographic origin, showing that only eight
monophyletic groups were detectable against the 17
examined (Table 1) [7]. According to these authors, in the
L. donovani complex, only L. donovani retained the status
of species and only L. donovani infantum should be
considered a subspecies. Similarly, only L. tropica and not
L. aethiopica conserved the status of species, while they
proposed to consider L. major as an independent species
[7]. As far as the New World Leishmania and Viannia are
concerned, only L. (L) mexicana, L. (V) braziliensis, L.
guyanensis, and L. (V) lainsoni were recognized as
individual species, with the status of L. naiffi awaiting
further investigations. The results of the study by Fraga et
al. have been proposed as “work in progress” in the
revision and simplification of Leishmania’s nomenclature,
given the caveats arising from the use of a single genetic
marker of the parasite [8].
Epidemiology
There is a growing body of data highlighting the notion that
the global health impact of the leishmaniases is grossly
underestimated due to multiple factors (i.e., increasing
prevalence of the disease, unrecorded cases, expanding
areas of endemicity). In this regard, secondary data may be
useful to calculate the true burden of the disease [9]. The
need to arrange reliable epidemiological surveillance data is
strongly supported by the final assessment of the World
Health Organization (WHO) Elimination Initiative. It is
well known that more than 90% of visceral leishmaniasis
(VL) are reported from the Indian subcontinent and Sudan,
and that the Indian state of Bihar alone accounts for nearly
90% of all cases. However, the 200,000 cases of L.
donovani infection officially reported from Bihar since
1977 are, most probably, an underestimate of the real
incidence of the disease. In fact, two population-based

Table 1 Newly proposed nomenclature for Leishmania species based on the heat shock protein 70 (hsp70) gene sequence

Genus Complex Species Geographic distribution Species according

to hsp70 analysis

L. (Leishmania) L. donovani L. donovani China, Indian subcontinent, Ethiopia, Sudan, Kenya, Iran, L. donovani
Saudi Arabia, Yemen
L. infantum Albania, Algeria, France, Greece, Italy, Morocco,
Portugal, Spain, Syria, Tunisia, Turkey, Yemen
L. chagasi Argentina, Bolivia, Brazil, Colombia, Ecuador, El Salvador,
Guadalupe, Guatemala, Honduras, Martinique, Mexico,
Nicaragua, Paraguay, Suriname, Venezuela
L. archibaldi India, Sudan, Ethiopia, Lebanon, Israel
L. tropica L. tropica Afghanistan, Algeria, Azerbaijan, Greece, Iran, Iraq, L. tropica
Israel, Morocco, Tunisia, Turkey, Yemen
L. aethiopica Ethiopia, Kenya
L. major Afghanistan, Algeria, Chad, Iran, Iraq, Israel, Libya, L. major
Mauritania, Morocco, Syria, Sudan
L. mexicana L. mexicana Belize, Colombia, Costa Rica, Dominican Republic, L. mexicana
Ecuador, Guatemala, Honduras, Mexico, Panama, Venezuela
L. amazonensis Bolivia, Brazil, Colombia, Costa Rica, Ecuador, French Guyana,
Panama, Peru, Venezuela
L. garnhami Venezuela
L. (Viannia) L. guyanensis L. guyanensis Brazil, Colombia, Ecuador, French Guyana, Peru, Suriname, L. guyanensis
Venezuela
L. panamensis Belize, Colombia, Costa Rica, Ecuador, Honduras, Nicaragua,
Panama, Venezuela
L. naiffi Brazil, French Guyana, Ecuador, Peru L. naiffi
L. braziliensis L. braziliensis Argentina, Belize, Bolivia, Brazil, Colombia, Costa Rica, L. braziliensis
Ecuador, Guatemala, Honduras, Nicaragua
L. peruviana Peru
L. lainsoni Brazil, Bolivia, Peru L. lainsoni?
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
studies conducted in Bihar’s sub-districts documented an
annual VL incidence rate of 2.5 and 5.7 cases per 1,000,
thus, supporting the fact that official figures underestimate
the incidence of the disease by a factor of 8 and 4,
respectively [10, 11] . Another recent study that included in
the sample more than 5% of the population of a rural
district of Bihar and 35% of the population of high
incidence areas demonstrated an annual incidence of VL
of 2.2 cases per 1,000 [12]; in this regard, the authors
suggest that, in order to achieve the VL elimination goal by
2015 (i.e., less than 0.1 cases per 1,000), a 22- to 35-fold
reduction of the disease’s incidence will be required.
In Europe, both cutaneous leishmaniasis (CL) and VL
are well established diseases in the Mediterranean basin,
with an incidence ranging from 0.02/100,000 to 0.49/
100,000 that roughly translates to 700 cases per year
[13]. However, there is concern that changes in the
environment, human behavior, and the climate, as well as
increasing dog travel, will trigger the introduction of L.
infantum into Northern Europe [14]. Several entomolog-
ical surveys have shown that two VL vectors (namely,
Phlebotomus perniciosus and P. neglectus) have increased
in density and have expanded their range to cover the
Italian Alpine regions, where they were previously
undetected [15, 16]. Moreover, confirmed or suspected
autochthonous cases of canine and human visceral
leishmaniases have been reported not only from northern
Italy, but as north as Germany [17–19].
In the Eastern Mediterranean Region of the WHO, both
CL (zoonotic and anthroponotic) and VL (zoonotic) occur
in 14 of the 22 countries (i.e., Afghanistan, Egypt, Islamic
Republic of Iran, Iraq, Jordan, Libyan Arab Jamahiriya,
Morocco, Pakistan, Saudi Arabia, Somalia, Sudan, Syrian
Arab Republic, Tunisia, and Yemen) [20]. In 2008, nearly
100,000 new cases of CL were reported from 12 countries,
with the highest incidences from Afghanistan (24,585
cases), Syrian Arab Republic (29,140 cases), and Iran
(26,824 cases). However, a recent survey conducted in the
Jordan River valley found an incidence rate for CL of 75/
100,000, which is a figure higher than that observed in the
Syrian Arab Republic [21]. In the same year, around 5,000
cases of VL were reported from Sudan and Somalia, with
another 500 cases from five countries (Iran, Morocco,
Saudi Arabia, Syria, and Tunisia), but these figures
probably still represent an underreporting of the total
burden of the disease [20].
In Latin America, Brazil is the country with the highest
burden of VL, with an increased incidence from an average
of 1,500 cases per year in the 1980s to an average of more
than 3,000 cases per year between 2000 and 2006 [22]. In
this country, the disease spreading southward and eastward
has been observed in the states of Saõ Paulo and Mato
Grosso do Sul.
111
Hosts
The global spread of human immunodeficiency virus (HIV)
infection was responsible, starting from the mid-1980s, for
the upsurge of HIV/VL coinfection in four Mediterranean
countries (i.e., Spain, France, Italy, and Portugal), with such
cases occurring almost exclusively among intravenous drug
users [23]. It was shown that the risk of developing overt
VL was increased by a factor of 100–1,000 in HIV-infected,
as opposed to HIV-uninfected, individuals [24]. HIV
infection was also responsible in these countries for a shift
of leishmaniases from a predominantly pediatric to an adult
disease. The peak incidence of HIV/VL coinfection was
registered during the period from January 1996 to June
1998, when the introduction of highly active antiretroviral
therapy (HAART) became widespread in Europe [25]. In
the ensuing years, a sharp decrease of HIV/VL incidence
was observed throughout southern Europe, with the
possible exception of Portugal [26, 27]. On the contrary,
HIV/VL coinfection is presently expanding in sub-Saharan
Africa, the Indian subcontinent, and South America, not
only as a consequence of social phenomena such as mass
migration and wars, but also of growing local resistance to
antimonials and restricted access to combination antiretro-
viral therapy. For instance, in Ethiopia, 35% of all cases of
VL in Addis Ababa are associated with HIV infection and
higher figures are observed in the Humera area of western
Tigray (i.e., the main region of Leishmania endemicity in
that country) among migrant workers involved in the cotton
and sesame field agriculture, where the proportion of
patients with VL coinfected was as high as 40% in 2006
[28]. Preliminary data obtained by Médecins Sans Fron-
tières in Nasir (Sudan) showed a 25% prevalence rate of
HIV/VL coinfection, whereas in Khartoum, hospital-based
studies documented a prevalence of 5–9.4% [29]. In Brazil,
2% of cases of VL reported in the period 2001–2005 were
coinfected with HIV, but it is worth noting that, contrary to
what is observed in southern Europe, VL represents only
37% of all clinical forms of the disease among coinfected
cases, with mucocutaneous leishmaniases being seen in at
least 43% of HIV-positive patients [23].
However, also in Europe, the hosts at risk of developing
VL are quite variable, as demonstrated by a recent study
conducted in Albania, where it was shown that VL is still a
pediatric disease, with nearly 90% of the total cases still
observed in patients aged below 15 years, with the highest
incidence (25/100,000) in the age group between 0 and
6 years [30].
The leishmaniases, both cutaneous and visceral, are, not
unexpectedly, emerging as bona fide opportunistic infec-
tions among immunocompromised hosts such as those
undergoing solid organ and bone marrow transplantation, in
patients with autoimmune diseases being treated with
112
immunosuppressive agents, and, more recently, with bio-
logic drugs (i.e., infliximab, etanercept, adalimumab) [31–
37]. Another category of patients who may probably be at
higher risk of developing leishmaniasis is represented by
those affected by cancer. In a recent review involving 44
patients, four possible associations between cancer and
leishmaniasis were identified: leishmaniasis mimicking
cancer; a difficult to diagnose infection in patients receiving
chemotherapy for the underlying malignancy; coexistence
of the two diseases; and, finally, the putative role of
Leishmania spp. infection as a trigger for cutaneous and
mucosal malignancies [38].
Another group of individuals who are recognized as
being at increasing risk to develop leishmaniasis are
international travellers and military personnel (Fig. 1)
deployed in areas of high endemicity [39–43]. In 2004,
more than 600 cases of CL were diagnosed in American
soldiers deployed to Iraq, Kuwait, and Afghanistan [42] .
Subsequently, van Thiel et al. reported an attack rate of
18.3% for CL among Dutch troops in Afghanistan [43].
In the GeoSentinel Network, CL ranked 10th among all
dermatologic conditions observed in returning travellers
(Fig. 2); the disease was generally associated with male
predominance and long duration of travel, as well as
Central and South American destinations (particularly
Bolivia) [44].
Clinical aspects
Clinical manifestations of leishmaniasis depend on both the
infecting parasite species and the immune response of the
host [45]. In HIV-infected patients, the presentation of VL
is not significantly different from that observed in HIV-
uninfected individuals. In fact, the classic features of VL
Fig. 1 Cutaneous leishmaniasis “wet form” caused by Leishmania
major in an Italian soldier deployed in Afghanistan
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
Fig. 2 Cutaneous leishmaniasis with ulcerated “volcano-like” appear-
ance due to L. panamensis in an Italian traveller who had visited
several South American countries (Costa Rica, El Salvador, Guate-
mala, Mexico, Panama)
(i.e., fever, weight loss, hepatosplenomegaly, and pancyto-
penia) are observed in about 80–90% of patients. However,
what is markedly different in HIV-positive patients is the
lower rate of response to treatment and the high rate of
disease relapse that approaches 90% in those who are not
receiving HAART [46]. Although HAART is associated
with a reduced incidence of VL relapse, it is not universally
effective in preventing disease recurrence. In contrast to the
classic acquired immune deficiency syndrome (AIDS)-
related opportunistic infections, in the case of HIV/VL, a
more pronounced HAART-induced rise of CD4 T-cell count
should be achieved in order to gain control of the infection.
Several studies using quantitative or semi-quantitative
polymerase chain reaction (PCR) monitoring of parasitemia
in HIV-infected patients have demonstrated low-level
continuous persistence of Leishmania DNAemia, in spite
of adequate clinical response to specific therapy [47, 48].
Bourgeois et al. proposed that the above-mentioned
condition, characterized by alternating asymptomatic and
symptomatic periods, be recognized as a new clinical entity
that the authors name “active chronic visceral leishmania-
sis” [49]. In addition, post-kala-azar dermal leishmaniasis
(PKDL), a cutaneous entity observed in patients with a
previous history of treated VL and generally considered to
be confined to the Indian subcontinent and Sudan, has been
recognized as a manifestation of anti-Leishmania immune
reconstitution inflammatory syndrome (IRIS) in HIV-
positive patients following the administration of antiretro-
viral therapy [50]. A single case of diffuse cutaneous
leishmaniasis caused by L. chagasi was also described in a
Nicaraguan patient with AIDS as IRIS [51].
Among solid organ transplant recipients, fever and
pancytopenia are the main clinical manifestations of VL
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
[31]; since the clinical picture may simulate other infec-
tions, for those patients living outside endemic areas, a
careful travel history should be elicited. In general, the
onset of VL has been observed as a late complication of
transplantation, but in a recent series of kidney recipients, it
was diagnosed in the early (median 17 days) post-transplant
period [32]. Kidney involvement by the parasite with the
development of nephritis or the occlusion of renal vascu-
lature and subsequent graft dysfunction has also been
recently reported [52, 53]. As observed among HIV-
infected patients, multiple episodes of VL relapse can occur
in kidney transplant recipients, sometimes with atypical
mucosal or cutaneous presentations [53].
Insightful reviews on CL have recently appeared in the
literature, to which the readers are referred for additional
information [41, 54, 55]. Interestingly, Akilov et al.
reviewed the known morphologic types of CL and
proposed a new classification based on pathogenesis and
histologic picture [55]. These authors distinguish between
exogenous (localized and disseminated) and endogenous
CL (recurrent or lupoid and PKDL). Localized cutaneous
leishmaniasis (LCL) is divided into typical (with lesions
appearing as papule, nodule, plaque, nodulo-ulcerative, and
impetiginous) and atypical forms. The latter may vary in
morphology (i.e., zosteriform, eczematoid, erysipeloid,
verrucoid, psoriasiform) or localization (fingers, palms
and soles, lips, eyelids, and genitals). Disseminated
cutaneous leishmaniasis (DCL) is distinguished from
diffuse (or pseudolepromatous) CL by the presence, in the
former, of subcutaneous nodules. The presentation with
multiple lesions may be the consequence of multiple
inoculations or secondary to the dissemination of the
parasite mediated by circulating immune cells or represent
an allergic reaction (sometimes triggered by therapy), with
the appearance of leishmanids. Although parasite dissem-
ination during CL is generally observed in patients affected
by L. major and L. tropica infections, a multifocal form of
CL caused by L. infantum has been recently described in
the Mediterranean basin [56]. Finally, in South American
HIV-positive patients, a high prevalence of tegumentary
leishmaniasis with atypical presentations (53% mucocuta-
neous) or unusual localizations (27% in the genital areas)
has been described [57] .
Diagnosis
Although a standardized, commercially available PCR
assay for Leishmania diagnosis is presently still unavail-
able, it is well accepted that PCR can be applied to different
clinical samples with higher sensitivities than conventional
parasitological methods for the diagnosis of VL and CL
[58, 59]. Real-time PCR allows the consistent quantifica-
113
tion of parasite DNA with an analytical sensitivity of
around 1 fg, which corresponds to 0.01 parasites per
reaction [60]. Leishmania parasites are rare and hard to
visualize in skin lesions of patients affected by PKDL with
macular/papular presentation, making it extremely difficult
to differentiate PKDL from leprosy by traditional methods.
However, real-time PCR readily detected Leishmania DNA
in all 25 cutaneous samples of patients with PKDL [60].
Using quantitation by the real-time PCR of 7SL RNA gene
expression levels, Romero et al. provided proof that viable
parasites are present in extralesional sites (including normal
skin, tonsils, and blood monocytes) of patients with dermal
leishmaniasis [61].
Direct agglutination (DAT) and immunochromato-
graphic (ICT) strip tests using the k39 antigen have become
popular in Africa and the Indian subcontinent for the rapid
and sensitive diagnosis of Leishmania infection in the field,
with the latter being more user-friendly [62]. However, the
k39Ag test was found to be less reliable when used in East
Africa than in the Indian subcontinent, with sensitivities
and specificities of, respectively, 75% versus 85% and 70%
versus 92% [63]. A newly developed assay based on the
detection of the k28 fusion protein has shown, in studies
performed in Sudan and Bangladesh, a sensitivity of,
respectively, 96% and 98% [64]. If these preliminary results
can be confirmed in large-scale field evaluations, this novel
assay could be implemented as a first-line, point-of-care test
for the diagnosis of Leishmania infection.
Treatment
Liposomal amphotericin B (L-AMB) is, at present, unambig-
uously considered to be the drug of choice for the treatment of
VL in high-income countries, but its prohibitively high cost
precludes its widespread use in low-income, highly endemic
countries. However, the preferential price offered to the
governments of these areas, together with the recent imple-
mentation of short-course, high-dose regimens, make this
option attractive also for developing countries [65–67].
Recently, in a non-inferiority study conducted in Bihar, it
was shown that a single, high dose of L-AMB (i.e., 10 mg/
kg of body weight) is as effective as, but less expensive than,
15 alternate-day infusions of amphotericin B deoxycholate at
the dose of 1 mg/kg of body weight (cure rates at 1 and
6 months of 100% and 95.7% for the former and 98% and
96.3% for the latter, respectively) [65]. This study extends a
previous experience by the same group in which different
dosages of L-AMB were used and another investigation
conducted in Greece, where two single infusions of L-AMB
at a dosage of 10 mg/kg of body weight were employed [66–
68]. Moreover, it is worth noting that this high dosage of L-
AMB was not associated with an increase of adverse events.
114 Eur J Clin Microbiol Infect Dis (2012) 31:109–118

Miltefosine, a phosphatidylcholine analog, is the only
oral treatment licensed in India and Germany for the
therapy of VL and in Colombia and Bolivia for CL. In a
phase IV open-label trial conducted in India in more than
1,100 adult and pediatric patients with VL, miltefosine
showed an efficacy rate of 82% in the intention-to-treat
analysis and of 95% in the per protocol analysis [69]. The
drug was well tolerated, with diarrhea and vomiting being
the most common adverse events observed in 8% of
patients during the first week of treatment. A randomized
controlled trial conducted in both HIV-positive and HIV-
negative adult Ethiopian males compared miltefosine
(100 mg/kg day) with standard antimony therapy: the cure
rate at 6 months were similar in HIV-negative patients (77%
vs. 76%) but were lower in HIV-positive subjects (46% vs.
57%), although statistical significance was not achieved
[70]. Miltefosine was previously used in a compassionate
program in 39 HIV-coinfected patients with VL: 41%
achieved initial cure and 23% improved upon a second
course of treatment [71]. Several trials have employed
miltefosine in comparison with placebo or antimonials for
the treatment of Old and New World CL (Table 2) [72–78].
In a double-blind, placebo-controlled trial, a marked
difference in response rates was initially noted according
to the country and Leishmania species involved. Unsatis-
factory responses were evidenced in patients infected by
L.(V.) braziliensis in Guatemala, while the contrary was
recorded in individuals infected by L.(V.) panamensis in
Colombia [72]. However, a subsequent study conducted in
Bolivia showed that the 6-month response rate induced by
miltefosine in patients infected by L.(V.) braziliensis was
statistically similar to that obtained with intramuscular
antimony (88% vs. 94%), although antimony achieved
clinical cure more rapidly [74]. More recently, an open-label
randomized study conducted in Colombia demonstrated a
higher response rate (both in the per protocol and intention-to-
treat analyses) in patients treated with meglumine antimoniate
versus those treated with miltefosine, without any association
emerging between drug efficacy and infecting Leishmania
species [75]. Experiences on the treatment with miltefosine
of Old World CL caused by L. major and L. tropica are quite
limited, but they seem to support an activity of the drug also
for these infections [73, 76, 79].
The best treatment approach for CL is, at present, still a
matter of debate. A recent systematic analysis of published
studies included in two Cochrane reviews evidenced
several flaws in the criteria of randomization, the identifi-
cation of causative species, adopted cure criteria, and time
of follow-up, making it difficult to draw any conclusive
indication [80].
A systematic review of 22 articles on the treatment of
mucosal leishmaniasis in Latin America showed statistical-
ly significant better cure rates with meglumine antimoniate
in comparison with stibogluconate (88% vs. 51%, p<0.05),
whereas pentamidine and amphotericin B deoxycholate
were found to be as effective as meglumine [81].
Paromomycin has been registered for VL treatment in
India after a multicenter phase III study demonstrated that

Table 2 Experience on the use of oral miltefosine for the treatment of cutaneous leishmaniasis (CL)

Reference, year Type of study Drug(s) and dosage/duration Leishmania spp. (country) Response rate at Response rate at
6 months PP 6 months ITT

[72], 2004 Double-blind, Miltefosine 2.5 mg/kg/d vs. L.(V.) panamensis (Colombia) 40/44 (91%) 82%
placebo-controlled placebo/28 days L.(V.) braziliensis (Guatemala) 20/38 (53%) 50%
[73], 2007 Randomized, open-label Miltefosine 150 mg d for 28 days L. major (Iran) 26/28 (92.9%) 81.3%
comparative (1:1) vs. meglumine antimoniate 25/31 (83.3%) 80.6%
20 mg/kg/d for 14 days
[74], 2008 Randomized, open-label Miltefosine 2.5 mg/kg/d for L.(V.) braziliensis (Bolivia) 36/41 (88%) NR
comparative (2:1) 28 days vs. meglumine 15/16 (94%) NR
antimoniate 20 mg/kg/d for
20 days
[75], 2010 Randomized, open-label Miltefosine 150 mg d for 28 days L.(V.) braziliensis 85/122 (69.8%) 85/145 (58.6%)
comparative (1:1) vs. meglumine antimoniate (Colombia)
20 mg/kg/d for 20 days L.(V.) panamensis 103/121 (85.1%) 103/143 (72%)
[76], 2010 Observational Miltefosine 150 mg d for 28 days L. major (Afghanistan) 30/34 (88.2%) NR
retrospective
[77], 2010 Randomized, open-label Miltefosine 2.5 mg/kg/d vs. L.(V.) braziliensis (Brazil) 45/60 (75%) NR
meglumine antimoniate 18/30 (53.3%)
20 mg/kg/d for 20 days
[78], 2011 Randomized, open-label Miltefosine 2.5 mg/kg/d vs. L. (V.) guyanensis (Brazil) 71.4% NR
comparative (2:1) meglumine antimoniate 53.6%
20 mg/kg/d for 20 days

PP = per protocol; ITT = intention-to-treat; NR= not reported

Eur J Clin Microbiol Infect Dis (2012) 31:109–118
this drug, at the dosage of 15 mg/kg/d for 21 days, is safe,
affordable, and efficacious [82]. However, in a multicenter
phase III trial conducted in East Africa (Sudan, Kenya, and
Ethiopia) comparing three treatment regimens (paromomy-
cin, sodium stibogluconate, and a combination of both), the
paromomycin arm had to be discontinued due to poor
efficacy, especially in Sudan [83]. Although sodium
stibogluconate remains an effective treatment in this area,
there is growing evidence that it is associated with a higher
mortality risk among patients older than 45 years [84].
Given that, in East Africa, miltefosine is neither registered
nor available and L-AMB remains an unaffordable drug,
there was a rationale to pursue studies employing paromo-
mycin. A phase II dose-finding study conducted in Sudan
showed that, in fact, increasing the dose of paromomycin
(20 mg/kg/d for 21 days) or extending treatment duration
(15 mg/kg/d for 28 days) improves efficacy of this drug to
80–81% cure rates at 6 months, a figure that is closer to
what was originally observed in India [85]. Parenteral and
topical paromomycin has also been used for the treatment
of CL, but with cure rates ranging from 4 to 93%. A recent
meta-analysis of 14 randomized controlled trials that
included 1,221 patients showed that topical paromomycin
administration has therapeutic activity against Old and New
World CL [86]. Moreover, when compared with pentava-
lent antimony compounds, topical paromomycin had a
similar efficacy to intralesionally administered antimonials
in Old World CL, but was inferior to parenteral antimonials
in treating New World CL [86]. However, no significant
differences in efficacy emerged when parenteral paromo-
mycin was compared to parenteral antimonials in the
treatment of New World CL.
Finally, recent years have witnessed a growing interest
in exploring the use of combination therapy also for the
treatment of VL in order to: achieve shorter treatment
duration; reduce the total drug dose administered; limit
the emergence of drug resistance; and enhance the
clinical and parasitological cure rates in difficult-to-treat
populations, such as HIV-infected patients [87, 88]. An
analysis of the cost-effectiveness of Leishmania combina-
tion therapy for the Indian subcontinent shows that the
association of miltefosine with paromomycin represents
the most economically attractive strategy, with a cost of
US$92 per single averted death, followed by liposomal
amphotericin B plus paromomycin (US$652 per single
averted death) [89]. A phase III non-inferiority, open-label
trial conducted in India comparing standard treatment
(amphotericin B infusion on alternate days for 30 days)
with three drug combinations (single-dose L-AMB and
10-day paromomycin; 10 days each of miltefosine and
paromomycin; single dose L-AMB and 7-day miltefosine)
showed cure rates at 6 months of at least 97% for all
combinations [90].
115
Conclusions
The last 10 years have witnessed an extraordinary progress
in our capacity in classifying, diagnosing, and treating
Leishmania infection. The challenge is to translate such
progress in effective strategy toward programs aimed to
control and eliminate the disease.
References
1. Al-Mutawakel K, Scutaru C, Shami A, Sakr M, Groneberg
DA, Quarcoo D (2010) Scientometric analysis of the world-
wide research efforts concerning Leishmaniasis. Parasit Vectors
3:14
2. Pratt DM, David JR (1981) Monoclonal antibodies that distin-
guish between New World species of Leishmania. Nature
291:581–583
3. Lainson R, Shaw JJ (1987) Evolution, classification and geo-
graphical distribution. In: Peters W, Killick-Kendrick R (eds) The
leishmaniases in biology and medicine. Academic Press, London,
pp 1–120
4. Rioux JA, Lanotte G, Serres E, Pratlong F, Bastien P, Perieres J
(1990) Taxonomy of Leishmania. Use of isoenzymes. Suggestions
for a new classification. Ann Parasitol Hum Comp 65:111–125
5. Bañuls AL, Hide M, Prugnolle F (2007) Leishmania and the
leishmaniases: a parasite genetic update and advances in taxon-
omy, epidemiology and pathogenicity in humans. Adv Parasitol
64:1–109
6. Lukes J, Mauricio IL, Schönian G, Dujardin JC, Soteriadou K,
Dedet JP, Kuhls K, Tintaya KW, Jirků M, Chocholová E,
Haralambous C, Pratlong F, Oborník M, Horák A, Ayala FJ,
Miles MA (2007) Evolutionary and geographical history of the
Leishmania donovani complex with a revision of current
taxonomy. Proc Natl Acad Sci USA 104:9375–9380
7. Fraga J, Montalvo AM, De Doncker S, Dujardin JC, Van der
Auwera G (2010) Phylogeny of Leishmania species based on the
heat-shock protein 70 gene. Infect Genet Evol 10:238–245
8. Schönian G, Mauricio I, Cupolillo E (2010) Is it time to revise the
nomenclature of Leishmania? Trends Parasitol 26:466–469
9. Bern C, Maguire JH, Alvar J (2008) Complexities of assessing the
disease burden attributable to leishmaniasis. PLoS Negl Trop Dis
2:e313
10. Singh SP, Reddy DC, Rai M, Sundar S (2006) Serious under-
reporting of visceral leishmaniasis through passive case reporting
in Bihar, India. Trop Med Int Health 11:899–905
11. Singh VP, Ranjan A, Topno RK, Verma RB, Siddique NA,
Ravidas VN, Kumar N, Pandey K, Das P (2010) Estimation of
under-reporting of visceral leishmaniasis cases in Bihar, India. Am
J Trop Med Hyg 82:9–11
12. Das P, Samuels S, Desjeux P, Mittal A, Topno R, Siddiqui NA,
Sur D, Pandey A, Sarnoff R (2010) Annual incidence of visceral
leishmaniasis in an endemic area of Bihar, India. Trop Med Int
Health 15(Suppl 2):4–11
13. Dujardin JC, Campino L, Cañavate C, Dedet JP, Gradoni L,
Soteriadou K, Mazeris A, Ozbel Y, Boelaert M (2008) Spread of
vector-borne diseases and neglect of Leishmaniasis, Europe.
Emerg Infect Dis 14:1013–1018
14. Ready PD (2010) Leishmaniasis emergence in Europe. Euro
Surveill 15:19505
15. Maroli M, Rossi L, Baldelli R, Capelli G, Ferroglio E, Genchi C,
Gramiccia M, Mortarino M, Pietrobelli M, Gradoni L (2008) The
northward spread of leishmaniasis in Italy: evidence from
116
retrospective and ongoing studies on the canine reservoir and
phlebotomine vectors. Trop Med Int Health 13:256–264
16. Morosetti G, Bongiorno G, Beran B, Scalone A, Moser J,
Gramiccia M, Gradoni L, Maroli M (2009) Risk assessment for
canine leishmaniasis spreading in the north of Italy. Geospat
Health 4:115–127
17. Biglino A, Bolla C, Concialdi E, Trisciuoglio A, Romano A,
Ferroglio E (2010) Asymptomatic Leishmania infantum infection
in an area of Northwestern Italy (Piedmont Region) where such
infections are traditionally nonendemic. J Clin Microbiol 48:131–
136
18. Naucke TJ, Schmitt C (2004) Is leishmaniasis becoming endemic
in Germany? Int J Med Microbiol 293:179–181
19. Naucke TJ, Menn B, Massberg D, Lorentz S (2008) Sandflies and
leishmaniasis in Germany. Parasitol Res 103(Suppl 1):S65–S68
20. Postigo JA (2010) Leishmaniasis in the World Health Organiza-
tion Eastern Mediterranean Region. Int J Antimicrob Agents 36
(Suppl 1):S62–S65
21. Mosleh IM, Geith E, Natsheh L, Abdul-Dayem M, Abotteen N
(2008) Cutaneous leishmaniasis in the Jordanian side of the
Jordan Valley: severe under-reporting and consequences on public
health management. Trop Med Int Health 13:855–860
22. Romero GA, Boelaert M (2010) Control of visceral leishmaniasis
in Latin America—a systematic review. PLoS Negl Trop Dis 4:
e584
23. Alvar J, Cañavate C, Gutiérrez-Solar B, Jiménez M, Laguna F,
López-Vélez R, Molina R, Moreno J (1997) Leishmania and
human immunodeficiency virus coinfection: the first 10 years.
Clin Microbiol Rev 10:298–319
24. Kubar J, Marty P, Lelièvre A, Quaranta JF, Staccini P, Caroli-
Bosc C, Le Fichoux Y (1998) Visceral leishmaniosis in HIV-
positive patients: primary infection, reactivation and latent
infection: impact of the CD4+ T-lymphocyte counts. AIDS
12:2147–2153
25. Paredes R, Munoz J, Diaz I, Domingo P, Gurgui M, Clotet B
(2003) Leishmaniasis in HIV infection. J Postgrad Med 49:39–49
26. Alvar J, Aparicio P, Aseffa A, Den Boer M, Cañavate C, Dedet JP,
Gradoni L, Ter Horst R, López-Vélez R, Moreno J (2008) The
relationship between leishmaniasis and AIDS: the second 10 years.
Clin Microbiol Rev 21:334–359
27. de la Rosa R, Pineda JA, Delgado J, Macías J, Morillas F, Mira
JA, Sánchez-Quijano A, Leal M, Lissen E (2002) Incidence of and
risk factors for symptomatic visceral leishmaniasis among human
immunodeficiency virus type 1-infected patients from Spain in the
era of highly active antiretroviral therapy. J Clin Microbiol
40:762–767
28. ter Horst R, Collin SM, Ritmeijer K, Bogale A, Davidson RN
(2008) Concordant HIV infection and visceral leishmaniasis in
Ethiopia: the influence of antiretroviral treatment and other factors
on outcome. Clin Infect Dis 46:1702–1709
29. Gorski S, Collin SM, Ritmeijer K, Keus K, Gatluak F, Mueller M,
Davidson RN (2010) Visceral leishmaniasis relapse in Southern
Sudan (1999–2007): a retrospective study of risk factors and
trends. PLoS Negl Trop Dis 4:e705
30. Petrela R, Kuneshka L, Foto E, Zavalani F, Gradoni L (2010)
Pediatric visceral leishmaniasis in Albania: a retrospective
analysis of 1,210 consecutive hospitalized patients (1995–2009).
PLoS Negl Trop Dis 4:e814
31. Antinori S, Cascio A, Parravicini C, Bianchi R, Corbellino M
(2008) Leishmaniasis among organ transplant recipients. Lancet
Infect Dis 8:191–199
32. Veroux M, Corona D, Giuffrida G, Cacopardo B, Sinagra N,
Tallarita T, Giaquinta A, Zerbo D, Veroux PF (2010) Visceral
leishmaniasis in the early post-transplant period after kidney
transplantation: clinical features and therapeutic management.
Transpl Infect Dis 12:387–391
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
33. Weisser M, Khanlari B, Terracciano L, Arber C, Gratwohl A,
Bassetti S, Hatz C, Battegay M, Flückiger U (2007) Visceral
leishmaniasis: a threat to immunocompromised patients in non-
endemic areas? Clin Microbiol Infect 13:751–753
34. Xynos ID, Tektonidou MG, Pikazis D, Sipsas NV (2009)
Leishmaniasis, autoimmune rheumatic disease, and anti-tumor
necrosis factor therapy, Europe. Emerg Infect Dis 15:956–959
35. Cascio A, Iaria M, Iaria C (2010) Leishmaniasis and biologic
therapies for rheumatologic diseases. Semin Arthritis Rheum 40:
e3–e5
36. De Leonardis F, Govoni M, Lo Monaco A, Trotta F (2009)
Visceral leishmaniasis and anti-TNF-α therapy: case report and
review of the literature. Clin Exp Rheumatol 27:503–506
37. Mueller MC, Fleischmann E, Grunke M, Schewe S, Bogner JR,
Löscher T (2009) Relapsing cutaneous leishmaniasis in a patient
with ankylosing spondylitis treated with infliximab. Am J Trop
Med Hyg 81:52–54
38. Kopterides P, Mourtzoukou EG, Skopelitis E, Tsavaris N, Falagas
ME (2007) Aspects of the association between leishmaniasis and
malignant disorders. Trans R Soc Trop Med Hyg 101:1181–1189
39. Antinori S, Gianelli E, Calattini S, Longhi E, Gramiccia M,
Corbellino M (2005) Cutaneous leishmaniasis: an increasing
threat for travellers. Clin Microbiol Infect 11:343–346
40. Pavli A, Maltezou HC (2010) Leishmaniasis, an emerging
infection in travellers. Int J Infect Dis 14:e1032–e1039
41. Schwartz E, Hatz C, Blum J (2006) New world cutaneous
leishmaniasis in travellers. Lancet Infect Dis 6:342–349
42. Weina PJ, Neafie RC, Wortmann G, Polhemus M, Aronson NE
(2004) Old world leishmaniasis: an emerging infection among
deployed US military and civilian workers. Clin Infect Dis
39:1674–1680
43. van Thiel PP, Leenstra T, de Vries HJ, van der Sluis A, van Gool
T, Krull AC, van Vugt M, de Vries PJ, Zeegelaar JE, Bart A, van
der Meide WF, Schallig HD, Faber WR, Kager PA (2010)
Cutaneous leishmaniasis (Leishmania major infection) in Dutch
troops deployed in northern Afghanistan: epidemiology, clinical
aspects, and treatment. Am J Trop Med Hyg 83:1295–1300
44. Lederman ER, Weld LH, Elyazar IRF, von Sonnenburg F, Loutan
L, Schwartz E, Keystone JS (2008) Dermatologic conditions of
the ill returned traveler: an analysis from the GeoSentinel
Surveillance Network. Int J Infect Dis 12:593–602
45. Pintado V, Martín-Rabadán P, Rivera ML, Moreno S, Bouza E
(2001) Visceral leishmaniasis in human immunodeficiency virus
(HIV)-infected and non-HIV-infected patients. A comparative
study. Medicine (Baltimore) 80:54–73
46. López-Vélez R (2003) The impact of highly active antiretroviral
therapy (HAART) on visceral leishmaniasis in Spanish patients
who are co-infected with HIV. Ann Trop Med Parasitol 97(Suppl
1):143–147
47. Mary C, Faraut F, Lascombe L, Dumon H (2004) Quantification
of Leishmania infantum DNA by a real-time PCR assay with high
sensitivity. J Clin Microbiol 42:5249–5255
48. Antinori S, Calattini S, Piolini R, Longhi E, Bestetti G, Cascio A,
Parravicini C, Corbellino M (2009) Is real-time polymerase chain
reaction (PCR) more useful than a conventional PCR for the
clinical management of leishmaniasis? Am J Trop Med Hyg
81:46–51
49. Bourgeois N, Bastien P, Reynes J, Makinson A, Rouanet I,
Lachaud L (2010) ‘Active chronic visceral leishmaniasis’ in HIV-
1-infected patients demonstrated by biological and clinical long-
term follow-up of 10 patients. HIV Med 11:670–673
50. Antinori S, Longhi E, Bestetti G, Piolini R, Acquaviva V, Foschi
A, Trovati S, Parravicini C, Corbellino M, Meroni L (2007) Post-
kala-azar dermal leishmaniasis as an immune reconstitution
inflammatory syndrome in a patient with acquired immune
deficiency syndrome. Br J Dermatol 157:1032–1036
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
51. Sinha S, Fernández G, Kapila R, Lambert WC, Schwartz RA
(2008) Diffuse cutaneous leishmaniasis associated with the
immune reconstitution inflammatory syndrome. Int J Dermatol
47:1263–1270
52. Dettwiler S, McKee T, Hadaya K, Chappuis F, van Delden C,
Moll S (2010) Visceral leishmaniasis in a kidney transplant
recipient: parasitic interstitial nephritis, a cause of renal dysfunc-
tion. Am J Transpl 10:1486–1489
53. Simon I, Wissing KM, Del Marmol V, Antinori S, Remmelink M,
Nilufer Broeders E, Nortier JL, Corbellino M, Abramowicz D,
Cascio A (2011) Recurrent leishmaniasis in kidney transplant
recipients: report of 2 cases and systematic review of the literature.
Transpl Infect Dis. doi:10.1111/j.1399-3062.2011.00598.x
54. Reithinger R, Dujardin JC, Louzir H, Pirmez C, Alexander B,
Brooker S (2007) Cutaneous leishmaniasis. Lancet Infect Dis
7:581–596
55. Akilov OE, Khachemoune A, Hasan T (2007) Clinical manifes-
tations and classification of Old World cutaneous leishmaniasis.
Int J Dermatol 46:132–142
56. Maniscalco M, Noto G, Zichichi L, Veraldi S (2007) Multifocal
cutaneous leishmaniasis: a new clinical presentation of the
disease. Acta Derm Venereol 87:275–276
57. Lindoso JA, Barbosa RN, Posada-Vergara MP, Duarte MI,
Oyafuso LK, Amato VS, Goto H (2009) Unusual manifestations
of tegumentary leishmaniasis in AIDS patients from the New
World. Br J Dermatol 160:311–318
58. Antinori S, Calattini S, Longhi E, Bestetti G, Piolini R, Magni C,
Orlando G, Gramiccia M, Acquaviva V, Foschi A, Corvasce S,
Colomba C, Titone L, Parravicini C, Cascio A, Corbellino M
(2007) Clinical use of polymerase chain reaction performed on
peripheral blood and bone marrow samples for the diagnosis and
monitoring of visceral leishmaniasis in HIV-infected and HIV-
uninfected patients: a single-center, 8-year experience in Italy and
review of the literature. Clin Infect Dis 44:1602–1610
59. Bensoussan E, Nasereddin A, Jonas F, Schnur LF, Jaffe CL (2006)
Comparison of PCR assays for diagnosis of cutaneous leishman-
iasis. J Clin Microbiol 44:1435–1439
60. Verma S, Kumar R, Katara GK, Singh LC, Negi NS, Ramesh V,
Salotra P (2010) Quantification of parasite load in clinical samples
of leishmaniasis patients: IL-10 level correlates with parasite load
in visceral leishmaniasis. PLoS One 5:e10107
61. Romero I, Téllez J, Suárez Y, Cardona M, Figueroa R, Zelazny A,
Gore Saravia N (2010) Viability and burden of Leishmania in
extralesional sites during human dermal leishmaniasis. PLoS Negl
Trop Dis 4:e819
62. Srivastava P, Dayama A, Mehrotra S, Sundar S (2011) Diagnosis
of visceral leishmaniasis. Trans R Soc Trop Med Hyg 105:1–6
63. Boelaert M, El-Safi S, Hailu A, Mukhtar M, Rijal S, Sundar S,
Wasunna M, Aseffa A, Mbui J, Menten J, Desjeux P, Peeling
RW (2008) Diagnostic tests for Kala-azar: a multi-centre study
of the freeze-dried DAT, rK39 strip test and KAtex in East
Africa and the Indian subcontinent. Trans R Soc Trop Med
Hyg 102:32–40
64. Pattabhi S, Whittle J, Mohamath R, El-Safi S, Moulton GG,
Guderian JA, Colombara D, Abdoon AO, Mukhtar MM, Mondal
D, Esfandiari J, Kumar S, Chun P, Reed SG, Bhatia A (2010)
Design, development and evaluation of rK28-based point-of-care
tests for improving rapid diagnosis of visceral leishmaniasis.
PLoS Negl Trop Dis 4:e822
65. Sundar S, Chakravarty J, Agarwal D, Rai M, Murray HW (2010)
Single-dose liposomal amphotericin B for visceral leishmaniasis
in India. N Engl J Med 362:504–512
66. Sundar S, Agrawal G, Rai M, Makharia MK, Murray HW (2001)
Treatment of Indian visceral leishmaniasis with single or daily
infusions of low dose liposomal amphotericin B: randomised trial.
BMJ 323:419–422
117
67. Sundar S, Jha TK, Thakur CP, Mishra M, Singh VP, Buffels R
(2003) Single-dose liposomal amphotericin B in the treatment of
visceral leishmaniasis in India: a multicenter study. Clin Infect Dis
37:800–804
68. Syriopoulou V, Daikos GL, Theodoridou M, Pavlopoulou I,
Manolaki AG, Sereti E, Karamboula A, Papathanasiou D, Krikos
X, Saroglou G (2003) Two doses of a lipid formulation of
amphotericin B for the treatment of Mediterranean visceral
leishmaniasis. Clin Infect Dis 36:560–566
69. Bhattacharya SK, Sinha PK, Sundar S, Thakur CP, Jha TK,
Pandey K, Das VR, Kumar N, Lal C, Verma N, Singh VP, Ranjan
A, Verma RB, Anders G, Sindermann H, Ganguly NK (2007)
Phase 4 trial of miltefosine for the treatment of Indian visceral
leishmaniasis. J Infect Dis 196:591–598
70. Ritmeijer K, Dejenie A, Assefa Y, Hundie TB, Mesure J, Boots G,
den Boer M, Davidson RN (2006) A comparison of miltefosine
and sodium stibogluconate for treatment of visceral leishmaniasis
in an Ethiopian population with high prevalence of HIV infection.
Clin Infect Dis 43:357–364
71. Sindermann H, Engel KR, Fischer C, Bommer W (2004) Oral
miltefosine for leishmaniasis in immunocompromised patients:
compassionate use in 39 patients with HIV infection. Clin Infect
Dis 39:1520–1523
72. Soto J, Arana BA, Toledo J, Rizzo N, Vega JC, Diaz A, Luz M,
Gutierrez P, Arboleda M, Berman JD, Junge K, Engel J,
Sindermann H (2004) Miltefosine for New World cutaneous
leishmaniasis. Clin Infect Dis 38:1266–1272
73. Mohebali M, Fotouhi A, Hooshmand B, Zarei Z, Akhoundi B,
Rahnema A, Razaghian AR, Kabir MJ, Nadim A (2007)
Comparison of miltefosine and meglumine antimoniate for the
treatment of zoonotic cutaneous leishmaniasis (ZCL) by a
randomized clinical trial in Iran. Acta Trop 103:33–40
74. Soto J, Rea J, Balderrama M, Toledo J, Soto P, Valda L, Berman
JD (2008) Efficacy of miltefosine for Bolivian cutaneous
leishmaniasis. Am J Trop Med Hyg 78:210–211
75. Vélez I, López L, Sánchez X, Mestra L, Rojas C, Rodríguez E
(2010) Efficacy of miltefosine for the treatment of American
cutaneous leishmaniasis. Am J Trop Med Hyg 83:351–356
76. van Thiel PP, Leenstra T, Kager PA, de Vries HJ, van Vugt M, van
der Meide WF, Bart A, Zeegelaar JE, van der Sluis A, Schallig
HD, van Gool T, Faber WR, de Vries PJ (2010) Miltefosine
treatment of Leishmania major infection: an observational study
involving Dutch military personnel returning from northern
Afghanistan. Clin Infect Dis 50:80–83
77. Machado PR, Ampuero J, Guimarães LH, Villasboas L, Rocha
AT, Schriefer A, Sousa RS, Talhari A, Penna G, Carvalho EM
(2010) Miltefosine in the treatment of cutaneous leishmaniasis
caused by Leishmania braziliensis in Brazil: a randomized and
controlled trial. PLoS Negl Trop Dis 4:e912
78. Chrusciak-Talhari A, Dietze R, Chrusciak Talhari C, da Silva RM,
Gadelha Yamashita EP, de Oliveira Penna G, Lima Machado PR,
Talhari S (2011) Randomized controlled clinical trial to assess
efficacy and safety of miltefosine in the treatment of cutaneous
leishmaniasis caused by Leishmania (Viannia) guyanensis in
Manaus, Brazil. Am J Trop Med Hyg 84:255–260
79. Keynan Y, Larios OE, Wiseman MC, Plourde M, Ouellette M,
Rubinstein E (2008) Use of oral miltefosine for cutaneous
leishmaniasis in Canadian soldiers returning from Afghanistan.
Can J Infect Dis Med Microbiol 19:394–396
80. González U, Pinart M, Reveiz L, Rengifo-Pardo M, Tweed J,
Macaya A, Alvar J (2010) Designing and reporting clinical trials
on treatments for cutaneous leishmaniasis. Clin Infect Dis 51:409–
419
81. Amato VS, Tuon FF, Siqueira AM, Nicodemo AC, Neto VA
(2007) Treatment of mucosal leishmaniasis in Latin America:
systematic review. Am J Trop Med Hyg 77:266–274
118
82. Sundar S, Jha TK, Thakur CP, Sinha PK, Bhattacharya SK (2007)
Injectable paromomycin for visceral leishmaniasis in India. N
Engl J Med 356:2571–2581
83. Hailu A, Musa A, Wasunna M, Balasegaram M, Yifru S,
Mengistu G, Hurissa Z, Hailu W, Weldegebreal T, Tesfaye S,
Makonnen E, Khalil E, Ahmed O, Fadlalla A, El-Hassan A,
Raheem M, Mueller M, Koummuki Y, Rashid J, Mbui J, Mucee
G, Njoroge S, Manduku V, Musibi A, Mutuma G, Kirui F,
Lodenyo H, Mutea D, Kirigi G, Edwards T, Smith P, Muthami L,
Royce C, Ellis S, Alobo M, Omollo R, Kesusu J, Owiti R,
Kinuthia J; Leishmaniasis East Africa Platform (LEAP) group
(2010) Geographical variation in the response of visceral
leishmaniasis to paromomycin in East Africa: a multicentre,
open-label, randomized trial. PLoS Negl Trop Dis 4:e709
84. Chappuis F, Alirol E, Worku DT, Mueller Y, Ritmeijer K (2011)
High mortality among older patients treated with pentavalent
antimonials for visceral leishmaniasis in East Africa and rationale
for switch to liposomal amphotericin B. Antimicrob Agents
Chemother 55:455–456
85. Musa AM, Younis B, Fadlalla A, Royce C, Balasegaram M,
Wasunna M, Hailu A, Edwards T, Omollo R, Mudawi M,
Kokwaro G, El-Hassan A, Khalil E (2010) Paromomycin for the
Eur J Clin Microbiol Infect Dis (2012) 31:109–118
treatment of visceral leishmaniasis in Sudan: a randomized, open-
label, dose-finding study. PLoS Negl Trop Dis 4:e855
86. Kim DH, Chung HJ, Bleys J, Ghohestani RF (2009) Is
paromomycin an effective and safe treatment against cutaneous
leishmaniasis? A meta-analysis of 14 randomized controlled trials.
PLoS Negl Trop Dis 3:e381
87. Olliaro PL (2010) Drug combinations for visceral leishmaniasis.
Curr Opin Infect Dis 29:595–602
88. van Griensven J, Balasegaram M, Meheus F, Alvar J, Lynen L,
Boelaert M (2010) Combination therapy for visceral leishmania-
sis. Lancet Infect Dis 10:184–194
89. Meheus F, Balasegaram M, Olliaro P, Sundar S, Rijal S, Faiz MA,
Boelaert M (2010) Cost-effectiveness analysis of combination
therapies for visceral leishmaniasis in the Indian subcontinent.
PLoS Negl Trop Dis 4:e818
90. Sundar S, Sinha PK, Rai M, Verma DK, Nawin K, Alam S,
Chakravarty J, Vaillant M, Verma N, Pandey K, Kumari P, Lal CS,
Arora R, Sharma B, Ellis S, Strub-Wourgaft N, Balasegaram M,
Olliaro P, Das P, Modabber F (2011) Comparison of short-course
multidrug treatment with standard therapy for visceral leishmaniasis
in India: an open-label, non-inferiority, randomised controlled trial.
Lancet 377:477–486